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辐射致癌效应是电离辐射远期效应中对受照者健康危害最严重的效应。辐射流行病学研究提供了辐射致癌的主要证据,其中大部分研究基于日本原子弹爆炸的幸存者,也有部分基于工业和医疗辐射工作者和接受放疗的肿瘤患者。这些研究结果表明,中剂量至高剂量的电离辐射会增加人体多数器官的患癌风险[1]。其中,对于甲状腺癌、乳腺癌、肺癌和白血病的风险评估已非常精确,且在相对较低的照射剂量(<0.2 Gy)下发现了相关性;辐射与涎腺癌、胃癌、结肠癌、膀胱癌、卵巢癌、中枢神经系统肿瘤和皮肤癌之间的关系也有报道[1]。而电离辐射是否可诱发非霍奇金淋巴瘤(non-Hodgkin lymphoma,NHL),目前的研究结果尚未取得一致结论。本研究通过对河南“4.26” 60Co源辐射事故中1例中度骨髓型急性放射病患者受照后第13年患NHL的病因进行探讨,为电离辐射致NHL提供辐射流行病学依据。
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患者“天”,1999年4月26日在河南省封丘县一起非法倒卖60Co治疗机和放射源的辐射事故中受照,受照时年龄37岁,受照后诊断为中度骨髓型急性放射病,事故详情见文献[2]。患者“天”的个人资料、受照剂量估算和最终临床诊断见表1[2-4]。参照国家相关标准[5],卫生部核事故医学应急中心第一临床部于患者受照后半年开始对其进行系统的医学随访。
患者 性别 年龄(岁) 物理剂量(Gy) 生物剂量(Gy) 全身平均剂量(Gy) 红骨髓计权
平均剂量(Gy)造血干细胞活存
计权等效剂量(Gy)临床诊断 “天” 男 37 2.60 2.61 2.40 2.30 2.30 中度骨髓型急性放射病 表 1 患者“天”1999年60Co受照剂量估算结果及临床诊断
Table 1. 60Co radiation dose estimation results and clinical diagnosis of patient "Tian" in 1999
患者“天”确诊慢性乙型病毒性肝炎23年;1999年有射线误照射史;有输血史;否认有肿瘤及其他家族性遗传性疾病史。患者于2012年6月出现无明显诱因的间断性上腹部隐痛,伴恶心、呕吐,呕吐物为胃内容物,含咖啡色液体,2~3次/d,非喷射性,无头痛、发热,无腹胀、腹泻、便血,无黑便。2012年6月,患者于当地医院行胃镜和下腹部、盆腔CT检查。胃镜检查结果诊断为胃NHL(弥漫大B型);CT检查结果示胰尾旁、脾肾间隙高密度影,左侧肾前筋膜增厚,腹膜后高密度影,盆腔未见明显肿大淋巴结。免疫组织化学检查结果:CD79a(+)、人类B细胞淋巴瘤因子6(BCL6,+)、多发性骨髓瘤癌基因1(MUM1,少量+)、CD5( −)、CD3( −),CK( −)、CD10( −)、CyclinD1( −)、CD21( −)。组织病理学检查结果诊断为胃黏膜非特指弥漫大B细胞淋巴瘤。结合影像学和组织病理学检查结果,患者“天”确诊为Ⅳ期胃黏膜非特指弥漫大B细胞淋巴瘤。
患者“天”确诊后,累计进行了连续24个周期(共计3个方案)的全身静脉化疗,末次化疗时间为2014年2月,未行放疗。患者化疗期间出现Ⅳ度骨髓抑制,给予造血刺激因子和利可君片、地榆升白片等药物治疗后情况改善。其后每年定期复查,患者病情稳定,肿瘤无复发转移征象。目前一般情况良好。
河南“4.26”60Co源辐射事故一例受照者患非霍奇金淋巴瘤的病因探讨
Inquire into the etiology of non-Hodgkin lymphoma in a victim of Henan "4.26" 60Co source radiation accident
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摘要: 关于电离辐射是否可诱发非霍奇金淋巴瘤(NHL),目前的研究结果尚未获得一致结论。笔者报道了河南“4.26” 60Co源辐射事故中1例中度骨髓型急性放射病患者受照后第13年患NHL的病例,结合患者的受照史、病史特点、诊断及国际多项大型研究,从流行病学资料和影响因素两方面分析了患者“天”患非霍奇金淋巴瘤与电离辐射的关系,为电离辐射致NHL提供辐射流行病学依据。Abstract: As for whether ionizing radiation can induce non-Hodgkin lymphoma (NHL), the current study results have not yet reached a consensus conclusion. The authors reported a case of NHL, who was diagnosed with moderate bone marrow form of acute radiation sickness in Henan "4.26" 60Co source radiation accident and suffered from NHL 13 years after exposure. And analyzed from two aspects of epidemiological data and influence factors in combined with the patient's exposure history, characteristics of medical history, diagnosis and many international large-scale studies to provide radiation epidemiology for NHL caused by ionizing radiation.
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表 1 患者“天”1999年60Co受照剂量估算结果及临床诊断
Table 1. 60Co radiation dose estimation results and clinical diagnosis of patient "Tian" in 1999
患者 性别 年龄(岁) 物理剂量(Gy) 生物剂量(Gy) 全身平均剂量(Gy) 红骨髓计权
平均剂量(Gy)造血干细胞活存
计权等效剂量(Gy)临床诊断 “天” 男 37 2.60 2.61 2.40 2.30 2.30 中度骨髓型急性放射病 -
[1] Ron E. Ionizing radiation and cancer risk: evidence from epidemiology[J]. Radiat Res, 1998, 150(5 Suppl): S30−41. DOI: 10.2307/3579806. [2] 姚仲甫, 卢国甫, 张钦富, 等. 河南“4.26” 60Co源辐射事故的经过和早期物理剂量估算[J]. 中华放射医学与防护杂志, 2001, 21(3): 163−164. DOI: 10.3760/cma.j.issn.0254-5098.2001.03.007.
Yao ZF, Lu GF, Zhang QF, et al. Course and early physical dose estimation of "4.26" 60Co source radiation accident in Henan province[J]. Chin J Radiol Med Prot, 2001, 21(3): 163−164. DOI: 10.3760/cma.j.issn.0254-5098.2001.03.007.[3] 卢志娟, 李旭光, 郝建秀, 等. 河南“4.26” 60Co辐射事故3例中、重度骨髓型急性放射病患者造血系统改变20年比较分析[J]. 国际放射医学核医学杂志, 2021, 45(7): 434−442. DOI: 10.3760/cma.j.cn121381-202010035-00073.
Lu ZJ, Li XG, Hao JX, et al. A comparative analysis of hematopoietic system in three cases with moderate or severe bone marrow form of acute radiation sickness for 20 years after the "4.26" 60Co radiation accident in Henan[J]. Int J Radiat Med Nucl Med, 2021, 45(7): 434−442. DOI: 10.3760/cma.j.cn121381-202010035-00073.[4] 贾德林, 苑淑渝, 戴光复, 等. 河南“4.26”60Co源辐射事故受照人员剂量的模拟测量和估算[J]. 中华放射医学与防护杂志, 2001, 21(3): 150−152. DOI: 10.3760/cma.j.issn.0254-5098.2001.03.002.
Jia DL, Yuan SY, Dai GF, et al. Simulating measurement and dose estimation for exposed persons in "4.26" 60Co radiation source accident in Henan province[J]. Chin J Radiol Med Prot, 2001, 21(3): 150−152. DOI: 10.3760/cma.j.issn.0254-5098.2001.03.002.[5] 国家卫生和计划生育委员会. GBZ/T 163-2017 职业性外照射急性放射病的远期效应医学随访规范[S]. 北京: 中国标准出版社, 2017.
National Health and Family Planning Commission. GBZ/T 163-2017 Occupational medical follow up specifications for late effect of acute radiation syndrome after external exposure[S]. Beijing: Standards Press of China, 2017.[6] Nishiyama H, Anderson RE, Ishimaru T, et al. The incidence of malignant lymphoma and multiple myeloma in Hiroshima and Nagasaki atomic bomb survivors, 1945−1965[J]. Cancer, 1973, 32(6): 1301−1309. DOI: 10.1002/1097-0142(197312)32:6<1301::AID-CNCR2820320602>3.0.CO;2-Z. [7] Preston DL, Kusumi S, Tomonaga M, et al. Cancer incidence in atomic bomb survivors. Part Ⅲ: Leukemia, lymphoma and multiple myeloma, 1950−1987[J]. Radiat Res, 1994, 137(2 Suppl): S68−97. DOI: 10.2307/3578893. [8] Hsu WL, Preston DL, Soda M, et al. The incidence of leukemia, lymphoma and multiple myeloma among atomic bomb survivors: 1950−2001[J]. Radiat Res, 2013, 179(3): 361−382. DOI: 10.1667/RR2892.1. [9] Gluzman D, Imamura N, Sklyarenko L, et al. Malignant diseases of hematopoietic and lymphoid tissues in Chernobyl clean-up workers[J/OL]. Hematol J, 2005, 5(7): 565−571[2021-09-23]. DOI: 10.1038/sj.thj.6200568. [10] Kesminiene A, Evrard AS, Ivanov VK, et al. Risk of hematological malignancies among Chernobyl liquidators[J]. Radiat Res, 2008, 170(6): 721−735. DOI: 10.1667/RR1231.1. [11] Gluzman D, Imamura N, Sklyarenko L, et al. Patterns of hematological malignancies in Chernobyl clean-up workers (1996−2005)[J/OL]. Exp Oncol, 2006, 28(1): 60−63[2021-09-23]. https://exp-oncology.com.ua/article/667/patterns-of-hematological-malignancies-in-nbsp-chernobyl-clean-up-workers-1996-2005. [12] Hunter N, Haylock R. Radiation risks of lymphoma and multiple myeloma incidence in the updated NRRW-3 cohort in the UK: 1955−2011[J]. J Radiol Prot, 2022, 42(1): 011517. DOI: 10.1088/1361-6498/abee96. [13] De González AB, Ntowe E, Kitahara CM, et al. Long-term mortality in 43 763 U.S. radiologists compared with 64 990 U. S. psychiatrists[J]. Radiology, 2016, 281(3): 847−857. DOI: 10.1148/radiol.2016152472. [14] Harbron RW, Pasqual E. Ionising radiation as a risk factor for lymphoma: a review[J]. J Radiol Prot, 2020, 40(4): R151−R185. DOI: 10.1088/1361-6498/abbe37. [15] Zablotska LB, Lane RSD, Frost SE, et al. Leukemia, lymphoma and multiple myeloma mortality (1950−1999) and incidence (1969−1999) in the Eldorado uranium workers cohort[J]. Environ Res, 2014, 130: 43−50. DOI: 10.1016/j.envres.2014.01.002. [16] Hernández-Ramírez RU, Qin L, Lin HQ, et al. Association of immunosuppression and HIV viraemia with non-Hodgkin lymphoma risk overall and by subtype in people living with HIV in Canada and the USA: a multicentre cohort study[J]. Lancet HIV, 2019, 6(4): e240−e249. DOI: 10.1016/S2352-3018(18)30360-6. [17] 阮长耿, 沈志祥, 黄晓军. 血液病学[M]. 北京: 中华医学电子音像出版社, 2016.
Ruan CG, Shen ZX, Huang XJ. Hematology[M]. Beijing: China Medical Electronic Audio and Video Publishing House, 2016.[18] Engels EA, Cho ER, Jee SH. Hepatitis B virus infection and risk of non-Hodgkin lymphoma in South Korea: a cohort study[J]. Lancet Oncol, 2010, 11(9): 827−834. DOI: 10.1016/S1470-2045(10)70167-4. [19] Cerhan JR, Wallace RB, Dick F, et al. Blood transfusions and risk of non-Hodgkin's lymphoma subtypes and chronic lymphocytic leukemia[J]. Cancer Epidemiol Biomarkers Prev, 2001, 10(4): 361−368. DOI: 10.1016/S0887-7963(02)80019-0. [20] 中华人民共和国国家卫生和计划生育委员会. GBZ 97-2017 职业性放射性肿瘤判断规范[S]. 北京: 中国标准出版社, 2017.
National Health and Family Planning Commission of the People's Republic of China. GBZ 97-2017 Judgment standard of occupational radiogenic neoplasms[S]. Beijing: Standards Press of China, 2017.