#16
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åñëè â äèàãíîçå íåò ñîìíåíèÿ, òî ìàáòåðà ìîæåò áûòü ïðèìåíåíà âìåñòå ñ õèìèîòåðàïèåé ïðè ëå÷åíèè äàííîãî çàáîëåâàíèÿ, ìàáòåðà äîñòóïíà â ÐÔ èëè íà Óêðàèíå, öåíà ïðàâäà âíóøèòåëüíàÿ, ñàìîñòîÿòåëüíî Âû ëå÷åíèå ïðîâåñòè âðÿä ëè ñìîæåòå, òàê ÷òî ê ìàáòåðå âñå ðàâíî íåîáõîäèì î÷íûé ñïåöèàëèñò, êîòîðûé çíàåò êàê ëå÷èòü è âåñòè ïàöèåíòà.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#17
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Öèòàòà:
Ìåñòíîãî ñïåöèàëèñòà ïûòàþñü íàéòè, ïûòàþñü...  ìåñòíûõ àïòåêàõ ìàáòåðû íåò, ïîïðîáóþ ÷åðåç ÐÔ èëè Óêðàèíó... |
#18
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èíîãäà ïðåïàðàò ìîæåò ââîäèòüñÿ è â âèäå ìîíîòåðàïèè (áåç õèìèîòåðàïèè), ïîäðîáíåå îò èçðàèëüñêèõ ñïåöèàëèñòîâ:
Semin Hematol. 2010 Apr;47(2):143-7. Treatment of splenic marginal zone lymphoma: splenectomy versus rituximab. Bennett M, Schechter GP. Department of Hematology, Ha'Emek Medical Center, Afula, Israel. Splenic marginal zone lymphoma (SMZL) is an uncommon indolent B-cell lymphoma causing marked splenic enlargement with CD20-rich lymphoma cells infiltrating blood and bone marrow. In the pre-rituximab era, the treatment of choice for patients with symptomatic splenomegaly or threatening cytopenia was splenectomy, since chemotherapy had limited efficacy. Responses to splenectomy occurred in approximately 90% of patients. However, SMZL patients are often elderly and poor surgical risks. Since approval of rituximab, treatment of such patients with the anti-CD20 antibody both alone or in combination with chemotherapy has shown remarkable responses. In retrospective series of rituximab monotherapy totaling 52 patients, including both chemotherapy-naive and -refractory patients, overall responses of 88% to 100% were noted with marked and prompt regression of splenomegaly and improvement of cytopenias. Sustained responses occurred both with and without rituximab maintenance in 60% to 88% of patients at 3 years. Relapsed patients responded to second courses of rituximab monotherapy. Overall survival was comparable to that reported following splenectomy. Rituximab in combination with purine nucleosides may provide further improvement in progression-free survival; however, confirmatory prospective trials are necessary. These results suggest that splenectomy should no longer be considered as initial therapy for SMZL but rather as palliative therapy for patients not responsive to immunotherapy with or without chemotherapy.
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |
#19
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Áåç ãèñòîëîãèè äèàãíîç ìîæíî òîëüêî ïðåäïîëàãàòü. ×òî íàèáîëåå âåðîÿòíà èìåííî ëèìôîöèòîìà-áûëî î÷åâèäíî ñ ñàìîãî íà÷àëà-ïðîñòî èç âàøèõ ïîñòîâ íå ñëåäîâàëî, ÷òî îáñëåäîâàíèå ïàöèåíòêè çàòÿíåòñÿ äî òàêîé ñòåïåíè ÷òî àäåêâàòíîå ïîäòâåðæäåíèå äèàãíîçà ñòàíåò íåâîçìîæíûì. Õîòü òðåïàí-òî ìîãóò âûïîëíèòü ïåðåä íà÷àëîì òåðàïèè?
Ñåé÷àñ íåò íåîáõîäèìîñòè ñðî÷íî èñêàòü ìàáòåðó. Ïðîâåäèòå áîëüíîé ïðèìèòèâíûé CHOP, åñëè ýòî ïîçâîëÿåò ñîðäå÷íàÿ ôóíêöèÿ(ôðàêöèÿ âûáðîñà?). Åé ñêîðåå âñåãî ðåçêî ïîëåã÷àåò-è äàëüøå áóäåòå 21 äåíü äî ñëåä. êóðñà äóìàòü-õîòèòå òðàòèòü áåøåíûå äåíüãè íà ìàáòåðó èëè íåò. Ñâåò íà íåé êëèíîì íå ñîøåëñÿ. Îíà óëó÷øàåò ïðîãíîç - íî íå ïðèíöèïèàëüíî. Ýòî ïðîñòî î÷åíü ìîäíîå ëåêàðñòâî. |
#20
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Òàê à ÷òî ñ îïåðàöèåé äåëàòü?
Îíà ëåæèò â õèðóðãè÷åñêîì îòäåëåíèè â îíêîëîãè÷åñêîì öåíòðå. Òàì âñå âîêðóã õèðóðãè à íå ãåìàòîëîãè, îíè ðàññìàòðèâàþò îïåðàöèþ êàê åäèíñòâåííóþ îïöèþ. Íàñêîëüêî ÿ ïîíÿë èõ ëîãèêó, îíè õîòÿò ïîäíÿòü åé ãåìîãëîáèí ïåðåëèâàíèÿìè êðîâè è ñäåëàòü îïåðàöèþ äàæå â òàêîì ñîñòîÿíèè êàê îíà ñåé÷àñ, â ïÿòíèöó èëè â ïîíåäåëüíèê. Ïðîñèòü èõ îòëîæèòü îïåðàöèþ? Äîïîëíèòåëüíûé âîïðîñ: çàïàäíûå ïðîôåññîðà ðåêîìåíäîâàëè äåëàòü âàêöèíàöèþ îò ïíåâìîêîêêà ïåðåä îïåðàöèåé. Òàì ýòî ñòàíäàðòíî. Òóò ýòî íå ïðèíÿòî, è âàêöèíû â ïðèíöèïå â ñòðàíå íåò, íî ÿ çàêàçàë âàêöèíó â Ðîññèè è â ïÿòíèöó ìíå åå íàäåþñü ïðèâåçóò ïîåçäîì. Âîïðîñ: ìîæíî ëè äåëàòü âàêöèíàöèþ âàêöèîíîé Ïðåâåíàð â îñëàáëåííîì ñîñòîÿíèè â ïÿòíèöó, ååñëè îïåðàöèÿ â ïîíåäåëüíèê? |
#21
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×åì çàíèìàòüñÿ âñÿêèìè òðåòüåñòåïåííûìè ïî âàæíîñòè ïðîáëåìàìè òèïà ïðåâåíàðà è êîíñóëüòèðâîàòü ÷åðåç èíòåðíåò- ïåðåâåëè áû ìàìó â ãåìàòîëîãè÷åñêîå ó÷ðåæäåíèå, ÷òî ëè, ðàç ó âàñ ñòîëüêî ýíåðãèè è âñÿêèõ çíàêîìûõ ...
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#22
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ïî îôèöèàëüíûì ãîñóäàðñòâåííûì ïðàâèëàì òîé ñòðàíû ÑÍà ãäå ìû íàõîäèìñÿ, ëèìôîìó ëå÷àò â îíêîëîãè÷åñêèõ öåíòðàõ. Ñïåöèàëèçèðîâàííûå ãåìàòîëîãè÷åñêèå îòäåëåíèÿ â äðóãèõ áîëüíèöàõ íå èìåþò ïðàâà îïåðèðîâàòü áîëüíûõ ñ ïîäîçðåíèåì íà îíêîëîãèþ. ß â êîíòàêòå ñ ãåìàòîëîãàìè èç äðóãèõ áîëüíèö - ìû ñíà÷àëà ëåæàëè â äðóãîé áîëüíèöå, è áåç òîëêó, äàæå ãåìàòîëîãè ñàìè ñêàçàëè ïåðåâåñòèñü â îíêîëîãè÷åñêèé öåíòð, ïîòîìó ÷òî â äðóãèõ êëèíèêàõ îíêîëîãèþ íå îïåðèðóþò. Åäèíñòâåííûé âàðèàíò òåïåðü ñìåíèòü êëèíèêó - ýòî âûåõàòü çà ãðàíèöó, íî ýòî â äàííîì ñîñòîÿíèè äîïîëíèòåëüíûé ðèñê èíôèöèðîâàíèÿ ïðè ïåðååçäå, ê òîìó æå äîïîëíèòåëüíàÿ çàäåðæêà ëå÷åíèÿ êàê ìèíèìóì íà íåäåëþ, ïîòîìó ÷òî ëþáàÿ íîâàÿ êëèíèêà çàõî÷åò ïîâòîðèòü âñå àíàëèçû ó ñåáÿ. Âàðèàíò âûåçäà çà ðóáåæ ïî ïðåæíåìó âîçìîæåí. Íî Âû æå ñàìè ïðîòèâ íåãî âîçðàæàëè â ïåðâûõ ïîñòàõ. Ìåíÿåòå ìíåíèå â ïîëüçó ýòîãî âàðèàíòà?
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#23
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ß ìîãó Âàì ñêàçàòü ÷åãî ÍÅ íàäî äåëàòü.
ÍÅ íàäî ïðåïÿòñòâîâàòü ëå÷àùèì âðà÷àì â íà÷àëå òåðàïèè(ëþáîé-õîòÿò è ìîãóò îïåðèðîâàòü-ïóñòü îïåðèðóþò) , â îæèäàíèè ïîêà Âû íàéäåòå ïðåâåíàð, ìàáòåðó è ïðî÷åå íåîáÿçàòåëüíîå. |
#24
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Ñäåëàëè îïåðàöèþ, íåòîðîïëèâî âîññòàíàâëèâàåìñÿ ïîñëå íåå, æäåì ðåçóëüòàòîâ ãèñòîëîãèè. Âîçíèêëè äîïîëíèòåëüíûå âîïðîñû:
Âîïðîñ 1: ïðèìåíÿåòñÿ ëè ìàáòåðà áåç õèìèîòåðàïèè? Âîïðîñ 2: ñêîëüêî êóðñîâ R-CHOP îáû÷íî ïðîâîäÿò? Âîïðîñ 3: R-CHOP ëó÷øå äåëàòü ñ ãîñïèòàëèçàöèåé? Ñïàñèáî! |
#25
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1. äà-íî íå ïðè ëå÷åíèè ëèìôîì.
2. äî äîñòèæåíèÿ ðåìèññèè + 2 êîíñîëèäèðóþùèõ. Èëè äî ðàçâèòèÿ æèçíåóãðîæàþùèõ îñëîæíåíèé. Èëè äî ïðîãðåññèè, òî åñòü ïðè îòñóòñòâèè ýôôåêòà. 3.ïåðâûé êóðñ-åñëè ïîäîçðåâàåòñÿ ðàçùâèòèå òÿæêèõ ñîìàòè÷åñêèå ïîñëåäñòâèé ëèáî åñòü áîëüøîé îáúåì áûñòðîðàñòóùåé îïóõîëè è ñîîòâ.- ðèñê òóìîð-ëèçèñ ñèíäðîìà. Íó èëè ïðè ðåàêöèè íà ââåäåíèå Ìàáòåðû-èíîãäà îêàçûâàåòñÿ íóæíûì ðàñòÿíóòü ââåäåíèå íà 10 è áîëåå ÷àñîâ. Ýòî âñå ðåäêî. Îáû÷íî ãîñïèòàëäèòçàöèÿ íå òðåáóåòñÿ. |
#26
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Öèòàòà:
Âîò ýòà ôðàçà îñîáåííî çàèíòåðåñîâàëà: "Responses to splenectomy occurred in approximately 90% of patients." Îçíà÷àåò ëè ýòî, ÷òî ñïëåíýêòîìèåé â ïðèíöèïå ìîæíî îãðàíè÷èòüñÿ? ×òî îçíà÷àåò â äàííîì êîíòåêñòå "response"? Îçíà÷àåò ëè ýòî, ÷òî ïîñëå ñïëåíýêòîìèè ìîæåò íàñòóïèòü äëèòåëüíàÿ ðåìèññèÿ è õèìèîòåðàïèÿ áóäåò íå íóæíà? |
#27
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#28
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response-â ëþáîì êîíòåêñòå îçíà÷àåò , ÷òî òå æàëîáû êîòîðûå áûëè-ïðåêðàòèëèñü.
Ôàêò íàñòóïëåíèÿ ðåìèññèè îïðåäåëÿåò âðà÷. Ïî îòñóòñòâèþ ïðèçíàêîâ íàëè÷èÿ áîëåçíè â îðãàíèçìå. Äà, êàêîå-òî âðåìÿ ïîñëå ñïëåíýêòîìèè (åñäè ýòî åäèíñòâåííûé î÷àã) áóäåò ïðîäîëæàòüñÿ ðåìèññèÿ. Êàê äîëãî-íå ïðåäóãàäàòü. |
#29
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Åñëè ëèõîðàäêè (òåìïåðàòóðû) óæå íåò, ãåìîãëîáèí ïîâûñèëñÿ, íî êàøåëü îñòàåòñÿ. Ýòî ðåìèññèÿ?
Åñëè ðåìèññèÿ, òî ìîæåò ïðîñòî êóðñ ìàáòåðû ïðèíÿòü? |
#30
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Èñêðåííå, Âàäèì Âàëåðüåâè÷. |