119.2 📚 國考版醫垫國考 / PGY OSCE

119.2.0.1 📌 Cram Sheet

119.2.0.1.1 🔥 高 yield 12
  1. HLA matchingA/B/C/DRB18/8兄匟姐効 25%MUD ~ 60% (Caucasian 75%, Black 18%)
  2. Stem cell sources: BM > PBSC > cord bloodPBSC 范快 engraftment 䜆 ↑ cGVHD
  3. Plerixafor (CXCR4 antagonist) for poor mobilizer
  4. Conditioning: MA (young/fit) vs RIC (老/共病) vs NMA (frail)
  5. PTCy 革呜: 改 haploidentical 為䞻流BMT CTN 1703 證 PTCy + matched 也范奜
  6. aGVHD: 皮膚 + GI + 肝< 100 daysteroid-refractory → ruxolitinib (REACH-2)
  7. cGVHD: > 100 day, autoimmune mimicker; belumosudil + ruxolitinib + ibrutinib approved
  8. SOS = day 16 peak; tender hepatomegaly + ascites + jaundice → defibrotide
  9. CMV prophy: letermovir × 100 day standard 22E
  10. PCP prophy: TMP-SMX 6 mo+ until off immunosuppression
  11. Live vaccine 2 yr 埌 + off immunosuppression (MMR, varicella, yellow fever)
  12. 22E: CAR-T 取代郚分 lymphoma alloexa-cel (CRISPR) approved for SCD/thalassemia
119.2.0.1.2 🔢 必背敞字
項目 æ•žå­—
兄匟姐効 HLA-identical 機率 25% (1/4)
Caucasian MUD match rate 75%
Black MUD match rate 18%
HLA matching standard 8/8 (A/B/C/DRB1)
ABO incompatibility 占 transplant 30%+
ANC 500 recovery PBSC day 16
ANC 500 recovery BM day 22
ANC 500 recovery cord day 30
aGVHD timing < 100 day, peak 28-40
cGVHD timing 3 mo - 2 yr, peak 6 mo
SOS peak day 16
Letermovir prophy duration × 100 day
Acyclovir prophy duration × 1 yr
TMP-SMX prophy until off immunosuppression

119.2.0.2 ⭐ 高 yield è¡š

119.2.0.2.1 Donor / Source 比范
䟆源 Match Engraftment GVHD Cell dose
Matched sibling BM 8/8 22 d Mod 1.5-5×10⁞/kg
Matched sibling PBSC 8/8 16 d ↑ cGVHD > 2.5×10⁶ CD34/kg
MUD 8/8 8/8 16-22 d ↑ —
MUD 7/8 7/8 similar ↑↑ GVHD —
Haploidentical + PTCy 半 match similar mod (with PTCy) —
Cord blood single 4-6/6 30 d ↓ 兒童倚 (limited cells)
Cord blood double 4-6/6 30 d ↓ 成人 ok
119.2.0.2.2 Conditioning Regimens
匷床 䟋子 適應
MA TBI 12 Gy + CyBuCy (busulfan + cyclophosphamide)FluTBI Young, fit
RIC Flu + Mel; Flu + busulfan reduced 老 / 共病
NMA Flu + 200 cGy TBI 極 frail
特殊 (Aplastic) Cyclophosphamide + ATG Aplastic anemia
特殊 (Fanconi) 䜎 doseFanconi 對 alkylator 敏感 Fanconi anemia
119.2.0.2.3 GVHD Prophy
組合 现節
CNI + MTX Cyclosporine/tacrolimus + methotrexate (standard)
CNI + MMF + mycophenolate
CNI + PTCy + post-transplant cyclophosphamide (haplo)
CNI + MTX + abatacept 22E enhanced for MUD
CNI + MTX + PTCy (BMT CTN 1703) matched related + MUD 22E
+ ATG 高 GVHD risk donor
119.2.0.2.4 aGVHD Stage / Grade
Stage Skin Liver bili Gut diarrhea
1 < 25% BSA 2-3 mg/dL 500-1000 mL/d
2 25-50% 3-6 1000-1500
3 Erythroderma 6-15 > 1500
4 Bullae/desquamation > 15 Ileus
Grade 治療
I None (mild only)
II Steroid prednisolone 1-2 mg/kg/d
III + Ruxolitinib if steroid-refractory
IV Aggressive multi-modal + 預埌差
119.2.0.2.5 Major Complications Timeline
Day Complication
-7 to 0 Conditioning toxicity (mucositis, nausea)
0-7 Cytokine release
5-10 Mucositis peak
10-30 Bacterial / fungal infection (neutropenic)
16 SOS peak
16-22 ANC recovery
28-40 aGVHD peak
30-100 CMV reactivation, BK, HHV-6
100-365 cGVHD develops
6 mo - 2 yr Late infections, BO, secondary cancer
> 2 yr Endocrine, late cancer, infertility, AVN
119.2.0.2.6 22E 重芁 Trials
Trial 結論
REACH-2 (NEJM 2020) Ruxolitinib > best available for steroid-refractory aGVHD
REACH-3 (NEJM 2021) Ruxolitinib > best available for steroid-refractory cGVHD
ROCKstar Belumosudil for steroid-refractory cGVHD
iNTEGRATE Ibrutinib for cGVHD
BMT CTN 1703 PTCy in matched-related/MUD; ↓ GVHD without ↑ relapse
Letermovir trial CMV prophy in seropositive recipients
Exa-cel CLIMB SCD/thal CRISPR autologous edits BCL11A → 取代 allo for SCD/thalassemia

119.2.0.3 🎯 自我檢枬 12 題

  1. 兄匟姐効 HLA-identical 機率 → 25%
  2. HLA matching 甚哪些 loci → HLA-A, B, C, DRB1 (8/8)
  3. Plerixafor 機制 → CXCR4 antagonist for stem cell mobilization
  4. PTCy day? → +3 + +4 post-infusion
  5. aGVHD 䞉倧暙靶噚官 → 皮膚 + GI + 肝
  6. cGVHD 與哪 graft source 范盞關 → PBSC
  7. Steroid-refractory aGVHD 22E? → Ruxolitinib (REACH-2)
  8. Steroid-refractory cGVHD 22E approved 䞉藥 → Ibrutinib + Ruxolitinib + Belumosudil
  9. SOS 治療 → Defibrotide
  10. CMV prophy 22E? → Letermovir × 100 day
  11. Live vaccine timing post-allo? → 2 yr 埌 + off immunosuppression
  12. 取代郚分 HSCT for SCD/thalassemia 22E? → Exa-cel (CRISPR)

119.2.0.4 🩺 PGY OSCE 堎景

119.2.0.4.1 Scenario 135 æ­² AML CR1 with intermediate cytogenetics
  • 評䌰 HSCT eligibility
  • HLA typing 病人 + 党兄匟姐効25% chance match
  • 若 matched sibling: MA conditioning + tacrolimus/MTX + PTCy
  • 若無 sibling: NMDP search → MUD 8/8 ± haplo + PTCy 同步 listing
  • Conditioning chemo + supportive care + isolation + neutropenic precautions
  • Pre-conditioning fertility preservation 諮詢
  • 衛教 GVHD 譊蚊 + infection 預防
119.2.0.4.2 Scenario 2post-allo-SCT day 30 maculopapular rash + 嚎重 diarrhea + bilirubin 高
  • 鑑別 aGVHD vs CMV vs drug
  • 切片皮膚 / 內芖鏡確認
  • 確蚺 → grade III aGVHD → Methylprednisolone 1-2 mg/kg/d
  • 䞍應 → Ruxolitinib + 䜏院 + ICU 評䌰
  • 同時 broad-spectrum abx + monitor for infection
119.2.0.4.3 Scenario 3解釋 HSCT 絊家屬
  • 流皋HLA typing → conditioning chemo (5-10 day) → infusion → engraftment 2-3 wk → 100 day intensive monitoring → 1-2 yr 完敎 immune recovery
  • 颚險GVHD (30-50% acute), infection, organ toxicity, secondary cancer, infertility (倚)
  • Curative chance + 預埌䟝疟病
  • Long-term follow-up 終生

⚠ AI 草皿。