碘-125放射粒子组织间植入治疗恶性肿瘤.ppt

PrimaryClinicalStudyofCT guidedIodine 125SeedImplantationTherapyinPatientswithAdvancedPancreaticCancer上海交通大学医学院附属瑞金医院卢湾分院王忠敏 Brachytherapy 1898年居里夫人发现镭1905年即进行了第1例镭针插管治疗1930年Paterson及Parker建立了曼切斯特 Manchester 系统1935年小居里夫妇发现了人工放射性同位素80年代中期 现代近距离治疗迅速发展 生物学优势 外放疗相比 肿瘤局部治疗的持续时间长放射治疗的剂量较低对周围正常组织的损伤小对肿瘤细胞的杀伤力强 Implantradioactiveseedsintotumors Emitcontinueouslowenergy rays Injuryoftissuesandcells Celldeathandmutationleadingtocancer Interactwithbiomacromolecule Animalexperiment Clinicalresearch HumanpancreaticcancerSw1990cellBABL cwasinoculatedintothedorsalsideofrightlowerextremityinguinalregionofnudemicePassagedfor3timssubcutaneously initiatetheexperimentsaftertumorformationwasstablized Experimentaldesign Subcutaneouspancreaticcancerxenograftinnudemice Seedimplantationgroup Controlgroup Experimentalmethod Changeofxenograftvolumeinnudemice Comparisonoftumorinhibitionrate ObviousliquefactionnecrosiscanbeseeninthecenteralareaofExperimentalgrouptumor therearesparsecellsaroudthenecrosisarea 100 HEstaining Thereisnoorlittlenecrosisareaincenterofcontrolgrouptumor therearemultipletumorcells 100 ExperimentalgrouppositiveTK1stainingcellsareexiguous 200 ControlgrouppositiveTK1stainingcellsareabundent 200 HEstaining 碘 125放射粒子组织间植入治疗属放射治疗 对周围正常器官组织无明显放射损伤裸鼠移植瘤组织植入碘 125粒子后 实验组心 肺 肝 肾 脾脏外观大致正常 病理检查未见明显放射性炎症表现 Preliminaryresult ZM WangMD ShanghaiRuijinHospital Introduction PancreaticcancerisadevastatingdiseaseandtheprognosisremainspoorFewpatientsareeligibleforcurativesurgicalresectionAlternativetherapeuticoptionsareindemand Traditionaltherapyvs Externalirradiationtherapyvs percutaneousseedimplantation ZM WangMD ShanghaiRuijinHospital ExternalirradiationtherapywasregardedasinsensitivetopancreaticcancerandassociatedwithmoresystemicsideeffectsRadioactiveiodine 125seedimplantationhasminimalsurgicaltraumaandfewcomplicationsThemostcommonlyusedisotopeisiodine 125125IplacementwasroutinelyusedatourinstitutionforrecurrenttumorsatvarioussitesTheaimofthisstudywastotestitsfeasibilityforpancreaticlesions CurrentControversies 11thIO2010 May23 Methodsandmaterials PatientpopulationDecember2004toAugust2007 31consecutivepatientswereincludedinthisprospective nonrandomizedstudyPatientswerediagnosedbyCTorMRIwithhistologicalconfirmationofthediagnosisbyFNAAllpatientsenrolleddisplayedcontraindicationstosurgeryorhadrejectedsurgicaltreatmentduetopersonalreasons ZM WangMD ShanghaiRuijinHospital Methodsandmaterials Thetotalvolumeofeachtumorwascalculatedwiththetreatmentplanningsystem TPS beforeimplantationTheexpectednumberofimplantedseedwascalculatedaccordingtothemodifiedlevelformulaPatientswerekeptinourradiooncology interventionalwardwithanusualstayof4fulldays Methodsandmaterials Clinicalbenefitresponsewasderivedfrommeasurementofpain functionalimpairmentandweightlossPatientswereexaminedbyCTaftertheoperationResponseratewasdefinedasthesumofCRandPRLocaltumorcontrolwasdefinedastheabsenceoftumorprogression SD PR CR Methodsandmaterials 10patientsreceivedconcurrentchemotherapywitharterialinfusionofgemcitabinand5 fluorouracil 5 Fu ChemotherapywasinitiatedoneweekafterandrepeateduptofourcyclesFollow upvisitsat1month 3month andevery3monthsforclinicalexamination bloodsampling andCTexamination ZM WangMD ShanghaiRuijinHospital 适应症 实体瘤 如前列腺癌 的根治性治疗实体瘤术后残余组织的预防性治疗转移性肿瘤病灶或术后孤立性肿瘤转移灶而失去手术价值者无法手术的原发肿瘤的姑息性治疗 禁忌证 放射性治疗不宜 如血液病等 及有麻醉禁忌等病灶范围广泛恶液质 全身衰竭肿瘤部位有活动性出血 坏死或溃疡严重糖尿病 Iodine 125TherapyinAdvancedPancreaticCancer Results ChangeofKarnofskyphysicalscore cases Results Changeofpainscore cases Iodine 125TherapyinAdvancedPancreaticCancer Results Overallrespondingrate CR PR 61 3 Localtumorcontrolratewas90 3 Mediansurvivaltimeforthewholegroupwas10 31monthsMediansurvivaltimeforpureseedsimplantation 21cases was7monthsmediansurvivaltimefordrug seedscombinedwas11month Pre implantCTscan Caseone ZM WangMD ShanghaiRuijinHospital Post implantCTscan ZM WangMD ShanghaiRuijinHospital Pre implantCTscan CaseTwo 术后CT扫描 术中穿刺碘粒子植入 Post implantCTscan Post implantCTscan 病例2男性76岁胰腺癌 胰体尾部 Pre implantCTscan CaseThree 术后CT扫描 Post implantCTscan Pre implantCTscan CaseFour Post implantCTscan 术后CT二维重建 Post implantCTscan Complications Noseriouscomplicationsencountered2seedsofradioactive125Ifoundtomigratetoliverin2patientsLeukopeniaandrenalfunctionimpairmentwerefoundin4patientsofdrug seedscombinationgroup Iodine 125TherapyinadvancedPancreaticCancer Discussion Percutaneousimage guidedseedimplantationhasattractedincreasingattentionExtensiveexperienceswiththistechniquehadbeencollectedtargetingliverandlungmalignanciesThemostcommonlyusedisotopeis125I and125Iplacementhasbecomearoutinetreatmentforrecurrenttumorsatvarioussitesinourinstitution ZM WangMD ShanghaiRuijinHospital Technicalpointsduringtheprocedure Patientsfastedfor24hoursEnsuresteadybreathmovementduringtheprocedurePancreaticsecretionwasinhibitedTransgressstomachissaferthanintestine avoidingcolonespeciallywhenusinglarge boreneedlesForpatientswithjaundice doPTCDfirstImmediateCTscanpostimplantationwasdonetoverifythedistributionoftheseeds ZM WangMD ShanghaiRuijinHospital Drug seedscombinedtherapy ThereisdatasuggeststhatlocalcontrolratescanbeenhancedbytheadditionofchemotherapyInourstudythemediansurvivaltimebetweenthetwogroupsreachedstatasticallysignificantandencouragedfurtherevaluation ZM WangMD ShanghaiRuijinHospital Conclusions ThisstudysuggestedthatCT guidedbrachytherapyusing125Iseedsimplantationappearedtobesafe effective lesscomplicatedandcouldproduceadequatepainrelieffortreatingunresectablepancreaticcancer Iodine 125TherapyinAdvancedPancreaticCancer 国内临床尚有许多问题需要解决 临床应用适应症选择标准不一 造成不同医院应用放射性粒子植入治疗技术后疗效评价缺乏标准 尤其在