不可切除肺癌的支氣管動(dòng)脈化療栓塞及冷凍消融治療課件

1、不可切除肺癌的經(jīng)支氣管動(dòng)脈化療栓塞及經(jīng)皮冷凍消融治療Cancer statistics, 2016. CA CANCER J CLIN 2016; 66:730一、肺 癌治 療 手術(shù)治療：最重要和最有效的治療手段，手術(shù)后5年生存率30%-40%，早期50-70%不可切除肺癌(unresectable and inoperatable)非手術(shù)治療：消融：物理（射頻、微波、冷凍、HIFU）、化學(xué)消融化療（系統(tǒng)化療、區(qū)域性動(dòng)脈介入化療栓塞）放療（包括外照射、刀、粒子內(nèi)放療、核素等）分子靶向治療、免疫治療、生物治療、基因治療祖國(guó)醫(yī)學(xué)、中醫(yī)藥 治 療 應(yīng)當(dāng)采取多學(xué)科綜合治療與個(gè)體化治療相結(jié)合原則 即根據(jù)

2、患者的機(jī)體狀況、腫瘤的病理組織學(xué)類型和分子分型、侵及范圍和發(fā)展趨向采取多學(xué)科綜合治療的模式，有計(jì)劃、合理地應(yīng)用手術(shù)、化療、放療和分子靶向治療等手段，以期達(dá)到最大程度地延長(zhǎng)患者的生存時(shí)間、提高生存率、控制腫瘤進(jìn)展和改善患者的生活質(zhì)量中國(guó)原發(fā)性肺癌診療規(guī)范(2015年版)二、支氣管動(dòng)脈灌注化療栓塞肺是雙重血供器官：肺循環(huán)（肺動(dòng)脈）體循環(huán)（支氣管動(dòng)脈）肺癌主要由體循環(huán)支氣管動(dòng)脈供血，可有膈動(dòng)脈、肋間動(dòng)脈、胸廓內(nèi)動(dòng)脈等參與供血。肺動(dòng)脈不參與供血，是介入治療的解剖基礎(chǔ)。支氣管動(dòng)脈及肺動(dòng)脈造影比較研究右上肺癌肺轉(zhuǎn)移瘤支氣管動(dòng)脈灌注化療 (bronchial arterial infusion, BAI)支

3、氣管動(dòng)脈化療栓塞術(shù) (bronchial arterial chemoembolization, BACE)動(dòng)脈灌注提高了局部藥物濃度化療副反應(yīng)和腫瘤耐藥性減少栓塞阻斷腫瘤供血?jiǎng)用}可抑制腫瘤的生長(zhǎng)、提高化療藥物敏感性肺癌經(jīng)支氣管動(dòng)脈治療支氣管動(dòng)脈解剖起自胸主動(dòng)脈（少數(shù)升主動(dòng)脈、鎖骨下動(dòng)脈、腹主動(dòng)脈）直徑1-2mm50%開口T56（T4-9）水平插管成功率95%以上分 型支氣管動(dòng)脈起源多支支氣管動(dòng)脈異位起源支氣管動(dòng)脈支氣管動(dòng)脈灌注化療及栓塞適應(yīng)證1.失去手術(shù)機(jī)會(huì)局限胸內(nèi)2.有手術(shù)禁忌證或拒絕3.手術(shù)前新輔助化療4.治療復(fù)發(fā)或肺內(nèi)轉(zhuǎn)移 禁忌證惡液質(zhì)、心、肝、肺、腎功能衰竭高熱、嚴(yán)重感染、白細(xì)胞明顯

4、降低（3000）嚴(yán)重出血傾向碘過敏、插管及造影禁忌不能避開脊髓動(dòng)脈灌注、栓塞技術(shù) 灌注化療化療藥物的選擇 根據(jù)腫瘤病理類型，細(xì)胞生長(zhǎng)規(guī)律、藥物作用原理和藥代動(dòng)力，采用聯(lián)合用藥,慎用吉西他濱、奧鉑將每種化療藥分別溶于50 ml NS（GS），15-30分鐘（1.5-2ml/s)緩慢注入以動(dòng)脈泵維持灌注(1-2h) 栓塞劑選擇肺癌供血豐富，栓塞后腫瘤處于無氧環(huán)境，提高化療敏感性，同時(shí)阻斷營(yíng)養(yǎng)無脊髓動(dòng)脈共干及交通支，如有肋間動(dòng)脈共干，微導(dǎo)管超選明膠海綿顆粒不用、慎用超液化碘油微球，載藥微球聚乙烯醇（PVA）（300-500um）彈簧圈？肺癌支氣管動(dòng)脈造影特征病變區(qū)呈邊緣尚清楚的團(tuán)塊影或多個(gè)結(jié)節(jié)融合形

5、態(tài)血管侵犯不規(guī)則狹窄閉塞僵直腫瘤包繞血管池改變依據(jù)腫瘤供血?jiǎng)用}是否增粗、新生血管的多少和腫瘤染色的深淺分為3型： 富血型、稍多血管型、乏血型肺癌伴有咯血，造影中可見對(duì)比劑溢出血管外，呈片狀模糊影男，87歲，發(fā)現(xiàn)右上肺占位進(jìn)行性增大半年余。BAI-BACEF，51y，左肺占位，右肺、縱隔頸部淋巴結(jié)轉(zhuǎn)移，上腔靜脈綜合征：右上肢、頭頸部腫脹2012-8-16上腔靜脈支架植入術(shù)，緩解上腔靜脈綜合征2012-8-222012-8-16穿刺活檢2012-8BAI：培美曲塞+順鉑，連續(xù)6周期病理：左肺低分化腺癌F，51y，左肺低分化腺癌，右肺、縱隔頸部淋巴結(jié)轉(zhuǎn)移，上腔靜脈綜合征：右上肢、頭頸部腫脹2015-

6、7-232014-6F，51y，左肺低分化腺癌，右肺、縱隔頸部淋巴結(jié)轉(zhuǎn)移，上腔靜脈綜合征：右上肢、頭頸部腫脹2016-1-182016-8-4腫瘤指標(biāo)變化F，51y，左肺低分化腺癌，右肺、縱隔頸部淋巴結(jié)轉(zhuǎn)移，無瘤生存期超過52月2012-82016-72013-72014-4女，61歲，因腰痛發(fā)現(xiàn)腰椎占位，骨水泥術(shù)后發(fā)現(xiàn)肺低分化腺癌，骨、腦轉(zhuǎn)移。L2內(nèi)固定術(shù)、化療、分子靶向治療后進(jìn)展第一次BAI第一次BAI后2月第二次BACE兩次腰動(dòng)脈灌注化療及栓塞顯著緩解腰痛及下肢癥狀2014-6-102015-7-202014-8-252015-9-142015-11-182016-1-11詹某，女，87

7、歲，肺腺癌，咳喘詹某，女，87歲，肺腺癌，咳喘詹某，女，87歲，肺腺癌，咳喘，12次BAI+BACE,OS:64m2014-2-212015-7-22夏某，男，71歲，支氣管鏡活檢肺腺癌，咳痰多2014-12-4BACE2014-11-3BACE2015-2-13BACE2015-4-15BACE2015-4-202015-6-18夏某，男，71歲，肺腺癌，一年演變，咳痰消失，OS:22月2015-1-42014-12-42015-2-112015-4-152015-12-22015-9-82015-6-182015-3-13劉某，女，68歲，肺癌，咳痰血2014-2-14劉某，女，68歲，肺

8、癌，咳痰血，第一次BACE2013-11-20劉某，女，68歲，肺癌，咳痰血2015-6-2419月以后第二次BACE2015-6-18多支支氣管動(dòng)脈供血肺動(dòng)脈無供血?jiǎng)⒛常?8歲，肺癌，咳痰血2015-10-15再過4月以后劉某，女，68歲，肺癌，咳痰血2015-10-15劉某，女，68歲，肺癌，咳痰血2015-10-15劉某，女，68歲，肺癌，咳痰血2015-10-15易瑞沙劉某，女，68歲，肺癌，咳痰血2015-10-15劉某，女，68歲，肺癌，咳痰血2016-9-9再過11月以后劉某，女，68歲，肺癌，咳痰血2016-9-9劉某，女，68歲，肺癌，咳痰血2016-9-9劉某，女，68

9、歲，肺癌，咳痰血2016-9-9劉某，女，68歲，肺癌，咳痰血2016-9-9支氣管動(dòng)脈殷某，男，62歲，右上肺穿刺腺癌，PET-CT雙肺及縱隔轉(zhuǎn)移胸外側(cè)動(dòng)脈內(nèi)乳動(dòng)脈姜某，男，59歲，腎癌術(shù)后4年，肺肝轉(zhuǎn)移3年2014-2-3姜某，男，59歲，腎癌術(shù)后4年，肺肝轉(zhuǎn)移姜某，男，59歲，腎癌術(shù)后4年，肺肝轉(zhuǎn)移2015-7-27吳某，F(xiàn)，85y，左肺癌雙肺轉(zhuǎn)移，呼吸困難2015-2-62015-10-8從放棄治療呼吸困難開始經(jīng)過BACE5次，生存18個(gè)月2016-9-8沈某，F(xiàn)，61y，盲腸癌肝肺轉(zhuǎn)移靜脈化療抵抗后2015-1-202015-8-25兩次BAI沈某，F(xiàn)，61y，盲腸癌肝、肺轉(zhuǎn)移術(shù)后2

10、015-1-202015-4-242015-8-252016-1-7Prospective study of TAI of docetaxel and cisplatin to treat nsclc in patients contraindicated for standard chemotherapyNakanishi, et al. Lung Cancer 77 (2012) 353358Prospective study of TAI of docetaxel and cisplatin to treat nsclc in patients contraindicated for s

11、tandard chemotherapyNakanishi,et al. Lung Cancer 77 (2012) 353358Prospective study of TAI of docetaxel and cisplatin to treat nsclc in patients contraindicated for standard chemotherapyNakanishi,et al. Lung Cancer 77 (2012) 353358Intra-arterial Infusion Chemotherapy for Advanced Non-SCLC: Preliminar

12、y Experience on the Safety, Efficacy, and Clinical Outcomes Zheng Yuan. JVIR 2013; 24:15211528Intra-arterial Infusion Chemotherapy for Advanced Non-SCLC: Preliminary Experience on the Safety, Efficacy, and Clinical Outcomes Zheng Yuan. JVIR 2013; 24:15211528BAI(BACE)并發(fā)癥及處理 脊髓損傷原因A.支氣管動(dòng)脈與脊髓動(dòng)脈存在吻合，直徑小

13、于0.3mm的小動(dòng)脈DSA不顯影B.支氣管動(dòng)脈與肋間動(dòng)脈共干C.高濃度對(duì)比劑刺激D.化療藥物及誤栓 脊髓損傷表現(xiàn) 術(shù)后立刻及數(shù)小時(shí)出現(xiàn)橫斷性脊髓損傷癥狀，損傷平面以下感覺、運(yùn)動(dòng)功能降低或消失，尿潴留、甚至截癱 預(yù)防方法1.選用非離子對(duì)比劑、稀釋2.支氣管動(dòng)脈造影后，仔細(xì)觀察有無肋間動(dòng)脈共干、脊髓動(dòng)脈顯影，微導(dǎo)管超選擇插管3.利多卡因試驗(yàn)：灌注化療前，注入1%利多卡因5ml,觀察有無脊髓損傷癥狀4.隨時(shí)詢問病人感受及肢體肌力王某，F(xiàn),53y,大腸癌肝肺轉(zhuǎn)移化療后四度骨髓抑制，嚴(yán)重咳嗽肋間支氣管干利多卡因試驗(yàn)陽性，避開肋間動(dòng)脈后灌注化療并栓塞多支支氣管動(dòng)脈供血姒某，M,63y,肺腺癌脊髓動(dòng)脈顯影，

14、出現(xiàn)下肢麻木，超選擇插管至支氣管動(dòng)脈后安全化療栓塞舒某，男，63歲，右下肺腺癌避開肋間動(dòng)脈脊髓、神經(jīng)損傷治療方法1.血管擴(kuò)張藥：罌粟堿、低右、丹參等改善脊髓循環(huán)2.大劑量激素、甘露醇，減輕脊髓水腫3.經(jīng)脊髓損傷動(dòng)脈注入安定5mg4.腰穿，以等滲鹽水置換腦脊液，每5分鐘10ml，總量200ml5.營(yíng)養(yǎng)神經(jīng)藥物：甲鈷胺、彌可保、神經(jīng)妥樂平、神經(jīng)節(jié)苷脂盡量減少外周神經(jīng)損傷肋間動(dòng)脈、胸外側(cè)動(dòng)脈、甲頸干、內(nèi)乳動(dòng)脈等Approach(Super-) selective approach = easyNo risk of spinal cordischemia(Super-) selective treat

15、ment= more complicatedAdditional risk of spinal cord ischemiaTranspulmonaryTransbronchialInstitute of Diagnostic and Interventional Radiology, J.W. Goethe University, Frankfurt三、關(guān)于TPCETPCE: Technique Treatment 6. Repeated embolization: 1-5 treatment coursesInstitute of Diagnostic and Interventional

16、Radiology, J.W. Goethe University, FrankfurtDyna CT: Route Planning ToolInstitute of Diagnostic and Interventional Radiology, J.W. Goethe University, FrankfurtTPCEInstitute of Diagnostic and Interventional Radiology, J.W. Goethe University, FrankfurtTPCE: High Lipiodol Uptake in Hypervascular Tumors

17、Institute of Diagnostic and Interventional Radiology, J.W. Goethe University, FrankfurtNo progression of tumor growth 69 y/o patient Small cell carcinoma 3 treatments Low Lipiodol uptake Stable diseaseRegional chemotherapy of thelung: transpulmonary chemoembolizationin malignant lung tumors.A 60-yea

18、r-old woman with primary non-small cell lung carcinoma in the right lung, segment 6, undergoing treatment with transpulmonary chemoembolization. (A) Nonenhanced computed tomography (CT) image of lung before chemoembolization, demonstrating a 41 35 mm right lobe lesion (arrow). (B) T2-weighted nonenh

19、anced magnetic resonance imaging (MRI) (2300/90 TR/TE) demonstrating the pretreatment tumor extension in the lung (arrow). (C) Angiographic verification of the catheter position in the main right pulmonary artery during the treatment. (D) CT image of the same patient during follow-up at 9 months, de

20、monstrating significant downsizing of the tumor volume (36 25 mm) (arrow). (E) T2-weighted nonenhanced MRI of lung on 9-month follow-up, again demonstrating significant shrinkage of the tumor (arrow) A 71-year-old man with primary non-small cell lung carcinoma in a right perihilar location, with pro

21、gression following regional chemoembolization. (A) Nonenhanced computed tomography (CT) image of lung before chemoembolization. The initial lesion measured 39 32 mm (arrow). (B) Axial T2-weighted nonenhanced magnetic resonance imaging (2500/90 TR/TE) presenting primary lung cancer spreading before c

22、hemoembolization (arrow). (C) Transpulmonary chemoembolization with catheter placement in the right perihilar region (arrow). (D) Axial CT follow-up study 4 months after transpulmonary chemoembolization (TPCE) demonstrating tumor progression (59 58 mm) (arrow). (E) Axial T2-weighted nonenhanced MRI

23、of the lung, 4 months post-TPCE with further tumor progression (arrow). A 64-year-old woman with breast cancer therapy and resistant lung metastasis. (A) Nonenhanced computed tomography (CT) image of the lung demonstrating metastatic breast cancer before chemoembolization. Lesion initially measured

24、27 26 mm in diameter (arrow). (B) Axial T2-weighted nonenhanced magnetic resonance imaging (MRI) of the lung demonstrating metastasis of lung cancer before chemoembolization (arrow). (C) Transpulmonary chemoembolization (TPCE) with catheter positioned in the middle segment of the left lung (arrow).

25、(D) Axial CT follow-up study 12 months post-TPCE with significant downsizing of the tumor, now measuring 15 10 mm (arrow). (E) Axial T2-weighted nonenhanced MRI of the lung in a follow-up study 12 months post-TPCE. Again demonstrated is the significant decrease in lesional diameter (arrow). 關(guān)于TPCE腫瘤供血解剖缺乏研究肺動(dòng)脈造影腫瘤染色不明顯肺動(dòng)脈栓塞碘油沉積不明顯臨床研