腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛的临床应用研究

目的评价腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛的止痛效果。方法105例晚期癌症患者,67例伴有后腹膜淋巴结广泛肿大并包绕神经、血管,均有顽固性上腹痛,经CT导引穿入膈脚前及后腹膜肿大淋巴结内行两侧腹腔神经丛乙醇阻滞术。结果经4个月随访观察,在2周,1,2,3,4个月,止痛总有效率分别为100.0%、98.1%、97.1%、93.8%和90.4%。止痛效果显著的患者,可观察到乙醇扩散较完全,能从两侧包绕腹主动脉,肿大的淋巴结有明显坏死。本组无一例严重并发症发生。结论CT导引下腹腔神经丛阻滞术治疗上腹部顽固性癌性疼痛是一种安全、有效的方法,值得推广应用。     

CT-Monitored Percutaneous Cryoablation of Uterine Fibroids after Uterine Artery Embolization

OBJECTIVE To investigate the effects of percutaneous cryoablation on uterine fibroids using computed tomographic (CT) guidance after uterine artery embolization. METHODS Twelve patients who failed to respond to uterine artery em- bolization were treated using percutaneous cryoablation. All patients had undergone previous uterine artery embolization an average of 1.2 years (0.7~1.6 years) ago. Two cases had abnormal bleeding, and the other 10 suf- fered from pressure and/or pelvic pain. Myoma diameters were 4 cm to 16.5 cm. By using CT guidance, 2.0, 2.4, 3.0 or 3.8 mm cryoprobes were placed into the fibroid, and two 15~20 min freezing processes were performed. He- mostasis was achieved only by pressing the incisions for several minutes. MR-imaging was performed before the procedure to measure the size and number of fibroid tumors, and follow- up MR-imaging determined the reduc- tion of the lesions. RESULTS All patients were discharged within 48 h of treatment. Almost no hemorrhage was found in all of the cases. No bladder or bowel injury or significant postsurgery pain was reported. Ice spheres were readily visual- ized at CT. Beam-hardening artifact from the metal probes was present, but did not interfere with the procedure. Myomas regressed up to 76.3% after 12 months of treatment, and the primary symptoms improved in all treated women. CONCLUSION CT-monitored percutaneous cryoablation is an effective and minimally invasive therapy for symptom relief and fibroid shrinkage after the failure of uterine artery embolization.     

经皮冷冻消融联合椎体成形术治疗椎体和椎旁转移瘤所致的疼痛

背景与目的：恶性肿瘤出现椎体转移并累及椎旁组织后,不仅引起疼痛,而且会导致椎体强度下降,诱发骨折,临床处理比较棘手。本研究旨在评估经皮冷冻消融联合椎体成形术治疗恶性肿瘤患者椎体及椎旁转移瘤所致疼痛的安全性和有效性。方法：回顾性分析2015年3月—2017年3月接受椎体成形术联合冷冻消融术的患者资料,纳入单一椎体和椎旁转移的恶性肿瘤患者,所有患者在相应的椎体层面伴有中、重度疼痛,并且需要服用止痛药物,其中有2例患者曾接受放疗,疼痛缓解不明显。为了控制疼痛,所有患者首先在CT引导下完成经皮冷冻消融治疗,然后转移至数字减影血管造影（digital substraction angiography,DSA）室接受椎 体成形术,采用视觉模拟评分法（visual analogue scale,VAS）评分法评估患者术前及术后1、3和6个月时的疼痛程度。记录患者术前及术后的任何不适主诉。结果：共有16例患者成功接受了冷冻消融联合椎体成形术治疗,平均年龄58.1岁,其中男性10例（10/16）,骨水泥平均注射量为4.2 mL。通过配对t检验,同术前相比,所有患者术后1个月的VAS评分均显著降低（P＜0.05）,随访3个月时进一步降低（P ＜0.05）,6个月时稳定（P＞0.05）。2例患者术后出现神经障碍,表现为股神经受损,单侧下肢麻木,抬腿困难,经过治疗后症状逐步缓解并最终消失。1例患者术后出现右侧腹壁肿胀,MRI检查显示血肿和右侧胸腔少量积液,未处理,后逐渐缓解。结论：我们的研究结果显示,经皮冷冻消融联合椎体成形术治疗单一椎体及椎旁转移瘤所致的疼痛,止痛效果明显,但有可能出现累及神经的并发症,术中需要仔细布针,结合CT引导并实时监控冰球范围。     

Functional CT in a rabbit model: evaluation of the perfusion characteristics before and after Ar-He cryoablation therapy

The objective of this study was to investigate the perfusion characteristics of rabbit liver tumours before and after Ar-He (argon-helium) cryoablation using functional CT and to evaluate the therapeutic effect of Ar-He cryoablation. VX-2 tumour was implanted into the livers of 30 New Zealand white rabbits. Two weeks after tumour implantation, Ar-He cryoablation was performed on these rabbits. Functional CT was performed on the rabbits before and after treatment on days 1, 5, 14, 21 and 35. In the meantime, five rabbits were killed, and the livers were removed for histopathological examination at each of the time points mentioned above. Perfusion characteristics of the tumour and hot spot, such as blood flow (BF), blood volume (BV) and permeability, were analysed based on multislice CT. Histopathological studies corresponding to functional CT were observed, and the therapeutic effects (whether the tumour disappeared completely or still remained) were judged. The two-tailed student's t-test was used to compare the differences between the effect of pre- and post-Ar-He cryoablation treatment on tumour perfusion parameters. After cryoablation treatment, the number of tumours exhibiting complete necrosis was 13 (52%), and their perfusion parameters, such as BF, BV and permeability values, were significantly lower than those before treatment (P < 0.05, P < 0.01 and P < 0.05, respectively). After treatment, the number of incomplete necrotic tumours was 12 (48%). In the earlier stage (within 14 days of treatment), the whole tumour perfusion parameters of BF, BV and permeability were significantly lower than those before treatment (P < 0.05). In the late stage (more than 14 days of treatment), the whole tumour perfusion parameters of BF, BV and permeability were not significantly different compared with the pretreatment results (P > 0.05). The hot spot perfusion parameters of incomplete necrotic tumours, such as BF, BV and permeability values, showed no significant differences compared with pretreatment (P > 0.05). Functional CT can measure the perfusion characteristics of hepatic tumours and is consistent with histopathological changes in the tumour after Ar-He cryoablation. Functional CT might also be accurate in judging the therapeutic effect of Ar-He cryoablation.     

未能切除胰腺癌患者术中NCPB的临床意义

目的 研究术中腹腔神经丛阻滞对无法切除胰腺癌患者的镇痛疗效及并发症。方法 41例患者经腹行直视下的腹腔神经丛阻滞，每人次注射无水酒精20－50ml，同时行胆肠转流或／和胃肠转流，部分患者行区域动脉化疗。结果 腹腔神经丛阻滞后6个月内或已死亡者中有32例患者疼痛完全缓解，4例明显减轻，5例无明显效果。38例术中出现血压下降，15例术后腹泻，结论 术中直视下经腹行无水酒精腹腔神经丛阻滞对缓解未能切除胰腺癌患者的疼痛具有明显的镇痛效果。     

Coeliac plexus block: utility of the anterior approach and the real time colour ultrasound guidance in cancer patient

AIMS: The aim of our study was to demonstrate the efficacy of ultrasound-guidance compared with computed tomography (CT) guidance for coeliac plexus block in cancer patients. METHODS: Coeliac plexus block (30 ml ethanol) was performed in 34 cancer patients (sex ratio: 10F, 24M), mean age: 54.8 years (range 26-67) under CT (n=21) and ultrasound-guidance (n=13). All patients had excruciating epigastric and generalized abdominal pain caused by cancer of the pancreas (n=13) or upper abdominal viscera (n=9) or a malignancy of extra-digestive origin (n=12). Feasibility and complication rates were analysed. RESULTS: Notable pain relief was obtained in 27 (79%) of the patients. The technical success rate was 100% for CT-guidance and 93% (13/14) for ultrasound guidance. There were six minor complications (17%): chemical peritonitis (n=2), orthostatic arterial hypotension (n=2) and transient left shoulder pain (n=2), no major complications occurred. The target route was transhepatic in 6/13 of the ultrasound cases and mean length was 6 cm (range 3-12 cm). Colour Doppler sonography improved visualization of the 21 Gauge Chiba needle when the needle shaft was vibrated. Echogenic foci were observed around the origin of the coeliac trunk and superior mesenteric artery in all cases. CT coeliac block was successfully performed after failure of ultrasound guidance in one patient. CONCLUSION: Ultrasound guidance is safe and effective and should be attempted for coeliac plexus block whenever possible.     

冷冻消融治疗椎旁恶性间叶组织肿瘤疼痛疗效研究

目的: 评价冷冻消融对于椎旁恶性间叶组织肿瘤疼痛治疗的有效性及安全性。 方法: 收集31例伴随疼痛的椎旁恶性间叶组织肿瘤患者,均不能或不能耐受手术切除,其疼痛使用传统的止痛治疗效果不佳。肿瘤直径3~20 cm。使用简明疼痛量表（BPI）,对患者术前基线水平及冷冻消融治疗后1天、1周、1个月、3个月的疼痛进行评估。 结果: BPI的分数被分为两类:疼痛的严重程度和疼痛对生活的影响,在冷冻消融术后,均呈现下降的趋势。疼痛严重程度评分在术后1天及1个月下降明显（P=0.001,t=3.862;P=0.031,t=2.261）,疼痛影响评分在术后1天及1周下降明显（P=0.016,t=2.566;P=0.036,t=2.195）。2例患者（6.45%）出现轻微并发症,无严重并发症发生。 结论: 对于合并癌性疼痛的不能手术切除的椎旁恶性间叶组织肿瘤患者,冷冻消融治疗是一种风险低,耐受性好的局部治疗手段,具有较好的疼痛治疗效果。      

氦氩冷冻治疗癌性疼痛的临床观察

目的探讨氩氦刀冷冻治疗癌性疼痛的疗效及安全性。方法 67例肿瘤患者在CT引导下行经皮穿刺氩氦刀冷冻治疗疼痛相关性瘤灶,观察术后患者疼痛缓解状况及瘤灶影像学改变。结果 67例患者在术后24小时、1周、1个月和3个月时疼痛缓解有效率分别为74.6%、86.6%、86.6%和73.1%,CT复查提示冷冻瘤灶呈坏死样改变,PET/CT提示病灶无活性或活性明显降低。全组术中、术后未出现严重并发症,主要不良反应包括寒战、血压波动、气胸或胸腔积液、术后发热、伤口渗血和周围神经损伤。结论氩氦刀冷冻治疗能有效缓解晚期肿瘤患者的癌性疼痛,改善生活质量,且安全性高,值得临床推广。     

Percutaneous image‐guided cryoablation of painful metastases involving bone

BACKGROUND:

This study sought to describe the results of a single‐arm multicenter clinical trial using image‐guided percutaneous cryoablation for the palliation of painful metastatic tumors involving bone.

METHODS:

Over a 44‐month period, 61 adult patients with 1 or 2 painful bone metastases with a score of 4 or more on a scale of 0 to 10 (≥4/10) worst pain in a 24‐hour period who had failed or refused conventional treatment were treated with percutaneous image‐guided cryoablation. Patient pain and quality of life was measured using the Brief Pain Inventory prior to treatment, 1 and 4 days after the procedure, weekly for 4 weeks, and every 2 weeks thereafter for a total of 6 months. Patient analgesic use was also recorded at these same follow‐up intervals. Complications were monitored. Analysis of the primary endpoint was undertaken via paired comparison procedures.

RESULTS:

A total of 69 treated tumors ranged in size from 1 to 11 cm. Prior to cryoablation, the mean score for worst pain in a 24‐hour period was 7.1/10 with a range of 4/10 to 10/10. At 1, 4, 8, and 24 weeks after treatment, the mean score for worst pain in a 24‐hour period decreased to 5.1/10 (P < .0001), 4.0/10 (P < .0001), 3.6/10 (P < .0001), and 1.4/10 (P < .0001), respectively. One of 61 (2%) patients had a major complication with osteomyelitis at the site of ablation.

CONCLUSIONS:

Percutaneous cryoablation is a safe, effective, and durable method for palliation of pain due to metastatic disease involving bone. Cancer 2013. © 2012 American Cancer Society.     

Use of positron emission tomography in evaluation of brachial plexopathy in breast cancer patients

18-Fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) has previously been used successfully to image primary and metastatic breast cancer. In this pilot study, 19 breast cancer patients with symptoms/signs referrable to the brachial plexus were evaluated with 18FDG-PET. In 11 cases computerized tomography (CT) scanning was also performed. Of the 19 patients referred for PET study, 14 had abnormal uptake of 18FDG in the region of the symptomatic plexus. Four patients had normal PET studies and one had increased FDG uptake in the chest wall that accounted for her axillary pain. CT scans were performed in 9 of the 14 patients who had positive brachial plexus PET studies; six of these were either normal or showed no clear evidence of recurrent disease, while three CTs demonstrated clear brachial plexus involvement. Of two of the four patients with normal PET studies, one has had complete resolution of symptoms untreated while the other was found to have cervical disc herniation on magnetic resonance imaging (MRI) scan. The remaining two patients almost certainly had radiation-induced plexopathy and had normal CT, MRI and PET study. These data suggest that 18FDG-PET scanning is a useful tool in evaluation of patients with suspected metastatic plexopathy, particularly if other imaging studies are normal. It may also be useful in distinguishing between radiation-induced and metastatic plexopathy.     

Endoscopic ultrasound-fine needle injection for oncological therapy

The minimal invasiveness and precision of endoscopic ultrasound (EUS) has lead to both its widespread use as a diagnostic and staging modality for gastrointestinal and pancreaticobiliary malignancies, and to its expanding role as a therapeutic modality. EUS-guided celiac plexus neurolysis is now a well-accepted modality for palliation of pain in patients with pancreatic cancer. EUS-guided ablation, brachytherapy, fiducial marker placement, and antitumor agent injection have been described as methods of performing minimally invasive oncological therapy. EUS-fine needle injection may be performed as adjunctive, alternative, or palliative treatment. This review summarizes the studies to date that have described these methods. A literature search using the PubMed/MEDLINE databases was performed. While most published studies to date are limited with disappointing outcomes, the concept of a role of EUS in oncological therapy seems promising.     

氩氦刀冷冻治疗兔VX2肝肿瘤的疗效分析

 目的 探讨氩氦刀治疗兔VX2肝脏肿瘤的疗效。方法 兔VX2肝肿瘤模型兔30只随机分为A、B和C组,每组10只,分别给予假手术、手术切除和氩氦冷冻,干预后第14、28天行CT平扫和增强检查,观察3组CT动态表现,并比较3组肝内转移有无差异。结果 术后14天C组表现为消融区低密度、无强化,消融区边缘呈环形强化。术后28天,两组消融区平扫均表现为低密度区;强化扫描时,部分边缘未见强化,部分边缘强化环较前扩大,病理提示强化部分有残瘤形成。治疗后35天,病理证实B、C两组肿瘤原位完全清除率比较差异无统计学意义(P>0.05); A、C两组肝内转移率差异有统计学意义(P<0.05)。结论 氩氦刀治疗能够杀灭肿瘤细胞,不会增加肿瘤的转移概率,CT可作为评价肝癌冷冻治疗疗效的有效手段。     

An Effective Therapy to Painful Bone Metastases: Cryoablation Combined with Zoledronic Acid

Approximately half or more of patients diagnosed with late malignant tumors may suffer from metastatic bone pain, effective palliation of pain becomes an important part of comprehensive therapy for malignant tumors. In this study, we examined the efficacy and safety of the combined regimen of cryoablation and zoledronic acid in patients of bone metastatic pain. A total of 84 subjects were randomly divided into three groups, and underwent treatments of cryoablation plus zoledronic acid, cryoablation alone, zoledronic acid alone between June 2009 and March 2012. Patients responses had been assessed for a total of 6 months by using the Brief Pain Inventory (BPI)-Short Form. The results showed that the mean response of worst and average pain significantly dropped at week 2 (all P?P?P?Cryoablation plus zoledronic acid regimen showed significant drop in worst and average pain between week 1 and week 4 compared to zoledronic acid alone (all P?P?相似文献   

氩氦刀靶向冷冻治疗肝癌的初步研究

目的初步建立氩氦刀靶向冷冻治疗肝癌的技术和探讨其原理、安全性及近期疗效.方法8例无法手术的原发和继发性肝癌,其中3例术前行肝动脉栓塞化疗,采用氩氦超导手术系统(简称氩氦刀),分别在CT、DSA定位或术中直视下对肿瘤病灶行冷冻治疗.结果8例患者冷冻治疗后无手术死亡、出血、胆瘘、皮肽冻伤、感染、穿刺道种植转移等严重并发症.术后CT影像能观察到病灶冷冻治疗的有效范围,3例术前接受肝动脉栓塞化疗者术后1～6个月瘤体有进一步不同程度的缩小.3例原发性肝癌术前AFP值增高的患者术后均有下降.治疗后随访2～11个月,仅1例死于全身转移,其余均存活.结论CT、DSA引导和术中直视氩氦刀冷冻治疗肝癌技术可靠,创伤小,安全性高,是治疗无手术机会肝癌的一种有效的新手段,其远期疗效和在肝癌综合治疗中的价值尚有待于进一步的前瞻性临床试验研究说明.     

腹腔神经丛阻滞术的应用进展

腹腔神经丛阻滞术（neurolytic celiac plexus block，NCPB）是缓解胰腺癌或其他恶性肿瘤所致上腹部及背部疼痛的有效方法。腹腔神经丛松解术是治疗上腹部癌痛的常规和有效方法，在缓解疼痛的同时减少了镇痛药物导致的不良反应，提高了患者的生存质量。本文对临床常用的腹腔神经丛阻滞术的方法学研究和进展进行综述。      

B超引导下经皮氩氦刀治疗肝癌

目的：探讨经皮穿刺氩氦刀治疗肝癌的原理,方法及安全性。方法：15例肝癌患者,超声引导下穿刺,CRY Ocare-TM低温手术系统冷冻头插至瘤体远端冷冻。结果：15例病人冷冻治疗后无手术死亡,无肝破裂,出血,胆瘘,皮肤冻伤及穿刺道种植转移或感染等并发症,术后有1例出现气胸及反应性胸腔积液,术后低热有8例,术前AFP值增高的8例病人,术后AFP值均有下降,其中4例恢复正常。术后彩色多普勒B超显示肝癌内血供消失,术后1－5个月所有病人均进行了一次以上CT检查,见瘤体均有不同程度缩小,增强扫描亦未见强化灶。结论：B超引导下经皮穿刺氩氦刀治疗肝癌是一种合理,安全,有效,微创的新治疗方法。     

氩氦刀冷冻消融治疗老年早期非小细胞肺癌的临床疗效观察

目的:观察氩氦刀冷冻消融治疗老年早期非小细胞肺癌的疗效及安全性。方法:非小细胞肺癌（NSCLC)患者28 例,经病理或细胞学确诊,不愿接受手术或无手术适应证的早期（I期及部分II期）的70岁以上老年患者,全部行CT引导氩氦刀冷冻消融术,观察局部病灶变化、疗效、并发症及生存情况。结果:术后1个月复查CT,按实体瘤评价标准缓解率（CR+PR)为71.4%（20/28）。术后3个月及6个月评价疗效（CR+PR)分别为67.9%和64.3%。1~2年随访过程中7例（25.0%）出现转移,其中5例患者出现纵隔淋巴结转移,2例患者出现远处转移,死亡2例,21例（75.0%）患者未见肿瘤复发或转移征象。所有患者均未出现严重并发症。结论:氩氦刀冷冻消融治疗老年早期非小细胞肺癌疗效较好,安全性高,是老年早期NSCLC治疗的新选择,具有较好的临床应用前景。     

CT引导下直肠癌根治术后局部复发冷冻消融治疗的研究

背景与目的：结直肠癌的局部复发是接受根治性手术切除的患者治疗失败的主要原因之一。该研究旨在探索直肠癌根治术后局部复发冷冻消融治疗的可行性、安全性及有效性。方法：2013年10月-2015年1月共入组22例直肠癌根治术后局部复发患者,行27次冷冻消融术,术后随访12~32个月。治疗后影像学随访采用盆腔增强CT或MRI。统计技术成功率、并发症发生及处理情况、1年内靶病灶局部控制率,比较术前、术后患者疼痛评分。结果：该组研究技术成功率为100%,主要并发症发生率为18.5%,包括小便困难、患侧肌力下降、脓肿形成、重度组织冻伤。术后1年内靶病灶局部控制率为72.7%,局部病灶进展时间为(11.1±4.3)个月。患者术前与术后第3天进行数字疼痛评分(numerical rating scale,NRS),术前与术后6个月NRS差异有统计学意义(P＜0.05);术前与术后12个月NRS差异无统计学意义(P=0.854)。结论：CT引导下冷冻消融作为一种治疗直肠癌根治术后局部复发的新方法,安全可行,靶病灶局控率高,短期内疼痛缓解明显。     

Cryoablation or radiofrequency ablation of the small renal mass : a meta-analysis

BACKGROUND.

The incidence of renal cell carcinoma is rising because of incidental detection of small renal masses (SRMs). Although surgical resection remains the standard of care, cryoablation and radiofrequency ablation (RFA) have emerged as minimally invasive treatment alternatives. The authors of this report performed a comparative meta‐analysis evaluating cryoablation and RFA as primary treatment for SRMs.

METHODS.

A search of the MEDLINE database was performed reviewing the world literature for clinically localized renal masses treated by cryoablation or RFA.

RESULTS.

Forty‐seven studies representing 1375 kidney lesions treated by cryoablation or RFA were analyzed. No differences were detected between ablation modalities with regard to mean patient age (P = .17), tumor size (P = .12), or duration of follow‐up (P = .53). Pretreatment biopsy was performed more often for cryoablated lesions (82.3%) than for RFA (62.2%; P < .0001). Unknown pathology occurred at a significantly higher rate for SRMs that underwent RFA (40.4%) versus cryoablation (24.5%; P < .0001). Repeat ablation was performed more often after RFA (8.5% vs 1.3%; P < .0001), and the rates of local tumor progression were significantly higher for RFA (12.9% vs 5.2%; P < .0001) compared with cryoablation. The higher incidence of local tumor progression was found to be correlated significantly with treatment by RFA on univariate analysis (P = .001) and on multivariate regression analysis (P = .003). Metastasis was reported less frequently for cryoablation (1.0%) versus RFA (2.5%; P = .06). Cryoablation usually was performed laparoscopically (65%), whereas 94% of lesions that were treated with RFA were approached percutaneously.

CONCLUSIONS.

Ablation of SRMs is a viable strategy based on short‐term oncologic outcomes. Although extended oncologic efficacy remains to be established for ablation modalities, the current data suggest that cryoablation results in fewer retreatments and improved local tumor control, and it may be associated with a lower risk of metastatic progression compared with RFA. Cancer 2008. © 2008 American Cancer Society.     

A 6-year survival case of locally advanced unresectable pancreatic tail cancer treated with chemo-radiation therapy

We report a case of locally advanced unresectable pancreatic tail cancer patient who survived over 6 years by chemo-radiation therapy (CRT). A 61-year-old male was pointed out by CT to have pancreatic tail cancer of 5.6 cm in diameter that invaded to the stomach, left kidney and adrenal gland, nerve plexus of celiac and superior mesenteric artery, was diagnosed as locally advanced unresectable pancreatic tail cancer. CRT of gemcitabine (GEM) with RT to a primary lesion was successful. After two years and 11 months, Schnitzler's metastasis appeared and RT was effective to recover from rectal stricture. At three years and 3 months, GEM was converted to S-1. After 4 years and 5 months, paraaortic lymph node metastasis was enlarged, so chemotherapy was changed to combination of GEM + S-1. After 4 years and 10 months, upper mediastinal lymph node metastasis appeared. At 6 years and 1 month, RT to upper mediastinum for pain control was performed. Finally, 6 years and 6 months after the first diagnosis, he died of pancreatic cancer. A long-term survival of locally advanced unresectable pancreatic cancer is very rare. In the case of pancreatic cancer that CRT is effective to the remission of primary lesion, CRT is potentially useful to perform for the control of metastatic lesion or palliative therapy.