恶性梗阻性黄疸患者内支架植入术后近距离治疗的临床价值

背景与目的:恶性梗阻性黄疸行单纯引流仅解决黄疸问题,没有对肿瘤本身进行治疗,患者常在短期内死于肿瘤的进展.近年来出现的经外引流管胆管内后装放疗、多极射频消融(rodiofrequency ablation,RFA)及动脉药盒(port-cathetersystem,PCS)局部化疗栓塞等介入微创技术,因其对肿瘤的直接治疗作用而在恶性梗阻性黄疸的治疗中得到广泛应用.本研究拟对恶性梗阻性黄疸行内支架(expandablemetallic biliary endoprothesis,EMBE)植入术后,经外引流管胆管内后装放疗、RFA及PCS局部化疗栓塞的临床价值进行探讨.方法:49例不能或不宜行外科手术治疗的恶性梗阻性黄疸患者,其中肝门区肿瘤25例(肝门原发性肝癌17例,肝门转移性肝癌8例),胆管癌11例,胰头癌6例,汇管区胆管腺癌7例.分4组,第1组为单纯EMBE组;第2组为EMBE加后装放疗组;第3组EMBE加RFA组;第4组为EMBE加PCS组.所有患者先行经皮胆管引流内支架植入术,然后第2组行经外引流管后装放疗;第3组行经皮RFA;第4组行PCS植入术,按肿瘤生物学特性及药代动力学特点,经药盒泵入化疗药物.结果:49例胆管引流内支架植入术成功,其中13例行单纯EMBE植入术,16例在EMBE植入术后行胆管内后装放疗,9例行RFA,11例在EMBE植入术后行PCS植入术.随访1～12个月,EMBE组:1～3个月内6例(46.1%)出现再闭塞,2～6个月内死亡8例(61.5%),12个月内死亡11例(84.6%);EMBE加后装放疗4例(25%)1～3个月内出现再闭塞,2～6个月内死亡5例(31.25%),12个月内死亡6例(37.5%);EMBE加RFA组1～3个月内2例(22.2%)出现再闭塞,2～6个月内死亡2例(22.2%),12个月内死亡3例(33.33%);EMBE加PCS组3例(27.27%)1～3个月内出现冉闭塞,2～6个月内死亡5例(45.45%),12个月内死亡6例(54.54%).EMBE组分别与近距离治疗3组的死亡率及再闭塞率相比,均有显著差异性(P＜0.01).结论:对恶性梗阻性黄疸患者EMBM后应主动进行抑癌治疗,以提高其疗效.     

经皮肝穿胆道内支架置入术治疗恶性梗阻性黄疸(附25例报告)

经皮肝穿胆道内支架置入术治疗恶性梗阻性黄疸,是临床重要姑息性治疗手段,可替代传统的胆管内、外引流术和外科姑息性胆肠吻合术[1].     

恶性高位梗阻性黄疸的介入治疗

背景与目的:侵犯或压迫肝门部胆管的恶性肿瘤造成的胆道高位梗阻,因梗阻部位多位于胆总管上段、肝总管,左右叶肝管甚至互不相通,单侧PTBD引流只能局限于引流管头端所放置的单一分支肝管,部分病例PTBD术后黄疸没有明显减退,甚至短期内加重,导致病情进一步恶化。本研究探讨左右叶双侧PTBD结合内支架术治疗恶性高位梗阻性黄疸的疗效。方法:17例高位恶性梗阻性黄疸的患者(男性11例,女性6例,平均年龄63.4岁),行左、右叶双侧PTBD结合内支架治疗。置入2枚支架的15例;2例为一侧肝管至胆总管置入支架,另一侧留置引流管。15例PTBD术后行TAI/TACE或放疗。结果:全部患者PTBD手术成功。治疗后总胆红素明显下降,由(357.7±142.5)μmol/L降至(174.7±87.6)μmol/L。引流通畅中位时间8.9个月,全组生存中位时间11.2个月。结论:左右叶双侧PTBD结合内支架治疗高位恶性梗阻性黄疸近期疗效肯定,早期引流与多支引流同样重要。     

经皮肝内支架近距离照射治疗梗阻性黄疸

对28例梗阻性黄疸进行了介入治疗，认为行经皮经肝胆汁引流术（PTCD)、内支架置人术，加近距离照射是治疗恶性梗阻性黄疸的有效方法，明显改善患者生活质量，延长存活时间。     

金属胆道支架植入联合介入化疗治疗恶性梗阻性黄疸的疗效

目的评价金属胆道支架植入联合介入化疗治疗恶性梗阻性黄疸的疗效。方法对20例接受金属胆道支架植入联合介入化疗治疗的恶性梗阻性黄疸患者,回顾性分析血清总胆红素和谷丙转氨酶的变化,以及联合介入化疗后的生存时间和生存率。结果术后两周,血清总胆红素和谷丙转氨酶较术前明显下降,术后四周,9例患者的血清总胆红素和谷丙转氨酶恢复正常。本组病例的中位生存时间为6个月,半年及一年生存率分别为60%及35%。结论对于无法外科手术治疗的恶性梗阻性黄疸患者,金属胆道支架植入联合介入化疗能明显提高其生活质量及生存率。     

恶性梗阻性黄疸的诊断治疗

梗阻性黄疸是临床上常见的体征,涉及面较广,内外科医生在诊断其发病原因方面有时会遇到一定困难。近年来由于新检查方法的应用,对梗阻性黄疸的正确诊断率有明显提高。以下就恶性梗阻性黄疸的诊断、治疗做一介绍。1 恶性梗阻性黄疸的诊断:临床依据病史、体检和一般检查,梗阻性黄疸的术前确诊率可达80%。诊断困难者尚需依靠一些特殊检查,B型超声扫描,电子计算机X线照像,逆行胰胆管造影,经皮肝穿刺胆道造影,胰腺功能和形态学检查等方能明确诊断。1.1 生化试验诊断:血清酶学检查和生化检查对于鉴别肝内肝外阻塞性黄疸以及良恶性病变的诊断有一定参考价值。     

恶性梗阻性黄疸的介入治疗

目的：探讨介入治疗恶性梗阻性黄疸的临床价值。方法：31例恶性梗阻性黄疸患者先行PTCD（17例）及金属支架入术（14例）,1周后行肝动脉灌注化疗或栓塞治疗,结果：31例PTCD或胆道内支架置入后,血清总胆红素下降,2例患者2个月内死于与本治疗无关的原因,2例支架再狭窄,所有病例均获随访,平均生成9个月,最长26个月。结论：介入治疗恶性梗阻性黄疸是一种有效的方法;介入治疗可以延长恶性梗阻性黄疸患者的生存时间。     

58例恶性梗阻性黄疸的治疗分析

目的:对58例恶性梗阻性黄疸的治疗进行分析.方法:回顾性分析恶性梗阻性黄疸患者58例,男性30例,女性28例,平均年龄(60±29)岁,所有患者均经CT及MRI检查,结合临床确诊为恶性梗阻性黄疸,全部行PTCD或胆道支架置入,28例患者术后给予TACE治疗,3例患者行PTGD治疗.结果:58例患者均胆道穿刺成功,置入引流管或放置胆道支架,各项胆红素(TBL,DBL,IBL)下降至正常者50例,无明显下降者5例,升高者3例,28例行TACE治疗,6例行PTGD治疗.结论:PTCD及阴道支架置入缓解梗阻性黄疸明显,先TACE治疗患者生存期超过未行TACE治疗患者,高位梗阻患者(特别是老年患者)预后较差.     

58例恶性梗阻性黄疸的治疗分析

目的：对58例恶性梗阻性黄疸的治疗进行分析。方法：回顾性分析恶性梗阻性黄疸患者58例,男性30例,女性28例,平均年龄（60±29）岁,所有患者均经CT及MRI检查,结合临床确诊为恶性梗阻性黄疸,全部行PTCD或胆道支架置入,28例患者术后给予TACE治疗,3例患者行PTGD治疗。结果：58例患者均胆道穿刺成功,置入引流管或放置胆道支架,各项胆红素（TBL,DBL,IBL）下降至正常者50例,无明显下降者5例,升高者3例,28例行TACE治疗,6例行PTGD治疗。结论：PTCD及胆道支架置入缓解梗阻性黄疸明显,先TACE治疗患者生存期超过未行TACE治疗患者,高位梗阻患者（特别是老年患者）预后较差。     

恶性梗阻性黄疸介入治疗进展

恶性梗阻性黄疸（MOJ）患者因肝功能逐渐恶化、肿瘤不断进展．生存时间极短暂,经皮肝穿刺胆管引流和支架植入（PTBD）具有创微性、可重复性等优点,已经成为MOJ的首选疗法,在此基础上联合局部放疗、化疗、射频消融等综合治疗,可望进一步提高疗效。全文着重对PTBD技术、疗效,以及联合多种抗肿瘤局部治疗疗效进行综述和展望。     

内镜下胆道支架治疗恶性胆道梗阻临床观察与护理

目的:总结通过纤维十二指肠镜逆行胆胰管造影(ERCP)放置胆道内支架治疗晚期恶性胆道梗阻的临床观察和护理.方法:32例恶性梗阻性黄疸的患者,均行ERCP(经内镜逆行胰胆管造影)术,根据情况置人不同支架.结果:术后黄疸逐渐消退,皮肤瘙痒等症状消失或减轻.插管成功的30例患者血清总胆红素从(170.84±101.72)μmol/L下降到术后l周(105.42±82.44)μmol/L,发生并发症2例,其中急性胰腺炎1例,胆管炎l例,并发症发生率均为3.33％.结论:全部患者经过精心护理和健康教育,临床症状显著缓解,生存质量明显改善.     

ERCP胆管支架置入与传统手术方法解除恶性胆道梗阻的临床疗效及安全性比较

目的：比较内镜下逆行胰胆管造影（ ERCP）胆管支架置入与传统手术方法解除恶性胆道梗阻的临床疗效及安全性。方法根据患者手术方法不同将92例恶性胆道梗阻患者分入A组、B组及C组,3组患者分别接受传统外科手术治疗、ERCP置入塑料支架治疗及ERCP置入金属支架治疗。结果3组生存时间无显著差别（P＞0．05）。 C组术后胆道通畅时间显著长于B组,差别具有统计学意义（P＜0．05）。 B组及C组住院时间显著少于A组（P＜0．05）。术后1周B组及C组肝功能检测指标显著优于A组（P＜0．05）。 A组、B组及C组并发症发生率分别为43．8％、14．3％和15．6％（P＜0．05）。结论 ERCP支架置入与传统手术方法解除胆道恶性梗阻疗效相当,但前者术后并发症少,患者肝功能指标恢复快,行金属支架置入者引流效果更为理想。     

顺铂联合生物反应调节剂腔内治疗恶性胸腹腔积液

目的探讨顺铂(DDP)联合生物反应调节剂(BRM)治疗恶性胸腹腔积液的疗效.方法对80例恶性胸腹腔积液患者,先抽尽积液,再腔内注射DDP-BRM(包括高聚金葡素、沙培林、胞必佳、白细胞介素-2),每周1次,连续2～3周,1个月后观察疗效.结果DDP联合BRM治疗恶性胸腹腔积液总有效率为85.0%,不同的BRM与DDP联合运用,有效率无显著性差异(P＞0.05),并发症少.结论DDP联合BRM治疗恶性胸腹腔积液疗效肯定,是1种较好的治疗方法.     

良性肿瘤和恶性实体瘤患者血浆Lp（a）和其它脂类的变化

本文对５７例良性肿瘤、５２例恶性实体瘤患者和８０例正常人血浆中Ｌｐ（ａ）和ＴＣ、ＴＧ、ＡｐｏＢ、ＡｐｏＡ－Ⅰ的水平进行了比较。结果发现，上述指标在良性肿瘤与正常人之间无统计学差异。恶性实体瘤患者的Ｌｐ（ａ）水平明显高于良性肿瘤患者和正常人，ＴＣ水平明显低于良性肿瘤患者和正常人，ＡｐｏＢ和ＡｐｏＡ－Ⅰ明显低于正常人。本文认为，Ｌｐ（ａ）可能通过影响凝血系统而对肿瘤的生长和转移发挥一定的促进作用，Ｌｐ（ａ）和ＴＣ水平有可能成为恶性肿瘤辅助诊断的生化指标。脂质、脂蛋白和载脂蛋白与肿瘤的关系，值得进一步研究。     

含羟基喜树碱联合方案治疗中晚期非小细胞肺癌

目的 :观察含羟基喜树碱 (HCPT)联合方案治疗中晚期非小细胞肺癌 (NSCLC)患者的客观疗效及毒副作用。方法 :4 6例中晚期非小细胞肺癌患者为治疗组 ,应用含羟基喜树碱方案化疗 ,其中 2 5例肺腺癌患者接受HFAP方案 ,2 1例肺鳞癌患者接受HCAP方案 ,4周为一周期 ,2周期为一疗程 ;以同期住院的未用HCPT联合化疗的同类患者 4 2例作为对照组 ,其剂量、周期、疗程与治疗组相同 ,但不用HCPT。结果 :治疗组 4 3例患者完成一疗程治疗 ,肺腺癌有效率为 5 6 % ,CR 2例 ,PR 12例 ;肺鳞癌有效率为 5 5 5 % ,CR为 0 ,PR 10例 ,总有效率 (CR +PR)为 5 5 8% ;对照组 4 2例均完成一疗程治疗 ,肺腺癌有效率为37 5 % ,CR 1例 ,PR 9例 ;肺鳞癌有效率为 33 3% ,PR 6例 ,有效率 35 7% ;两组间差异显著 (P <0 0 5 )。治疗组和对照组的毒副反应主要表现为食欲不振、脱发、恶心呕吐和白细胞及血小板减少 ,两组毒副反应发生率无显著性差异 (P >0 0 5 )。结论 :羟基喜树碱联合化疗治疗中晚期非小细胞肺癌疗效确切 ,副作用可耐受 ,该药是治疗非小细胞肺癌较为有效的药物 ,值得进一步在临床中观察和研究。     

Malignant mucosal melanoma treated with carbon ion radiotherapy with concurrent chemotherapy: Prognostic value of pretreatment apparent diffusion coefficient (ADC)

Background and purpose

To evaluate the potential of apparent diffusion coefficient (ADC) value before carbon ion radiotherapy (C-ion RT) for malignant mucosal melanoma (MMM) to predict prognosis.

Materials and methods

We recruited 37 patients with MMM in the head and neck treated by C-ion RT with concomitant chemotherapy. Univariate and multivariate analyses of minimum ADC, mean ADC, tumor volume, age, PS, and gender were performed to identify prognostic factors.

Results

The 3-year local control rate, distant metastasis-free survival rate and overall survival rate of all patients were 81.1%, 37.6% and 65.3%, respectively, with a median follow-up period of 19.0 months. In univariate analyses, lower minimum ADC (?0.6380 × 10⁻³ mm²/s) and lower mean ADC (?1.1523 × 10⁻³ mm²/s) were unfavorable prognostic factors for distant metastasis (p = 0.029 and p = 0.014, respectively), and lower minimum ADC was an unfavorable prognostic factor for overall survival (p = 0.019). However, there was no significant prognostic factor of local control including ADC value. In multivariate analyses, only minimum ADC was selected as a prognostic factor of distant metastasis-free survival and overall survival (p = 0.015 and p = 0.006, respectively).

Conclusion

Minimum ADC can be a prognostic factor of MMM in the head and neck after C-ion RT.     

Peritoneal dissemination from high-grade appendiceal cancer treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC)

Background

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown variability in survival outcomes when used to treat peritoneal surface disease (PSD) from appendiceal and colorectal cancers. The primary goal of this study was to examine outcomes for high-grade appendiceal (HGA) and high-grade colonic primaries after CRS-HIPEC to determine if a significant difference exists between the two groups.

Methods

A retrospective analysis of patients with peritoneal dissemination from appendiceal and colonic primaries were identified in a prospectively maintained database of 1,223 CRS-HIPEC procedures performed between 1991 and 2015. Patient demographics, performance status resection status, tumor grade, nodal status, morbidity, mortality, and survival were reviewed with biopsy-proven PSD being classified according to primary site. Univariate and multivariate analyses were performed, and outcomes compared.

Results

The study identified 171 CRS-HIPEC procedures for 165 patients: 110 (66.7%) for HGA and 55 (33.3%) for high-grade colonic lesions. Observed median disease-free survival (DFS) and overall survival (OS) for both groups were the same at14.4 and 18 months, respectively. Median survival according to resection status for R0/R1, R2a, and R2b/c were 36, 15.6, and 8.4 months (P<0.0001). Median OS for those who received preoperative chemotherapy versus those who did not were 14.4 and 20.4 months, respectively (P=0.01). For those who received preoperative chemotherapy, no difference was apparent in the DFS interval (P=0.34). Multivariate predictors of OS included resection status (P<0.0001) and lymph node involvement (P=0.0005).

Conclusions

Preoperative chemotherapy offered no clear DFS or OS benefit, for HGA or high-grade colon cancer patients. Complete cytoreduction offered the greatest survival benefit to both groups with a correlating drop in survival to resection status. Outcomes for high grade appendiceal cancer are remarkably similar to colon cancer.     

External validation of COMPASS and BIOSCOPE prognostic scores in colorectal peritoneal metastases treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC)

IntroductionThe selection of patients undergoing cytoreductive- surgery (CRS) followed by hyperthermic intraperitoneal chemotherapy (HIPEC) is crucial. BIOSCOPE and COMPASS are prognostic scores designed to stratify survival into four classes according to clinical and pathological features. The purpose of this study is to analyze the prognostic role of these scores using a large cohort of patients as an external reference.MethodsOverall survival analysis was performed using Log-Rank and Kaplan-Meier curves for each score. The probability of survival at 12, 36, and 60 months was tested using receiver operating characteristic (ROC) curves to determine sensitivity and specificity.ResultsFrom the validation cohort of 437 patients, the analysis included 410 patients in the COMPASS group and 364 patients in the BIOSCOPE group (100% data completeness). We observed a different patient distribution between classes (high-risk for BIOSCOPE compared to COMPASS, p = 0.0001). Nevertheless, both COMPASS and BIOSCOPE effectively stratified overall survival (Log-Rank, p = 0.0001 in both cases), with a lack of discrimination between COMPASS classes II and III (p = n.s.). COMPASS at 12 m and BIOSCOPE at 60 m showed the best performance in terms of survival prediction (AUC of 0.82 and 0.81). The specificity of the two tests is good (median 81.3%), whereas sensibility is quite low (median 64.2%).ConclusionFollowing external validation in a large population of patients with CRC-PM who are eligible for surgery, the COMPASS and BIOSCOPE scores exhibit high inter-test variability but effectively stratify cancer-related mortality risk. While the quality of the scores is similar, BIOSCOPE shows better inter-tier differentiation, suggesting that tumor molecular classification could improve test discrimination capability. More powerful stratification scores with the inclusion of novel predictors are needed.     

Thrombotic events in metastatic colorectal cancer patients treated with leucovorin,fluorouracil and irinotican (FOLFIRI) plus bevacizumab

Objective

To determine the incidence and risk factors for thrombotic events (TEs) in patients with metastatic colorectal cancer (mCRC) who received bevacizumab (BV) and FOLFIRI (leucovorin, fluorouracil and irinotican) compared to FOLFIRI alone.

Methods

Single institution retrospective study of 450 mCRC patients who received either BV plus FOLFIRI or FOLFIRI alone between April 2004 and August 2012. Demographics, TE risk factors, and treatment data were abstracted from patients’ records. Multivariate analysis was used to identify factors that contributed to thromboembolism.

Results

Two-hundred-sixty-one mCRC patients received BV plus FOLFIRI [64.8% males, mean body mass index (BMI) of 27.6] compared to 189 control patients who received FOLFIRI alone (61.9% males, BMI 27.2). The incidence of TEs was 14.9% in the BV plus FOLFIRI group, compared to 15.9% in the control group. Multivariate analysis controlling for age, BMI, gender, malignancy, metastatic sites, line of treatment, and risk factors did not suggest a significant increase in the risk of TE with the addition of BV (OR =0.83 95% CI: 0.40-1.70; P=0.602). No difference in the site of TEs was observed between the treatment groups. The only statistically significant risk factor for thrombosis in the FOLFIRI plus BV group was increased BMI (OR =1.05; 95% CI: 1.01-1.10; P=0.01).

Conclusions

This study does not support a significant increase in the risk of TE in patients with mCRC who received BV in addition to FOLFIRI. Increased BMI may be a risk factor for thrombosis in patients treated with BV.     

Proposed modification of the eighth edition of the AJCC-ypTNM staging system of esophageal squamous cell cancer treated with neoadjuvant chemotherapy: Unification of the AJCC staging system and the Japanese classification

BackgroundThe eighth edition of the American Joint Committee on Cancer (AJCC) tumor node metastasis (AJCC-TNM 8th) system adopted the newly separate post-neoadjuvant pathologic stage group (ypTNM). However, it is not compatible with the Japanese pathologic classification after neoadjuvant chemotherapy (JPN-CT-pTNM). The aim of this study is to clarify the subjects of the AJCC-ypTNM 8th and propose a unification of the AJCC and Japanese systems to create novel AJCC-CT-pTNM 8th.MethodsParticipants were 304 esophageal squamous cell carcinoma (ESCC) patients who underwent neoadjuvant chemotherapy followed by 3 stage esophagectomy between 2010 and 2019. Predictive probabilities of pN, pM in AJCC-ypTNM 8th and JPN-CT-pTNM 11th systems were evaluated to propose novel system.ResultsIn training data from 234 patients, the overall survival rate was statistically better for ypStage IIIA than ypStage II (P = 0.040) resulting in staging inversion in AJCC-ypTNM 8th. Predictive probability of pathological N status in AJCC-ypTNM 8th (Akaike Information Criterion: AIC = 979.53) was superior to that in JPN-CT-pTNM 11th (AIC = 999.07). In AJCC-ypTNM 8th, 71% (15/21) of ypM1 diseases were supraclavicular lymph nodes (No. 104 L/N as regional in JPN-CT-pTNM 11th) metastases with considerably good prognosis. The predictive probability of the novel AJCC-CT-pTNM 8th [unification of ypStage II and IIIA, conversion of supraclavicular L/Ns metastases from ypM to ypN] (AIC = 1054.24) was superior to that of the existing AJCC-ypTNM 8th (AIC = 1070.74). The feasibility of novel system was validated using test data from 70 patients.ConclusionsUnification of the AJCC and Japanese systems yields a simpler and more precise predictive system after neoadjuvant chemotherapy.