2024年6月23日 (日) 14:05的版本

多柔比星-环磷酰胺与多柔比星-达卡巴肼辅助治疗犬血管肉瘤的比较

Comparison of doxorubicin-cyclophosphamide with doxorubicin-dacarbazine for the adjuvant treatment of canine hemangiosarcoma

https://doi.org/10.1111/vco.12139

1 摘要

犬血管肉瘤 （HSA） 是一种血管内皮起源的肿瘤，具有侵袭性生物学行为，在诊断后 12 个月内存活的狗不到 10%。首选的治疗包括手术，然后以阿霉素为基础的辅助化疗。我们前瞻性地比较了阿霉素和达卡巴嗪（ADTIC）辅助治疗与传统的多柔比星和环磷酰胺（AC）治疗，旨在确定安全性并评估该方案是否能延长生存期和转移时间（TTM）。招募了 27 只狗;分期检查后，18 例接受 AC 治疗，9 例接受 ADTIC 治疗。与接受AC治疗的狗相比，接受ADTIC治疗的狗的中位TTM和生存时间更长（分别为>550天和112天，P=0.021和>550天和142天，P=0.011）。两种方案的耐受性都很好，不需要减少剂量或增加治疗间隔。由多柔比星和达卡巴嗪联合组成的方案在患有 HSA 的狗中是安全的，并延长了 TTM 和生存时间。

Canine hemangiosarcoma (HSA) is a neoplasm of vascular endothelial origin that has an aggressive biological behaviour, with less than 10% of dogs alive at 12-months postdiagnosis. Treatment of choice consists of surgery followed by adjuvant doxorubicin-based chemotherapy. We prospectively compared adjuvant doxorubicin and dacarbazine (ADTIC) to a traditional doxorubicin and cyclophosphamide (AC) treatment, aiming at determining safety and assessing whether this regimen prolongs survival and time to metastasis (TTM). Twenty-seven dogs were enrolled; following staging work-up, 18 were treated with AC and 9 with ADTIC. Median TTM and survival time were longer for dogs treated with ADTIC compared with those receiving AC (>550 versus 112 days, P = 0.021 and >550 versus 142 days, P = 0.011, respectively). Both protocols were well tolerated, without need for dose reduction or increased interval between treatments. A protocol consisting of combined doxorubicin and dacarbazine is safe in dogs with HSA and prolongs TTM and survival time.

2 介绍

3 材料与方法 (Materials and methods)

患者资格 (Patient eligibility)

前瞻性地招募了由任何腹部器官或皮下引起的具有手术切除、经组织学证实的 HSA 的客户拥有的狗。术前检查包括体格检查、血液学、血清生化、腹部超声和至少两次胸部 X 线片的侧视图。如果使用超声心动图确定的收缩期缩短分数为 <25%，则认为狗发生多柔比星相关心脏毒性的高风险。具有这种心脏功能的狗没有参加这项研究。患有与 HSA 不同的限制生命的疾病的狗和患有真皮 HSA 的狗也被排除在外。根据世界卫生组织 （WHO） 的家畜分期系统对狗进行分期.29.第1组包括提及一位作者（D.S.）机构的狗，而提及两位不同作者（L.M.和R.F.）机构的狗被列入第2组。

Client-owned dogs with a surgically removed, histologically confirmed HSA, arising from any abdominal organ or subcutis, were prospectively recruited. Presurgical investigations included physical examination, haematology, serum biochemistry, abdominal ultrasound and at least two lateral views thoracic radiographs. Dogs were considered to be at high risk of developing doxorubicin-related cardiotoxicity if systolic fractional shortening determined by using echocardiography was <25%. Dogs with such cardiac function were not enrolled in this study. Dogs with life-limiting diseases different than HSA and those with dermal HSA were also excluded. Dogs were staged according to the World Health Organization (WHO) staging system for domestic animals.29. Dogs referred to the institution of one author (D. S.) were included in group 1, whereas dogs referred to the institutions of two different authors (L. M. and R. F.) were included in group 2.

3.1 治疗方案 (Treatment protocol)

目的是在手术干预后 7-10 天内开始化疗。第 1 组的狗接受辅助多柔比星 （Doxorubicina， Ebewe Italia s.r.l.， Roma， Italy） 和环磷酰胺 [Endoxan®， Baxter s.r.l.， Lurago d'Erba， Como， Italy （AC）] 治疗，而第 2 组的狗接受辅助多柔比星和达卡巴嗪 [Deticene®， Aventis Pharma S.p.A， Milano， Italy （ADTIC）]。与AC相比，ADTIC更昂贵，并且由于该研究没有得到资助，因此无法随机分组。由于与传统的 AC 协议相比，ADTIC 在进行本研究时完全处于研究阶段，因此所有选择 ADTIC 的业主都被要求在注册前签署书面知情同意书。

The objective was to initiate chemotherapy within 7–10 days after surgical intervention. Dogs included in group 1 were treated with adjuvant doxorubicin (Doxorubicina, Ebewe Italia s.r.l., Roma, Italy) and cyclophosphamide [Endoxan®, Baxter s.r.l., Lurago d’Erba, Como, Italy (AC)], whereas dogs included in group 2 received adjuvant doxorubicin and dacarbazine [Deticene®, Aventis Pharma S.p.A, Milano, Italy (ADTIC)]. ADTIC was more expensive compared with AC, and as the study was not supported by a grant, groups could not be randomized. Because ADTIC was completely investigational at the time this study was carried out compared with the traditional AC protocol, all owners electing ADTIC were asked to sign a written informed consent prior to enrolment.

在任一治疗组中，阿霉素以 30 mg/m^2 的剂量静脉注射，每 3 周一次，持续四个周期。阿霉素在 20 分钟内以缓慢静脉推注给药。

In either treatment groups, doxorubicin was administered IV at the dose of 30 mg/m^2 every 3 weeks for four cycles. Doxorubicin was administered as a slow IV bolus within 20 min.

在第 1 组中，环磷酰胺以 75 mg/m^2 口服给药，连续 4 天，从每次阿霉素给药当天开始。在第 2 组中，达卡巴嗪以 200 mg/m^2 的剂量静脉注射（每天不超过 250 mg），每天一次，持续 5 天，从每次多柔比星给药之日开始。简言之，将达卡巴嗪与注射用水复溶，以获得10mg/mL的浓度。然后通过先前放置的留置导管静脉输注 1 分钟以上给药复溶药物，以给予多柔比星。然后移除导管，并在接下来的四次给药中反复放置新导管。表1.30列出了两种方案的分数和总和剂量强度（SDI）

In group 1, cyclophosphamide was administered orally at 75 mg/m^2 for 4 consecutive days, starting on the day of every doxorubicin administration. In group 2, dacarbazine was administered IV at the dose of 200 mg/m^2 (without exceeding 250 mg total daily) once daily for 5 days, starting on the day of every doxorubicin administration. Briefly, dacarbazine was reconstituted with water for injection to obtain a concentration of 10 mg mL−1. Reconstituted drug was then given by intravenous infusion over 1 min via the indwelling catheter previously placed to administer doxorubicin. The catheter was then removed, and a new catheter was repeatedly placed for the following four administrations. Fractional and summation dose intensities (SDIs) for the two protocols are listed in Table 1.[30]

在任一组中，标准止吐治疗包括从化疗第一天开始连续 3 天以 2 mg/kg q24h 的剂量口服 maropitant（Cerenia®、Pfizer、Latina、Italy）。克拉维酸增强阿莫西林（Synulox®，辉瑞，拉丁，意大利）以 12.5-20 mg/kg q12h 的频率预防性口服给药，直到预期的中性粒细胞减少性最低点，此后如图所示。抗生素剂量取决于临床医生的偏好。

In either group, standard antiemetic therapy consisted in maropitant (Cerenia®, Pfizer, Latina, Italy) administered orally at the dose of 2 mg kg−1 q24h for 3 consecutive days starting on the first day of chemotherapy. Clavulanate-potentiated amoxicillin (Synulox®, Pfizer, Latina, Italy) was prophylactically administered orally at 12.5–20 mg kg−1 q12h until the time of the expected neutropenic nadir, and as indicated thereafter. Antibiotic dosage depended on clinician’s preference.

在两个周期的化疗后，进行了重复的临床分期检查，包括胸片和腹部超声检查。如果没有观察到局部复发和/或转移性疾病，则将相同的化疗方案继续两个周期。在疾病进展的情况下，提供了抢救方案。随访重新分期包括在方案结束后 1 个月和之后每 3 个月进行一次胸片和腹部超声检查，以确定对治疗的反应。

A repeated clinical staging work-up consisting of thoracic radiographs and abdominal ultrasoundo was performed after two cycles of chemotherapy. If no local recurrence and/or metastatic disease were observed, the same chemotherapy protocol was continued for two additional cycles. In case of disease progression, a rescue protocol was offered. Follow-up re-staging consisted of thoracic radiographs and abdominal ultrasound performed 1 month after the end of the protocol and every 3 months afterwards to define response to treatment.

3.2 毒性评估 (Assessment of toxicity)

根据第 7-10 天和每个周期开始前进行的狗的病史、体格检查和全血细胞计数 （CBC），在第 1 组中评估化疗产生的毒性，如兽医合作肿瘤学组所述.31 在第 2 组中，在每个化疗周期的第 1、4、5 和 10 天检查 CBC。第 1 天被认为是阿霉素给药的日子。

Toxicity resulting from chemotherapy was assessed in group 1 based on the dog’s history, physical examination and complete blood count (CBC) performed 7–10 days after doxorubicin and before the beginning of each cycle, as stated by the Veterinary Co-operative Oncology Group.31 In group 2, CBC was checked on days 1, 4, 5 and 10 of each chemotherapy cycle. Day 1 was considered as the day of doxorubicin administration.

3.3 统计分析 (Statistical analysis)

从诊断之日到最后一次就诊或死亡之日的随访和生存时间是根据在作者所在机构进行的复查计算的。对于两组，使用 Kaplan-Meier 乘积限值方法探索生存时间和 TTM（超出区域淋巴结），然后进行对数秩检验。在两组中，手术切除的时机都被认为是。在生存分析中，如果狗在数据累积关闭时还活着或死于没有肿瘤相关原因，则对狗进行审查，而对于TTM狗，如果在最后一次检查中没有发生远处转移，则被审查。

Follow-up and survival times were calculated from the date of diagnosis to the date of last visit or death based on the rechecks performed at one of the authors’ institutions. For both groups, survival time and TTM (beyond regional lymph nodes) were explored using the Kaplan–Meier product limit method followed by log-rank test. In either group, timing was considered from surgical excision. In the survival analysis, dogs were censored if they were alive at the time of data accrual closure or died of no tumour-related causes, whereas for TTM dogs were censored if, by the last examination, distant metastases had not developed.

为了验证两个治疗组的特征在入院时是否不同，使用 Mann-Whitney 检验比较年龄和体重，并使用 Fisher 精确检验比较品种（纯种与杂交）、性别（雄性与雌性）、肿瘤的主要位置（脾脏与其他部位）、临床分期（II 与 III）和手术切缘（完全与不完全）。如果狗出现内脏破裂，则认为手术切缘不可评估。Fisher 精确测试还用于比较治疗周期中发生的骨髓毒性（存在与不存在）的频率。P <0.05 被认为是显著的。

To verify whether characteristics of the two treatment groups differed at admission, the Mann–Whitney test was used to compare age and body weight, and the Fisher’s exact test was used to compare breed (pure- versus cross-breed), sex (male versus female), primary location of the tumour (spleen versus other sites), clinical stage (II versus III) and surgical margins (complete versus incomplete). Surgical margins were deemed not assessable if the dog was presenting with visceral rupture. The Fisher’s exact test was also used to compare the frequency of bone marrow toxicity (present versus absent) that occurred during treatment cycles. P <0.05 was considered significant.

3.4 结论 (Results)

在2008年至2014年期间，有27只狗符合纳入标准并被招募：其中18只（66.6%）接受了辅助AC（第1组），而其余9只（33.3%）接受了ADTIC治疗（第2组）。狗的特征列于表2。

Between 2008 and 2014, 27 dogs met the inclusion criteria and were enrolled: 18 (66.6%) of them received adjuvant AC (group 1), whereas the remaining 9 (33.3%) were treated with ADTIC (group 2). Features of the dogs are listed in Table 2.

入院时，两个治疗组在年龄、体重、品种、性别、肿瘤的主要位置和分期方面没有差异，而分配接受ADTIC的狗的手术切缘往往不完全，而不是接受AC的狗[分别为9例中的5例（55.6%）和18例中的2例（11.1%）;P =0.024]。

At admission, the two treatment groups did not differ for age, body weight, breed, sex, primary location of the tumour and stage, whereas surgical margins were more often incomplete in dogs allocated to receive ADTIC than in those allocated to receive AC [5 of 9 (55.6%) versus 2 of 18 (11.1%), respectively; P =0.024].

第 1 组

有九只混种犬，两只拳击手，两只德国牧羊犬，两只金毛猎犬，一只英国二传手，一只拉布拉多猎犬和一只意大利甘蔗犬。中位年龄为 9.5 岁（范围：6-13 岁），中位体重为 31 公斤（范围：5.2-46.4 公斤）。有 11 只雄性（n=3 只绝育）和 7 只雌性狗（n=4 只绝育）。15 只狗的原发部位是脾脏，其中 11 只因脾破裂而出现腹血。其余三只狗分别患有肾脏、肝脏和皮下 HSA。

根据癌症位置，每只狗都接受了手术，包括脾切除术、左肝叶切除术、肾切除术或切除皮下肿瘤。组织病理学评估显示肝脏和皮下 HSA 的手术切缘干净。

根据 TNM 分类，16 只狗被认为患有 II 期，2 只患有 III 期 HSA。两只患有III期疾病的狗都有脾脏HSA和网膜转移的宏观证据;在腹腔切开术中怀疑转移性疾病，并通过组织病理学检查证实。观察到多发性粟粒病变，无法进行转移灶切除术。没有区域淋巴腺肿大和/或其他转移部位的记录。表2总结了案例。

从手术到化疗开始的中位时间为 9 天（范围：7-10 天）。化疗周期的中位数为 4 个（范围：2-5），多柔比星的中位累积剂量为 120 mg m-2，环磷酰胺的中位累积剂量为 1200 mg m-2。该协议接受的 SDI 中位数与预期的 SDI 相对应，因为没有一只狗需要减少剂量和/或延迟治疗。

Group 1

There were nine mixed breed dogs, two Boxer, two German shepherd, two Golden retrievers, one English setter, one Labrador retriever and one Italian cane corso. Median age was 9.5 years (range: 6–13 years) and median weight was 31 kg (range: 5.2–46.4 kg). There were 11 males (n=3 neutered) and 7 female dogs (n=4 spayed). HSA occurred in the spleen as primary site in 15 dogs: 11 of them presented with hemoabdomen because of splenic rupture. The remaining three dogs had a renal, hepatic and a subcutaneous HSA, respectively.

Each dog underwent surgery, consisting of splenectomy, left hepatic lobectomy, nephrectomy or removal of the subcutaneous tumour, according to cancer location. Histopathological evaluation revealed clean surgical margins in the hepatic and subcutaneous HSA.

According to the TNM classification, 16 dogs were considered having stage II and 2 having stage III HSA. Both dogs with stage III disease had a splenic HSA and macroscopic evidence of metastasis to the omentum; metastatic disease was suspected during celiotomy, and this was confirmed through histopathological examination. Multiple miliary lesions were observed, and metastasectomy could not be performed. No regional lymphadenomegaly and/or other metastatic sites could be documented. Cases are summarized in Table 2.

The median time from surgery to the initiation of chemotherapy was 9 days (range: 7–10 days). The median number of chemotherapy cycles was 4 (range: 2–5), with a median cumulative dose of doxorubicin of 120 mg m–2 and a median cumulative dose of cyclophosphamide of 1200 mg m−2. The median received SDIs for this protocol corresponded to the intended SDIs, as none of the dogs required dose reductions and/or treatment delays.

第 2 组

有六只混种犬，一只美国斯塔福德郡梗犬，一只金毛猎犬和一只拉布拉多猎犬。中位年龄为 9 岁（范围：8-14 岁），中位体重为 26.4 公斤（范围：10-39.2 公斤）。有三只雄性（n=1 绝育）和六只雌性狗（n=4 绝育）。HSA发生在5只狗的脾脏中，是主要部位;所有患者均因脾破裂而出现腹腔积血。两只狗有皮下HSA，一只狗有肾，一只有肠系膜HSA。根据TNM分类，6只狗患有II期HSA（n=2脾脏，n=2皮下，n=1肾和n=1肠系膜），3只狗患有III期HSA（n=3脾脏）。一只患有皮下 II 期 HSA 的狗患有同侧区域淋巴结淋巴腺肿大;手术切除，组织病理学证实转移性疾病。患有III期疾病的三只狗中有两只有腹膜转移，一只有肝转移。所有狗都接受了手术，包括脾切除术、肾切除术、肠系膜和皮下肿瘤切除术，具体取决于癌症位置;在所有III期疾病病例中，由于转移灶数量众多，无法进行转移灶切除术。切除两个边缘不完整的皮下 HSA。表2总结了案例。

从手术到化疗开始的中位时间为 9 天（范围：7-10 天）。化疗周期的中位数为 4 个（范围：2-4 个周期），阿霉素的中位累积剂量为 120 mg m-2（范围：60-120 mg m-2），达卡巴嗪的中位累积剂量为 4000 mg m-2（范围：2000-4000 mg m-2）。化疗周期的中位数为4个（范围：2-4）。该协议接收的 SDI 中位数与预期的 SDI 相对应。

Group 2

There were six mixed breed dogs, one American Staffordshire terrier, one Golden retriever and one Labrador retriever. Median age was 9 years (range: 8–14 years) and median weight was 26.4 kg (range: 10–39.2 kg). There were three males (n=1 neutered) and six female dogs (n=4 spayed). HSA occurred in the spleen as primary site in five dogs; all of them presented with hemoperitoneum because of splenic rupture. Two dogs had subcutaneous HSA, one dog had a renal and one had a mesenteric HSA. According to the TNM classification, six dogs had stage II HSA (n=2 splenic, n=2 subcutaneous, n=1 renal and n=1 mesenteric), and three dogs had stage III HSA (n=3 splenic). One dog with subcutaneous stage II HSA had lymphadenomegaly of the ipsilateral regional lymph node; this was surgically excised, and metastatic disease was confirmed on histopathology. Two of the three dogs with stage III disease had peritoneal metastases, and one had liver metastases. All dogs underwent surgery, consisting of splenectomy, nephrectomy, removal of mesenteric and subcutaneous tumour, according to cancer location; in all cases with stage III disease, metastasectomy was not possible because of the multiple number of metastases. Two subcutaneous HSA were removed with incomplete margins. Cases are summarized in Table 2.

The median time from surgery to the initiation of chemotherapy was 9 days (range: 7–10 days). The median number of chemotherapy cycles was 4 (range: 2–4 cycles), with a median cumulative dose of doxorubicin of 120 mg m−2 (range: 60–120 mg m−2) and a median cumulative dose of dacarbazine of 4000 mg m−2 (range: 2000–4000 mg m−2). The median number of chemotherapy cycles was 4 (range: 2–4). The median received SDIs for this protocol corresponded to the intended SDIs.