电视硬质气管镜在大气道狭窄治疗中的应用

背景与目的大气道狭窄是内、外科和麻醉科都较难处理的重大疾病,如不及时处理易引起窒息。本文旨在探讨应用电视硬质气管镜消除气道狭窄的可行性、有效性和安全性。方法回顾分析2007年8月27日-2010年9月30日收治的194例大气道狭窄病例(平均年龄(57.5±1.3)岁,其中男性140例,女性54例;恶性气道狭窄145例,良性气道狭窄49例)在全身麻醉支持下经口插入硬质镜,连接高频通气,结合电子支气管镜对声门部、气管内及支气管内狭窄采用电圈套器、冷冻、氩等离子体凝固(argon plasma coagulation,APC)等综合治疗措施进行治疗的情况。结果 194例患者共接受了325次硬质镜检查,平均每例患者接受1.6次操作,硬质镜检查占所有气管镜检查的21.3%(325/1,525)。气道内肿瘤包括原发肿瘤76例,转移性肿瘤69例。良性狭窄最常见病因为瘢痕狭窄,其次为良性肿瘤、原发性肉芽组织增生、异物、气管软化和复发性多发性软骨炎。硬质镜首次治疗后气道狭窄程度均明显下降,其中支气管的下降程度要大于主气管。首次治疗后KPS明显升高,气促指数明显下降。硬质镜下取出气管支架26个,放置气管支架13个。硬质镜治疗比较安全,术中死亡1例。结论硬质镜治疗大气道狭窄较快速、有效、安全,能提高患者生存质量。     

氩等离子体凝固联合分叉型被膜金属内支架置入治疗气管隆突周围复合狭窄和气管食管瘘

背景与目的气管下端、隆突和双侧主支气管发生的狭窄称为多发性狭窄或复合狭窄,治疗非常棘手.本研究旨在探讨氩等离子体凝固(argon plasma coagulation,APC)联合分叉型被膜金属内支架(covered Z-type stents,CZTS)置入治疗气管隆突周围狭窄和气管食管瘘的安全性和疗效.方法回顾性分析32例气道病变的患者,在支气管镜引导下行APC,在X线透视和/或支气管镜引导下置入CZTS.结果 19例伴有气道狭窄的患者先行APC,术前气道狭窄发生率为57.4%-72.1%,术后均明显缓解(气道狭窄发生率仅为12.8%-25.8%).32例患者中30例技术上成功放置32个支架,2例失败.APC及成功放置支架的患者术后气促指数明显下降,KPS明显升高.13例气管下端瘘口置入分叉型CZTS,12例(92.3%)达临床治愈.术中、术后未出现大出血等并发症.两种术式术后短期内均产生大量分泌物,用气管镜可有效清除.置入内支架的患者1个月后易在支架两端形成肉芽,用APC结合冷冻可有效处理.结论使用APC联合CZTS置入治疗气道复合狭窄和气管食管瘘快速有效,安全可靠.     

硬质气管镜结合可弯曲性支气管镜治疗大气道内肿瘤

背景与目的 大气道内肿瘤常伴有严重呼吸困难,患者难以平卧,局麻下气管镜检查受限.硬质气管镜具有通气功能,全麻下行硬质气管镜检查、治疗比较安全.本研究旨在探讨硬质气管镜结合可弯曲性支气管镜,应用冷冻联合氩等离子体凝固(APC)治疗大气道内恶性肿瘤的效果及可行性.方法 回顾性分析两组经病理明确的气道内恶性肿瘤,分别采取两种不同的气管镜治疗模式.①A组:采取硬质气管镜结合可弯曲性电子支气管镜,应用冻取结合APC治疗大气道内肿瘤19例.全麻下经口插入硬质镜,然后结合电子支气管镜,采用冻取联合APC的方法,尽量一次性消除气道内肿瘤;②B组:单独采用电子支气管镜下单用APC治疗20例类似气道内病变患者,仅用APC烧灼肿瘤,然后用活检钳取出或冻取坏死物质,根据病人的最大耐受程度,尽量清除气道内肿瘤.结果 A组气管及支气管术前阻塞程度均明显重于B组.但A组气管和支气管首次消融范围均大于B组,两组气管和支气管消融范围均无明显差别.A组所需气管镜操作次数明显少于B组,对患者的改善程度也优于B组.两组治疗过程中均无严重并发症发生.结论 硬质气管镜结合可弯曲性支气管镜能快速冻取肿瘤,联合APC也能快速凝切肿瘤和止血,两种镜子结合应用,是严重气道阻塞快速、有效的治疗方法.单独应用电子支气管镜仅适合硬质气管镜有效治疗后的维持治疗或气道肿瘤较小、阻塞程度不重的患者.     

经气管镜电圈套器联合CO2冷冻及氩等离子体凝固等治疗77例气道内肿瘤和息肉

背景与目的采用电圈套器联合CO2冷冻等治疗气道内大的肿瘤或息肉,探讨其疗效和安全性。方法 77例大气道内肿瘤或息肉患者(恶性肿瘤70例,良性病变7例)在硬质镜引导下,结合电子支气管镜,利用电圈套器联合CO2冷冻等进行治疗。结果 77例患者进行电圈套器治疗85例次。病变位于右侧支气管42.9%,主气管38.3%和左侧支气管21.4%,少数位于亚段支气管开口。恶性肿瘤混合型占89.7%,单纯管内型仅占10.3%。圈套器治疗前气道内堵塞约4/5,术后约1/5;KPS评分和气促指数治疗后均有明显改善。未发生大出血、穿孔等并发症。结论电圈套器联合CO2冷冻等治疗气道内肿瘤或息肉,安全、有效、快速。     

国产镍钛支架治疗气道狭窄

目的　评价国产镍钛合金气管支架治疗气管支气管良恶性狭窄的疗效。方法　气管、支气管良恶性狭窄13例 ,狭窄部位 :气管 5例、气管主支气管 6例 ,主支气管 2例 ,经纤支镜和X线合用共放置 15枚支架。结果　全部支架均放置成功 ,呼吸困难改善 ,死亡病例平均存活时间 11.4个月 ,1例仍存活。结论　经纤支镜和X线合用 ,植入国产镍钛合金支架是治疗气管、支气管良恶性狭窄的有效方法。     

自扩金属支架治疗气管支气管恶性狭窄

观察和评价Ｇｉａｎｔｕｒｃｏ气管支气管自扩金属支架治疗气管支气管恶性狭窄的疗产及并发症。材料和方法：在Ｘ光支纤镜指引下应用Ｇｉａｎｔｕｒｃｏ气管支气管自扩金属支架１３个治疗气管支气管恶性狭窄１０例,狭窄原因：食管鳞直接侵怨或纵隔淋巴结转移压迫气道６例,     

经电子支气管镜氩气刀联合冷冻治疗气道肿瘤7例疗效观察

目的 探讨经电子支气管镜氩等离子体凝固疗法(氩气刀APC)联合冷冻治疗气管、支气管内恶性肿瘤引起的气道狭窄及阻塞的疗效及安全性.方法 采用内镜专用氩气刀及冷冻治疗仪,经电子支气管镜介入治疗7例气管、支气管内恶性肿瘤所造成的气道狭窄,对患者症状、镜下表现与治疗前进行比较,并观察其疗效.结果 7例患者先后进行了12次氩气刀治疗(1例3次,3例2次,3例1次).其刺激性咳嗽、呼吸困难等症状均有不同程度的缓解.其中显效4例,有效3例,有效率100.0％,无手术相关死亡.结论 经电子支气管镜介入氩气刀治疗,可以缓解咳嗽、呼吸困难等气道狭窄引起的症状,明显提高生活质量,是一种简便、有效的微创方法.     

支气管镜介入冷冻治疗气管、支气管腔内恶性肿瘤24例分析

[目的]探讨支气管镜介入冷冻治疗气管、支气管内恶性肿瘤引起的气道狭窄及阻塞的疗效。[方法]经支气管镜介入对24例气管、支气管内恶性肿瘤造成的气道狭窄患者进行冷冻治疗，症状、镜下表现同治疗前进行比较，以观察其疗效。[结果]24例患者咳嗽、呼吸困难、咯血等症状均有不同程度缓解；管腔再通、阻塞性肺炎和肺不张均有缓解。显效50％（12／24），有效41．7％（10／24），总有效率91．7％，无严重并发症和死亡。[结论]支气管镜介入冷冻治疗气管、支气管腔内恶性肿瘤，能缩小瘤体，通畅管腔，缓解阻塞性肺炎，缓解咳嗽、呼吸困难、咯血等症状，明显提高生活质量，是一种简便、有效的做创方法。     

气管支气管树腺样囊性癌MSCT表现

  目的  观察分析气管支气管树腺样囊性癌（adenoid cystic carcinoma,ACC）的MSCT表现,以期提高对该病的认识。  方法  回顾性分析和总结天津医科大学肿瘤医院2004年4月至2013年4月经组织病理证实的19例原发气管支气管树腺样囊性癌的MSCT表现。  结果  19例中气管病变7例,段及以上支气管病变10例,周围型病变2例;腔内外生长型15例（79%）,腔内生长型2例（11%）。气管ACC有明显的沿气管黏膜下浸润延伸趋势,表现为气管壁弥漫环周增厚2例,移行状增厚3例;10例段及以上支气管ACC均表现为腔内外型肿物,8例病变相邻支气管腔内可见息肉样影隆起或突入,7例腔外部分大于腔内。13例增强检查中3例无强化,5例轻度强化,4例中度强化,1例明显强化。  结论  气管支气管树腺样囊性癌MSCT表现具有一定特点,CT可定性诊断,但明确诊断需依靠病理。      

经鼻安放气道支架治疗恶性气管支气管狭窄

[目的]评价经鼻安放气道支架治疗恶性肿瘤引起的气管支气管狭窄的可行性和疗效.[方法]17例肺癌、食管癌等恶性肿瘤压迫或侵犯气管、支气管,引起气道狭窄和呼吸困难,在X线透视下由纤支镜配合进行,经鼻植入国产镍钛自扩型Wallstent支架.6例患者进行了后续的支气管动脉灌注化疗或放疗.[结果]10例狭窄位于主气管,置入支架10个;7例狭窄位于气管-支气管(4例)或支气管(3例)共置入支架11个.所有患者呼吸困难立即缓解.3例失访.8例未进行后续抗肿瘤治疗者生存时间45～90天,平均73天.6例术后进行放疗或支气管动脉灌注化疗者生存时间110天～1年6个月,平均12个月.[结论]在X线透视下由纤支镜配合经鼻行气道支架放置术优越性较多.国产气管支气管支架能缓解晚期恶性肿瘤引起的呼吸困难,改善生活质量;需结合后续的抗肿瘤治疗才能延长生存时间.     

Treatment outcomes of patients with adenoid cystic carcinoma of the airway

Background

Adenoid cystic carcinoma (ACC) of the airway is a slowly growing tumor and airway narrowing is one of the main causes of death. The purposes of this study were to investigate treatment outcomes, prognostic factors, and the indications and outcomes of bronchoscopic interventions in patients with ACC of the airway.

Methods

We retrospectively analyzed the clinical characteristics, treatment modalities, and clinical outcomes of patients with histologically-proven ACC of the airway treated between January 1995 and June 2009 at Samsung Medical Center.

Results

A total of 30 patients were included in the study. Sixteen patients were male and the median age was 45 years. Multiple treatment modalities were required for the patients; 17 for surgery, 13 for definitive radiation therapy, 10 for adjuvant radiation therapy, and 1 for adjuvant chemotherapy. Bronchoscopic interventions were required to improve airway narrowing in 20 patients. After bronchoscopic intervention, 19 patients (95%) showed immediate improvement of airway narrowing and suffered no serious complications. The 5- and 10-year overall survival (OS) rates in these patients were 84% and 70%, respectively. The prognostic factors associated with OS were tumor size, tumor location, clinical T stage, surgery as an initial treatment, and bronchoscopic intervention.

Conclusions

ACC of the airway had a good long-term prognosis but bronchoscopic interventions were frequently required during the course of the disease due to the development of airway narrowing. Bronchoscopic interventions may be considered as a bridge therapy before surgery or radiation therapy and as a palliative therapy for airway narrowing.     

液氮冷冻治疗肝癌的临床应用：附20例报告

对20例中晚期肝癌病人进行液氮冷冻治疗。肿瘤直径7～20cm,平均13cm。肝细胞性肝癌16例,肝母细胞瘤1例,胆管细胞癌3例,全组病人进行了随访,死亡5例,平均存活10个月。余15例1、2、3年生存率各占60％、35％和10％。能够独立生活的11例中,5例可参加轻体力劳动。结果说明液氮冷冻治疗可作为中晚期肝癌的一种姑息疗法,可以缓解症状,延长寿命。     

Ultrasound-guided hepatic cryosurgery in the treatment of metastatic colon carcinoma. Preliminary results

Cryosurgery, the in situ freezing of cancer, has been proposed in the past as a possible treatment for unresectable hepatic tumors. Its advantage lies in the fact that it is a very focal treatment sacrificing less normal tissue than surgical resection, allowing treatment of multiple lobes. Because cryosurgery does not affect large vessels, tumors in difficult locations, such as adjacent to the inferior vena cava (IVC), can be treated. With the use of intraoperative ultrasound to place the cryoprobes and monitor the freezing process, 18 patients with unresectable metastatic colon carcinoma confined to the liver were treated. Of the 18 patients treated, 4 (22%) are in complete remission as determined by computed tomography (CT) scans and carcinoembryonic antigen (CEA) levels, with a mean follow-up of 28.8 months. Four patients (22%) were not adequately treated at the time of cryosurgery. The number of lesions frozen in each patient ranged from 1 to 12, with a mean of 6 lesions. Fourteen patients had bilobar disease; three patients had previous right lobectomies with recurrences in their remaining left lobes prior to cryosurgery, and one patient had unilobar disease. Mean survival of the 14 cases with recurrence was 21.4 months, with 2 of the 14 still alive. Ultrasound-guided hepatic cryosurgery appears to be an effective treatment for metastatic colon carcinoma to the liver that is unresectable (including patients with bilobar and multiple lesions). These preliminary results indicate that the procedure warrants further study.     

冷冻治疗肛管直肠癌：附41例报告

Fourty-one patients with rectal carcinoma treated by cryosurgery in our hospital from 1973 to 1982 are presented. The 5, 4, 3, 2, and 1-year survival rates were 34.1%, 41%, 56%, 66% and 90%, respectively Eighteen patients who underwent radical cryosurgery gave a 5-year survival rate of 66%. The results showed that cryosurgery inhibited the multiplication of cancer cells and improved immune response through observing the changes of DNA content, ultrastructures, anti-bodies (IgG, A, M), T-cell subpopulations (OKT3, OKT4, OKT8) and so on. Cryosurgery could avert colostomy when used for rectal carcinoma.     

Detection of tumor-specific autoantibodies in sera of patients with lung cancer

The presence of autoantibodies (AAs) in sera from two pulmonary carcinoma patients, adenocarcinoma (AD) and small cell carcinoma (SCLC) was screened by immunoblotting using cell lysate of four cell lines (LCN1, large cell neuroendocrine carcinoma (LCNEC); N231, SCLC; A549, AD; RERF-LC-AI, squamous cell carcinoma (SCC)). To identify the antigens recognized by AAs, two-dimensional gel electrophoresis was immunoblotted and target spots were cut out from the membrane and gel. After trypsin digestion, the proteins were analyzed by mass-spectrometry using a liquid chromatography-tandem mass spectrometer. By this method, cytokeratin18 (CK18) and villin1 were identified with AAs in sera from patients with AD and SCLC, respectively. Thus, the expressions of CK18 and villin1 were further immunohistochemically studied on 124 formalin-fixed and paraffin-embedded pulmonary carcinomas of various histologic types (44 AD, 27 SCC, 29 SCLC, and 34 LCNEC) using commercially available CK18 and villin1 antibodies. Positive CK18 immunostaining was observed in almost all cases with staining intensities significantly higher in AD and LCNEC than in SCC and SCLC. Villin1 was detected in 17/44 (38.6%) of AD and 21/34 (61.8%) of LCNEC, respectively, while in only one each of SCLC and SCC. Thus, villin1 and CK18 may be useful markers to distinguish LCNEC/AD from SCLC/SCC, and the present method might be useful to identify specific tumor-associated molecules in sera from pulmonary carcinoma patients with different histologic types.     

氩氦刀治疗恶性肿瘤103例临床观察

目的:观察氩氦刀冷冻消融治疗实体瘤灶的临床疗效。方法:对接受氩氦刀局部冷冻联合治疗的103例恶性中晚期实体瘤患者共计115个瘤灶进行术中评价及术后随访。结果:术中对115个瘤灶疗效评价总有效率达93·9%;术后3个月和6个月对追访到的病例疗效评价显示3个月时肿瘤控制率(CR PR NC)为48·6%;6个月时肿瘤控制率为36·1%。所有病例不良反应轻微。结论:氩氦刀冷冻消融治疗中晚期实体瘤灶疗效较好,扩大冷冻范围可明显提高患者的肿瘤控制率,是一种具有推广价值的治疗手段。     

Quality-of-life outcomes for men treated with cryosurgery for localized prostate carcinoma.

BACKGROUND: Cryosurgery was introduced as an alternative to radiotherapy or radical prostatectomy in the mid-1960s. Although it met the primary objective of achieving local control, it was largely abandoned due to a high incidence of complications. Technologic advances in the areas of imaging and urethral warming have renewed interest in this treatment methodology. The aim of the current study was to determine the quality of life of men enrolled in a Phase II clinical trial of cryosurgery for the treatment of localized prostate carcinoma. METHODS: Men were administered the Functional Assessment of Cancer Treatment-Prostate (FACT-P) prior to their treatment and at 6 weeks and 3, 6, and 12 months posttreatment. RESULTS: By 12 months after cryosurgery, most of the FACT-P subscales had returned to pretreatment levels, following a decline in well-being immediately after cryosurgery. There were two exceptions to this general trend: At 12 months, impairments in social/family well-being and sexual function still remained. The average time to return to work after therapy was 3 weeks. Stay in hospital after treatment was limited to 1 day for 94% of the participants. Compared with men who received the standard treatments of radical prostatectomy and radical radiotherapy, men treated with cryosurgery appeared to have a similar quality of life, with perhaps the exception of decreased sexual function. CONCLUSIONS: The quality-of-life outcomes of this study support the current renewed interest in cryosurgery. The severe impairments reported in other studies were not seen in this sample. In fact, it appeared that all aspects of the participants' well-being had returned to pretreatment levels by 12 months, with the exception of sexual function.     

胸腔镜治疗肺部微小结节（129例报告）

背景与目的影像技术的发展导致肺部微小结节尤其是肺磨玻璃结节（ground-glass opacity, GGO）检出逐年增多,但术前定性困难。本研究探讨肺部微小结节的临床诊断及微创手术治疗的必要性和可行性、病理诊断,微创切除及淋巴结切除的手术方式。方法对2013年12月-2016年11月接受电视胸腔镜手术（video-assisted thoracic surgery, VATS）治疗并有明确病理诊断的共129例患者的临床资料回顾性分析。所有患者术前行薄层计算机断层扫描（computed tomography, CT）扫描,其中21个微小结节术前行CT引导下Hook-wire定位,并根据病理性质及患者身体状况采用不同手术方式。结果共129个微小结节,实性结节（solid pulmonary nodule, SPN）37个,恶性比例是24.3%（9/37）,术后病理结果为：肺原发性鳞状细胞癌3个,浸润性腺癌（invasive adenocarcioma, IA）3个,转移癌2个,小细胞肺癌（small cell lung cancer, SCLC）1个,错构瘤16个,其他炎症等良性病变12个;49个混合性GGO（mixed ground-glass opacity, mGGO）的恶性比例是63.3%（31/49）,术后病理结果为：IA 19个,微浸润腺癌（micro invasive adenocarcioma, MIA）6个,原位腺癌（adenocarcioma in situ, AIS）4个,非典型性腺瘤样增生（atipical adenomatous hyperplasia, AAH）1个,SCLC 1个,炎症等良性病变18个;43个纯GGO（pure ground-glass opacity, pGGO）的恶性比例是86.0%（37/43）,术后病理结果为：AIS 19个,MIA 6个,IA 6个,AAH 6个,炎症等良性病变6个;GGO总的恶性比例是73.9%（68/92）。52个良性病变均采用VATS肺楔形切除;原发性非小细胞肺癌（non-small cell lung cancer, NSCLC）共73例,VATS肺叶切除和淋巴结清扫33例,VATS肺楔形切除和选择性淋巴结切除6例,VATS肺段切除和选择性淋巴结切除6例,VATS肺楔形切除28例;2个转移癌和2个SCLC,采用VATS肺楔形切除术。另有6例患者术中冰冻病理存在误差,其中2例选择二次手术行肺叶切除和淋巴结清扫。45例有淋巴结病理结果NSCLC只有两例以SPN为表现的IA出现纵隔淋巴结转移,其余均未出现淋巴结转移。术后随访1个月-35个月,平均（15.1±10.2）个月,无复发及转移。结论肺部微小结节尤其是GGO,是恶性病灶的概率大,应积极外科处理;围手术期应与患者及家属充分告知冰冻病理结果存在误差可能性,避免医疗纠纷。