bavSvTa asakis avTvisebiani limfomebis · PDF filefollowing cytotoxic chemotherapy on bone...
Transcript of bavSvTa asakis avTvisebiani limfomebis · PDF filefollowing cytotoxic chemotherapy on bone...
hojkinis limfoma (HD)
saqarTvelos pediatr-hematologTada
onko hematologTa kavSiri
Tbilisi2007
gaidlainis aucilebloba BbavSvTa asakSi avTvisebiani limfomebis
maRaldozirebuli qimiTerapiuli programebis gamoyeneba mniSvnelovani
win gadadgmuli nabijia mosalodneli mogvianebiTi garTulebebis Tavidan
acilebisa da daavadebis optimaluri gamosavlis misaRwevad vinaidan
programuli Terapia iTvaliswinebs qimiopreparatebis dozirebisa da
Seyvanis zustad gansazRvrul reJims mizanmimarTul kvlevebs
garTulebebis marTvis algoriTmebs xangrZliv monitorings amitom
simsivnuri daavadebebis swori menejmentis gansaxorcieleblad
gaidlainis Seqmna umniSvnelovaniesi pirobaa
hojkinis limfoma (HD)(Hodgkinlsquos Disease)
1 daavadebis definicia
hojkinis limfomalimfogranulematozi aris simsivnuri daavadeba
romelis drosac xdeba limfoiduri qsovilis neoplaziuri
transformacia limfoiduri qsovili aris mTel organizmSi ris gamoc
simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier nawilSi da
gavrceldes organizmis nebismier qsovilSi
sinonimebi hojkinis limfoma HD limfogranulematozi LG
2 epidemiologia
statistikuri monacemebiT hojkinis lmfomis sixSire bavSvTa asakSi
Seadgens 36 SemTxvevas erT milion bavSvTa mosaxleobaze
2
0
20
40
60 Hhojkinis daavadebis ganawileba asakis gaTvaliswinebiT
Ppac
inti
S
asaki
0-4 5-9 10-14 15-19 20-24 25-29 35-39 30-39
daavadebis piki aRiniSneba 5-dan 8 wlamde asakis bavSvebSi da biWebi
avadoben ufro xSirad bavSvTa asakis simsivnuri daavadebebis
struqturaSi hojkinis limfoma Seadgens 12-15 -s
0
20
40
60
80
100
gogobiWi lt7 8- dan 11 weli gt12
Hohojkinis limfomebis SemTxvevebi asakisa da sqesis mixedviT
Series2
hojkinis daavadebis ganawu
saqarTveloSi bavSvTa sakSi hojkinis limfomis SemTxvevebis sarwmuno
statistikuri monacemebi ar arsebos ukanasknel wlebSi SeiniSneba
bavSvTa onko-hematologiur centrSi hojkinis limfomiT daavadebuli
pirveladi pacientebis momarTvianobis Semcireba da meoradi pacientebis
(daavadebis recidivi) momarTvianobis momateba rac aixsneba imiT rom
hojkinis limfomiT daavadebuli bavSvebi mkurnalobas itareben
sxvadasxva klinikebSi
3 etiopatogenezi daavadebis substrats warmoadgens rid-Sternbergis
avTvisebiani ujredi daavadebis gamomwvevi mizezi ucnobia Tumca
arsebobs monacemebi hojkinis limfomis virusuli etiologiis (EBV)
virusis sasargeblod (Levine Stein 19900
4 daavadebis zogadi simptomebi
bull limfuri kvanZebis umtkiveulo hiperplazia
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3
5 klasifikacia -
hojkinis limfomis tipebi (histolgiuri diagnozi)
klasikuri hojkinis daavadeba
bull nodularuli sklerozi
bull Sereulujredovan
bull limfocitebis siWarbiT
bull limfoiduri ganvleviT
6 gamokvlevis sqema
6 1 inicialuri diagnozis dadgena (mtkicebuleba 1 rekomendaciis
xarisxi A)
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis siCqare
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
6 2 inicialuri stadirebis gansazrvrisTvis saWiro radiologiuri
kvlevebi (mtkicebuleba 1 rekomendaciis xarisxi A)
bull valdeieris rgolis kisris subklavikularuli aqsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an magnitur
rezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis II stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
4
7 daavadebis stadiebi
stadia I
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis limfour
kvanZSi
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis organoSi
eqstranodalurad (IE)
stadia II
bull simsivnuri dazianeba aRiniSneba 2 an met regionalur limfuri
kvanZSi diafragmis mxolod erT mxares (zmoT an qvemoT)
bull simsivne nanaxia regionaluri limfuri kvanZebSi da mimdebare
qsovilSi (IIE )
stadia III
bull simsivnuri dazianeba aRiniSneba limfur kvanZebSi diafragmis orive
mxres
bull simsivnuri dazianeba aRiniSneba rogorc limfur kvanZebSi aseve
elenTaSi (IIIS) da an eqstranodalur regionSi an organoSi (IIIS) an
oriveSi erTadroulad(IIISE)
stadiaIV
bull adgili aqvs eqstranodalurad mxolod erTi organos
diseminirebul dazianebas simsivnuri ujredebi SeiZeleba
arsebobdes an ar asebobdes limfur kvanZebSi
bull adgili aqvs eqstranodalurad mxolod erTi organos simsivnur
dazianebas rasac Tan axlavs araregionaluri limfuri kvanZebis
procesSi CarTva
yoveli stadia A da B kategoriad aris dayofili
bull stadia A - zogadi simptomebis ar arseboba
bull stadia B - araumcires erT-erTi zemoT moyvanili zogadi
simptomebidan
5
8 hojkinis limfomis mkurnaloba (mtkicebuleba I rekomendaciis xarisxi A)
M81 bavSvTa asakSi hojkinis limfomis mkurnalobis ZiriTadi principebi
bull simsivniT daavadebuli yvela bavSvi unda mkurnalobdes bavSvTa
specializirebul samkurnalo centrSi
bull mkurnaloba unda emyarebodes daavadebis stadirebas
bull mkurnalobis ori ZiriTadi samkurnalo meTodia qimioTerapia
da sxivuri Terapia
82 mkurnalobis koncefcia
6
inicialuri diagnozis procedurebi
diagnizi
warmosaxviTi kvlevbi stadireba mkurnaloba gankurneba
qimioTerapia radiaciuli Terapi
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
gaidlainis aucilebloba BbavSvTa asakSi avTvisebiani limfomebis
maRaldozirebuli qimiTerapiuli programebis gamoyeneba mniSvnelovani
win gadadgmuli nabijia mosalodneli mogvianebiTi garTulebebis Tavidan
acilebisa da daavadebis optimaluri gamosavlis misaRwevad vinaidan
programuli Terapia iTvaliswinebs qimiopreparatebis dozirebisa da
Seyvanis zustad gansazRvrul reJims mizanmimarTul kvlevebs
garTulebebis marTvis algoriTmebs xangrZliv monitorings amitom
simsivnuri daavadebebis swori menejmentis gansaxorcieleblad
gaidlainis Seqmna umniSvnelovaniesi pirobaa
hojkinis limfoma (HD)(Hodgkinlsquos Disease)
1 daavadebis definicia
hojkinis limfomalimfogranulematozi aris simsivnuri daavadeba
romelis drosac xdeba limfoiduri qsovilis neoplaziuri
transformacia limfoiduri qsovili aris mTel organizmSi ris gamoc
simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier nawilSi da
gavrceldes organizmis nebismier qsovilSi
sinonimebi hojkinis limfoma HD limfogranulematozi LG
2 epidemiologia
statistikuri monacemebiT hojkinis lmfomis sixSire bavSvTa asakSi
Seadgens 36 SemTxvevas erT milion bavSvTa mosaxleobaze
2
0
20
40
60 Hhojkinis daavadebis ganawileba asakis gaTvaliswinebiT
Ppac
inti
S
asaki
0-4 5-9 10-14 15-19 20-24 25-29 35-39 30-39
daavadebis piki aRiniSneba 5-dan 8 wlamde asakis bavSvebSi da biWebi
avadoben ufro xSirad bavSvTa asakis simsivnuri daavadebebis
struqturaSi hojkinis limfoma Seadgens 12-15 -s
0
20
40
60
80
100
gogobiWi lt7 8- dan 11 weli gt12
Hohojkinis limfomebis SemTxvevebi asakisa da sqesis mixedviT
Series2
hojkinis daavadebis ganawu
saqarTveloSi bavSvTa sakSi hojkinis limfomis SemTxvevebis sarwmuno
statistikuri monacemebi ar arsebos ukanasknel wlebSi SeiniSneba
bavSvTa onko-hematologiur centrSi hojkinis limfomiT daavadebuli
pirveladi pacientebis momarTvianobis Semcireba da meoradi pacientebis
(daavadebis recidivi) momarTvianobis momateba rac aixsneba imiT rom
hojkinis limfomiT daavadebuli bavSvebi mkurnalobas itareben
sxvadasxva klinikebSi
3 etiopatogenezi daavadebis substrats warmoadgens rid-Sternbergis
avTvisebiani ujredi daavadebis gamomwvevi mizezi ucnobia Tumca
arsebobs monacemebi hojkinis limfomis virusuli etiologiis (EBV)
virusis sasargeblod (Levine Stein 19900
4 daavadebis zogadi simptomebi
bull limfuri kvanZebis umtkiveulo hiperplazia
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3
5 klasifikacia -
hojkinis limfomis tipebi (histolgiuri diagnozi)
klasikuri hojkinis daavadeba
bull nodularuli sklerozi
bull Sereulujredovan
bull limfocitebis siWarbiT
bull limfoiduri ganvleviT
6 gamokvlevis sqema
6 1 inicialuri diagnozis dadgena (mtkicebuleba 1 rekomendaciis
xarisxi A)
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis siCqare
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
6 2 inicialuri stadirebis gansazrvrisTvis saWiro radiologiuri
kvlevebi (mtkicebuleba 1 rekomendaciis xarisxi A)
bull valdeieris rgolis kisris subklavikularuli aqsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an magnitur
rezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis II stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
4
7 daavadebis stadiebi
stadia I
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis limfour
kvanZSi
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis organoSi
eqstranodalurad (IE)
stadia II
bull simsivnuri dazianeba aRiniSneba 2 an met regionalur limfuri
kvanZSi diafragmis mxolod erT mxares (zmoT an qvemoT)
bull simsivne nanaxia regionaluri limfuri kvanZebSi da mimdebare
qsovilSi (IIE )
stadia III
bull simsivnuri dazianeba aRiniSneba limfur kvanZebSi diafragmis orive
mxres
bull simsivnuri dazianeba aRiniSneba rogorc limfur kvanZebSi aseve
elenTaSi (IIIS) da an eqstranodalur regionSi an organoSi (IIIS) an
oriveSi erTadroulad(IIISE)
stadiaIV
bull adgili aqvs eqstranodalurad mxolod erTi organos
diseminirebul dazianebas simsivnuri ujredebi SeiZeleba
arsebobdes an ar asebobdes limfur kvanZebSi
bull adgili aqvs eqstranodalurad mxolod erTi organos simsivnur
dazianebas rasac Tan axlavs araregionaluri limfuri kvanZebis
procesSi CarTva
yoveli stadia A da B kategoriad aris dayofili
bull stadia A - zogadi simptomebis ar arseboba
bull stadia B - araumcires erT-erTi zemoT moyvanili zogadi
simptomebidan
5
8 hojkinis limfomis mkurnaloba (mtkicebuleba I rekomendaciis xarisxi A)
M81 bavSvTa asakSi hojkinis limfomis mkurnalobis ZiriTadi principebi
bull simsivniT daavadebuli yvela bavSvi unda mkurnalobdes bavSvTa
specializirebul samkurnalo centrSi
bull mkurnaloba unda emyarebodes daavadebis stadirebas
bull mkurnalobis ori ZiriTadi samkurnalo meTodia qimioTerapia
da sxivuri Terapia
82 mkurnalobis koncefcia
6
inicialuri diagnozis procedurebi
diagnizi
warmosaxviTi kvlevbi stadireba mkurnaloba gankurneba
qimioTerapia radiaciuli Terapi
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
daavadebis piki aRiniSneba 5-dan 8 wlamde asakis bavSvebSi da biWebi
avadoben ufro xSirad bavSvTa asakis simsivnuri daavadebebis
struqturaSi hojkinis limfoma Seadgens 12-15 -s
0
20
40
60
80
100
gogobiWi lt7 8- dan 11 weli gt12
Hohojkinis limfomebis SemTxvevebi asakisa da sqesis mixedviT
Series2
hojkinis daavadebis ganawu
saqarTveloSi bavSvTa sakSi hojkinis limfomis SemTxvevebis sarwmuno
statistikuri monacemebi ar arsebos ukanasknel wlebSi SeiniSneba
bavSvTa onko-hematologiur centrSi hojkinis limfomiT daavadebuli
pirveladi pacientebis momarTvianobis Semcireba da meoradi pacientebis
(daavadebis recidivi) momarTvianobis momateba rac aixsneba imiT rom
hojkinis limfomiT daavadebuli bavSvebi mkurnalobas itareben
sxvadasxva klinikebSi
3 etiopatogenezi daavadebis substrats warmoadgens rid-Sternbergis
avTvisebiani ujredi daavadebis gamomwvevi mizezi ucnobia Tumca
arsebobs monacemebi hojkinis limfomis virusuli etiologiis (EBV)
virusis sasargeblod (Levine Stein 19900
4 daavadebis zogadi simptomebi
bull limfuri kvanZebis umtkiveulo hiperplazia
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3
5 klasifikacia -
hojkinis limfomis tipebi (histolgiuri diagnozi)
klasikuri hojkinis daavadeba
bull nodularuli sklerozi
bull Sereulujredovan
bull limfocitebis siWarbiT
bull limfoiduri ganvleviT
6 gamokvlevis sqema
6 1 inicialuri diagnozis dadgena (mtkicebuleba 1 rekomendaciis
xarisxi A)
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis siCqare
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
6 2 inicialuri stadirebis gansazrvrisTvis saWiro radiologiuri
kvlevebi (mtkicebuleba 1 rekomendaciis xarisxi A)
bull valdeieris rgolis kisris subklavikularuli aqsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an magnitur
rezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis II stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
4
7 daavadebis stadiebi
stadia I
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis limfour
kvanZSi
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis organoSi
eqstranodalurad (IE)
stadia II
bull simsivnuri dazianeba aRiniSneba 2 an met regionalur limfuri
kvanZSi diafragmis mxolod erT mxares (zmoT an qvemoT)
bull simsivne nanaxia regionaluri limfuri kvanZebSi da mimdebare
qsovilSi (IIE )
stadia III
bull simsivnuri dazianeba aRiniSneba limfur kvanZebSi diafragmis orive
mxres
bull simsivnuri dazianeba aRiniSneba rogorc limfur kvanZebSi aseve
elenTaSi (IIIS) da an eqstranodalur regionSi an organoSi (IIIS) an
oriveSi erTadroulad(IIISE)
stadiaIV
bull adgili aqvs eqstranodalurad mxolod erTi organos
diseminirebul dazianebas simsivnuri ujredebi SeiZeleba
arsebobdes an ar asebobdes limfur kvanZebSi
bull adgili aqvs eqstranodalurad mxolod erTi organos simsivnur
dazianebas rasac Tan axlavs araregionaluri limfuri kvanZebis
procesSi CarTva
yoveli stadia A da B kategoriad aris dayofili
bull stadia A - zogadi simptomebis ar arseboba
bull stadia B - araumcires erT-erTi zemoT moyvanili zogadi
simptomebidan
5
8 hojkinis limfomis mkurnaloba (mtkicebuleba I rekomendaciis xarisxi A)
M81 bavSvTa asakSi hojkinis limfomis mkurnalobis ZiriTadi principebi
bull simsivniT daavadebuli yvela bavSvi unda mkurnalobdes bavSvTa
specializirebul samkurnalo centrSi
bull mkurnaloba unda emyarebodes daavadebis stadirebas
bull mkurnalobis ori ZiriTadi samkurnalo meTodia qimioTerapia
da sxivuri Terapia
82 mkurnalobis koncefcia
6
inicialuri diagnozis procedurebi
diagnizi
warmosaxviTi kvlevbi stadireba mkurnaloba gankurneba
qimioTerapia radiaciuli Terapi
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
5 klasifikacia -
hojkinis limfomis tipebi (histolgiuri diagnozi)
klasikuri hojkinis daavadeba
bull nodularuli sklerozi
bull Sereulujredovan
bull limfocitebis siWarbiT
bull limfoiduri ganvleviT
6 gamokvlevis sqema
6 1 inicialuri diagnozis dadgena (mtkicebuleba 1 rekomendaciis
xarisxi A)
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis siCqare
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
6 2 inicialuri stadirebis gansazrvrisTvis saWiro radiologiuri
kvlevebi (mtkicebuleba 1 rekomendaciis xarisxi A)
bull valdeieris rgolis kisris subklavikularuli aqsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an magnitur
rezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis II stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
4
7 daavadebis stadiebi
stadia I
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis limfour
kvanZSi
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis organoSi
eqstranodalurad (IE)
stadia II
bull simsivnuri dazianeba aRiniSneba 2 an met regionalur limfuri
kvanZSi diafragmis mxolod erT mxares (zmoT an qvemoT)
bull simsivne nanaxia regionaluri limfuri kvanZebSi da mimdebare
qsovilSi (IIE )
stadia III
bull simsivnuri dazianeba aRiniSneba limfur kvanZebSi diafragmis orive
mxres
bull simsivnuri dazianeba aRiniSneba rogorc limfur kvanZebSi aseve
elenTaSi (IIIS) da an eqstranodalur regionSi an organoSi (IIIS) an
oriveSi erTadroulad(IIISE)
stadiaIV
bull adgili aqvs eqstranodalurad mxolod erTi organos
diseminirebul dazianebas simsivnuri ujredebi SeiZeleba
arsebobdes an ar asebobdes limfur kvanZebSi
bull adgili aqvs eqstranodalurad mxolod erTi organos simsivnur
dazianebas rasac Tan axlavs araregionaluri limfuri kvanZebis
procesSi CarTva
yoveli stadia A da B kategoriad aris dayofili
bull stadia A - zogadi simptomebis ar arseboba
bull stadia B - araumcires erT-erTi zemoT moyvanili zogadi
simptomebidan
5
8 hojkinis limfomis mkurnaloba (mtkicebuleba I rekomendaciis xarisxi A)
M81 bavSvTa asakSi hojkinis limfomis mkurnalobis ZiriTadi principebi
bull simsivniT daavadebuli yvela bavSvi unda mkurnalobdes bavSvTa
specializirebul samkurnalo centrSi
bull mkurnaloba unda emyarebodes daavadebis stadirebas
bull mkurnalobis ori ZiriTadi samkurnalo meTodia qimioTerapia
da sxivuri Terapia
82 mkurnalobis koncefcia
6
inicialuri diagnozis procedurebi
diagnizi
warmosaxviTi kvlevbi stadireba mkurnaloba gankurneba
qimioTerapia radiaciuli Terapi
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
7 daavadebis stadiebi
stadia I
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis limfour
kvanZSi
bull simsivnuri dazianeba aRiniSneba mxolod erTi regionis organoSi
eqstranodalurad (IE)
stadia II
bull simsivnuri dazianeba aRiniSneba 2 an met regionalur limfuri
kvanZSi diafragmis mxolod erT mxares (zmoT an qvemoT)
bull simsivne nanaxia regionaluri limfuri kvanZebSi da mimdebare
qsovilSi (IIE )
stadia III
bull simsivnuri dazianeba aRiniSneba limfur kvanZebSi diafragmis orive
mxres
bull simsivnuri dazianeba aRiniSneba rogorc limfur kvanZebSi aseve
elenTaSi (IIIS) da an eqstranodalur regionSi an organoSi (IIIS) an
oriveSi erTadroulad(IIISE)
stadiaIV
bull adgili aqvs eqstranodalurad mxolod erTi organos
diseminirebul dazianebas simsivnuri ujredebi SeiZeleba
arsebobdes an ar asebobdes limfur kvanZebSi
bull adgili aqvs eqstranodalurad mxolod erTi organos simsivnur
dazianebas rasac Tan axlavs araregionaluri limfuri kvanZebis
procesSi CarTva
yoveli stadia A da B kategoriad aris dayofili
bull stadia A - zogadi simptomebis ar arseboba
bull stadia B - araumcires erT-erTi zemoT moyvanili zogadi
simptomebidan
5
8 hojkinis limfomis mkurnaloba (mtkicebuleba I rekomendaciis xarisxi A)
M81 bavSvTa asakSi hojkinis limfomis mkurnalobis ZiriTadi principebi
bull simsivniT daavadebuli yvela bavSvi unda mkurnalobdes bavSvTa
specializirebul samkurnalo centrSi
bull mkurnaloba unda emyarebodes daavadebis stadirebas
bull mkurnalobis ori ZiriTadi samkurnalo meTodia qimioTerapia
da sxivuri Terapia
82 mkurnalobis koncefcia
6
inicialuri diagnozis procedurebi
diagnizi
warmosaxviTi kvlevbi stadireba mkurnaloba gankurneba
qimioTerapia radiaciuli Terapi
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
8 hojkinis limfomis mkurnaloba (mtkicebuleba I rekomendaciis xarisxi A)
M81 bavSvTa asakSi hojkinis limfomis mkurnalobis ZiriTadi principebi
bull simsivniT daavadebuli yvela bavSvi unda mkurnalobdes bavSvTa
specializirebul samkurnalo centrSi
bull mkurnaloba unda emyarebodes daavadebis stadirebas
bull mkurnalobis ori ZiriTadi samkurnalo meTodia qimioTerapia
da sxivuri Terapia
82 mkurnalobis koncefcia
6
inicialuri diagnozis procedurebi
diagnizi
warmosaxviTi kvlevbi stadireba mkurnaloba gankurneba
qimioTerapia radiaciuli Terapi
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
83 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis Sedegebis misaRebad rekomendirebulia - GPOH_HD 2002 programa 831 mkurnalobis programa gogonebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
832 mkurnalobis programa biWebisTvis(mtkicebuleba I rekomendaciis xarisxi A)
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
7
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
9 daavadebis gamosavali -gadarCenis sixSire stadiebis mixedviT
stadia 5 wliani gadarCenis sixSire1 90 - 9511 90 - 95111 80 - 851V daaxloebiT ndash 75
91 pacientTa garkveul raodenobas aReniSneba daavadebis progresi
911 parcialuri remisia - qimiTerapiis fonze adgili aqvs
simsivnuri substratis arasrul iradikacias rac qimioTerapiisa
da sxivuri Terapiis gaZlierebas saWiroebs Tumca pacientebis am
jgufisTvis blokebis raodenoba winaswar ar aris mkacrad
gansaxRvruli da damokidebulia pasuxze
912 daavadebis recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
8
40
34
26 TG 1 TG 2
TG 3
Terapiuli jgufebiSi (TG) ganawileba
bull pirveli Terapiuli jgufi (TG1) I AB da IIA
bull meore Terapiuli jgufi(TG2) I EAB II EA IIB an IIIA
bull mesme Terapiuli jgufi(TG3) II EB III EAB an IVAB
pacientTa ganawileba Terapiul jgufebSi
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
recidivis mkurnalobisTvis rekomendirebulia Sesabamisi kursebi
IEPABVD kursebi COPP da ChICEP reJimebTan erTad am SemTxvevaSi
blokebis raodenoba winaswar ar aris mkacrad gansaxRvruli da
damokidebulia pasuxze Tu pacients aReniSneba kargi pasuxi pirvel
IEPABVD Terapiaze qimioTerapia sruldeba sxivuri TerapiiT cudi
pasuxis SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
(mtkicebuleba I rekomendaciis xarisxi A) (ixprotokoli)
913 hojkinis limfomiT daavadebul pacientTa 90 - s aReniSnebaT sruli
remisia (CR ndash cmplite remission) da aqvs gankurnebis Sansi Tumca mkurnalobis
dasrulebis Semdeg saWiroeben xuTi wlis ganmavlobaSi konkretul
kliniko-laboratoriul kvlevebsa da meTvalyureobas (ix protokoli)
10 eTikur-samarTlebrivi rekomendaciebi
hojkinis limfomebiT daavadebuli bavSvebis ojaxebi uzrunvelyofilni
unda iyvnen damakmayofilebeli socialuri pirobebiT ris gamoc maT
esWiroebaT materialuri daxmareba pensiis saxiT rac xels Seuwyobs
gankurnebuli bavSvebis socialur garemoSi adaptaciis sakiTxis
mogvarebasa da Sesabamisad maTi cxovrebis xarisxis gaumjobesebas
11 praqtikaSi adaptaciis da protokolebis SemuSavebis rekomendaciebi
m iaSvilis sax bavSvTa centraluri saavadmyofos onko-hematologiuri
centris aTwliani muSaobis Sedegebis Sefasebis safuZvelze
rekomendirebulia bavSvTa asakSi hojkinis limfomebis mkurnaloba
Catardes mkurnalobis optimizirebuli oqmebiT mogvianebiTi
garTulebebis Sesamcireblad rogoricaa hormonaluri ukmarisoba
farisebri jirkvlisa da mkerdis simsivneebi limfomiT daavadebuli
yvela bavSvis (0-dan 18 wlamde) mkurnaloba unda Catardes pediatriuli
protokolis mixedviT mesame donis bavsvTa saavadmyofoSi
rekomendacia efuZneba damoukidebeli eqspertis qfraiburgis
sauniversiteto klinikis pediatriuli onkologiisa da hematologiuri
ganyofilebis xelmZRvanelis prof Nnimaieris Sefasebas (Tbilisi 2003w
13-20 ianvari)
9
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
12 gaidlainis gadasinjvis da ganaxlebis vada
GPOH-HD 2002 ndash programa (mtkicebuleba I rekomendaciis xarisxi A)ndash
iTvaliswinebs hojkinis limfomis mkurnalobas optimizirebuli oqmebiT
romlis mizania qimioTerapiis toqsiurobisa da mogvianebiTi
garTulebebis Semcireba gadarCenis sixSiris gazrda aRniSnulidan
gamomdinare gaidlinis gadasinjvis vada rekomendirebulia ganisazRvros
5 wliT
13 gaidlainis miRebis xerxiwyaro
GPOH-HD 2002 ndash programa romelic Targmnilia qarTul enaze da
adaptirebulia saqarTveloSi gamoyenebisaTvis aRniSnuli programis
gamoyeneba saqarTveloSi m iaSvilis sax bavSvTa centraluri
saavadmyofondashs onko-hematologiur ganyofilebaSi da eqspertirdeba q
fraiburgis sauniversiteto klinikis profesor nimaieris mier
10
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
14 literatuara
Apperley JF Reddy N (1995) Mechanisms and management of treatment-related gonadal failure
in chemoradiotherapy Blood 9 93 -116
Bumann D Beyer W Herbst K Clausen M Hossfeld DK (1997) Whole-body positron emission
tomography (PET) for diagnosis of residual mass in patients with lymphoma Ann Oncol 8 57-
60
Benenson L Wickenhauser C Starostik P Staratschek-Jox A Muumlller-Hermelink HK Diehl V
Wolf J (2002) Proficient mismatch repair protein expression in Hodgkin and Reed Sternberg cells
Int J Cancer 97 205-210
Bernardo MP Weller E Backstrand KH Silver B Marcus KC Tarbell NJ Friedberg J Canellos
GP Mauch PM (2002) Long-term survival and competing causes of death in patients with early-
stage Hodgkins disease treated at age 50 or younger J Clin Oncol 20 2101ndash2108
Buzaid AC Lippman SM Miller TP (1987) Salvage therapy of advanced Hodgkinrsquos disease
Critical appraisal of curative potential Am J Med 83 523ndash532
Harris NL Jaffe ES Diebold J Flandrin G Muller-Hermelink HK Vardiman J Lister TA
Bloomfield CD (1999) The World Health Organization classification of neoplastic diseases of the
hematopoietic and lymphoid tissues Report of the Clinical Advisory Committee meeting Airlie
House Virginia November 1997Ann Oncol 101419-1432
Hassel JU Braumlmswig JH Schlegel W Schelong G (1991) Testicular function after OPACOMP
chemotherapy without Procarbazin for boys and girls with Hodgkinrsquos disease Klin Paumldiat 203
268-272
Henry-Amar M Pellae-Cosset B Bayle-Weisgerber C Hayat M Cosset JM Carde P Tubiana M
(1989) Risk of secondary acute leukaemia and preleukamia after Hodgkinrsquos disease The Institute
Gustave-Roussy experience Rec Results canser Res 117 270-283
Hoh CK Glaspy J Rosen P Dahlbom M Lee SJ Kunkel L Hawkin RA Maddahi J Phelps ME
(1997) Whole-body FDG-PET imaging for staging of Hodgkins disease and lymphoma J Nucl
Med 38 343-348
11
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
Howell SJ Radford JA Adams JE Shalet SM (2000) The impact of mild Leydig cell dysfunction
following cytotoxic chemotherapy on bone mineral density (BMD) and body composition Clin
Endocrinol 52 609-616
Kuppers R Schwering I Brauninger A Rajewsky K Hansmann ML (2002) Biology of
Hodgkins lymphoma Ann Oncol 13 11-18
Kuppers R Klein U Hansmann ML Rajewsky K (1999) Cellular origin of human B-cell
lymphomas N Engl J Med 3411520ndash1529
Lister TA Crowther D Sutcliffe SB Sutcliffe SBGlatstein E Canellos GP Young RC
Rosenberg SA Coltman CA Tubiana G (1989) Report of a committee convened to discuss the
evaluation and staging of patients with Hodgkins disease Cotswolds meeting J Clin Oncol 7
1630-1636
Le Deley MC Leblanc T Shamsaldin A Raquin MA Lacour B Sommelet D Chompret A
Cayuela JM Bayle C Bernheim A de Vathaire F Vassal G Hill C (2003) Risk of secondary
leukemia after a solid tumor in childhood according to the dose of epipodophyllotoxins and
anthracyclines a case-control study by the Socieacuteteacute Franccedilaise dOncologie Peacutediatrique J Clin
Oncol 21 1074-1081
Longo DL Duffey PL Young RC Hubbard SM Ihde DC Glatstein E Phares JC Jaffe ES Urba
WJ DeVita VT Jr (1992) Conventional-dose salvage combination chemotherapy in patients
relapsing with Hodgkinrsquos disease after combination chemotherapy the low probability for cure J
Clin Oncol 10 210 -218
Partridge S Timothy A OrsquoDoherty MJ Hain SF Rankin S Mikhaeel G (2000) 2-fluorine-18-
fluoro-2-deoxy-D glucose positron emission tomography in the pretreatment staging of Hodgkins
disease influence on patient management in a single institution Ann Oncol 111273-1279
Pileri SA Ascani S Leoncini L Sabattini E Zinzani PL Piccaluga PP Pileri A Jr Giunti M
Falini B Bolis GB Stein H (2002) Hodgkins lymphoma the pathologists viewpoint J Clin
Pathol 55 162-176
12
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
Rehwald U Schulz H Reiser M Sieber M Staak JO Morschhauser F Driessen C Rudiger T
Muller-Hermelink K Diehl V Engert A (2003) Treatment of relapsed CD20+ Hodgkin
lymphoma with the monoclonal antibody rituximab is effective and well tolerated results of a
phase 2 trial of the German Hodgkin Lymphoma Study Group Blood 101 420ndash424
Ruhl U Albrecht M Dieckmann K Luders H Marciniak H Schellenberg D Wickmann L
Dorffel W (2001) Response-adapted radiotherapy in the treatment of pediatric Hodgkins disease
an interim report at 5 years of the German GPOH-HD 95 trial Int J Radiat Oncol Biol Phys 51
1209-1218
Rigo P Paulus P Kaschten BJ Hustinx R Bury T Jerusalem G Benoit T Foidart-Willems J
(1996) Ontological applications of positron emission tomography with fluorine-18 fluorodeoxy-
glucose Eur J Nucl Med 231641
Phillips JK Spearing RL Davies JM Hay CR Parry H Nash JR Cawley JC (1990) VIM-D
salvage chemotherapy in Hodgkinrsquos disease Cancer Chemother Pharmacol 27161-163
Schellong G Poumltter R Braumlmswig J Wagner W Prott F Doumlrffel W Koumlrholz D Mann G Rath
B Reiter A Weissbach G Riepenhausen M Thiemann M Schwarze EW (1999) High Cure
rates and reduced long-term toxicity in paediatric Hodgkins disease The German-Austrian
Multicenter Trial DAL-HD-90 J Clin Oncol 17 3736-3744
Schellong G Hornig-Franz I Rath B Ritter J Riepenhausen M Kabisch H Goldschmitt-Wuttge
B Schmidt P Niethammer D Gaedicke G (1994) Reduzierung der Strahlendosen auf 20-30Gy im
Rahmen einer kombinierten ChemoRadiotherapie beim Morbus Hodgkin im Kindesalter-ein
Bericht der kooperativen Therapiestudie DAL-HD-87 Klin Paumldiat 206 253-263
13
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
bavSvTa asakSi hojkinis limfomis (HD)
mkurnalobis klinikuri praqtikis nacionaluri
rekomendacia
(protokoli)
programa - GPOH_HD 2002
14
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
1 hojkinis limfoma (HD- Hodgkinlsquos Disease) daavadebis definicia
hojkinis limfomahojkinis daavadeba aris ujredebis simsivnuri zrda
limfoidur sistemaSi limfoiduri qsovili aris mTel organizmSi ris
gamoc simsivnuri procesi SeiZleba aRmocendes sxeulis nebismier
nawilSi da gavrceldes organizmis nebismier qsovilSisinonimebi
hojkinis limfoma (HD) limfogranulematozi (LG)
2 daavadebis simptomebi
bull limfuri kvanZebis umtkiveulo SeSupeba
bull ucnobi genezis gaxangrZlivebuli cxeleba
bull Ramis Zlieri oflianoba
bull qavili
3 diagnostikur-laboratoriuli kvlevebi
31 inicialuri diagnozis dadgena
bull pacientis fizikaluri gamokvleva da anamnezis Segroveba
bull gulmkerdis rentgenografia
bull muclis Rrus organoebis eqoskopia
bull limfuri kvanZis biofsia ndashhistologiuri diagnozi
bull sisxlis saerTo analizi
bull eriTrocitebis daleqvis reaqcia
bull RviZlisa da Tirkmlis funqciebis Seswavla (albuminis CaTvliT)
32 inicialuri stadirebis gansazrvrisTvissaWiro radiologiuri
kvlevebi
bull valdeieris rgolis kisris subklavikularuli axsilaruli
mediastinaluri paratraqealuri abdominaluri da sazardulis
limfuri kvanZebis kompiuteruli tomografia (CT) an
magniturrezonansuli tomografia (MRI)
bull gulmkerdis kompiuteruli tomografia (CT)
bull ConCxis scintigrafia (saWiroebis SemTxvevaSi)
bull Zvlis tvinis aspiracia da biofsia (Cveneba ndash daavadebis 11 stadia)
bull seleqtiuri laparaskopia (iSviaT SemTxvevaSi)
15
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
4 bavSvTa asakis hojkinis limfomebis optimalur mkurnalobis gaidlaini
GPOH_HD 2002 programa 41 mkurnalobis programa gogonebisTvis
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOPPA
2xOPPA 2xCOPP
2xOPPA 4 x COPP
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
42 mkurnalobis programa biWebisTvi
TG 1IABIIA
TG 2IEABIIEA
IIBIIIA
TG 3IIEBIIIEABIIIBIVAB
2xOEPA
2xOEPA 2xCOPDIC
2xOEPA 4 x COPDIC
sruli remisia - dasxiveba ara
Aarasruli remisia -dasxiveba
Ppirveladi velebisdasxiveba
43 Terapiuli jgufebiSi ganawileba
bull pirveli Terapiuli jgufi I AB da IIA
bull meore Terapiuli jgufi I EAB II EA IIB an IIIA
16
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
bull mesme Terapiuli jgufi II EB III EAB an IVAB
5 qimioTerapiis gverdiTi movlenebi
qimioTerapiis zogadi gverdiTi movlenebia gulisreva Rebineba wonaSi
kleba Tmis cvena da meoradi simsivnis ganviTarebis riski
damxmare Terapia romelic moicavs infeqciebis profilaqtikas
neitropeniul cxelebas dadasturebuli infeqciebis marTvas Rebinebisa
da tkivilis menejments identuria mwvave limfoiduri leikemiis damxmare
Terapiisa ixileT mwvave limfoiduri leikemiis samkurnalo protokoli
6 sxivuri Terapia
61 sxivuri Terapiis dawyeba
bolo qimioTerapiuli reJimis damTavrebidan 3 kviris Semdeg
62 Cvenebebi da dozireba
1 pacientebi romlenic ganekuTvnebian pirvel Terapiul jgufs sruli
remisiis SemTxvevaSi ar sxivdebian
2 pacientebi romlebic ganekuTvnebian pirvel Terapiul jgufs
arasruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
3 pacientebi romlenic ganekuTvnebian meore da mesame Terapiul
jgufs sruli remisiis SemTxvevaSi sxivdebian doziT 20 grei
4 yvela pacientebi romelTa narCeni masa sawyisTan SedarebiT 25
metia anu 75 isev rCeba sxivdebian doziT 30 grei
5 yvela pacienti romelTa narCeni masa gt75-ze sxivdebian doziT 35
grei
6 dazianebuli eqstralimfoiduri organoebi (Zvlis tvinis
gamoklebiT) eqvemdebarebian sxivur Terapias doziT 12 ndash 15 grei
7 sxivuri Terapia tardeba fraqciulad da dRiuri doza aris 18
grei gamonakliss warmoadgens filtvebi da am SemTxvevaSi dRiuri
doza ar unda aRematebodes 1-12 greis
8 recidivis SemTxvevaSi sayuradReboa pirveladi doza ganmeorebiTi
Terapiis sumaruli doza ar unda aRematebodes 40 greis
17
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
63 sxivuri Terapiis principebi
aucilebelia sxivuri Terapia Catardes pirveladi dagegmarebiT da
sxivuri aqseleratoris gamoyenebiT rac miznad isaxavs janmrTeli
qsovilebis maqsimalur dacvas sxivebis mavne moqmedebisgan da samizne
qsovilebis efeqtur dasxivebas
teqnikuri procesebis srul dacvaze pasuxismgebelia radioTerapevti
64 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
7 mkurnalobis progresi da regresi
71 mkurnalobis progresi
71sruli remisia (CR)
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
bull gnadgurebulia pirveladi simsivnuri masis 95-ze gt narCeni masa lt 2 sm
-ze
71 2 daudasturebuli sruli remisia
bull daavadebis yvela simptomi alagebulia
bull ar aris axali limfuri Tu eqstralimfuri regionebi dazianebuli
- ganadgurebulia pirveladi simsivnuri masis 75-ze gt magram lt 95
narCeni masa lt 2sm-ze
71 3 parcialuri remisia
bull ar aris sruli remisia an sruli remisiis dadastureba ver xerxdeba
bull ar SeiniSneba daavadebis progresi
SeniSvna- anti-recidiuli Terapiis Catareba naCvenebia mxolod im
SemTxvevaSi roca dadasturebulia daavadebis progresi an recidivi
18
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
72 mkurnalobis regresi 721 recidivi
- Zalian adreuli - Terapiis dasrulebidan sam TveSi ganviTarebuli
- adreuli - Terapiis dasrulebidan sami Tvidan Tormet Tvemde
ganviTarebuli
- mogvinebiTi - Terapiis dasrulebidan Tormet Tvis Semdeg
ganviTarebuli
722 Terapia im pacientebisTvis visTanac standartuli mkarnaloba iyo araefeqturi - gamoixata daavadebis progresireba mkurnaloba iwyeba kvlav qimioTerapiiT Ggamoiyeneba IEPABVD kursebi
COPP da ChICEP reJimebTan erTad pacientebis am jgufisTvis blokebis
raodenoba winaswar ar aris mkacrad gansaxRvruli da damokidebulia
pasuxze Tu pacients aReniSneba kargi pasuxi pirvel IEPABVD Terapiaze
qimioTerapia sruldeba sxivuri TerapiiT cudi pasuxis
SemTxvevaSi emateba COPP da ChICEP Terapia Semdgomi dasxivebiT
723 recidivis sawinaaRmdego sqemebi
1Ifosfamidi 2000mgm2 24 saaTis ganmavlobaSi+mesna 1ndash5 dRe
2Etoposidi 125mgm2 iv 2 saaTis ganmavlobasi 1-5 dRe
3Prednisone 100mgm2Ppo sam miRebaze 1-5 dRe
1Adriamycin 25mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
2Dacarbazin 375mgm2 iv 2saaTis ganmavlobasi 1+15 dRe
3bleomocyni 10mgm2 iv neli nakadiT 1+15 dRe
4Vinblastini 6mgm2 iv neli nkadiT 1+15 dRe
19
bull ABVD=AdriamicynDacarbazinBleomycinVinblastin
bull IEP=IfosfamidEtoposidPrednison
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
1CCNU 80mgm2 po 1 dRe
2Etoposid 100mgm2 po 1-5 dRe
3Prednison 40mgm2 po 1-5 dRe
4Chlorambuzil 6mgm2 po 1-5 dRe
724 recidivis mkurnalobis taqtikis SerCevisas gaTvaliswinebulia
inicialuri diagnozis dros Terapiuli jgufebi
recidivis sawinaaRmdego Terapia pacientebSi romlebic
1 miekuTvnebodnen pirvel Terapiul jgufs
bull pacientebi romelTac inicialurad ar CautardaT sxivuri Terapia
unda miiRon IEP- ABVD- COPP-(IEP) + dazianebuli velebis dasxiveba
doziT 25-30 grei
bull 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
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebuli an dausxivebeli regionebiT utrdebaT IEP- ABVD-
COPP-IEP ndashABVD ndash COPP + sxivuri Terapia 10- 15 grei ukve
dasxivebuli da 25-30 greiT dausxivebeli velebis
2 miekuTvnebodnen meore da mesame Terapiul jgufebs
bull pacientebi romelTac ganuviTardad recidivi axali dausxivebel
regionebSi utardebaT IEP - ABVD - IEP ndashABVD ndash (IEP) + radioTerapia
doziT 25-30grei
bull Pacientebi romelTac ganuviTardaT ukve 20 greiT dasxivebuli an
dausxivebeli regionebSi utrdebaT IEP- ABVD- IEP- ABVD - IEP +
sxivuri Terapia 20-25 grei ukve dasxivebuli da 25-30 greiT
dausxivebeli velebis
bull Pacientebi romelTac ganuviTardaT ukve 20 greize meti doziT
dasxivebul an dausxivebel regionebSi utrdebaT IEP- ABVD- -IEP ndash
20
bull ChICEP=CCNUEtoposidPrednisonChlorambuzil
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
ABVD ndash IEP + sxivuri Terapia 10- 15 grei ukve dasxivebuli da 25-30
greiT dausxivebeli velebis
pacientebs romlebsac antirecidiul Terapiaze aReniSnebaT simsivnis
neli an araefeqturi regresi SeZlebisdagvarad ezrdebaT sxivuri
Terapiis doza Tu es SesaZlebelia (sxivuri Terapiis sumaruli doza ar
unda iyos 45 Gr- ze gt)da damatebiT utardeba qimioTerapiuli kursi
ChICEP
21
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
helliphelliphelliphellip
22
valdeieris rgoli
kisris laviwzeda
laviwqveSaaqsilarulipeqtoruli
mediastinaluri
paraaortalurielenTis kariRviZlis kari
iliakaluri
sazardulisbarZayis
elenTa
8 sxivuri Terapiis sqemalimfuri kvanZebis regionebi
karis
mezenterialuri
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
9 samkurnalo sqemebi
91 kursi OPPA
prednizoloni prokarbazini
vinkristini
adriamicini
92 kursi OEPA
prednizoloni
vinkristini
adriamicini
etopozidi
23
1 2 3 4 5 8 15 dRe
1 8 15 dRe
M
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
93 kursi COPP
prednizoloni
prokarbazini
vinkristini
ciclofosfa midi
mesna + +
94 kursi COPDIC
prednizoloni
dakarbazin
vinkristini
ciclofosfamidi
mesna + +
24
1 8 15 dRe
1 8 15 MdRe
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
95 kursi IEP
prednizoloni
ifosfamidi
messna
etopozidi
96 kursi ABVD
adriamicini
dakarbazini
bleomicini
vinblastini
97 kursi ChICEP
ccnu
etapozidi
prednizoloni
qlorambucili
25
1 2 3 4 5 6 7 dRe
1 15MdRe
M1 15 dRe
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26
10 pacientTa meTvalyureoba da kvlevebi mkurnalobis dasrulebis Semdeg
kvlevebi Mmkurnalobis damtavrebidan1-2 weli 3-4 weli 5-10 weli
1 sisixlissaerTo analizi2 gulmkeris rentgenograma3 mucli Rruseqoskopia
yovel 3 TveSi
yovel 6TveSi yovelwliurad
gulmkerdis Rrus kompiuteruli tomografiaekgeqokardiografia
yovel 6TveSi yovelwliurad gansakuTrebulSemTxvevebSi
TBG TSHT4 yovelwliurad
testosteroni
estradioli
maluTinizirebeli hormoniLH-RH-Test
biWebSi 16-20 wlis asakSi weliwadSi erTxel
gogonebSi amenoreis drosara ugvianes 15 wlis asakisa
26