Lymphoma nini ya B-cell lymphoma (DLBCL), ubwoko bw'indwara zo mu gice cy'imbere kitari izuru, ifata izuru n'utuzuru-02

Muri Werurwe 2021, umurwayi w'umugabo w'imyaka 52 wo mu majyaruguru y'uburasirazuba bw'u Bushinwa yagaragaye afite ikibyimba cy'amazuru cyabonetse ubwo yari ari gusuzumwa buri gihe. Yagaragaje ibimenyetso byo kuzura izuru, kuribwa umutwe, kutabona neza, no kubira ibyuya nijoro, nta muriro cyangwa ngo ananuke ibiro.

Isuzuma rya mbere ryagaragaje ko hari igice kinini cy'imitsi yoroshye irimo umwobo w'izuru ry'iburyo n'amasese, bigira ingaruka ku ngingo zikomeye nka orbit, igice cy'umutwe w'imbere, sinus ya sphenoid, na sinus ya ethmoid y'ibumoso kuri MRI. Isuzuma ry'indwara rya sinus y'iburyo ryagaragaje ko lymphoma nini ya B-cell (DLBCL) (ubwoko bw'imitsi yo hagati itari iy'ingirabuzimafatizo).

Indwara zo mu bwoko bwa immunohistochemistry (IHC) zagaragaje ko hari ubukana bwinshi bw’indwara ziterwa na Ki-67 (90%+), CD20 (+), c-Myc (>80%+), Bcl-2 (>90%), Bcl-6 (+), CD10 (-), Mum1 (+), CD79a (+), CD30 (-), na CyclinD1 (-), nta virusi ya Epstein-Barr ifite RNA nto (EBER) ishobora kugaragara.

Guhuza imiterere y’uturemangingo (FISH) byabonye ko Bcl-6 na c-myc zahindutse, ariko nta gene ya Bcl-2 yahindutse. Uburyo bushya bwo gukurikirana imiterere y’uturemangingo (NGS) bwemeje impinduka mu turemangingo twa MYD88, CD79B, IGH-MYC, BAP1, na TP53, bigaragaza ko hari lymphoma yo mu rwego rwo hejuru ya B-cell hamwe na MYC na BCL2 cyangwa BCL6 yahindutse.

Isuzuma rya Positron emission tomography-computed tomography (PET-CT) ryagaragaje uduce tw’umubiri tworoshye tudasobanutse neza mu ruhu rw’izuru ry’iburyo n’iry’imbere, ingano ya cm 6.3x3.8, dufite imbibi zidasobanutse neza. Igikomere cyazamutse kijya mu ruhu rw’iburyo rw’inyuma, inyuma kigera ku rukuta rwo hagati rw’inyuma n’agace k’imbere k’inyuma, ndetse n’inyuma kigera ku ruhu rw’inyuma n’ishingiro ry’umutwe. Igikomere cyagaragaje kwiyongera kwa fluorodeoxyglucose (FDG) hamwe na SUVmax ya 20. Ubunini bw’amagufwa bwagaragaye mu ruhu rw’ibumoso rw’inyuma n’iry’imbere, hamwe n’imikorere isanzwe ya FDG.

Uyu murwayi yari yarigeze kuvura indwara ya R2-CHOP, R-ESHAP, BEAM+ASCT, ndetse anakorerwa isuzuma ry’imirasire mu gace runaka, aho indwara yagaragaye ko ikomeza kwiyongera. Bitewe no kudakira kwa chimiotherapie no kugira uruhare runini mu ngingo nyinshi (harimo ibihaha, umwijima, urwagashya, n’amagufwa), umurwayi yasuzumwe afite DLBCL y’ibanze idashobora kuvura. Iyi ndwara yakomeje kwihuta cyane, ifite urugero rwa LDH rwinshi, amanota ya 5 yahinduwe mu gipimo mpuzamahanga cy’ibipimo (NCCN-IPI), TP53 mutation, na MCD subtype, yongera kurwara mu mezi 6 nyuma yo guterwa autologous.

Nyuma yo guhabwa imiti igabanya ubukana bw'indwara, umurwayi yahawe imiti igabanya ubukana bw'indwara za steroid ariko nta gisubizo cyiza atanze. Nyuma yo guhabwa imiti harimo n'udukoko twa CD79 monoclonal antibodies twahujwe na bendamustine na mechlorethamine hydrochloride, bituma urugero rwa LDH rugabanuka cyane ndetse n'ikibyimba kigabanuka cyane.

Nyuma yo gutegura neza ubuvuzi bwa CAR-T, umurwayi yafashwe imiti ya chimiotherapie yo kugabanuka kwa limfositike (lymphodepletion) akoresheje regimen ya FC, bituma limfositike igabanuka ndetse hakaza no kugabanuka cyane kwa leukopenia. Ariko, iminsi itatu mbere yo guterwa CAR-T, umurwayi yagize umuriro, herpes zoster mu gice cyo hasi cy'umugongo, ndetse n'urugero rwa lactate dehydrogenase (LDH) mu maraso rugera kuri 25.74ng/ml, bigaragaza ko ashobora kuba afite ibyago byinshi byo kwandura indwara zitandukanye (AE). Bitewe n'uko ibyago byo guterwa CAR-T byariyongereye bitewe n'ubwandu busanzwe, bishobora gutuma habaho urupfu, umurwayi yahawe imiti ya antibiyotike ikoresha uburyo bwagutse ikubiyemo udukoko dutandukanye.

Nyuma yo guterwa CAR-T, umurwayi yagize umuriro mwinshi ku munsi wo guterwa, akomeza kubura umwuka, gucika amaraso, ndetse n'ibimenyetso by'ibihaha byiyongera ku munsi wa gatatu. Isuzuma rya CT mu mitsi yo mu maraso ku munsi wa gatanu ryagaragaje ko hari ibirahure bitambitse kandi ko hari impinduka hagati y'ibihaha, ryemeza ko kuva amaraso mu maraso mu maraso byatangiye. Nubwo mbere yabanje kwirinda gukoresha steroid bitewe n'uko CAR-T ishobora kugabanya, ndetse no kuvura indwara zishingiye ku micungire y'ubwandu, ubuzima bw'umurwayi bwagaragaje ko nta kibazo cyabayeho.

Ku munsi wa karindwi, umubare munini w’uturemangingo twa CAR wagaragaye mu maraso yo mu gice cy’imbere, bituma habaho ihinduka ry’uburyo bwo kuvura hakoreshejwe methylprednisolone ku gipimo gito (40mg-80mg). Nyuma y’iminsi itanu, guhindagurika kw’ibihaha byombi byaragabanutse, kandi ibimenyetso byo kwangirika kw’amaraso mu maraso byaragenzuwe cyane.

Ku munsi wa munani, ubuvuzi bwa CAR-T bwagaragaje imikorere itangaje. Mu gihe cy'ukwezi kumwe gusa nyuma yo kuvurwa na CAR-T, umurwayi yageze ku buremere bwuzuye (CR). Ibizamini byakurikiyeho kugeza muri Nyakanga 2023 byemeje ko umurwayi yagumye muri CR, bigaragaza ko yakiriye neza ubuvuzi bwa CAR-T kandi ko ashobora gukira.