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消化道肿瘤肝转移的介入治疗课件

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消化道肿瘤肝脏转移 消化道肿瘤肝转移 介入治疗消化道肿瘤肝转移 瘤肝转移介入治疗 治疗消化道肿瘤肝转移的 道肿瘤肝转移的 肝转移的介入治疗
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With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 消化道肝转移癌的介入治疗 裘华森 浙江中医药大学附属第一医院普外科 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 概述 n肝脏是消化道恶性肿瘤转移的最常见器官 n结直肠癌肝转移的发生率可高达50% n而能获得手术切除者仅占10% ~ 20% Cromheecke M, Jong KP, Hoekstra HJ.Current treatment for coIorectal cancer metastatic to the liver.Eur J Surg Oncol,1999,25:451.463. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society Nordlinger教授归纳1568例病例后认为肿瘤肝转移癌的不利因素 1.原发性肿瘤淋巴结侵犯 2 .原发肿瘤侵犯浆膜 3.原发肿瘤引起肝转移的时间间隔不超过2年 4.肝转移切除时“安全距离”未超过1CM 5.肝转移灶数目大于4个 6.病人年龄小于60岁 7.肝转移灶直径大于5CM 8.CEA大于30ug/ml Surgical resection of colorectal carcinoma metastases to the liver. A prognostic scoring system to improve case selection, based on 1568 patients. Association Francaise de Chirurgie With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 治疗观点 转移性肝癌 外科治疗: 肝叶切除 病灶切除 肿瘤学治疗: 系统化疗 介入治疗 化学性:栓塞化疗、动脉 灌注 酒精性:无水酒精注射 物理性:射频消融、冷 冻治疗、微波固化 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 介入治疗 介入治疗 化学性 物理性 经肝动脉: 化疗栓塞术(HACE) 灌注化疗 (TAI) 经门静脉化疗及栓塞 肝动脉和门静脉双路径治疗 酒精性:无水酒精注射 高温:射频消融(RFA) 微波固化(MTC) 低温:冷冻治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 介入治疗 介入治疗 血管内 间质内 肝动脉 门静脉 双路径 经皮超声引导下: 射频,微波,激光, 高频超声 开腹术中:冷冻,射频 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 一.超声介入治疗 n优势 创伤小、并发症少、恢复快和可反 复应用等 n适应症 肿块手术无法切除 可切除肿块但不宜手术 作为TACE后的补充治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (一)经皮瘤内无水乙醇注射(1) n原理 :乙醇在肿瘤组织内弥散,使肝癌细胞 发生凝固性坏死,从而达到杀灭肿瘤细胞的 目的 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 经皮瘤内无水乙醇注射(2) n适用于直径小于3cm,结节在5个以下 ,肿块有假包膜者效果佳 n禁忌症 肝衰竭倾向的患者 病变广泛或结节数超过5个 已有肝外转移 对无水乙醇过敏 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 经皮瘤内无水乙醇注射(3) n操作前常规测定患者的肝肾功能、凝血机 制。 n注射的量随肿瘤大小而定,以10~15 ml/ cm计算,但一般不应超过30 ml。 n应在肿瘤内多点、多方向、多层面注射,每 个注射点注入乙醇0.5~1.0 ml左右。 n通常每周1~2次,一个疗程为4~6次,也 可根据每个患者的耐受情况及反应而定 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society n局限性 经皮瘤内无水乙醇注射(4) 扩散的不均质性 扩散范围的相对局限 肿瘤周边残留 需结合其他方法 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (二)射频消融(1) n原理 电子发生器产生射频电流(460Khz) , 通过裸露的电极针使其周围组织产生高速 离子振动和摩擦,继而转化为热能。其热 能随时间逐渐向外周传导,从而使局部组 织细胞发生热凝固性坏死和变性。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(2) 目前进展主要体现在电极针的改进: n早期:组织被高温凝固发生干燥或炭化,局部阻抗 增高,消融坏死区直径仅1.5cm左右,实用价值有 限 n目前:在中空的电极针内滴注生理盐水或电极尖端 附设冷却装置,都可延缓阻抗增高使消融范围扩大 n 多电极的消融针,由4~10支记忆合金材料的细 电极组成,穿刺进入瘤内后伸展开来呈伞骨状排列 ,大大增加了电极针的表面积和拓宽了电流传导的 空间,1次治疗可获得横径3.5~5.0cm的扁球体 状凝固区。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(3) n仪器设备 RITA射频消融系统(RITA Medical System, Inc., Mountain View,CA) Radionics公司生产的500KHz单极RF发生器 (Radionics, Boston, MA) RTC公司生产的RF2000型RF消融仪 (RadioTherapeuticus Corporation, Mountain View, CA) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society RITA射频消融系统 Radionics:Cool-tip™ RF系统 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(4) 多电极的消融针:由4~10支记忆合金 材料的细电极组成,平时收拢在针鞘里 ,穿刺进入瘤内后伸展开来呈伞骨状排 列,结果是大大增加了电极针的表面积 和拓宽了电流传导的空间,1次治疗可 获得横径3.5~5.0cm的扁球体状凝固 区。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(5) Cooled-tip 电极:治疗过程 中冷却的纯净水通过专用的 动力泵在中空针内循环,这 样可防止由于温度过高使电 极周围组织炭化而增加阻抗, 使消融范围扩大 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(6) n适应症及禁忌症 1.适应应症 1.1 治愈性:当肿瘤直径小于5cm且射频治疗的安全距离在1cm 以上时,存在治愈可 能 1.2 姑息性:在肝脏局部肿瘤较大时,可控制肿瘤生长 2.禁忌症 2.1肿瘤直径大于5 cm或肿瘤病灶数目超过5个 2.2肝外肿瘤转移或患者生存时间 估计不足3个月 2.3肿瘤靠近大血管 2.4严重肝、肾功能不全或明显腹水 2.5术前2周内进行过化疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(7) n治疗途径: A、 经皮 B、与腹腔镜配合使用 C、开腹术中时使用 n方法: ①定位穿刺 ②开始先用20~40W的功率,以后每分钟加10W,最大功 率勿超过90W ③治疗中视具体情况可调整功率、时间或多电极针的伸展 程度,也可在功率输出停止后稍等片刻开始下一次能量释放或 移动电极重新发射。 n多点位治疗遵循先深部后浅部,先疑难部位后容易部位,先主要 病灶后次要原则。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融 术中进行射频消融 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 射频消融(8) n局限 1.肿瘤残留 1.1多电极下热场还缺乏具体研究 1.2靠近大血管的肿瘤,由于血流带走热 量,降低治疗温度 1.3定中心点不准确 2.隐性转移灶不能发现 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三)微波固化(1) n1994年始应用于肝癌治疗 n原理:B超引导下将穿刺针经皮插入肝癌组 织内,然后将微波电极通过穿刺针植入癌 灶内,在一定的外加磁场作用下,微波能 转变成热能,利用肿瘤不耐热的特点,使 肿瘤组织凝固性坏死 Morita T,Shibata T,Okuyama M ,et a1.Outcomes of patients undergoing microwave coagulation therapy for liver metastases from colorectal cancer. Gan To Kagaku Ryoho, 2003, 30:1595—1597. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 微波固化(2) n以国产UMC-Ⅰ型微波凝固治疗仪为例,该疗法 的特点为: 微波发生器频率2450MHz,输出功率1~ 100W,连续可调,通过电缆与经防粘处理的电 极(微波天线)相连。电极长30cm,外径16G, 先端为长2.7cm的微波辐射芯线。单电极穿刺一 次辐射可形成横径2.5cm、长径3.7cm左右的椭 球体状凝固区,天线周围半径1.5cm范围内最低 温度达50~60℃。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 微波固化(3) 操作方法: n先根据肿瘤的大小制定辐射方案。 直径≤2.0cm:单针穿刺 直径2.0cm以上:多针组合穿刺辐射(针距2.5cm,最多可布5 ~7针)或每针实行两点辐射(即1次辐射后将电极针上提3.0cm作另1次辐 射) n用14G引导针经皮经肝穿刺至肿瘤底部,拔出针芯导入微 波天线施行辐射,输出功率50~60W,辐射时间30 0~800s,间隔3~4d后再追加治疗1次。 n微波辐射中产生的高热使肿瘤组织内的水分发生汽化,形 成高回声团伴后方多重反射,会模糊瘤体的显像,妨碍下 一针的穿刺定位。因此实行多针穿刺辐射方案时,最好先 完成所有的预定穿刺,然后再逐个辐射。 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 微波固化(4) 1.单个病灶直径小于6 cm,小于3 cm更佳; 2.肝内病灶少于5个,每个直径不超过3 cm; 3.无肝外病灶或肝外原发病灶已切除; 4.无外科手术指征或需延迟手术及拒绝手术者; 5.凝血酶原活性≥5O ,血小板计数≥7O×1O /L; 6.对于合并肝硬化者,若无顽固性腹水且肝功能为Child A级或B 级,MCT亦行之有效 微波治疗适应症 M orita T,Shibata T,Okuyama M ,et a1.Outcomes of patients undergoing microwave coagulation therapy for liver metastases from colorectal cancer. Gan To Kagaku Ryoho, 2003, 30:1595—1597. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 微波固化(5) 评价: n对<3 cm肝癌微波单独疗法与肝切除相似 n获得肿瘤完全坏死的治疗要求:治疗达到 癌及癌周组织,确保治疗边缘达5 mm以上 n适合于小的转移灶,需结合其他治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 微波固化(6) n局限 ①治疗过程中天线杆温过高,造成穿刺引导针与 组织粘连,皮肤灼伤(目前采用冷循环微波刀可减少该类并 发症) ②治疗尚缺乏一个量化方案,不能做到个体化 ③ 超声监控治疗过程中天线周围的强回声影响了 进一步观察 ④较大的转移性肿瘤存在消融不彻底、局部复发 率较高的问题,需要多种方法联合使用 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 微波固化(7) n发展前景: ① 开发新一代影像监视设备,以便能适时观察瘤灶凝固 情况。 ②加快微波电极的研究,使之凝固范围更大,多根电极的 应用,使电极间的凝固区完全重叠,增加凝固区范围。 ③加强信息化研究,使能够精确控制凝固区大小,能更有 利于邻近大血管、肝门部肝癌的治疗 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (四)激光疗法(LITT) (1) nVogl等于9O年代中期首次发现 n基本原理是 :把一个激光头放在肝癌组织内,通过 光纤把低能激光(3W~15W) 传输给激光头,利用 光能转变为热能,把肝癌组织连续加热(3~30 分 钟) 到一定温度范围内(45 ℃~95 ℃) 使其凝固 坏死,而正常肝组织不受损伤。 n治疗途径:局麻下或全麻下B 超、CT 或MRI 引导 经皮穿刺或开腹直视下 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 激光疗法(2) 引导与监测 n超声:能使导管准确放置到肿瘤内,但治疗区域实时监测则欠准确( 在凝固期观察到的回声区域与凝固损伤不相关,这个影像是由组织水 蒸发发泡所产生) nCT:在治疗后增强螺旋CT被认为是评价的“金标准”.理想时机是1 ~4天,这与实验产生的凝固损伤有最大直径时间相一致,但术中不 能及时反映组织热损伤变化 nMRI:形态学:优质的软组织成像质量及直接三维成像能力。且对 温度敏感,使操作者准确估计热损伤的真实程度,增加了治疗过程中 组织变化的直观性,因此MRI是一个好的实时监测工具 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 激光疗法(3) n技术进展 光纤:裸光纤头:易致局部碳化, 进一步阻止激光的穿越 柱型发散光纤头:发散光纤可均匀破坏较大的肿瘤而避免碳化 光纤闭合套管系统:在治疗时,不断地灌洗生理盐水以降低中心温度 激光器:Nd : YAG 激光:具有较好的组织穿透率,但价格昂贵近 半导体激光器:体积小、性能稳定、价格低廉、可变波长等优点 测温技术:目前临床应用的测温工具有半导体温度计、热偶、光纤。 缺点: ①只能测出少数几个点,不能得到温度分布的三维概念; ②热敏探头对组织的损伤,不允许放入过多的点; ③过多的探头有可能对场分布干扰增大,进一步影响温度均匀 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 激光疗法(4) 评价 n磁共振术控制下LITT技术被公认为是介入 治疗肝转移癌的一种理想方法 n微创性、定位准确、监控性好、并发症少 、肿瘤复发率低 n治疗费用相对较高 Vogl TJ,M uller PK,Hammerstingl R,et a1. Malignant liver tumors treated with M R imaging--guided laser- induced thermotherapy:technique and prospective results. Radiology, 1995,196:257-265 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (五)冷冻治疗(CSA)(1) n原理 冷冻导致细胞内冰晶形成和冰晶的机 械性损伤、细胞脱水和皱缩、细胞膜脂蛋 白成分变性以及血流淤积微血栓形成的综 合作用 ,进而形成肿瘤坏死. With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 冷冻治疗(2) 仪器及优缺点 n单纯局部液氮冷冻 通过插入冷冻头进行,液氮冷冻头有3~5 cm 直径的盘形冷冻头和5~10 mm 粗的单针和多针冷冻头。冷冻范围与冷冻探头的直径大小有关 n局部冷冻—加温治疗(氩氦刀) ①具有4 或8 个能单独控制的热绝缘中空超导刀,可输入高压常温氩气(冷媒) 或高压常温氦气(热媒) 。 ②降温及升温的速度,时间和温度,冰球尺寸与形状是完全可控和精确设定的。 ③刀杆有很好的热绝缘,不会对穿刺路径上的组织产生损伤,可在超声等的引导 下经皮穿刺冷冻治疗。 ④冷热逆转疗法,对病变组织的摧毁尤为彻底,并可解决超低温对正常组织的冷 冻伤害 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 冷冻治疗(3) 评价 n对治疗较大肿瘤有效 n肝转移癌病灶贴近门静脉、肝静脉、腔静 脉等大血管亦是适应症 n对于处于肝脏较深部位且直径较小的肝转 移癌病灶,采取CSA更有利于保护正常肝 组织 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 直径5cm时,其主要血供来自肝动脉 --这为肝动脉栓塞及化疗治疗提供了理论依据 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 肝动脉栓塞化疗 (2) n适应症及禁忌症 1.适应症 1.1不可切除的肝癌或可切除但不宜手术 1.2经全身化疗疗 效不佳者 1.3肿瘤复发者 1.4外科手术前、后或肝移植前,用以缩小病灶或减少肿瘤复发 2.禁忌症 2.1肿瘤超过肝脏体积的75% 2.2肝功能不良、腹水或阻塞性黄疸 2.3白细胞明显减少 2.4严重感染或骨髓抑制 2.5患者一般情况较差 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 肝动脉栓塞化疗(3) n化疗药物 5一Fu FUDR n栓塞剂 碘油 带药微球 微囊 明胶海棉 自体血凝块 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 肝动脉栓塞化疗(4) n存在的主要问题 门脉产生栓塞者极少 对肝功能的影响 插管成功率受一定的限制 存在一定并发症 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (二)肝动脉插管灌注化疗 优势及适应症 n局部化疗药物浓度提高,体循环中血药浓 度低,降低了化疗药物的全身性副反应 n局部疗效优与全身化疗 n可作为原发灶或转移灶切除后的辅助化疗 n少血管型转移癌可选用 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 图1a: 肝右叶转移性肿瘤,多血供型 富血供的DSA表现:供血动脉增粗,新生血管 相对丰富,沿病灶周围分布,肿瘤染色明显,常 为周边部较浓,中心偏淡 图2a: 肝右叶多发转移瘤,乏血供型 乏血供的DSA表现:肝动脉分支弧形 移位和牵张拉直,,无或仅少量的纤 细新生血管,肿瘤多不染色而在肝实 质染色的基础上形成肝内多发充缺区 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society (三)肝动脉和门静脉双路径治疗(1) 理论依据 n门静脉参与肿瘤血供 n单纯TACE术后仅有20%~50%的肿瘤 组织呈完全性坏死 mamura H,Shimada R,Kubota M .Matsuyama Y,Nakayama A,Miyagawa S,Makuuchi M ,Kawasaki S. Preoperative portal vein embolization!an audit of 84 patients.Hepatology1999;29:1099~1l05 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 肝动脉和门静脉双路径治疗(2) 存在问题: n操作复杂,不利于推广 n副作用包括不同程度的肝区疼痛,低热, 恶心呕吐等 n未栓塞叶内有肿瘤的患者为栓塞禁忌症 (可导致未栓塞叶内的肿瘤加速生长 ) With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 三、联合治疗 Liver metastases: interventional therapeutic techniques and results,state of the art With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 四、预防性血管介入治疗(1) 理论依据 n术前肝脏已存在微转移灶,而一般检查不能检出,术中亦 难发现。 n术后个别微小和隐蔽的癌细胞仍可能存在于原发区,在适 当的条件下,仍可通过血运和淋巴系统向肝转移。 n手术过程挤压肿瘤可能导致癌细胞进人门静脉,从而增加 肝转移的危险性。 n体积微小肿瘤转移灶对化疗药物敏感性较高 因此,及时进行预防性的介入化疗,十分有必要 With the improving quality of life as well as the ever-accelerating pace of life, the quality of people's food needs and rate also changing.In order to meet the needs of society 预防性血管介入治疗(2) n术前:肝动脉化疗 n术中及术后:门静脉插管化疗 肝动脉插管
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