ࣈෂ˟ԠԈ֥ᢿ˟৫᥵ᨼᇹᲭ‫ׅ‬ԠԈ֥ᢿ˟ၐ̊౨᚛˟
ᇹᲯ‫ׅ‬Ꮝƕǜᄂᆮ˟․•‣ ࠰

உ․‥ଐ≋⁥⁓⁦ ≌৯‫ؙ‬ઃ

ᇹᲭ‫ׅ‬ԠԈ֥ᢿ˟ၐ̊౨᚛˟
ౠশ‫୴૸؞‬ਧ੕়୰੹ళลஓ৔ఐ৖শ‫ؙ‬గ௿༟಻੔ে





Ჴ
Ჴ


ْ‫ٓ؟ٕ؟‬ॽ঎ঝঐঈ਺ଖ॑ీਃप৅ඪखञൖ૾Ꮳਃચᕓਤඪभ  ୻প࿩ಧો୰੹৔ఐ
ি੨ౘপ‫ؚ‬௼ਣ࿓௶‫ؚ‬৛ম፮‫ؚ‬౱িᅔয‫ؚ‬੎িຶ੦‫ؚ‬஌মઌ૓৕

෗෿ᇯषभী৲॑થघॊபਙ๢Ⴭরຜᇯभ  ୻ഌ੘೉࿚ভ୰੹ళลஓ৔ఐ  ‫ؚ‬৊ళลஓਗఐ  ‫ؚ‬৊৔ఐ ೫ઢတ  ‫ؚ‬೔িඤ౓  ‫ؚ‬঱ি঳຤  ‫ؚ‬೔৔ઌဣ  ‫ؚ‬ഝ৙ೢ౴  ‫ؚ‬೔মඤ೗  ‫ؚ‬਴িഺ৥  ‫ؚ‬ির෥౴  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬ฝਉข  ‫ؚ‬೔িዹ঳ ૶சऩૡష॑⍻ढञ ([RQ6, ૗౮഻ਙཡቅभ  ୻র৖೉࿚ভ୰੹ਗఐ  ‫ؚ‬৊ଣೝ଍ఐ ఖম๒ೣ  ‫ؚ‬ি੨௏  ‫ؚ‬௖ઠྲ෦  ‫ؚ‬౱ਉ೨঳  ‫఻ؚ‬ಂමஇ঳  ቅঢ়৴ිჍ༇॑ಡ৅खञপ಍ཝઋ৽৔ীᆌ಍ཝཡቅभ঳୻
ਮ೎৘য়୰੹ళลஓ৔ఐ  ‫ؚ‬ਮ೎৘য়୰੹ᇯᯂ৔ఐ ൈেბ৕  ‫ؚ‬૝মႿಂ  ‫ؚ‬৵ਣਮื  ‫ؚ‬ળඤ৕  ‫ؚ‬஬ੇಋઅ  ‫ৣૈؚ‬อ಻  ‫ؚ‬শદਆಜ঳  ‫ૣؚ‬ળਫ೗ ౠশ‫؞‬ழஏ೉࿚ভ੕়୰੹৔ఐ৖শ‫ؙ‬ᅷেბฆ੔ে

ْ‫ٓ؟ٕ؟‬০ఛप৽ୡऔोञ੎ඪॖথইঝग़থ२क़ॖঝ५ཡ༇भ੸ඪ୻
૸୴ਧ੕়୰੹৔ఐ  ‫ؚ‬৊ళลஓ৔ఐ టઢጩ  ‫ؚ‬గ௿༟಻  ‫ؚ‬૝ম೦঳ ଂਚ๊࿵ৣ๢ᒷྰু୒॑ষढञ &23' ়ಡ୔੘ਙਞ๢भ  ୻ეવཨಠ੕়୰੹ళลஓਗఐ
஥੩ඤ୬‫ؚ‬૝মઉ຤‫ؚ‬᫖੨ઉ຤

ૌสਙཡ༇भ  ඪ୻‫ص‬ક೜୭୆भ੎ਏਙ
૸୴ਧ੕়୰੹৔ఐ  ‫ؚ‬৊ళลஓ৔ఐ পકစఘ  ‫ؚ‬టઢጩ  ‫ؚ‬గ௿༟಻  ‫ؚ‬૝ম೦঳ ᇹ  ‫ׅ‬ԠԈ֥ᢿ˟ၐ̊౨᚛˟ ȟȋȬǯȁȣȸ 
৑ସਙཡ༇भঐॿ४ওথॺ‫ع‬൧૵भ୔खऔधजभ੘௜‫ع‬൥పഌ੘೉࿚ভ୰੹‫ؙ‬ళลஓ৔ఐ ৖শ‫ؙ‬೔িඤ౓

ᇹᲯ‫ׅ‬Ꮝƕǜᄂᆮ˟ Ჴ

Lung cancer seminar for EGFR-TKI
ౠশഌ੘೉࿚ভ୰੹ళลஓ৔ఐ ৖শ೔িඤ౓੔ে

঳ಹ൥౰ ॔ই॓ॳॽঈभથ஍ਙ॑ણऊघञीभঐॿ४ওথॺ
౰঻ೣਮপ৾ୢ৾৖৔ఐ৾൥ౠ‫ؙ‬ᇯᯂ৔ఐ৾৖୅൥పલি೗௟ ੔েౠশਮ೎৘য়୰੹੕শૣળਫ೗੔ে

્શ൥౰ ਤষ਋ཡቅभఇ੟௜১
౰঻਎੃ਿয়ୢఐপ৾প৾੹ୢ৾ଢ଼஢ఐళลஓ৔ఐ৾൥ౠઇ౸ৈ৛ข঳ ੔ে



1ॽ঎ঝঐঈ਺ଖ॑ీਃप৅ඪखञൖ૾Ꮳਃચᕓਤඪभ  ୻প࿩ಧો୰੹৔ఐ
ি੨ౘপ‫ؚ‬௼ਣ࿓௶‫ؚ‬৛ম፮‫ؚ‬౱িᅔয‫ؚ‬੎িຶ੦‫ؚ‬஌মઌ૓৕

ඪ‫୻ؙ‬

‪ബ⅚
ဏࣱ

ਠ୰ഄ
… ബ଺↚᏿ၘ⅚᭗ ‵‷″ ᘉၐ⇁‫ڎ‬ೞ↚߼Ꮝၶ⅚иᏴ᠃ᆆ⅚ᐃᢿ∐∙⇷ራ᠃ᆆ↗ᚮૺↄ↻⅚߼ɥᓶЏᨊ↚↕ᐄၶ↗ᄩ‫ܭ‬ᚮૺ⇁ࢽ↎⅛ˌࢸ⅚∀∇⇮−⇓⇡⇯≎⇿⇶⇝⇠∄⇼⅚⇯⇡⇥⇓⇡∑⅚⇘∆⇝⇥⇹∙⅚⁅‟‣ ↝৲ɨ⇁Ӗↀ↕ⅼ↎⅛⁅ ‟‣ ↝৲ɨ↖јௐⅻࢽ↸↻↕ⅳ↎ⅻ⅚․•‣ ࠰‣உ↚⇱∂∑∄⇼‒‚ ⁀ ※⁈‛‒ⅻ᩼‫ݱ‬ኬᏘၶ↚‫↺ↈݣ‬ᢘࣖⅻᡙьↄ↻↎ↂ↗⇁ⅼ→ⅺↀ↚ஜʴ↝ࢍⅳࠎஓ↖ ⁀ ※ ⁈ ↚‫ ․ ⇁ ⁈ ※ ⁀⅛↎ↆ୼٭‬ᡵ ᧓ ᨠ↖
৲ɨↆ‧ ‫ׅ‬Ⴘ↝৲ɨЭ੔ᘉ↖⁆ ⁅›˯ɦ⅚‸ ⁆ ‥„‒‸ ⁆…ɥଞ⇁ᛐ↰↎⅛ᐯᙾၐཞ↞↙ⅺ→↎ⅻ⅚⁀ ※ ⁈↚↷↺
ဍཞᐄೞᏡʨᡶၐ↝ӳ́↗ᚮૺↆӷଐⅺ↸∇∑⇑⇤∞∑‒‚‿‿ ※ ‒‛‣• ⁙ ↝৲ɨ⇁᧏‫⅛↎ↆڼ‬ಏ෫৽ૌ‿ ‿ ※ ৲ɨ᧏‫↞ … ⁆ ‸‒„‥ ⁆ ‸↱ࢸڼ‬᭗͌↖ኺᢅↆ↎⅛‫ׅ‫‬Ⴘ↝⁀ ※ ⁈৲ɨЭ↝੔ᘉ↖ ″⁅⁆„‒″‾⁆„‒″‾⁂ ↝ɥଞ⇁ᛐ↰↎⅛⁀※⁈„‒‿ ‿ ※ ↝ⅳ↉↻↱Ꮑᨦ ܹ⇁ஹↈӧᏡࣱⅻⅱ→↎ⅻ⅚‵ ‷ ″ ↞˯ɦͼӼ↖ⅱ↹⁀ ※ ⁈↝јௐⅻⅱ↺↗Йૺↆ ⁀ ※ ⁈ ⇁৲ɨዒዓↆ⅚‿ ‿ ※ ⇁⇽∓⇺∑⇧⇐⇌∏⇝∑‒‚ ⁂ ⁆⁇ ‒‛‣‧• ⁙ ↚‫٭↚ ⁇ ⁆ ⁂⅛↎ↆ୼٭‬୼ࢸ⅚Ꮑᨦܹ↞ોծↆ↎↎↰⅚⁀ ※ ⁈↝৲ɨ⇁ዒዓↆ↕ⅳ↺⅛

અ‫ؙ‬௄⁀ ※ ⁈↚↷↺ဍཞᐄೞᏡʨᡶၐ↝‫إ‬ԓ↞•† ‪ ≉↖ⅱ↺⅛‫ٶ‬ⅾ↞ࢸ↚ဍཞᐄೞᏡ˯ɦၐ↚ᆆᘍↈ↺ኺᢅ
ⅻ‫إ‬ԓↄ↻↕ⅳ↺ⅻ⅚ஜ̊↞‣․ ‫ׅ‬৲ɨ଺ໜ↖↱ဍཞᐄೞᏡʨᡶၐ↝ཞ७ⅻዓⅳ↕ⅳ↺⅛‿ ‿ ※ ↞Ꮑᨦܹ↙↘↝и˺ဇ⇁ஹↈᕤд↖ⅱ↹⁀ ※ ⁈↝и˺ဇ↗ᦷКⅻ࣏ᙲ↚↙↺⅛ဍཞᐄೞᏡᨦܹ↧↝‫ࣖݣ‬↚ችᡫↈ↺ↂ↗↞⅚⁀ ※ ⁈⇁ዒዓↆ৴ᏽၨјௐ⇁෇ⅺↆ↕ⅳⅾɥ↖᣻ᙲ↗࣬↾↻↺⅛

੥‫ؙ‬૛
⁀ ※ ⁈৲ɨ⇁‫ڎ‬ೞ↚ဍཞᐄೞᏡʨᡶၐ⇁ႆၐↆ↎ၐ̊⇁ኺ᬴ↆ↎⅛

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෗෿ᇯषभী৲॑થघॊபਙ๢Ⴭরຜᇯभ  ୻ഌ੘೉࿚ভ୰੹ళลஓ৔ఐ  ‫ؚ‬৊ళลஓਗఐ  ‫ؚ‬৊৔ఐ ೫ઢ‫ؙ‬တ  ‫ؚ‬೔িඤ౓ ‫ؚ‬঱ি঳຤  ‫ؚ‬೔৔ઌဣ  ‫ؚ‬ഝ৙ೢ౴  ‫ؚ‬೔মඤ೗
਴িഺ৥  ‫ؚ‬ির෥౴  ‫≥ؚ‬ઢ๬಻  ‫ؚ‬ฝਉ‫ؙ‬ข  ‫ؚ‬೔িዹ঳ ඪ‫୻ؙ‬ၐ̊↞ ‫‫‬ബ⅚ဏࣱ⅚ᚐ˳ಅ⅚‣‪⊡․•ബ↭↖‥•ஜ‡ଐ↝տ໺ഭ⅛
⁊ ࠰…உⅺ↸↝߼ͨᏟᢿၘ↖Ӗᚮ⅚Ꮯᢿ ‵⁆⅚‿⁄※↖Ꮯᐏᏽၨⅻွ↾↻⅚⇎⇙∞⇒⇊⇯ɦဃ౨⇁଀ᘍↈ↺↱ᄩ‫ܭ‬ᚮૺⅻ↓ⅺ↙ⅺ→↎ⅻ⅚ᭌ⇝∙⇧⇖∏⇻⇉∞↖߼Ꮯᏸϋ↚࠼ⅻ↺ჽ໋҄⇁ˤⅵᏟᐏᏄҽ↚ɟᐲↆ↎ီࠝᨼᆢ⇁ᛐ↰⅚෇ѣࣱⅻᅆՐↄ↻↎⅛↌↝↎↰⅚ᭌ↧↝Ў҄ͼӼ⇁ԑↈ↺फࣱᏟᐏɶႝᏽ↱᪽ࣞ↚⅚μ៲౨ኧ↖ЏᨊӧᏡࣱ⇁౨᚛⅚※‿※ ‹Ў᫏⁆‥⁀•‿•‒⁥⁦⁓⁙⁗※※※↗ᚮૺ⅚⁊ ࠰ உ ‣‥ଐ↚ԠԈ֥‫ٳ‬ᅹ↖ᏟᐏᏍμઇᘐ‒‚μ࣎ᐏ∝߼್ᨠᐏӳ́Џᨊ⅚߼ᇹ
…∝‧∝ Ꮊᭌӳ́Џᨊ ‛‒⇁଀ᘍↆ↎⅛Ꮉაႎ↚‫ܦ‬μЏᨊ↖ⅱ→↎ⅻ⅚ኵጢᚮૺ↖ⅤᭌᎹᏽ↧↝Ў҄ͼӼ⇁ஊↈ↺फࣱᏟᐏɶႝᏽ Ⅵ↗ᄩ‫↎ↆܭ‬↎↰⅚ᘐࢸ ᡵ↖⇝⇟⇽∏⇧∙‒‚ ‧ ⁙‡≂ ‛‒”‒∀∇⇮−⇓⇡⇯‒‚‧•• ⁙‡≂ ‛‒↚↷↺ᘐࢸᙀя҄‫ܖ‬ၲඥ⇁‥⇛⇊⇕∑଀ᘍࢸ⅚⁊ ࠰‣‣உ․…ଐⅺ↸્‫ݧ‬ዴၲඥ‒‚※‿⁄⁆≝‧•†…‹⁫‛‒⇁ᡙьↆ↎⅛
⁊”‣࠰ ‪உ‣‣ଐ↝‵⁆↖ᐃᏸϋ↚ჽ໋҄⇁ˤⅵᏽၭⅻ‫ٶ‬ႆ⅚ӫᏍ⅚Ꮯᐏ∝ᐃᐏ↝ჽ໋҄⅚Ꮯᐃ൦ⅻЈྵↆ↕ϐႆ⅚ᘐࢸ ‣…∜உ↖൨჈ↆ↎⅛फࣱᏟᐏɶႝᏽ↞ɥႝ‫⅚׹‬Ꮉᏽ‫⅚׹‬ዴዜ࢟঺‫⅚׹‬ʚႻࣱ↚Ў᫏ↄ↻⅚Ꮉᏽ‫⇁׹‬ԃ↯‫ئ‬ӳ↞҄‫ܖ‬ၲඥⅻਖ਼
‫↺↻ↄڜ‬ⅻ⅚↌↝јௐ↞ᨂ‫ܭ‬ႎ↖ⅱ↺⅛ɶ↖↱ᭌᎹᏽ↧↝Ў҄⇁ᛐ↰↺ၐ̊↝‫إ‬ԓ↞‫↙ݲ‬ⅾ⅚Иႆ଺⅚ϐႆ଺↗↱↚‵⁆↖ჽ໋҄၏ߺⅻ၏Ѭ⇁ᅆↈᆇ↙ၐ̊↖ⅱ→↎⅛

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૶சऩૡష॑⍻ढञ([RQ6, ૗౮഻ਙཡቅभ୻
র৖೉࿚ভ୰੹ਗఐ  ৊ଣೝ଍ఐ ఖম๒ೣ  ‫ؚ‬ি੨௏  ‫ؚ‬௖ઠྲ෦  ‫ؚ‬౱ਉ೨঳  ‫఻ؚ‬ಂමஇ঳ ඪ‫୻ؙ‬… ബ↝տ໺ဏࣱ⅛․ ᡵ᧓Эⅺ↸ႆ༏↗฻ࣱԶ֏ⅻਤዓ⅛‵⁆↖ӫᏍɦᓶ↚߾‫ٻ‬ᏽၭ ⅚μᏍᓶ↚૝‫↺ↈנ‬ኽራⅹ↷↢ɲͨᏟ൦∝ֳ࣎෩ᝪသ⅚‫ͨݣ‬ጏᨠ∐∙⇷ራᏽ‫⇁ٻ‬ᛐ↰⅚ӫɦᓶᏍၶ ⁕⁆‥⁀‥‿‣⁓„‒⁅⁦⁓⁙⁗‒※⁈↗ᚮૺ⅛
ӫɥᓶᏑ᩿ͨ↚↾↉ⅺ↙᩼ғ؏ࣱ⇟∐⇒∏⇟ཞᨏࢨ⇁ᛐ↰↎⅛৴ᓏᕤ඙ၲ⇁έᘍↆɟ଺᠉ࣛↆ↎ⅻↈ
ⅿ↚ၐཞ‫ف‬फↆ↎⅛ဃ౨↚↕ᐄၶ↭↎↞৒࠯ɥႝၶ↝ᚮૺ↗↙→↎ⅻ⅚ज़௨Сࣂசᢋ↖ⅱ↺↗ЙૺↆൈኬᏘࣱ৴ၶд↞ᢤↀ⅚‷‹‸⁄‫ီ٭‬சᄩ‫↖ܭ‬ⅱ↺ⅻλᨈ ଐႸ↷↹⇎∑∓⇧⇱⇼⇁᧏‫⅛ڼ‬፻ଐ↚ԠԈཞ७फ҄∝⇟∐⇒∏⇟ᨏࢨ↝‫⇁ࢍف‬ᛐ↰ֳ࣎⇯−⇰∞⇞↖ɟ଺ႎ↚‫ࡍݱ‬ཞ७⇁ࢽ↎⅛ↆⅺↆӷ ‥•ଐႸ↚ԠԈཞ७फ҄ↆ⅚᧓ឋࣱᏍ໒ࣱ࣯‫ف‬फ↗ↆ↕⇟⇬∓⇊⇯⇷∑⇟‒‚ ⁂⁅‾‒‣••• ⁙‡⁖⁓⁫‛‒⇁ᘍ→↎ⅻ⅚
ӷ‥‪ଐႸ↚൨჈ↆ↎⅛രʧЭଐ↚‷‹‸⁄ᢡˡ‫↞ီ٭܇‬ࣱᨗ‒‚‷⁪⁡⁠․•‒⁅ ‪※‛‒ⅻЙଢↆ↎⅛
⅙‷⁪⁡⁠․•‒⁅ ‪※ ‫ီ٭‬Ꮝၶ↞‷‹‸⁄‟⁆‽※↚‫↺ↈݣ‬Ӓࣱࣖⅻൔ᠋ႎ↷ⅳ↗ⅳⅵ‫إ‬ԓⅻ‫ٶ‬ⅳ⅛
ஜၐ̊඙ၲɶ⅚Ⅎज़௨Сࣂசᢋཞ७↖↝ൈኬᏘࣱ৴ၶд̅ဇ↞ᅠ࣐≢⅚ℳ᧓ឋࣱᏍ໒ӳ́ⅻွ↾↻↕↱‷‹‸⁄‟⁆‽※ ↞ᚩܾↄ↻↺≢⅚ℴֳ࣎⇯−⇰∞⇞⇁ᘍⅵ⇥⇊∅∙⇖↞≢⅚ℵ‷‹‸⁄‫ီ٭‬சᄩᚮ↖↱‣⁥⁦‒‾⁛⁠⁗ ↖
⇎∑∓⇧⇱⇼↞ᚩܾↄ↻↺≢⅚ℶᐄၶ↗৒࠯ɥႝၶ↝ᦷКⅻ‫׉‬ᩊ↙சЎ҄↙ၐ̊↖↞⇿⇶⇝⇠∄⇼↞ᅠ࣐≢⅚ⅻွբ↖ⅱ→↎⅛

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ቅঢ়৴ිჍ༇॑ಡ৅खञপ಍ཝઋ৽৔ীᆌ಍ཝཡቅभ঳୻

ඪ‫୻ؙ‬

ਮ೎৘য়୰੹ళลஓ৔ఐ ‫ؙ‬ਮ೎৘য়୰੹ᇯᯂ৔ఐ ൈেბ৕  ‫ؚ‬૝মႿಂ  ‫ؚ‬৵ਣਮื  ‫ؚ‬ળඤ৕ ஬ੇಋઅ  ‫ৣૈؚ‬อ಻  ‫ؚ‬শદਆಜ঳  ‫ૣؚ‬ળਫ೗ ‥ബ⅚‫⅛ࣱڡ‬࣯ນ↙ᙻщ˯ɦ↗ᙻ᣼ᨦܹ⇁ᚫⅷ⅚ࠊϋዮӳ၏ᨈაᅹ↚ኰʼↄ↻↎ ⅛ᙻщ౨௹↖↞ӫ •†‥ ߼ •†•‪⅚ა‫ ↞ן‬⁄⁦†‒‣›⁙⅚‾⁦†‒‣‧›⁙⅛⇚≐∑⇯∄∙ᙻ᣼౨௹↖↞ɲͨ↗↱൭ࣱ࣎ᙻ᣼཰ᆵ⇁ԑↆ⅚ଢ଼ໜ↞ⅱ↺↱↝↝ᖩήაࡁᡯࢨ↖ዡᐏီࠝ↞↙ⅺ→↎⅛Ꮿ‿⁄ ※↖↞ီࠝ↞ᛐ↰↉⅚ዡᐏᩓ‫↞↖׋‬ɲͨ↝ዡᐏᩓˮ↝ᓸↆⅳ˯ɦ↗ਰࠢ↝ถ‫⇁ݲ‬ᛐ↰↎↎↰फࣱᏽၨ᨟ˤዡᐏၐ⇁ွⅳ࢘ᨈ↚ች௹̔᫂↗↙→↎⅛Ꮯᢿ ‵ ⁆ ౨௹↚ⅹⅳ↕߼ɦᓶ ⁅‣• ᪸؏↚ᡀጂЎᓶཞ↝Ⴚࢲ․•↝ᏽၭࢨ⇁ᛐ↰↎⅛⁂‷ ⁆‡‵⁆↖↞

߼ɦᓶኽራ↚⁅⁇⁈‣‣† ↝ᨼᆢ⇁ᛐ↰↺˂⅚
߼Ꮝᧉ∐∙⇷ራ↚‣‪†…⅚߼᫢ᢊͯ∐∙⇷ራ↚ †…↝ᨼᆢ⇁ᛐ↰ҾႆࣱᏍၶ⇁ࢍⅾွ↾↻↎⅛ኺൢሥૅᏍဃ౨↳ ‵ ⁆⇒⇊⇯ɦᏍဃ౨↖↞ᄩ‫ܭ‬ᚮૺ⇁ࢽ↸↻↉⅚ᏟᏸᦟɦᏍᢿЎЏᨊᘐ⇁଀ᘍↆ↎⅛၏ྸ౨௹ኽௐ↖↞⅚ฆӳ‫׹‬ᅕኺϋЎඣ‫ٻ‬ኬᏘၶ↗ᚮૺↄ↻↎⅛ᚮૺࢸ↞Ꮝ‫ݱ‬ኬᏘၶ↚แↇ↎҄‫ݧ્ܖ‬ዴ඙ၲ⇁᧏‫נྵ⅚ↆڼ‬ьၲɶ↖ⅱ↺⅛Ҿ‫׆‬ɧଢ↝ᡶᘍࣱᙻщᨦܹ⇁ᛐ↰↎‫ئ‬ӳ↚↞⅚फࣱᏽၨ↝‫ࣞ⇁נ܍‬᪽↚ⅳ↻μ៲ች௹⇁ᘍⅵ↨ⅼ↖ⅱ↺⅛

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5

০ఛप৽ୡऔोञ੎ඪॖথইঝग़থ२क़ॖঝ५ཡ༇भ੸ඪ୻

ඪ‫୻ؙ‬૸୴ਧ੕়୰੹৔ఐ  ‫ؙ‬৊ ళลஓ৔ఐ టઢጩ  ‫ؚ‬గ௿༟಻  ‫ؚ‬૝ম೦঳ ‥‥ബ⅚ဏࣱ⅛ɼᚫ≝ႆ༏⅚ԠԈ‫׉‬ᩊ⅛ਠ୰ഄЭ࠰↚⇊∙⇻∑⇎∙⇜∕⇕⇧∙੗ᆔⅱ↹⅛λᨈ ․ଐЭ↷↹ႆ༏⅚μ៲͎࣭ज़ⅻЈྵ⅚፻ଐ↚ᡈҔ↖⇊∙⇻∑⇎∙⇜″↗ᚮૺↄ↻∏⇱⇰⇹∑↝Ԉλ⇁Ӗↀ↎⅛
ႆ༏⅚
ԠԈ‫׉‬ᩊⅻዓⅼᏟᢿ ⁊ ዴ↖Ꮝ໒↗ᚮૺↄ↻λᨈ⅛᣻ࡇ↝ԠԈɧμ↖Ꮯᢿ ⁊ ዴ∝‵ ⁆↖↞ɲͨ࠼ር↚ේ๾ࢨ⇁ᛐ↰↎⅛Ҿႆࣱ⇊∙⇻∑⇎∙⇜⇌⇊∑⇟Ꮝ໒↗
ᚮૺↆʴ߻ԠԈሥྸ↗ↆ↎⅛⇟⇬∓⇊⇯⇷∑⇟ၲඥ↚∀∏∅⇹∑ •• ⁙⅚․ଐ᧓ᘍⅳԠԈཞ७ⅻોծ⅚ᇹ ‧၏ଐ↚↞ʴ߻ԠԈ֥↷↹ᩉᏮↆᇹ ‣‣ ၏ଐ↚᠉ࣛᡚᨈ↗↙→↎⅛⇊∙⇻∑⇎∙⇜›‣⁀‣৴˳↞ ․•℉ …•↗
ɥଞⅻᛐ↰↸↻↎ ⅛ඪ‫୻ؙ‬‧… ബ⅚‫∙⇧⇕∕⅚ࣱڡ‬ச੗ ᆔ⅛ɼᚫ≝ႆ༏⅚↊⇂‫⅛ ڨ‬ਠ୰ഄλᨈ‧ଐЭ↷↹ႆ༏ⅻⅱ↺↱્ፗ⅛λᨈЭଐⅺ↸↊⇂‫ڨ‬ⅻЈྵↆ૔࣯੿ᡛ⅛Ꮯᢿ⁊ዴ∝‵⁆ ↖ɲͨ↝ේ๾ࢨ⇁ᛐ↰↎⅛Ꮿ ‵ ⁆⅚᭒෩↚↞ီࠝ⇁ᛐ↰↙ⅺ→↎ⅻ⇊∙⇻∑⇎∙⇜″ࣱᨗ↖⇊∙⇻∑⇎∙⇜Ꮿၐ≎Ꮝ໒↗
ᚮૺↄ↻↎⅛ʴ߻ԠԈሥྸ↗ↆ⇟⇬∓⇊⇯⇷∑⇟ၲඥ↚∀∏∅⇹∑ •• ⁙⅚․ଐ᧓↝඙ၲ⇁ᘍⅳԠԈཞ७↞ોծↆ↎⅛ↆⅺↆॖᜤᨦܹ↞ᢟࡨↆࣱ࣯Ᏼɧμ↱ӳ́ↆᡢௌ⇁‫ݰ‬λↆ↎⅛↌↝ࢸ↱ॖᜤ↞ોծ↊↉
இኳႎ↚↞‫ބ‬ែज़௨ⅺ↸૗ᘉၐ↗↙↹ᇹ ‥‣ ၏ଐ↚രʧↄ↻↎⅛၏ྸᚐа↖↞ᓸଢ↙Ꮿූᏽⅻⅱ↹⇊∙⇻∑⇎∙⇜Ꮿၐⅻွ↾↻౨ኧɶ↖ⅱ↺⅛અ‫ؙ‬੧‫ܓ‬ራࣱ⇊∙⇻∑⇎∙⇜↞↭↻↚Ꮝ໒↳Ꮿၐ↙↘᣻ሶ↙ӳ́ၐԑↈ↺ↂ↗ⅻჷ↸↻↕ⅳ↺⅛Ҿ‫↞׆‬ज़௨ࢸ↚ႆဃↈ↺̾˳↝β၃Ӓࣖ↚↷↺⇛⇊⇮⇑⇊∙⇟⇮∞∆ⅻे‫↕↻ↄܭ‬ⅳ↺⅛඙ၲ↚↞ଔ஖↝৴⇊∙⇻∑⇎∙⇜ᕤ↝җЎ᣽↝৲ɨ↗↗↱↚⇟⇬∓⇊⇯⇷∑⇟ၲඥ↝ஊјࣱⅻ‫إ‬ԓↄ↻↕ⅳ↺⅛ʻ‫⅚ׅ‬Ꮝ໒⇁ԑↆ↎ʚၐ̊⇁ኺ᬴ↆⅳ↉↻↱ԠԈཞ७↝ોծⅻᛐ↰↸↻↎⅛ↆⅺↆ඙ၲⅻ᡿↻↎ɟ̊↞Ꮿၐ↖ɧ࠳↙
᠃ೞ⇁↗→↕ⅹ↹ଔ஖↝ᚮૺ∝඙ၲ↝᣻ᙲࣱⅻᛐᜤↄ↻↎ ⅛

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6

ଂਚ๊࿵ৣ๢ᒷྰু୒॑ষढञ&23'়ಡ୔੘ਙਞ๢भ୻
ეવཨಠ੕়୰੹ళลஓਗఐ
஥੩ඤ୬‫ؚ‬૝মઉ຤‫ؚ‬᫖੨ઉ຤

ඪ‫୻ؙ‬
ၐ̊↞‪ ബဏࣱ⅚‫ܤ‬᩺଺↚ᆳႆႎ↙ԠԈᒊ⇁ᐯᙾↆ↕࢘ᨈ ‷ ⁄ Ӗᚮ⅚Ꮯᢿ−∙⇮⇘∙↚↕ӫᏍൢᏟ⇁ᛐ↰࢘ᅹλᨈ⅛Ꮯᏸ⇯−⇰∞⇞↖ોծ⇁ᛐ↰↉⅛Ꮯᢿ ‵ ⁆ɥɲͨᏍൢᏽ↞ᓸଢ↖ⅱ↹⅚ԠԈᒊ⅚˳ѣ˯ɦ↱↮↸↻↎↎↰⅚λᨈ ․ଐႸ↷↹⇻⇉⇼∐∙ኁ↗⇈∑⇼∅∙ᙌд↚↕ၷბၲඥ⇁ᚘ ‥ ‫ׅ‬ᘍⅵ↱ોծ⇁ᛐ↰↙ⅺ→↎⅛μ៲᰺ᣓ↞ɧӧ↗࣬↾↻⅚
λᨈ ․…ଐႸ↚ᚮૺ∝඙ၲႸႎ↚‫ޅ‬৑᰺ ᣓɦ↚Ꮯᏸᦟ⇁਴λↆ⅚
ᚇ‫↖ݑ‬ⅼ↎⇼∏၏‫ ‹⁂ ↕ↆݣ↚٭‬″⇝∞⇮↗⇻⇉⇼∐∙ኁ↝‫↕↚ࠋر‬Ꮝၱ᧍ᦋ⇁଀ᘍ⅛ᘐࢸ ‣ଐႸ↷↹⇎⇈∐∞⇕↞ෞ‫⅚ڂ‬λᨈ ‥•ଐႸ↚Ꮯᏸ⇯−∞∙৷ӊ↗↙→↎⅛↌↝ࢸ↱ൢᏟϐႆ↞↙ⅾ‫ܡנ‬ᣠእ‫ݰ‬λↆᡚ
ᨈↆ↎⅛

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7
ඪ‫୻ؙ‬ૌสਙཡ༇भ ඪ୻  ક೜୭୆भ੎ਏਙ
૸୴ਧ੕়୰੹৔ఐ  ৊ళลஓ৔ఐ পકစఘ  ‫ؚ‬టઢጩ  ‫ؚ‬గ௿༟಻  ‫ؚ‬૝ম೦঳ ‒ ‫ ‫‬ബ⅚‫⅛ ࣱڡ‬ɼᚫ≝Զ⅚ၝ⅛˰‫≝އ‬ஙᡯ࡫ሰ…•࠰⅛

৽‫ؙ‬ૌ․ ࠰Э⅚‣ ࠰Э↚К↝Ҕၲೞ᧙↖᧓ឋࣱᏍ໒↗ᚮૺↄ↻ьၲ⇁Ӗↀ↎ⅻᐯࠁɶૺ⅛⁊ ࠰ உↂ↼↷↹Զ⅚
ၝⅻⅱ↹‫‫‬உ↚࢘ᨈ‫ٳ‬ஹ⇁ӖᚮↆᏍ໒ွⅳ↖λᨈ⅛Ꮯᢿ ⁊ ዴ↖ɲͨ↝ↈ↹⇒∏⇟ࢨ⅚‵ ⁆ ↖ɟᢿ↚ዴዜࣱ‫⇁∙∞⇥⇷⇕⇊⇜∈↝ࢨ⇟∏⇒∐⇟↗҄٭‬ᛐ↰↎⅛ဒ΂৑ᙸ↗ኺᢅⅺ↸ٰ‫׹‬ᢅ૓ࣱᏍ໒⇁ွⅳ໯඙ၲኺᢅᚇ‫↖ݑ‬ોծↆ↎⅛⁆‴ ‾‴”‴″‾↝৑ᙸ↱ٰ‫׹‬ᢅ૓ࣱᏍ໒↚ӳᐲↆ⅚
৴⇮∐⇙⇟∃∓∙৴˳ࣱᨗ↖ⅱ→↎⅛࠙‫ܡ‬ᚾ᬴ࣱᨗ↖⇟⇬∓⇊⇯඙ၲ↖ኺᢅᚇ‫⅛↎→↙↗ݑ‬ඪ‫୻ؙ‬‥ബ⅚‫⅛ࣱڡ‬ɼᚫ≝Զ⅚ԠԈ‫׉‬ᩊ⅛˰‫ᤧ≝އ‬ᭌ≎ஙᡯሰ‥•࠰⅛৽‫ؙ‬ૌ⁊࠰ உↂ↼ⅺ↸Զⅻⅱ↹і˺଺↝‫׉‬ᩊ↱Јྵↆ‣•உ↚λᨈ⅛Ҿ‫׆‬ɧଢ↝᧓ឋࣱᏍ໒↖ ‴″‾”⁆‴‾‴ ↖ᢅ૓ࣱᏍ໒ⅻⅵ↎ⅻ↾↻↎⅛λᨈࢸ↚ၐཞ↞ોծↆ↎ⅻ৴⇮∐⇙⇟∃∓∙৴˳↞ᨏࣱ↖ⅱ→↎⅛࠙‫ܡ‬ᚾ᬴ࣱᨗ↖᠃‫↹↷↚އ‬ၐཞ↞‫ܦ‬μ↚ෞ‫⅛↎ↆڂ‬ඪ‫୻ؙ‬… ബ⅚ဏࣱ⅛ɼᚫ≝ԠԈ‫׉‬ᩊ⅛˰‫≝އ‬ஙᡯܼ‫ދ‬ሰ…•࠰⅚ࡽⅼↂ↱↹↖⇚∅‫ދ‬૤ཞ७⅛

৽‫ؙ‬ૌ⁊࠰‪உ⅚‣ᡵ᧓Эⅺ↸↝ԠԈ‫׉‬ᩊ↖ዬ࣯λᨈ⅚‵ ⁆↖↞ɲͨ↚ɧᙹЩ↚Ўࠋↈ↺ↈ↹⇒∏⇟ࢨ↖⅚᣻ၐ᧓ឋࣱᏍ໒↗ↆ↕⇟⇬∓⇊⇯≎৴ဃд඙ၲ↖ᡮ↳ⅺ↚ોծↆ↎⅛‫‫‬உ↚ᡚᨈࢸ…ଐႸ↚ၐཞⅻϐႆↆϐλᨈↆ↎⅛⇟⇬∓⇊⇯↖ၐཞોծࢸ↚ᘍ→↎‴″‾”⁆‴‾‴↖↞᠉ࡇ↝᧓ឋࣱᏍ໒↝৑ᙸ↖ⅱ→↎⅛৴⇮∐⇙⇟∃∓∙৴˳↞ᨏࣱ↖ⅱ→↎ⅻኺᢅⅺ↸ᢅ૓ࣱᏍ໒↗ᚮૺↄ↻⇟⇬∓⇊⇯↖ኺᢅᚇ‫ݑ‬ɶ⅛੥‫ୁؙ‬ԠԈ֥ኒ↞տ໺↳ብ‫ٳ↘↙ػ‬ᢿ࿢‫ࢨ↝ؾ‬᪪⇁ࢍⅾӖↀ↺ᐥ֥↖ⅱ↺⅛Ꮀಅഭ↳ឯԛ∝։‫↪↝ڤ‬ⅺ↚˰‫އ‬࿢‫↺ↈݣ↚ؾ‬ᎋॾ↞᣻ᙲ↙բᚮ↝∃⇊∙⇮↗↙↺⅛Ҿ‫׆‬ɧଢ↝᧓ឋࣱᏍ໒↝ᦷК↚↞ࠝ↚ᢅ૓ࣱᏍ໒↝᧙ɨ⇁ᎋⅷ↙ↀ↻↟↙↸↙ⅳ⅛

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ȟȋȬǯȁȣȸᲫ‫ܢ‬඙ࣈෂ˟၏ᨈ
ԠԈ֥ϋᅹ ᢿᧈųᇦဋᨙʂ

㛫㉁ᛶ⫵⅖䛾䝬䝛䝆䝯䞁䝖䡚デ᩿䛾㞴䛧䛥䛸䛭䛾἞⒪䡚㻌
➨3ᅇ࿧྾ჾ㒊఍⑕౛᳨ウ఍ 䝭䝙䝺䜽䝏䝱䞊 (2016.Jul.23)㻌
㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 㻌 Ᏹ἞ᚨὪ఍⑓㝔㻌 ➉⏣ 㝯அ䞉㻌 ⫵䛾ゎ๗㻌 䞉Ẽ⟶ᨭᶞ

䞉⫵䛾ゎ๗䛸⏬ീ䛾ぢ䛛䛯(HRCT䛻䛚䛡䜛⪃䛘᪉)
䞉 䜃䜎䜣ᛶ⫵⑌ᝈ䛸≉Ⓨᛶ㛫㉁ᛶ⫵⅖ (IIP)
䞉≉Ⓨᛶ⫵⥺⥔⑕䛾デ᩿䛸㚷ู(IIP䛾⏬ീ䞉⭺ཎ⑓⫵)䞉≉Ⓨᛶ⫵⥺⥔⑕䛾⮬↛ྐ䞉Ṛᅉ䞉ホ౯㡯┠(ᣦᶆ)
䞉≉Ⓨᛶ⫵⥺⥔⑕䛾ᛴᛶቑᝏ䛻䛴䛔䛶䞉≉Ⓨᛶ⫵⥺⥔⑕䛾἞⒪
䞉⥺⥔໬䛾䝯䜹䝙䝈䝮䛸ᢠ⥺⥔໬⸆(Nintedanib / Pirfenidone)
䞉Nintedanib䜢ᑟධ䛧䛯⑕౛ᥦ♧ (2౛/15౛)

䞉㻌 ⫵䛾ゎ๗㻌  ( ஧ḟᑠⴥ䝺䝧䝹䛾ゎ๗䠖HRCT )䞉㻌 ༊ᇦᛶ䛸㠀༊ᇦᛶ( 䜃䜎䜣ᛶ⫵⑌ᝈ䛷䛾⪃䛘᪉ )㛫㉁ᛶ⫵⅖
( ⫵㛛ഃ )( ⫵㛛ഃ )

༊ᇦᛶศᕸ㠀༊ᇦᛶศᕸ

䞉1cm኱䛾⣽ⴥ䛜3~5ಶ㞟䜎䛳䛶䚸஧ḟᑠⴥ䜢ᙧᡂ

Miller䛾஧ḟᑠⴥ 䞉⫵ື⬦䛿ᑠⴥ୰ᚰ㒊䜢 (⤊ᮎ⣽)Ẽ⟶ᨭ䛻క㉮䞉㎶⦕䛻䛿⫵㟼⬦䚸ᑠⴥ㛫㝸ቨ䚸⬚⭷䛜Ꮡᅾ䞉㻌 ⫵䛾ゎ๗㻌  ( ஧ḟᑠⴥ䝺䝧䝹䛾⑓ኚศᕸ )Ẽ⟶ᨭ⫵ື⬦᮰䛾⭘኱ 㻌 㻌 㻌 ỗᑠⴥᛶ⑓ኚ
Ẽ⟶ᨭ⫵ື⬦᮰䛸ᑠⴥ䛸ᑠⴥ୰ᚰᛶศᕸ
(ᑠⴥ䜢ᇙ䜑ᑾ䛟䛩⑓ኚ) ㎶⦕ᵓ㐀䛾୧⪅䛾⭘኱(䛒䜛䛔䛿⤖⠇)
䞉Ẽ⟶ᨭ⫵⅖䞉ᢠ㓟⳦ឤᰁ⑕ (Tb., NTM)
䞉䜃䜎䜣ᛶỗ⣽Ẽ⟶ᨭ⅖
䞉㐣ᩄᛶ⫵⅖䞉⫵⬊ᛶ⫵⅖䞉⫵Ỉ⭘䞉䜃䜎䜣ᛶ⫵⬊ฟ⾑䞉ᾐ₶ᛶ⢓ᾮ⏘⏕ᛶ⭢⒴䞉䝃䝹䝁䜲䝗䞊䝅䝇
䞉⒴ᛶ䝸䞁䝟⟶⑕䞉ᝏᛶ䝸䞁䝟⭘䞉ሻ⫵ (⌛⫵䞉▼⥥⫵)䞉㛫㉁ᛶ⫵Ỉ⭘䞉㻌 ⫵䛾ゎ๗㻌  ( ஧ḟᑠⴥ䝺䝧䝹䛾⑓ኚศᕸ )ᑠⴥᵓ㐀䛸↓㛵ಀ䛻䝷䞁䝎䝮䛺ศᕸ䜢♧䛩ᑠ⤖⠇㻌 㻌 㻌 ⫵ᵓ㐀䛾ᨵኚ㻌 㻌 㻌 㻌 (Ⲩᗫ⫵)

䞉㌿⛣ᛶ⫵⭘⒆ (⾑⾜ᛶ)
䞉⢖⢏⤖᰾䞉ᩋ⾑⑕ᛶ⫵ሰᰦ䞉඲䛶䛾⑌ᝈ䛾⤊ᮎീ䞉(ჾ㉁໬)
䞉(⥺⥔໬)
䞉(Ẽ⟶ᨭᣑᙇ)ȟȋȬǯȁȣȸᲬ䞉㻌 㛫㉁ᛶ⫵⅖䛾HRCTᡤぢ䞉㻌 ⑓ኚ䛾ศᕸᵝᘧ㻌 䞉䛩䜚䜺䝷䝇㝜ᙳ䚸⥙≧ᙳ䚸⥺≧ᙳ䛜୺య䞉㢌ᑿ᪉ྥ䛷䛾ඃ఩ᛶ

䞉㛫㉁ᛶ⫵⅖䛿⫵⬊ቨ䛾⫧ཌ䛜୺య䛷 䚸⫵⬊⭍䛾⑓ኚ䛿ஈ䛧䛟䚸䞉ከ䛟䛾㛫㉁ᛶ⫵⅖䛿ୗ⫵㔝ඃ఩䛻ศᕸ䜢♧䛩(UIP/NSIP)

consolidation䜢࿊䛩䜛䛣䛸䛿ᑡ䛺䛔 (≉Ⓨᛶჾ㉁໬⫵⅖ (COP) 䜢㝖䛟)䞉ᑠⴥ୰ᚰᛶ㝜ᙳ䛿䜎䜜䞉ᶓ᩿㠃䛷䛾ඃ఩ᛶ䞉ከ䛟䛾㛫㉁ᛶ⫵⅖䛿እᒙ(ᮎᲈഃ) ඃ఩䛻ศᕸ䜢♧䛩(UIP/NSIP)䞉⤒Ẽ㐨ᛶ㐍ᒎ䜢♧၀䛩䜛㝜ᙳ䛿䚸៏ᛶ㐣ᩄᛶ⫵⅖௨እ䛷䛿䜎䜜䞉⑓ኚศᕸ䛸⫵༊ᇦ䛾㛵ಀᛶ䞉㻌 䜃䜎䜣ᛶ⫵⑌ᝈ䞉㻌 ≉Ⓨᛶ㛫㉁ᛶ⫵⅖(Idiopathic Interstitial Pneumonia)䞉 ≉Ⓨᛶ⫵⥺⥔⑕ ( idiopathic pulmonary fibrosis : IPF )䞉 㠀≉␗ᛶ㛫㉁ᛶ⫵⅖ ( nonspecific interstitial pneumonia : NSIP )䞉 ≉Ⓨᛶჾ㉁໬⫵⅖ ( cryptogenic organizing pneumonia : COP )䞉 ᛴᛶ㛫㉁ᛶ⫵⅖ ( acute interstitial pneumonia : AIP )䞉 ๤㞳ᛶ㛫㉁ᛶ⫵⅖ ( desquamative interstitial pneumonia : DIP )䞉 ࿧྾⣽Ẽ⟶ᨭ⅖㛵㐃㛫㉁ᛶ⫵⑌ᝈ ( RB-ILD )䞉 ≉Ⓨᛶ䝸䞁䝟⌫ᛶ⫵⅖ ( lymphoid interstitial pneumonia : LIP )᪥ᮏ࿧྾ჾᏛ఍ 䛂≉Ⓨᛶ㛫㉁ᛶ⫵⅖デ᩿䛸἞⒪䛾ᡭᘬ䛝䛃ᨵゞ➨2∧ (2011)䞉㻌 ≉Ⓨᛶ㛫㉁ᛶ⫵⅖(᪂ศ㢮)䞉 ୺せ≉Ⓨᛶ㛫㉁ᛶ⫵⅖ ( major idiopathic interstitial pneumonias )䞉 ៏ᛶ⥺⥔໬ᛶ㛫㉁ᛶ⫵⅖ ( chronic fibrosing interstitial pneumonia )䞉 ≉Ⓨᛶ⫵⥺⥔⑕ ( IPF ) 䞉 㠀≉␗ᛶ㛫㉁ᛶ⫵⅖ ( NSIP )䞉 ᛴᛶ/ளᛴᛶ㛫㉁ᛶ⫵⅖ ( acute / subacute interstitial pneumonia )䞉 ≉Ⓨᛶჾ㉁໬⫵⅖ ( COP ) 䞉 ᛴᛶ㛫㉁ᛶ⫵⅖ ( AIP )䞉 ႚ↮㛵㐃㛫㉁ᛶ⫵⅖ ( smoking-related interstitial pneumonia )䞉 ๤㞳ᛶ㛫㉁ᛶ⫵⅖ ( DIP ) 䞉 ࿧྾⣽Ẽ⟶ᨭ⅖㛵㐃㛫㉁ᛶ⫵⑌ᝈ ( RB-ILD )䞉 ⛥ᑡ≉Ⓨᛶ㛫㉁ᛶ⫵⅖ ( rare IIPs )䞉 ≉Ⓨᛶ䝸䞁䝟⌫ᛶ⫵⅖ ( LIP ) 䞉 PPFE (pleuropulmonary fibroelastosis )䞉 ศ㢮୙⬟ᆺ㛫㉁ᛶ⫵⅖ ( unclassifiable IIPs )䞉㻌 ≉Ⓨᛶ㛫㉁ᛶ⫵⅖䛾㚷ูデ᩿䞉 䛖䛳⾑ᛶᚰ୙඲
䞉 ⫵⅖ ( ␗ᙧ⫵⅖䛺䛹 )䞉 ᪤▱䛾ཎᅉ䛻䜘䜛ᛴᛶ⫵യᐖ䞉 ⭺ཎ⑓䞉⾑⟶⅖䞉䝃䝹䝁䜲䝗䞊䝅䝇䞉䝸䞁䝟⬦⟶➽⭘⑕䞉 㐣ᩄᛶ⫵⅖ ( ៏ᛶ㐣ᩄᛶ⫵⅖ )䞉 䛨䜣⫵䞉 ⸆๣ᛶ⫵⅖䞉ዲ㓟⌫ᛶ⫵⅖
䞉 ⫵⬊⺮ⓑ⑕䞉䝷䞁䝀䝹䝝䞁䝇⣽⬊⤌⧊⌫⑕䞉 䜃䜎䜣ᛶỗ⣽Ẽ⟶ᨭ⅖
䞉 ⒴ᛶ䝸䞁䝟⟶⑕䞉ᾐ₶ᛶ⢓ᾮ⏘⏕ᛶ⭢⒴ȟȋȬǯȁȣȸᲭ䞉㻌 㝜ᙳ䛾ศᕸ䞉ᛶ≧䛻䜘䜛㚷ู䞉㻌 ≉Ⓨᛶ⫵⥺⥔⑕䛾デ᩿
䞉 IPF/UIPデ᩿ᇶ‽ ( ATS-ERS-JRS-ALAT guideline 2011 )䞉 ୖ⫵㔝ඃ఩䠖㻌៏ᛶ㐣ᩄᛶ⫵⅖䞉Langerhans⣽⬊⤌⧊⌫⑕䞉⫵⤖᰾䝃䝹䝁䜲䝗䞊䝅䝇䞉䛨䜣⫵䞉 ୰⫵㔝ඃ఩䠖 䝃䝹䝁䜲䝗䞊䝅䝇䞉⫵Ỉ⭘1) 䛭䛾௚䛾ཎᅉ䛜᫂䜙䛛䛺㛫㉁ᛶ⫵⅖䛾㝖እ䞉 ୗ⫵㔝ඃ఩䠖 ≉Ⓨᛶ⫵⥺⥔⑕䞉㠀≉␗ᛶ㛫㉁ᛶ⫵⅖䞉⭺ཎ⑓⫵▼⥥⫵䞉䜃䜎䜣ᛶỗ⣽Ẽ⟶ᨭ⅖䞉⫵⬊⺮ⓑ⑕

2) HRCT䜎䛯䛿እ⛉ⓗ⫵⏕᳨䛾䛔䛪䜜䛛䛷UIP pattern䛜Ꮡᅾ䚸㻌 䛒䜛䛔䛿HRCT䛸እ⛉ⓗ⫵⏕᳨䛾୧᪉䛷UIP䜢ᨭᣢ䛩䜛ᡤぢ䞉 Ẽ⟶ᨭ⾑⟶᮰䛻ἢ䛖ศᕸ䠖 㠀≉␗ᛶ㛫㉁ᛶ⫵⅖䞉⭺ཎ⑓⫵䞉 ⼖ᙧ㝜ᙳ䠖 䛖䛳⾑ᛶᚰ୙඲䞉⫵Ỉ⭘䞉⫵⬊⺮ⓑ⑕䞉䝙䝳䞊䝰䝅䝇䝏䝇⫵⅖

ĺୖグ䛾2䛴䜢‶䛯䛩䜒䛾䜢IPF/UIP䛸デ᩿䛩䜛䞉 ㏫⼖ᙧ㝜ᙳ䠖 ៏ᛶዲ㓟⌫ᛶ⫵⅖䞉≉Ⓨᛶჾ㉁໬⫵⅖
䞉 ᗈ⩏㛫㉁ (䝸䞁䝟㊰)䠖 ⒴ᛶ䝸䞁䝟⟶⑕䞉䝃䝹䝁䜲䝗䞊䝅䝇䞉䝸䞁䝟ቑṪᛶ⑌ᝈĺCT + ⮫ᗋᡤぢ䛻䜘䜚IPF/UIP䛿デ᩿䛜ྍ⬟䞉 ⢏≧ᙳ䠖 ៏ᛶ㐣ᩄᛶ⫵⅖䞉䝃䝹䝁䜲䝗䞊䝅䝇Am J Respir Crit Care Med. 2011; 183: 788-824

䞉㻌 ≉Ⓨᛶ⫵⥺⥔⑕䛾デ᩿䞉㻌 ≉Ⓨᛶ⫵⥺⥔⑕䛾⏬ീデ᩿(HRCT)

IPF䛾␲䛔䛺䛧䛒䜚

HRCTᡤぢ
UIP patternPossible UIP䝟䝍䞊䞁(௨ୗ䛾3䛴䜢‶䛯䛩)

UIP䝟䝍䞊䞁
(௨ୗ䛾4䛴䜢‶䛯䛩)ཎᅉ䛾᫂䜙䛛䛺㛫㉁ᛶ⫵⅖

possible UIP pattern
inconsistent with UIP patternእ⛉ⓗ⫵⏕᳨

Inconsistent with UIP䝟䝍䞊䞁(௨ୗ䛾7䛴䛾ఱ䜜䛛䛻ヱᙜ)䞉⬚⭷┤ୗ䚸⫵ᗏ㒊ඃ఩䞉⥙≧ᙳ䞉⻏ᕢ⫵ (≌ᘬᛶẼ⟶ᨭᣑᙇ䛾䞉⬚⭷┤ୗ䚸⫵ᗏ㒊ඃ఩䞉ୖ୰⫵㔝ඃ఩䛾ศᕸ䞉⥙≧ᙳ䞉Ẽ⟶ᨭ⾑⟶࿘ᅖ䛻ඃ఩
䞉UIP䛻ྜ⮴䛧䛺䛔ᡤぢ䜢ᣢ䛯䛺䛔 䞉䛩䜚䜺䝷䝇㝜ᙳ䛜ඃ఩㻌㻌㻌㻌㻌㻌
᭷↓䛿ၥ䜟䛺䛔)䞉ከᩘ䛾⤖⠇ᙳ (ୖ୰⫵㔝ඃ఩)
䞉UIP䛻ྜ⮴䛧䛺䛔ᡤぢ䜢ᣢ䛯䛺䛔䞉ᄞ⬊䛜ᩓᅾ
䞉䝰䝄䜲䜽䝟䝍䞊䞁 (air trappingక䛖)䞉Ẽ⟶ᨭ䞉⫵༊ᇦ䞉⫵ⴥ䛻ཬ䜆㻌 consolidation

multidisciplinary
discussion (MDD)

IPF

IPF / not IPFnot IPFAm J Respir Crit Care Med. 2011; 183: 788-824

䞉㻌 Not UIP䝟䝍䞊䞁䛾᭱⤊デ᩿ (㛤⬚⫵⏕᳨)䞉㻌 ⫵⑓ኚ䜢క䛔䜔䛩䛔⭺ཎ⑓Final diagnosis(%)

䞉 㛵⠇䝸䜴䝬䝏 ( rheumatoid arthritis : RA )

IPF

37.7%

䞉 ከⓎᛶ➽⅖/⓶⭵➽⅖ ( polymyositis/dermatomyositis : PM/DM )NSIP
20.8% ⣙40%䛸ከ䛔1) Not UIP䝟䝍䞊䞁䛷䛾᭱ከ䛿IPF䛷䛒䜚䚸䞉 ඲㌟ᛶᙉ⓶⑕/◳໬⑕ ( systemic sclerosis : SSc )

COP

2.8%

䞉 䝅䜵䞊䜾䝺䞁⑕ೃ⩌ ( Sjögren’s syndrome : SS )Unclassifiable13.2%

䞉 ඲㌟ᛶ䜶䝸䝔䝬䝖䞊䝕䝇 ( systemic lupus erythematosus : SLE )2) ⏬ീᡤぢ䛻䜘䜚IPF䛾㝖እ䜢⾜䛖஦䛿ฟ᮶䛺䛔
Chr. HP
14.2%
3) Not UIP䝟䝍䞊䞁䛻䜒ຠᯝ䛜ᮇᚅ䛷䛝䜛⸆๣䜈䛾ᮇᚅ
Others11.3%

IPF : idiopathic pulmonary fibrosis, NSIP : nonspecific interstitial pneumonia,
COP : cryptogenic organizing pneumonia, HP : hypersensitivity pneumonia䞉 ΰྜᛶ⤖ྜ⤌⧊⑓ ( mixed connective tissue disease : MCTD )䞉 ANCA㛵㐃⾑⟶⅖ ( ANCA-associated vasculitis : AAV )ĺ⫵⑓ኚඛ⾜ᆺ⭺ཎ⑓⫵䜒ᛕ㢌䛻⨨䛟ᚲせȟȋȬǯȁȣȸᲮ䞉㻌 ⭺ཎ⑓⫵䛻䛚䛡䜛⏬ീ䛸≉ᚩ䞉㻌 ⭺ཎ⑓䛻䛚䛡䜛⫵⑓ኚ䛾ฟ⌧㒊఩䞉 㠀≉␗ᛶ㛫㉁ᛶ⫵⅖ ( nonspecific interstitial pneumonia : NSIP )䞉 ㏻ᖖᆺ㛫㉁ᛶ⫵⅖ ( usual interstitial pneumonia : UIP )㛫㉁ᛶ⫵⅖ Ẽ㐨⑓ኚ ⬚⭷⑓ኚ ⫵ື⬦⑓ኚ ⫵⬊ฟ⾑
RA

++

++

++

+

-

PM/DM

+++

-

-

+

-

䞉 䜃䜎䜣ᛶ⫵⬊㞀ᐖ ( diffuse alveolar damage : DAD )䞉 䝸䞁䝟⌫ᛶ㛫㉁ᛶ⫵⅖ ( lymphocytic interstitial pneumonia : LIP )

SSc

+++

-

-

+++

-

SS

++

++

+

+

-

ĺ䞉 ྛ䚻䛾⏬ീᡤぢ䛿≉Ⓨᛶ㛫㉁ᛶ⫵⅖䛸༊ู䛿ᅔ㞴䛰䛜䚸NSIP䛷ከ䛔

SLE

+

+

+++

+

++

ĺ䞉 ≉䛻䚸Ẽ⟶ᨭ⾑⟶࿘ᅖ᮰䛻ἢ䛳䛯NSIP䛷䛿✚ᴟⓗ䛻␲䛖

MCTD

++

+

+

++

-

ĺ䞉 ✀䚻䛾䝟䝍䞊䞁䛜ΰᅾ䛩䜛⑕౛䛿⭺ཎ⑓⫵䛷䛒䜛ྍ⬟ᛶ䛜㧗䛔ĺ䞉 ⭺ཎ⑓⫵䛷OP䝟䝍䞊䞁 (䝁䞁䝋䝸䝕䞊䝅䝵䞁) 䜢క䛖ሙྜ䛿ணᚋ୙Ⰻ䞉䞉䞉ᛴ㏿㐍⾜ᛶ䛾࿧྾୙඲䜢࿊䛩䜛amyopathic dermatomyositis (ADM) 䜒ᛕ㢌RA : rheumatoid arthritis, PM : polymyositis, DM : dermatomyositis,
SSc : systemic sclerosis, SS : Sjögren’s syndrome, SLE : systemic lupus erythematosus,
MCTD : mixed connective tissue disease䞉 ჾ㉁໬⫵⅖ ( organizing pneumonia : OP )䞉㻌 ⭺ཎ⑓⫵䛻䛚䛡䜛⤌⧊ᆺ䛾㢖ᗘ
UIP

NSIP

OP

LIP

DAD

RA

+++

++

++

+

+

PM/DM

+

+++

+++

-

++

SSc

+

+++

+

-

+

SS

+

++

-

++

+

SLE

+

++

+

+

++

MCTD

+

++

+

-

-

UIP : usual interstitial pneumonia, NSIP : nonspecific interstitial pneumonia,
OP : organizing pneumonia, LIP : lymphocytic interstitial pneumonia,
DAD : diffuse alveolar damage

Fischer A, du Bois R. Lancet 2012; 380: 689-98

䞉㻌 ࿧྾ჾෆ⛉䛷デ⒪䛩䜛⭺ཎ⑓䞉 ⭺ཎ⑓἞⒪୰䛾⫵⑓ኚ䞉࿧྾ჾྜే⑕䛾⌮ゎ䛜㔜せ䞉㛫㉁ᛶ⫵⅖䛾デ⒪䛷䛿䚸ྛ✀⭺ཎ⑓䛾≉ᚩ䛾⌮ゎ䛜㔜せ䞉≉䛻䚸⫵⑓ኚඛ⾜ᆺ⭺ཎ⑓䛾௒ᚋ䛾ᒎ㛤䜒ὀど䛜ᚲせȺLD-CTD (lung dominant-connective tissue disease), UCTD
(undifferentiated connective tissue disease), AFI-ILD (autoimmune
featured-interstitial lung disease) 䛺䛹䛾ືྥ䛻䜒ὀព䜢ᡶ䛔䚸⭺ཎ⑓ᑓ㛛་䛸䛾䜽䝻䝇䝖䞊䜽䜢⾜䛖஦䛜᪩ᮇデ᩿䞉἞⒪௓ධ䛻㔜せFischer A, du Bois R. Lancet 2012; 380: 689-98

䞉≉Ⓨᛶ⫵⥺⥔⑕䛾⮬↛ྐ(ᛴᛶቑᝏ/៏ᛶ࿧྾୙඲)Intern Med. 34: 388-92, 1995

䞉≉Ⓨᛶ⫵⥺⥔⑕䛾⮬↛ྐ

Am J Respir Crit Care Med. 190: 773-9, 2004ȟȋȬǯȁȣȸᲯ䞉≉Ⓨᛶ⫵⥺⥔⑕䛾Ṛᅉ䞉≉Ⓨᛶ⫵⥺⥔⑕䛾ணᚋつᐃᅉᏊĺ ᛴᛶቑᝏ䞉៏ᛶ࿧྾୙඲䞉⫵⒴䞉䛭䛾௚䞉୙᫂㻌
5%acute exacerbation
20%

chronic respiratory failure
40%lung cancer
others11%

unknown
24%
Am J Respir Crit Care Med. 190: 773-9, 2014䞉≉Ⓨᛶ⫵⥺⥔⑕䛾ᣦᶆ(%FVC䞉6MWD)䞉 ほᐹ㛤ጞ᫬
1) ࿧྾ᅔ㞴䛾⛬ᗘ2) %DLCO䛜40%ᮍ‶3) 6ศ㛫Ṍ⾜ヨ㦂䛷䛾desaturation (SpO2 88%௨ୗ)4) HRCT䛻䛚䛡䜛⻏ᕢ⫵䛾ᗈ䛜䜚5) ⫵㧗⾑ᅽ䜢క䛖䞉 ⤒㐣ほᐹ᫬ (6䞄᭶᫬Ⅼ)1) ࿧྾ᅔ㞴䛾⛬ᗘ䛜ᝏ໬2) FVC䛜10%௨ୖᝏ໬
3) DLCO䛜15%௨ୖᝏ໬
4) HRCT䛻䛚䛡䜛⫵⥺⥔໬䛾ᝏ໬
Am J Respir Crit Care Med. 183: 788-824, 2011䞉≉Ⓨᛶ⫵⥺⥔⑕䛾ᣦᶆ(6M change in %FVC)

ĺ6䞄᭶䛾᫬Ⅼ䛷FVC䛜5-10%䛾marginal䛺పୗ䛜䛒䜛㻌 ሙྜ䜒ணᚋ䛿୙Ⰻ䛷䛒䜚䚸ὀព䜢せ䛩䜛

Eur Respir J. 43: 1421-29, 2014䞉≉Ⓨᛶ⫵⥺⥔⑕ᛴᛶቑᝏ䛸䛿

Am J Respir Crit Care Med. 184: 1382-89, 2011䞉≉Ⓨᛶ⫵⥺⥔⑕ᛴᛶቑᝏ䛸䛿䞉 ⮬ぬ⑕≧䠖࿧྾ᅔ㞴䛾ቑᝏ (㼼တႿ䞉Ⓨ⇕)䞉 ⬚㒊༢⣧X⥺෗┿䞉HRCT䛷᪂つ䛾䛩䜚䜺䝷䝇㝜ᙳ䞉ᾐ₶ᙳ䞉 ື⬦⾑㓟⣲ศᅽ䛾పୗ䜢࿊䛩䜛 (ྠ୍᮲௳ୗ䛷PaO2 10Torr.௨ୖ)䞉 䛣䜜䜙඲䛶䜢1䞄᭶௨ෆ䛾⤒㐣䛷ㄆ䜑䜛
䞉 CRP䞉LDH䜔KL-6䞉SP-A䞉SP-D䛾ୖ᪼䜢క䛖஦䛜ከ䛔䞉 Diffuse type (ணᚋ୙Ⰻ) 䛸Peripheral type (ணᚋⰋዲ) 䛻ศ㢮
Respir Res. 14: 73, 2013ȟȋȬǯȁȣȸᲰ䞉≉Ⓨᛶ⫵⥺⥔⑕䛾἞⒪(GL2011)䞉≉Ⓨᛶ⫵⥺⥔⑕䛾἞⒪(GL2015)

䞉 Strong Yes1) Ᏻ㟼᫬ప㓟⣲⾑⑕䜢ㄆ䜑䜛IPFᝈ⪅䛻ᑐ䛩䜛㛗ᮇ㓟⣲⒪ἲ
2) 㐺ᛂ䛜䛒䜛IPFᝈ⪅䛻ᑐ䛩䜛⫵⛣᳜䞉 Weak Yes1) ᛴᛶቑᝏ᫬䛾䝇䝔䝻䜲䝗἞⒪2) ࿧྾ჾ䝸䝝䝡䝸䝔䞊䝅䝵䞁3) ⫶㣗㐨㏫ὶ䛾἞⒪䞉 Strong No1) 䝇䝔䝻䜲䝗䞉ච␿ᢚไ๣䛾༢⊂἞⒪䚸䜲䞁䝍䞊䝣䜵䝻䞁䞉䞉䞉䞉䞉䞉䞉 Weak No㻌 䞉䞉䞉䞉䞉䞉䞉1) Pirfenidone, 䞉䞉䞉䞉䞉䞉Am J Respir Crit Care Med. 183: 788-824, 2011

Am J Respir Crit Care Med. 192: e3-e19, 2015䞉㻌 ⥺⥔໬䛾䝯䜹䝙䝈䝮䞉㻌 ⥺⥔໬䛾䝯䜹䝙䝈䝮䞉ᛴᛶ⫵യᐖ(acute lung injury) 䛛䜙䛾㐍ᒎ䝰䝕䝹䞉⥺⥔໬䜢᮶䛩ྛ✀ᡂ㛗ᅉᏊ(growth factors) 䛾⏘⏕⣽⬊

myofibroblast

Lay K, Zarbock A. Nat Med. 2008; 14: 20-1䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉 Pirfenidone

Azuma A, et al. Core Evidence 2015; 10: 89-98

䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉 Pirfenidone : Phase III trials

䞉PDGF, TGF-ȕ IL-12䛾ᢚไ䞉⭷䛾Ᏻᐃ໬䚸ᢠ⅖⑕స⏝䞉CAPACITY-004 (A), -006 (B)Pirfenidone

Pirfenidone

Azuma A, et al. Core Evidence 2015; 10: 89-98

Lancet 2011; 377: 1760-69

ȟȋȬǯȁȣȸᲱ䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉 Pirfenidone : Phase III trials

䞉 Pirfenidone : Phase III trials

䞉CAPACITY-004 (A), -006 (B) : FVC change

䞉CAPACITY-004 (A), -006 (B) Ⱥ3)6䛿CAPACITY-004䛷䛾䜏᭷ពᕪ

Lancet 2011; 377: 1760-69

䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶

Lancet 2011; 377: 1760-69

䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉 Pirfenidone : definite IPF䛜95%䛸pure䛺㞟ᅋ䛷䛾෌᳨ド䞉ASCEND (Assessment of Pirfenidone to Confirm Efficacy and Safety in IPF)

䞉 Pirfenidone : definite IPF䛜95%䛸pure䛺㞟ᅋ䛷䛾෌᳨ド䞉ASCEND (Assessment of Pirfenidone to Confirm Efficacy and Safety in IPF)

N Engl J Med. 2014; 370: 2308-92䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉 Pirfenidone : Phase III trials
䞉ASCEND

N Engl J Med. 2014; 370: 2308-92

䞉 Pirfenidone

ȺASCEND䛷෌⌧ᛶ䜢䜒䛳䛶᭷ពᕪ䜢ㄆ䜑䛶ᢎㄆ

N Engl J Med. 2014; 370: 2308-92

䞉FVC䛜10%௨ୖపୗᚋ䛾Pirfenidone⥅⥆䛷FVC䛾᭦䛺䜛పୗ䜢ᢚไ

Thorax 2016; 0: 1-7

ȟȋȬǯȁȣȸᲲ䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶

䞉 Nintedanib䞉 Nintedanib : Phase III trials

䞉PDGF, FGF, VEGF䛾3⤒㊰䜢ไᚚ䞉INPULSIS-1, -2 (Change in FVC at week 52) 䞉%FVC䛜50%௨ୗ䛸䚸ASCEND䜘䜚䜒FVC䛜ᝏ䛔䜒䛾䜒ྵ䜑䜛䞉Definite UIP䛜ᚲ㡲䛷䛺䛟 (⻏ᕢ⫵䛿HRCTデ᩿䛷ᚲ㡲䛷䛺䛔)䚸
㻌 ⮫ᗋ་䛾⥲ྜุ᩿䛷IPF䛸デ᩿䛥䜜䜜䜀ᢞ୚ྍ⬟ĺPure䛺IPF䛷䛒䜛ᚲせ䛜䛺䛔 (㏫䛻ゝ䛘䜀௚䛾IIPs䛷䜒౑⏝䛧ᚓ䜛)ĺASCEND䜘䜚䜒FVC䛜ᝏ䛔䜒䛾䜒ྵ䜎䜜䜛䛯䜑䚸୰➼⑕௨ୖ䜈䛾ᮇᚅ

Azuma A, et al. Core Evidence 2015; 10: 89-98

䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶

N Engl J Med. 2014; 370: 2308-92䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶

䞉 Nintedanib : Phase III trials

䞉 Nintedanib : Phase III trials

䞉INPULSIS-1, -2 (Change in FVC at week 52) 䞉INPULSIS-1, -2 (Change in FVC at week 52) 

N Engl J Med. 2014; 370: 2308-92䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶

N Engl J Med. 2014; 370: 2308-92䞉ᢠ⥺⥔໬⸆䛻䛴䛔䛶(2๣䛾ẚ㍑)

䞉 Nintedanib : Phase III trials

䞉 Nintedanib vs. Pirfenidone

䞉INPULSIS-1, -2 (Acute Exacerbation) ȺINPULSIS-2䛷AEᢚไຠᯝ䜢♧၀ᑐ㇟

N Engl J Med 2014; 370: 2308 92

Nintedanib

Pirfenidone៏ᛶ⥺⥔໬ᛶ㛫㉁ᛶ⫵⅖ (IPF, fibrotic NSIP)≉Ⓨᛶ⫵⥺⥔⑕(+)⑌ᝈ㐍⾜䛾ᢚไ

(+)ᛴᛶቑᝏ䛾ᢚไ

(+)(-)἞⒪㛤ጞ᫬ᮇ

୰➼⑕௨ୖ䛾㐍⾜䛷䜒ຠᯝ䛿ᮇᚅ

㍍⑕౛䛷䛾ᑟධ䛜ᮃ䜎䛧䛔Ᏻ඲ᛶ㛗ᮇ౑⏝䛷ၥ㢟䜢ㄆ䜑䛺䛔㛗ᮇ౑⏝䛷ၥ㢟䜢ㄆ䜑䛺䛔᭷ᐖ஦㇟䛤䛟㍍ᚤ (ୗ⑩䞉ᝏᚰ䚸⫢ᶵ⬟㞀ᐖ䛺䛹)ග⥺㐣ᩄ⑕䚸ᝏᚰ䞉჎ྤ䚸ୗ⑩䚸⫢ᶵ⬟㞀ᐖ䛺䛹⸆≀┦஫స⏝

䜶䝸䝇䝻䝅䞁䚸䝅䜽䝻䝇䝫䝸䞁䛷⃰ᗘୖ᪼䝣䝹䝪䜻䝃䝭䞁䚸䝅䝥䝻䝣䝻䜻䝃䝅䞁䛾ຠᯝቑᙉ㔠㢠39୓෇/᭶

18୓෇/᭶

ౠশഌ੘೉࿚ভ୰੹ళลஓ৔ఐ ৖শ೔িඤ౓੔ে

঳ಹ൥౰ ॔ই॓ॳॽঈभથ஍ਙ॑ણऊघञीभঐॿ४ওথॺ
౰঻ೣਮপ৾ୢ৾৖৔ఐ৾൥ౠ‫ؙ‬ᇯᯂ৔ఐ৾৖୅൥పલি೗௟ ੔ে

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્શ൥౰ ਤষ਋ཡቅभఇ੟௜১
౰঻਎੃ਿয়ୢఐপ৾প৾੹ୢ৾ଢ଼஢ఐళลஓ৔ఐ৾൥ౠઇ౸ৈ৛ข ঳੔ে

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