不可切除肺癌的支气管动脉化疗栓塞及冷冻消融治疗课件

1、不可切除肺癌的经支气管动脉化疗栓塞及经皮冷冻消融治疗Cancer statistics, 2016. CA CANCER J CLIN 2016; 66:730一、肺 癌治 疗 手术治疗：最重要和最有效的治疗手段，手术后5年生存率30%-40%，早期50-70%不可切除肺癌(unresectable and inoperatable)非手术治疗：消融：物理（射频、微波、冷冻、HIFU）、化学消融化疗（系统化疗、区域性动脉介入化疗栓塞）放疗（包括外照射、刀、粒子内放疗、核素等）分子靶向治疗、免疫治疗、生物治疗、基因治疗祖国医学、中医药 治 疗 应当采取多学科综合治疗与个体化治疗相结合原则 即根据

2、患者的机体状况、肿瘤的病理组织学类型和分子分型、侵及范围和发展趋向采取多学科综合治疗的模式，有计划、合理地应用手术、化疗、放疗和分子靶向治疗等手段，以期达到最大程度地延长患者的生存时间、提高生存率、控制肿瘤进展和改善患者的生活质量中国原发性肺癌诊疗规范(2015年版)二、支气管动脉灌注化疗栓塞肺是双重血供器官：肺循环（肺动脉）体循环（支气管动脉）肺癌主要由体循环支气管动脉供血，可有膈动脉、肋间动脉、胸廓内动脉等参与供血。肺动脉不参与供血，是介入治疗的解剖基础。支气管动脉及肺动脉造影比较研究右上肺癌肺转移瘤支气管动脉灌注化疗 (bronchial arterial infusion, BAI)支

3、气管动脉化疗栓塞术 (bronchial arterial chemoembolization, BACE)动脉灌注提高了局部药物浓度化疗副反应和肿瘤耐药性减少栓塞阻断肿瘤供血动脉可抑制肿瘤的生长、提高化疗药物敏感性肺癌经支气管动脉治疗支气管动脉解剖起自胸主动脉（少数升主动脉、锁骨下动脉、腹主动脉）直径1-2mm50%开口T56（T4-9）水平插管成功率95%以上分 型支气管动脉起源多支支气管动脉异位起源支气管动脉支气管动脉灌注化疗及栓塞适应证1.失去手术机会局限胸内2.有手术禁忌证或拒绝3.手术前新辅助化疗4.治疗复发或肺内转移 禁忌证恶液质、心、肝、肺、肾功能衰竭高热、严重感染、白细胞明显

4、降低（3000）严重出血倾向碘过敏、插管及造影禁忌不能避开脊髓动脉灌注、栓塞技术 灌注化疗化疗药物的选择 根据肿瘤病理类型，细胞生长规律、药物作用原理和药代动力，采用联合用药,慎用吉西他滨、奥铂将每种化疗药分别溶于50 ml NS（GS），15-30分钟（1.5-2ml/s)缓慢注入以动脉泵维持灌注(1-2h) 栓塞剂选择肺癌供血丰富，栓塞后肿瘤处于无氧环境，提高化疗敏感性，同时阻断营养无脊髓动脉共干及交通支，如有肋间动脉共干，微导管超选明胶海绵颗粒不用、慎用超液化碘油微球，载药微球聚乙烯醇（PVA）（300-500um）弹簧圈？肺癌支气管动脉造影特征病变区呈边缘尚清楚的团块影或多个结节融合形

5、态血管侵犯不规则狭窄闭塞僵直肿瘤包绕血管池改变依据肿瘤供血动脉是否增粗、新生血管的多少和肿瘤染色的深浅分为3型： 富血型、稍多血管型、乏血型肺癌伴有咯血，造影中可见对比剂溢出血管外，呈片状模糊影男，87岁，发现右上肺占位进行性增大半年余。BAI-BACEF，51y，左肺占位，右肺、纵隔颈部淋巴结转移，上腔静脉综合征：右上肢、头颈部肿胀2012-8-16上腔静脉支架植入术，缓解上腔静脉综合征2012-8-222012-8-16穿刺活检2012-8BAI：培美曲塞+顺铂，连续6周期病理：左肺低分化腺癌F，51y，左肺低分化腺癌，右肺、纵隔颈部淋巴结转移，上腔静脉综合征：右上肢、头颈部肿胀2015-

6、7-232014-6F，51y，左肺低分化腺癌，右肺、纵隔颈部淋巴结转移，上腔静脉综合征：右上肢、头颈部肿胀2016-1-182016-8-4肿瘤指标变化F，51y，左肺低分化腺癌，右肺、纵隔颈部淋巴结转移，无瘤生存期超过52月2012-82016-72013-72014-4女，61岁，因腰痛发现腰椎占位，骨水泥术后发现肺低分化腺癌，骨、脑转移。L2内固定术、化疗、分子靶向治疗后进展第一次BAI第一次BAI后2月第二次BACE两次腰动脉灌注化疗及栓塞显著缓解腰痛及下肢症状2014-6-102015-7-202014-8-252015-9-142015-11-182016-1-11詹某，女，87

7、岁，肺腺癌，咳喘詹某，女，87岁，肺腺癌，咳喘詹某，女，87岁，肺腺癌，咳喘，12次BAI+BACE,OS:64m2014-2-212015-7-22夏某，男，71岁，支气管镜活检肺腺癌，咳痰多2014-12-4BACE2014-11-3BACE2015-2-13BACE2015-4-15BACE2015-4-202015-6-18夏某，男，71岁，肺腺癌，一年演变，咳痰消失，OS:22月2015-1-42014-12-42015-2-112015-4-152015-12-22015-9-82015-6-182015-3-13刘某，女，68岁，肺癌，咳痰血2014-2-14刘某，女，68岁，肺

8、癌，咳痰血，第一次BACE2013-11-20刘某，女，68岁，肺癌，咳痰血2015-6-2419月以后第二次BACE2015-6-18多支支气管动脉供血肺动脉无供血刘某，女，68岁，肺癌，咳痰血2015-10-15再过4月以后刘某，女，68岁，肺癌，咳痰血2015-10-15刘某，女，68岁，肺癌，咳痰血2015-10-15刘某，女，68岁，肺癌，咳痰血2015-10-15易瑞沙刘某，女，68岁，肺癌，咳痰血2015-10-15刘某，女，68岁，肺癌，咳痰血2016-9-9再过11月以后刘某，女，68岁，肺癌，咳痰血2016-9-9刘某，女，68岁，肺癌，咳痰血2016-9-9刘某，女，68

9、岁，肺癌，咳痰血2016-9-9刘某，女，68岁，肺癌，咳痰血2016-9-9支气管动脉殷某，男，62岁，右上肺穿刺腺癌，PET-CT双肺及纵隔转移胸外侧动脉内乳动脉姜某，男，59岁，肾癌术后4年，肺肝转移3年2014-2-3姜某，男，59岁，肾癌术后4年，肺肝转移姜某，男，59岁，肾癌术后4年，肺肝转移2015-7-27吴某，F，85y，左肺癌双肺转移，呼吸困难2015-2-62015-10-8从放弃治疗呼吸困难开始经过BACE5次，生存18个月2016-9-8沈某，F，61y，盲肠癌肝肺转移静脉化疗抵抗后2015-1-202015-8-25两次BAI沈某，F，61y，盲肠癌肝、肺转移术后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)并发症及处理 脊髓损伤原因A.支气管动脉与脊髓动脉存在吻合，直径小

13、于0.3mm的小动脉DSA不显影B.支气管动脉与肋间动脉共干C.高浓度对比剂刺激D.化疗药物及误栓 脊髓损伤表现 术后立刻及数小时出现横断性脊髓损伤症状，损伤平面以下感觉、运动功能降低或消失，尿潴留、甚至截瘫 预防方法1.选用非离子对比剂、稀释2.支气管动脉造影后，仔细观察有无肋间动脉共干、脊髓动脉显影，微导管超选择插管3.利多卡因试验：灌注化疗前，注入1%利多卡因5ml,观察有无脊髓损伤症状4.随时询问病人感受及肢体肌力王某，F,53y,大肠癌肝肺转移化疗后四度骨髓抑制，严重咳嗽肋间支气管干利多卡因试验阳性，避开肋间动脉后灌注化疗并栓塞多支支气管动脉供血姒某，M,63y,肺腺癌脊髓动脉显影，

14、出现下肢麻木，超选择插管至支气管动脉后安全化疗栓塞舒某，男，63岁，右下肺腺癌避开肋间动脉脊髓、神经损伤治疗方法1.血管扩张药：罂粟碱、低右、丹参等改善脊髓循环2.大剂量激素、甘露醇，减轻脊髓水肿3.经脊髓损伤动脉注入安定5mg4.腰穿，以等渗盐水置换脑脊液，每5分钟10ml，总量200ml5.营养神经药物：甲钴胺、弥可保、神经妥乐平、神经节苷脂尽量减少外周神经损伤肋间动脉、胸外侧动脉、甲颈干、內乳动脉等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、关于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). 关于TPCE肿瘤供血解剖缺乏研究肺动脉造影肿瘤染色不明显肺动脉栓塞碘油沉积不明显临床研