中心静脉导管在治疗恶性胸腔积液中的应用

恶性胸腔积液约占各种原因所致的胸腔积液的50%,对于化疗敏感的肿瘤如:小细胞肺癌、乳腺癌、恶性淋巴瘤等经全身化疗可使部分患者的少量胸水得到控制,其余大部分需要局部腔内药物治疗方可缓解,改善生活质量和延长生存时间[1].     

胸腔热灌注化疗治疗肺癌胸腔积液的临床观察

目的 观察胸腔热灌注化疗对比胸腔置管化疗治疗肺癌所致恶性胸腔积液的临床疗效及不良反应.方法 纳入103例肺癌胸腔积液患者,胸腔热灌注化疗组65例,胸腔置管化疗组38例.观察胸腔积液控制率、胸腔积液进展时间、胸腔积液中血管内皮生长因子(VEGF)浓度与疗效的关系以及不良反应发生情况.结果 热灌注化疗组和置管化疗组的胸腔积液控制率分别为81.5％和52.6％,差异有统计学意义(x2=9.834,P=0.002).两组患者的中位胸腔积液进展时间分别为3.10个月和2.15个月,差异有统计学意义(x2=10.512,P=0.001).胸腔积液中VEGF低浓度患者接受胸腔热灌注化疗和腔内置管化疗后的中位胸腔积液进展时间分别为3.34个月和2.20个月,差异有统计学意义(x2=9.409,P=0.002),但VEGF高浓度亚组,两种治疗方法的中位胸腔积液进展时间分别为2.85个月和2.10个月,差异无统计学意义(x2=2.429,P=0.119).两组患者的不良反应主要为消化道不良反应、乏力及血液毒性,热灌注化疗组患者乏力较置管化疗组常见(67.7％∶13.2％;x2 =28.595,P＜0.001).结论 胸腔热灌注化疗治疗肺癌所致恶性胸腔积液较常规腔内置管化疗提高了胸腔积液控制率,且可延长胸腔积液进展时间,不良反应易于耐受,胸腔积液进展时间延长在胸腔积液VEGF低浓度亚组中尤为明显,VEGF可作为胸腔热灌注化疗的疗效预测因素.     

曲妥珠单抗治疗141例人表皮生长因子受体2阳性乳腺癌的回顾性分析

目的 总结曲妥珠单抗在人表皮生长因子受体2(Her-2)阳性乳腺癌患者新辅助、辅助和复发转移治疗中的临床应用经验,评价其与化疗联用的疗效.方法 对2004年1月至2008年12月门诊应用曲妥珠单抗治疗的141乳腺癌患者进行回顾性分析.随访时间为3～319个月.分析患者的无病生存时间(DFS),比较患者辅助、复发转移一线及二线使用曲妥珠单抗治疗的总生存时间(OS)、治疗失败时间(TTF)和临床有效率的差异.结果 与曲妥珠单抗治疗联用的新辅助化疗中,紫杉醇联合卡铂方案占66.7%;辅助治疗中,蒽环类和蒽环类序贯紫杉类方案占53.9%.复发转移的患者治疗后中位DFS为17个月.复发转移的患者经一线曲妥珠单抗联合化疗治疗后,临床总有效 率为84.5%,中位TTF为24个月;二线治疗有效率为44.4%,中位TTF为5个月.两者比较,差异有统计学意义(P=0.002).结论 紫杉醇和卡铂化疗联合曲妥珠单抗,值得在新辅助治疗中推广,紫杉类和蒽环类联合或序贯靶向治疗仍是辅助治疗的标准方案.转移性乳腺癌一线应用曲妥珠单抗联合化疗比二线治疗的临床有效率更高,在继续应用曲妥珠单抗的基础上改用化疗方案,可提高治疗有效率,减少治疗失败的概率.     

乳腺癌新辅助化疗后病理未完全缓解患者预后及复发转移的危险因素分析

目的 探讨乳腺癌新辅助化疗后病理未完全缓解（non-pathologic complete response,non-pCR）患者的预后及复发转移的危险因素。方法 回顾性分析2016年1月至2020年12月期间在广西医科大学附属肿瘤医院乳腺外科及2020年1月至2022年12月在海南医学院第一附属医院乳腺外科诊断乳腺癌并接受新辅助化疗的500例患者的临床特征。比较病理完全缓解（pathologic complete response,pCR）及non-pCR患者的无病生存期（disease-free survival,DFS）和总生存期（overall survival,OS）,通过Cox比例风险模型筛选出新辅助化疗后non-pCR患者复发转移的独立危险因素。结果 本研究的中位随访时间为38个月（范围：6～81个月）,中位DFS及OS均未到达。新辅助化疗后的pCR率为19.4%(97/500)。pCR和non-pCR患者5年DFS率分别为91.9%和81.2%(P=0.003),5年OS率分别为96.1%和81.6%(P=0.007)。新辅助化疗后共有71例患者出现复发转移,其中pCR...     

奈达铂腔内灌注联合热疗治疗肺癌胸腔积液的临床观察

目的:观察奈达铂胸腔灌注联合热疗治疗肺癌胸腔积液的疗效、生活质量和不良反应。方法:确诊为肺癌恶性胸腔积液的患者50例,随机分成两组,采用中心静脉导管胸腔闭式引流排尽胸水后,A组(26例)给予胸腔灌注奈达铂化疗,随后进行患侧胸腔深部热疗;B组(24例)只给予胸腔灌注奈达铂化疗。结果:A组控制胸水的有效率为88.4%,B组为62.5%(P<0.05);A组与B组的生活质量好转率分别为84.6%和50.0%(P<0.05)。结论:采用热疗联合奈达铂胸腔灌注治疗肺癌恶性胸腔积液疗效确切,不良反应小,安全性高。     

胸水脱落细胞DNA含量及VEGF、p53表达对肺癌胸腔积液治疗和预后的预测

目的:探讨胸水细胞的DNA倍体以及VEGF、p53表达与恶性胸腔积液治疗疗效的关系和对湿性肺癌预后的预测价值。方法:随访43例恶性胸腔积液患者的生存期,39例用图像细胞光度技术(ICM)检测DNA含量,免疫组化Envision法检测VEGF、p53,29例经胸腔引流术后胸腔内药物治疗。结果:DNA异倍体与胸水治疗的疗效有相关趋势(P=0.054)。经Cox多因素分析,仅p53是肺癌胸腔积液患者影响预后的独立因素(P=0.05)。p53阴性组与p53阳性组的中位生存期分别为(10.4±3.5)个月,(2.8±0.6)个月(logrank=0.0132)。一年生存率p53阴性组与阳性组分别为17.7%和0。结论:ICM检测胸水细胞的DNA倍体与胸水治疗的疗效有相关趋势。免疫组化检测p53能预测肺癌胸腔积液患者的预后。     

红色诺卡氏菌细胞壁骨架治疗恶性胸腔积液的疗效观察

目的　探讨用红色诺卡氏菌细胞壁骨架 (CWS)胸腔内注射治疗恶性胸腔积液的疗效。方法　81例恶性胸腔积液患者分为顺铂组 30例、CWS组 35例及化疗CWS组 16例 ,前一组胸腔注射顺铂5 0mg/m2 ,后两组分别胸腔注射CWS6 0 0ug。结果　顺铂组、CWS组及化疗CWS组治疗恶性胸腔积液有效率分别为 46 6 %、85 71%、87 5 %(P <0 0 1)而各组胸水癌细胞转阴分别为 47 6 %、79 17%、81 2 %(P <0 0 5 )结论　CWS对治疗恶性胸腔积液有较好疗效。     

胸腔灌注化疗联合全身化疗治疗乳腺癌恶性胸水35例疗效分析

目的:观察采用一次性中心静脉导管胸腔闭式引流后,胸腔内局部灌注化疗联合全身化疗治疗乳腺癌大量胸腔积液的疗效.方法:在常规全身化疗的基础上,胸腔闭式引流完胸水后,通过导管在胸腔内注射博来霉素.结果:胸腔积液控制的有效率77.14%,毒副作用主要是骨髓抑制、消化道反应.结论:乳腺癌伴大量胸腔积液,常规化疗的同时,通过胸腔闭式引流管局部注射博来霉素,方法简单有效.     

三阴性对小肿块乳腺癌患者预后的影响

  目的  分析小肿块（直径≤1 cm）乳腺癌患者的临床及病理学特征,了解其生存状态,探讨三阴性对其预后的影响。  方法  收集本院收治的312例直径≤1 cm乳腺癌患者的临床病理学资料,比较三阴性乳腺癌及非三阴性乳腺癌的临床病理学特征、复发转移及生存情况。  结果  312例直径≤1 cm乳腺癌患者纳入研究,三阴组及非三阴组5年DFS分别为81.4%及90.5%（P= 0.038）,5年BCSS分别为84.7%及93.7%（P=0.047）。以淋巴结状态分组比较,淋巴结阴性患者中,三阴组及非三阴组5年DFS分别为82.8%及94.1%（P=0.033）,5年BCSS分别为85.0%及96.1%（P=0.019）。Cox比例风险模型多因素分析显示,淋巴结阳性患者复发转移风险增高（HR=3.721,95%CI:1.743~7.941,P=0.001）,死亡风险亦增高（HR=3.560,95%CI:1.521~8.330,P=0.003）,三阴性患者复发转移风险增高（HR=2.208,95%CI:1.028~4.742,P=0.042）。  结论  淋巴结阳性及三阴性是影响直径≤1 cm乳腺癌患者DFS的独立危险因素,淋巴结阳性是影响BCSS的唯一独立危险因素。淋巴结阴性三阴性乳腺癌组较非三阴组预后差。      

热疗联合腔内灌注化疗治疗恶性胸腔积液的疗效观察

目的:观察热疗加局部药物注射治疗恶性胸腔积液的疗效、生活质量和不良反应。方法:确诊为恶性胸腔积液的患者50例,随机分为两组,采用中心静脉导管胸腔闭式引流尽可能排尽胸水后,A组给予胸腔灌注DDP化疗,然后进行患侧的胸腔深部热疗;B组只给胸腔灌注DDP化疗。结果:A组控制胸水的总有效率为83.3%,B组为61.5%■P<0.05■,A组与B组生活质量好转率分别为70.8%和46.1%(P<0.05)。结论:采用热疗加局部药物注射治疗恶性胸腔积液疗效确切,不良反应小,安全性高。     

Malignant pleural effusion of multiple myeloma: prognostic factors and outcome

Malignant pleural effusion (MPE) in multiple myeloma (MM) is rare. Approximately 80 cases have been reported. To delineate optimal treatment and prognostic variables in these patients, we reviewed 11 MM patients with MPE. MPE developed at median of 12 months from diagnosis of MM. All the patients had high-risk disease based on complex karyotypic abnormalities including deletions of chromosome-13 (n = 9), elevated beta-2 microglobulin (B2M) (n = 9), high C-reactive protein (CRP) (n = 8), high plasma cell labeling index (n = 5) or high LDH (n = 5). A significant increase in B2M, LDH, and CRP was observed at the onset of MPE. The initial diagnosis of MPE was based on positive cytology (n = 9), pleural fluid cIg/DNA (n = 9) or pleural fluid cytogenetics (n = 4). Pleural tissue infiltration was found on pleural biopsy and autopsy in one patient each. Systemic chemotherapy comprising dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP) (n = 7) and pleurodesis (n = 7) were effective in resolving MPE but survival was short. High dose chemotherapy with peripheral blood stem cell support for MPE in six patients conferred no clear survival advantage. These patients died at median of four months from onset of MPE. Patients with bone marrow complex karyotypic abnormalities including deletion-13 (n = 9) had a shorter (median-18 months) overall survival compared to patients with normal cytogenetics (median-38 months). MPE in patients with MM is often associated with high-risk disease including deletion 13 chromosomal abnormality and heralds a poor prognosis despite aggressive local and systemic treatment.     

Malignant pleural effusions in lymphoproliferative disorders

In order to determine variables that correlate with malignant pleural effusion and mortality in patients with lymphoproliferative disorders and pleural effusion, a retrospective study was performed. Clinical data of hospitalized patients with a lymphoid malignancy and pleural effusion who underwent thoracentesis from January 1993 to December 2002 were collected. A logistic regression analysis was carried out to determine prognostic variables that predict malignant pleural effusion and hospital mortality. There were 86 patients who were admitted on 91 occasions. The median age was 70 years (range 4 - 92) and the male:female ratio was 44:42. Sixty-four patients (74%) had advanced disease, 43 (50%) had received prior chemotherapy and 9 (10%) were in remission. Of 91 cases of pleural effusions, 44 (48%) were bilateral, 80 (88%) were exudates and 48 (53%) were due to malignant involvement of pleura. In multivariate analysis, symptomatic pleural effusion (odds ratio 10.3, 95% confidence interval 1.7 - 98.3), pleural fluid mesothelial cell count < 5% (odds ratio 8.0, 95% confidence interval 1.4 - 58.2), pleural fluid:serum lactate dehydrogenase (LDH) > or =1 (odds ratio 6.4, 95% confidence interval 1.2 - 45.6) and pleural fluid lymphocyte percentage > or =50 (odds ratio 6.4, 95% confidence interval 1.2 - 50) were significantly correlated with malignant effusion. A secondary cancer (odds ratio 11.9, 95% confidence interval 2.3 - 88.8), pleural fluid:serum LDH > or =1 (odds ratio 10.9, 95% confidence interval 2.6 - 64.9), and pneumonia (odds ratio 6.4, 95% confidence interval 1.7 - 28.6) were significantly correlated with hospital mortality. In conclusion, malignant pleural effusion is the common etiology of pleural effusion in patients with lymphoid malignancy. Many clinical and cytochemical markers have discriminatory values in identifying malignant effusion. A high pleural fluid to serum LDH level correlates with malignant pleural involvement and hospital mortality.     

Therapeutical effect of intrapleural perfusion with hyperthermic chemotherapy on malignant pleural effusion under video-assisted thoracoscopic surgery

Background: Patients with malignant pleural effusions (MPEs) have limited life expectancy. This study aims to investigate the feasibility of intrapleural perfusion with hyperthermic chemotherapy (IPHC) under video-assisted thoracoscopic surgery on MPE patients.

Methods: MPE patients were enrolled in the study and treated with IPHC. The treatment response was classified as complete response (CR, no re-accumulation of pleural fluid for 4?weeks), partial response (PR, re-accumulation above the post-IPHC level but below the pre-IPHC level for four weeks), no response (NR; re-accumulation or above the pre-IPHC level). The change of Karnofsky performance score (KPS) and tumour markers were also recorded. Follow-up was done every two weeks during first month and monthly thereafter until death.

Results: Eighty patients included 46 males and 34 females were included in the study. The total response rate was 100%, with 71.3% of CR and 28.7% of PR. The KPS scores were significantly elevated and the level of tumour markers in pleural effusion were dramatically decreased after IPHC. The median survival was 16.8?months ranged from 2.1 to 67.4?months. One-year and two-year survival rates were 82.5% and 23.8%, respectively. There were no serious clinical compilations during IPHC treatment.

Conclusions: IPHC is a safety, effective and promising approach for MPE patients. It provides well survival benefit and minor toxicities.     

经多色流式细胞术确诊多发性骨髓瘤并发恶性胸腔积液6例临床特征分析

  目的:  分析由多色流式细胞术（flow cytometry,FCM）诊断的多发性骨髓瘤（multiple myeloma,MM）并发恶性胸腔积液（my-eloma pleural effusion,MPE）患者的临床特点。   方法:  回顾性分析江苏省苏北人民医院2016年7月至2020年5月经FCM确诊的6例MM并发MPE患者的临床特征、实验室指标和转归情况。   结果:  6例患者中位发病年龄为62（49~72）岁,男女比为2:1。其中,IgA型3例,IgG型2例,轻链型1例,所有患者常规脱落细胞学检查均为阴性,但FCM均能找到浆细胞。随访截至2020年5月1日,4例患者死亡,2例患者存活。FCM检测胸水浆细胞比例与胸水总蛋白、白蛋白、球蛋白、乳酸脱氢酶（lactate dehydrogenase,LDH）水平、腺苷脱氨酶（adenosine deaminase,ADA）及初诊时骨髓浆细胞比例成正相关（P < 0.05）,与胸水常规红细胞数、单个核细胞数、白细胞数以及血清血红蛋白、血小板、总蛋白、白蛋白、LDH水平、ADA、β2-微球蛋白均无明显相关性（P>0.05）。   结论:  MM并发MPE的患者较少见,FCM诊断的阳性率明显高于常规脱落细胞学检查,可将其作为常规胸水检查的必要联合检查项目,此类患者生存期短,预后较差。       

良恶性胸腔积液的临床特征及预测因素分析

目的:对比分析良恶性胸腔积液的临床特征,筛选恶性胸腔积液可能的预测因素。方法:收集良性胸腔积液患者30人和恶性胸腔积液患者32人的临床资料,分析胸腔积液及血液学相关指标（胸腔积液物理性状、胸腔积液和血液学生化、肿瘤标志物）。结果:恶性胸腔积液患者的年龄明显高于良性胸腔积液患者,但二者在性别分布上无差异。恶性胸腔积液的乳酸脱氢酶（LDH）、腺苷脱氨酶（ADA）、γ-干扰素（γ-IFN）显著低于良性胸腔积液,而癌胚抗原（CEA）、糖类抗原（CA19-9）、神经特异性烯醇化酶（NSE）显著高于良性胸腔积液（P均<0.05）。两组患者血液LDH、ADA、CEA、CA19-9的差异也具有统计学意义。条件Logistic回归分析发现CEA>10ng/ml、血性胸腔积液、ADA<15U/ml、CA19-9>20U/ml为恶性胸腔积液的预测因素。结论:非肿瘤标志物（如胸水颜色、ADA值）也有助于胸腔积液性质的判断。恶性胸腔积液的预测作用由大到小依次为CEA、血性胸腔积液、ADA、CA19-9。     

诱导化疗与放化疗联合治疗合并同侧胸腔积液局限期小细胞肺癌的对比研究

Objective: The aim of the study was to explore the effects and side effects of induction chemotherapy followed by chemoradiotherapy for limited-disease small cell lung cancer (LD-SCLC) patients with ipsilateral pleural effusion.Methods: From January 2005 to May 2009, 52 LD-SCLC patients with ipsilateral pleural effusion were treated with induction chemotherapy got disappearance of pleural effusion after chemotherapy were underwent thoracic radiotherapy (TRT; 50 Gy/25 fraction) or same chemotherapy regimen; patients without disappearance or with increasing of pleural effusion after chemotherapy were given same chemotherapy regimen.Therapeutic effect was evaluated every two cycles according to RECIST 1.0 and side-effects were evaluated every cycle according to NCI-CTC AE Grades.All patients were followed up, and the median follow-up time was 26 months.Results: The response rate of patients was 80.7% (42/52) after induction chemotherapy and 34 patients got disappearance of pleural effusion.The median survival time, 1- and 2-year survival rates were 15.4 months, 76.9% (40 /52) and 38.5% (20 /52) respectively.The median survival time, 1- and 2-year survival rates of patients with pleural effusion remission received chest radiotherapy (A group, n = 20), patients with pleural effusion remission received chemotherapy (B group, n = 14) and patients without pleural effusion remission received chemotherapy (C group, n = 18) were 21.5 months, including myelosuppression, fatigue, nausea and vomiting.No therapeutic related death was occurred.Conclusion: Induction chemotherapy plus chemoradiotherapy has shown better effect in prolonging survival of small cell lung cancer (SCLC) patients with ipsilateral pleural effusion than chemotherapy alone.The patients with decreased ipsilateral pleural effusion may receive benefit from subsequent TRT.     

吉西他滨联合多西紫杉醇方案治疗晚期肝癌的临床观察

目的评价吉西他滨联合多西紫杉醇治疗晚期肝细胞癌患者的疗效和不良反应。方法收集我科2006年2月-2010年2月间均诊断为晚期肝细胞癌患者42例。化疗方案剂量及方法设定：多西紫杉醇30 mg/m²,吉西他滨800 mg/m²在d1、d8天应用,静脉滴注。21天为 1周期,2周期后评价疗效。结果全组42例患者均可评价疗效。其中未见完全缓解患者,部分缓解率为21.4%(9/42),稳定47.6%(20/42),进展31.0%(13/42)。中位进展时间4.1月(95％CI：2.14~7.26月),中位生存时间9.2月(95％CI：4.25~18.12月)。无治疗相关死亡,主要不良反应为外周血粒细胞下降、血小板减少、轻度贫血、消化道反应、疲劳、外周神经毒性及偶发的腹泻和皮疹。结论吉西他滨联合多西他赛治疗晚期肝细胞癌具有显著的抗肿瘤作用,化疗期间出现血液学不良反应,食欲下降、乏力是普遍现象,需要临床重视。早期实施有效的干预可明显减少不良反应的发生率。     

胸腔热灌注治疗对肺癌胸水患者Th1/Th2免疫反应状态的影响

背景与目的:胸腔热灌注术是治疗肺癌胸水的独特方法,辅助性T细胞亚群(Th1/Th2)的平衡消长是反映机体抗肿瘤免疫功能的重要指标。本研究评价胸腔热灌注治疗肺癌胸水的临床综合疗效,同时观察胸腔热灌注治疗对肺癌胸水患者Th1/Th2免疫反应状态的影响。方法:在电视胸腔镜辅助下用43℃温盐水循环胸腔灌注60min,治疗24例肺癌胸水患者,观察随访胸水控制效果、副作用和生存时间。收集热疗前后患者外周血和胸水,用酶联免疫吸附法(ELISA)检测Th1型细胞因子白细胞介素2(interleukin-2,IL-2)、γ-干扰素(interferon-gamma,IFN-γ)和Th2型细胞因子白细胞介素4(IL-4)、白细胞介素10(IL-10)的浓度,同时用RT-PCR方法检测这些细胞因子mRNA的表达。结果:无手术死亡,无明显并发症。全组胸水控制总有效率达100%,完全缓解率为95.8%(23/24),部分缓解率为4.2%(1/24)。热疗后无胸水复发,生活质量有明显提高。全组中位生存期达18.3个月,1年生存率91.7%,2年生存率16.7%。与热疗前比较,热疗后肺癌胸水患者外周血或胸水中Th1型细胞因子浓度和mRNA阳性率均显著升高,而Th2型细胞因子则相反(P<0.05)。结论:电视胸腔镜辅助下胸腔热灌注术是一种安全、有效、微创的肺癌胸水治疗方法。胸腔热灌注治疗可促使肺癌胸水患者Th2免疫反应优势向Th1方向逆转。     

Bevacizumab plus chemotherapy for advanced non-squamous non-small-cell lung cancer with malignant pleural effusion

Purpose

The presence of malignant pleural effusion (MPE) indicates a poorer prognosis for patients with non-small-cell lung cancer (NSCLC) and impairs their quality of life. Because vascular endothelial growth factor (VEGF) is the key mediator MPE production, we evaluated the efficacy and safety of chemotherapy plus bevacizumab, an anti-VEGF antibody, in non-squamous NSCLC patients with MPE, especially regarding the control of pleural effusions.

Methods

From November 1, 2009 to September 30, 2011, medical charts of 13 consecutive patients with MPE who received bevacizumab plus chemotherapy as the initial or secondary treatment were retrospectively analyzed.

Results

Of the 13 patients, 6 did not undergo pleurodesis, 3 were unsuccessfully treated by pleurodesis, 2 had encapsulated pleural effusion, and 2 had no re-expansion of the lung. Twelve patients (92.3 %) achieved MPE control lasting >8 weeks following bevacizumab plus chemotherapy. Five of 10 patients with measurable lesions had confirmed partial responses. Of 3 patients without measurable lesions, one had confirmed CR. Median progression-free survival time without re-accumulation of MPE was 312 days. Grade 3 or 4 neutropenia, thrombocytopenia, hypertension, or proteinuria was observed in 2, 2, 1, or 1 patient, respectively.

Conclusions

This is the first study to report that bevacizumab plus chemotherapy is highly effective for the management of MPE in non-squamous NSCLC patients. Prospective clinical trials are warranted to investigate the efficacy of bevacizumab for MPE.