胆道支架置入术联合碘（~（125）Ⅰ）粒子植入术治疗恶性梗阻性黄疸
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摘要
目的:探讨胰腺癌伴梗阻性黄疸患者放置胆道支架后接受碘(125I)放射性粒子植入的可行性及疗效,旨在找出该介入疗法的适应症、禁忌症、并发症及防治方法。方法:本研究通过本院的18例胰腺癌伴梗阻性黄疸患者行经皮肝穿胆道支架(共计19枚)置入术后,采用碘(125I)放射性粒子(共计288颗)植入术的治疗方法。通过对术前、术后血清胆红素下降程度,和肿瘤负荷程度的观察,评价疗效,并随访患者生存期和胆道支架维持通畅时间。结果:显效11例(61.1%),改善6例(33.3%),1例无效,缓解恶性梗阻性黄疸的总有效率94.4%;粒子植入后,除1例在3周内死于肝功衰竭外,本组其余17例患者肿瘤负荷得到不同程度缓解,CR2例,PR7例,SD7例,PD1例,肿瘤缓解有效率50%(PR+CR)%;本组病例18例患者的生存期为1~12个月,平均7.8个月;2例患者支架置放术后血清胆红素水平降至正常,再次出现梗阻性黄疸的时间为术后5个月,7.5个月。3例患者支架置放术后血清胆红素水平低于原来水平的1/2,到再次上升的时间分别为4.5个月,5个月,6个月。支架置放术后直至死亡仍无黄疸者12例。支架置放术后——随访至2008年12月仍存活而无黄疸者1例。支架置放术后无一例失访。得出支架维持通畅1~12个月,平均7.2个月。结论:碘(125I)放射性粒子不同植入方式与胆道支架置入术(PTBD)相结合,治疗胰腺癌伴恶性梗阻性黄疸患者有较好的疗效。是一种微创、有效,即治标又治本的新疗法。
Objective: This paper investigates the feasibility and effect of metallic biliary stent insertion combined with radioactive seed 125I implantation in treatment of obstructive jaundice caused by pancreatic cancer, and aims to identify the indications, contraindications, complications and prevention methods of this interventional therapy.
Methods: The observation group is consisted of 18 cases of late pancreatic cancer patients with obstructive jaundice in our hospital between 2007 and 2008, who all have been treated by biliary stent insertion and radioactive seed 125I implantation. They are 12 male and 6 female, age between 45 and 79, with average of 60 years old and average weight of 45 ~ 70kg. Among them are 9 cases of pancreatic head carcinoma, 6 cases of Uncinate process carcinoma, 2 cases of ampullary carcinoma and one case of Pancreatic body cancer. 10 with hepatic metastases, 5 patients with abdominal lymph node metastases, 3 patients with lung matastases and 2 patients with Bone matastases. Pathological results show that all these patients have adenocarcinoma. Preoperative CT and/or MRCP finds intrahepatic biliary dilatation, with 4 moderate ones and14 severe one, all accompanied by increased gallbladder of various degrees. There is one case of obstructive sites located at upper pancreas of common bile duct, one at hilar (pancreatic cancer with transfer to lymph node), 12 at pancreas of common bile duct and 1 with distal obstructive at ampullary of common bile duct.
Results: These 18 cases has been diagnosed as pancreatic cancer with malignant obstructive jaundice by clinicopathological or imaging examination and biochemical examination of blood. We identify their obstructive sites, degree and situation through CT and/or MRCP in order to make operation plan.The success rate of this biliary stent insertion(with 10 cases of one-step and 8 of two-steps) and seed implantation are 100%, with 19 billary stents of tin-ti shape memory alloy and 288 radioactive seed 125I. There are 17 cases with sent located at upper and middle sections of common bile duct, one with double stents at both sides of hepatic duct.1 One patient die of hepatic failure 3 weeks after operation and the other one dies of MODS 3 months after operation, which has no direct causality with biliary stent insertion and seed implantation. During the follow-up period, 4 patients have jaundice recurrence and finds filling defect or complete occlusion by angiography in PTC operation. Their serum bilirubin lows after we reconstruct biliary drainage. Among these patients, the average serum bilirubin of 10 cases lowers to the normal level of 130.75umol/L(31.5~299.6umol/L)within 7 days, 6 cases are 1/2 lower than preoperational level. 11cases have effect(61.1%), 6 cases have improvement (33.3%)and only one has no effect, with total effective rate of 94.4%. Except for one case die of hepatic failure 3 weeks after operation, all the other 17 patients have take CT examination 2 months after seed implantation. We evaluate the efficacy according to WHO standard and combined with the maximum diameter and vertical diameter given by preoperational CT. The results show their tumor burden are alleviated in different degree. CR2,PR7,SD7,PD1, the effective rate is 50%(PR+CR)%. The survival time of this group is 1~12m with the average of 7.8m. Stent to maintain patency of the time according to the criteria: The standard we use to judge the unblocked time of the stent : A, time from the point of serum bilirubin lowering to normal standard to the one of obstructive jaundice reoccurrence after the implantation, or from the point of obvious serum bilirubin decrease(lower more than 100umol/L) or 1/2 less than the previous level to the one of increase again. B, how long there is no jaundice until death after operation; C, how long there is no jaundice with survival until Dec, 2008; D, time out of follow-up period (still no jaundice). A组:5例,B组:12例,C组:1例,D组:0例。
Another two cases die of hepatic failure 3 weeks and MOS 3 months after operation with bilirubin separation alt, while serum bilirubin has no obvious decrease. Angiography shows the stent is unblocked. Therefore, we conclude that the stent can maintain unblocked 1~12months with average of 7.2months. Statistical Treatment: all the data like total bilirubin level before and after the operation has been processed by rank sum test. It indicates remarkable differences if P<0.05.
Conclusion: 1. This research focus on the new method of using interventional minimally invasive technique-biliary stent insertion combined with radioactive seed implantation in the treatment of obstructive jaundice caused by pancreatic cancer. 2. This group proves this therapy has both temporary and permanent solutions to the treatment of obstructive jaundice.3. This therapy aims to investigate the reason of restenosis after biliary stent implantation and therefore delays the restenosis and controls the growth of tumor effectively by temporary and permanent solutions. 4. biliary stent drainage and seed implantation have small trauma and well-distributed dose around the target area, which has little injury to the surrounding normal organism and fewer complications. It has clear clinical efficacy and bright future. 5.As the continuous innovation of interventional equipments and techniques, the problems of stent insertion and its restenosis are expected to solve in order to make the stent unblocked longer. This has significant influence on prolonging the lifetime and improving life quality of late pancreatic cancer patient.
Objective: This paper investigates the feasibility and effect of metallic biliary stent insertion combined with radioactive seed 125I implantation in treatment of obstructive jaundice caused by pancreatic cancer, and aims to identify the indications, contraindications, complications and prevention methods of this interventional therapy.
Methods: The observation group is consisted of 18 cases of late pancreatic cancer patients with obstructive jaundice in our hospital between 2007 and 2008, who all have been treated by biliary stent insertion and radioactive seed 125I implantation. They are 12 male and 6 female, age between 45 and 79, with average of 60 years old and average weight of 45 ~ 70kg. Among them are 9 cases of pancreatic head carcinoma, 6 cases of Uncinate process carcinoma, 2 cases of ampullary carcinoma and one case of Pancreatic body cancer. 10 with hepatic metastases, 5 patients with abdominal lymph node metastases, 3 patients with lung matastases and 2 patients with Bone matastases. Pathological results show that all these patients have adenocarcinoma. Preoperative CT and/or MRCP finds intrahepatic biliary dilatation, with 4 moderate ones and14 severe one, all accompanied by increased gallbladder of various degrees. There is one case of obstructive sites located at upper pancreas of common bile duct, one at hilar (pancreatic cancer with transfer to lymph node), 12 at pancreas of common bile duct and 1 with distal obstructive at ampullary of common bile duct.
Results: These 18 cases has been diagnosed as pancreatic cancer with malignant obstructive jaundice by clinicopathological or imaging examination and biochemical examination of blood. We identify their obstructive sites, degree and situation through CT and/or MRCP in order to make operation plan.The success rate of this biliary stent insertion(with 10 cases of one-step and 8 of two-steps) and seed implantation are 100%, with 19 billary stents of tin-ti shape memory alloy and 288 radioactive seed 125I. There are 17 cases with sent located at upper and middle sections of common bile duct, one with double stents at both sides of hepatic duct.1 One patient die of hepatic failure 3 weeks after operation and the other one dies of MODS 3 months after operation, which has no direct causality with biliary stent insertion and seed implantation. During the follow-up period, 4 patients have jaundice recurrence and finds filling defect or complete occlusion by angiography in PTC operation. Their serum bilirubin lows after we reconstruct biliary drainage. Among these patients, the average serum bilirubin of 10 cases lowers to the normal level of 130.75umol/L(31.5~299.6umol/L)within 7 days, 6 cases are 1/2 lower than preoperational level. 11cases have effect(61.1%), 6 cases have improvement (33.3%)and only one has no effect, with total effective rate of 94.4%. Except for one case die of hepatic failure 3 weeks after operation, all the other 17 patients have take CT examination 2 months after seed implantation. We evaluate the efficacy according to WHO standard and combined with the maximum diameter and vertical diameter given by preoperational CT. The results show their tumor burden are alleviated in different degree. CR2,PR7,SD7,PD1, the effective rate is 50%(PR+CR)%. The survival time of this group is 1~12m with the average of 7.8m. Stent to maintain patency of the time according to the criteria: The standard we use to judge the unblocked time of the stent : A, time from the point of serum bilirubin lowering to normal standard to the one of obstructive jaundice reoccurrence after the implantation, or from the point of obvious serum bilirubin decrease(lower more than 100umol/L) or 1/2 less than the previous level to the one of increase again. B, how long there is no jaundice until death after operation; C, how long there is no jaundice with survival until Dec, 2008; D, time out of follow-up period (still no jaundice). A组:5例,B组:12例,C组:1例,D组:0例。
Another two cases die of hepatic failure 3 weeks and MOS 3 months after operation with bilirubin separation alt, while serum bilirubin has no obvious decrease. Angiography shows the stent is unblocked. Therefore, we conclude that the stent can maintain unblocked 1~12months with average of 7.2months. Statistical Treatment: all the data like total bilirubin level before and after the operation has been processed by rank sum test. It indicates remarkable differences if P<0.05.
Conclusion: 1. This research focus on the new method of using interventional minimally invasive technique-biliary stent insertion combined with radioactive seed implantation in the treatment of obstructive jaundice caused by pancreatic cancer. 2. This group proves this therapy has both temporary and permanent solutions to the treatment of obstructive jaundice.3. This therapy aims to investigate the reason of restenosis after biliary stent implantation and therefore delays the restenosis and controls the growth of tumor effectively by temporary and permanent solutions. 4. biliary stent drainage and seed implantation have small trauma and well-distributed dose around the target area, which has little injury to the surrounding normal organism and fewer complications. It has clear clinical efficacy and bright future. 5.As the continuous innovation of interventional equipments and techniques, the problems of stent insertion and its restenosis are expected to solve in order to make the stent unblocked longer. This has significant influence on prolonging the lifetime and improving life quality of late pancreatic cancer patient.
引文
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[2]Peretz,T,Nori D, Hilaris B, et al Treatment of primary carcinoma of the pancreas with I-125 implantation Int J Radiat Oncol Biol Phys 1989 ,17(5):931-935.
[3]Cox JD, Stetz J ,Pajak TF. To xicity criteria of the Radiation Therapy Oncology Group(RTOG)and the European Organization for Research and Treatment of Cancer(EORTC). Int J Radiat Oncol Biol Phys.1995 Mar30; 31(5): 1341-6.
[4]Dutreix J, Tubiana M, Pierquin B. The hazy dawn of brachytherapy. Radiother Oncol 1998,49:223-32.
[5]徐燮渊,俞受程,曾遨闻等.现代肿瘤放射治疗学.北京:人民军医出版社,2000,97.
[6]王迎选,王所亭,现代立体放射治疗学.北京:人民军医出版社,1999,137.
[7]Bethge N, Sommer A, Gross U, et al. Human tissue responses to Metal stents implanted invivo for the palliation of malignantste-nosis[J]. Gastrointes Endosc,1996,43(6):596-602.
[8]Eschelman DJ, Shapiro MJ, Bonn J, et al. Malignant biliary duct obstruction:long-term experience with Gianturconstents and Combined-modality radiation therapy[J].Radiology,1996,200(3):717-724.
[9]汤恢焕,肖广发,,汤旭涛.合金胆道支架治疗不能切除的恶性肿瘤所致的梗阻性黄疸[J].中国普通外科杂志,2003,12(8):574-575.
[10]Aumock A ,Birnbaum EH,Fleshman JW,et al .Treatment of rectal adenocarcinoma with endocavitary and external beam radiotherapy:results for 199 patients with localized tumors.Int J Radiat Oncol Biol Phys 2001 Oct1; 51(2): 363-70
[11] Nag S ,Kelly JF,Horton JL,et al .Brachytherapy for carcinoma of the lung Oncology(Huntingt).2001,15 (3):371-81.
[12] Ki Kuchi Y. Study on climical application of multiple fractions perday radiation therapy with concomitant boost technique for esophageal cancer [J],HoKKmdo Igaku Iasshi,1993,68(4):537-556.
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