王忠敏医生的科普号

上海医生首用纳米刀治疗肿瘤：不开腹“击穿”癌细胞2015年11月19日 18:45来源：中国新闻网 中新网上海11月19日电 (陈静 朱凡)不用开腹而利用局部1500伏高压脉冲电“击穿”癌细胞，让癌细胞出现大量纳米大小的微细穿孔来杀死癌细胞。19日，上海瑞金医院使用纳米刀消融技术为一名失去外科手术机会的胆管细胞癌患者进行治疗。19日,上海瑞金医院使用纳米刀消融技术为一名失去外科手术机会的胆管细胞癌患者进行治疗。 瑞金 摄医生在手术中 瑞金 摄中新网上海11月19日电 (陈静 朱凡)不用开腹而利用局部1500伏高压脉冲电“击穿”癌细胞，让癌细胞出现大量纳米大小的微细穿孔来杀死癌细胞。19日，上海瑞金医院使用纳米刀消融技术为一名失去外科手术机会的胆管细胞癌患者进行治疗。据悉，这也是上海开展的首例胆管细胞癌纳米刀消融术。医院方面披露，72岁的夏女士因右上腹痛伴黄疸来到瑞金医院。检查后发现是胆管细胞癌，由于病灶位于肝左叶靠近肝门部，并且已经侵犯到右肝动脉，所以已经无法进行外科手术。为了帮夏女士解除病痛，放射介入科科主任丁晓毅和副主任王忠敏带领科室成员进行了多次充分的讨论，决定利用肿瘤治疗的最新技术—纳米刀来为她治疗。据悉，为了达到最佳手术效果，放射治疗科和麻醉科、放射科共同制定了周密的手术方案。术前，医生为患者缓解黄疸症状后，在CT引导下利用纳米刀探针对肝门肿瘤消融区域进行精确定位，通过探针释放微秒级的高压脉冲，击穿肿瘤细胞的细胞膜，形成大量纳米级不可逆的微穿孔，造成肿瘤细胞凋亡瓦解，而消融区内血管、胆管、神经等结构得以保留。手术中，夏女士生命体征平稳。手术过程十分顺利。瑞金医院放射介入科主任丁晓毅介绍，和传统的消融治疗方式不同，纳米刀消融技术并非利用“热”或“冷”的作用进行物理消融，而是通过高压脉冲电流直接破坏肿瘤细胞的细胞膜使肿瘤细胞死亡，因此对一些位置靠近大的血管神经干以及胆管、胰管、气管、肠管、输尿管等重要区域的肿瘤治疗有着独特优势。丁晓毅说，纳米刀不仅减少肿瘤周边血管神经受损的可能性，也避免了操作过程中，因顾虑损伤神经或大血管而发生肿瘤消融不彻底的情况。据悉，治疗区域内，被“击穿”的癌细胞凋亡后，因为抗原暴露而被人体的免疫细胞吞噬，所在区域逐渐被正常组织取代，从而恢复正常机能。而正常血管的内皮细胞即使受到部分损伤也会在短期内恢复正常。丁晓毅说，一般直径3cm的肿瘤使用纳米刀消融时间不超过5分钟即可完成，消融区域内肿瘤细胞完全灭活，边界清晰，减少复发隐患，而且很少损伤肿瘤周围的血管、神经等重要组织，患者术后第二天即能下地行走。据悉，纳米刀技术于2012年4月被美国FDA批准用于临床，同年12月获欧盟批准，2015年6月中国正式批准IRE的临床应用。

Objective: The purpose of this study was to examine the safety and clinical efficacy of computedtomography (CT)-guided radioactive iodine-125 ( 125 I) seed implantation treatment in patientswith spinal metastatic tumors.Methods: We retrospectively analyzed 20 cases of spinal metastatic tumors, including nine menand eleven women aged 50–79 years (mean age: 61.1 years). We used treatment planning system(TPS) to construct three-dimensional images of the spinal metastatic tumors and to determine whatnumber and dose rate distribution to use for the 125 I seeds. The matched peripheral dose of the 125 Iseed implantation was 90–130 Gy. Twenty-four spinal metastatic tumors were treated by CT-guidedradioactive 125 I seed implantation. A median of 19 (range: 4–43) 125 I seeds were implanted.Results: Twenty cases were followed for a median of 15.3 months (range: 7–32 months). Therate of pain relief was 95%. The median control time for all of the patients was 12.5 months.The 3-, 6-, and 12-month cumulative local control rates were 100%, 95%, and 60%, respec-tively. The median survival time for all of the patients was 16 months. The cumulative 6- and12-month survival rates were 100% and 78.81%, respectively. No major complications wereobserved. No 125 I seeds were lost or migrated to other tissues or organs.Conclusion: CT-guided radioactive 125 I seed implantation is a safe, effective, and minimallyinvasive method for the treatment of patients with spinal metastatic tumors. It is a possiblealternative therapy for the treatment of spinal metastases.Keywords: spinal metastatic tumor, iodine isotopes, computed tomography guided, interven-tional treatment

Abstract Many patients with malignant gastroduodenalobstruction have an unresectable primary lesion and distantmetastases, which may prompt palliative management toallow the patient to eat and to improve the quality of life.Intraluminal metallic stent implantation (MSI) under fluo-roscopic guidance has been reported to be an effectiveoption for symptomatic relief in these patients, with a goodsafety record. An alternative, dual interventional therapy(DIT), has been used during the last decade, in whichprosthesis insertion is followed by intra-arterial chemo-therapy via the tumor-feeding arteries. The aim of thisstudy was to compare success rates, complication rates, andsurvival time between MSI and DIT in patients who pre-sented with gastroduodenal obstruction from advancedupper gastrointestinal tract cancer. All consecutive patientswith malignant gastroduodenal obstruction seen at ourcenter between October 2002 and August 2007 were ret-rospectively studied. Patients were treated palliatively byeither MSI or DIT by the patient’s or the next of kin’sdecision. Outcomes included technical and clinical success,complication rates, and survival. Of the 164 patients withmalignant gastric and duodenal outlet obstructions, 80(49%) underwent stent insertion as the primary therapy,while the remaining 84 (51%) received DIT. Clinicalcharacteristics were similar between the two groups. In theMSI cohort initial stent implantation was successful in 73patients (91%), two stents were used in 5 patients, anddelayed additional stent insertion for stent obstructionrelated to tumor overgrowth was required in 3 patientsduring follow-up. In the DIT cohort the technical successrate was 94%, 3 patients required two stents, and stentobstruction occurred in 2 patients after initial stent place-ment. Early postprocedural clinical success, indicated byaverage dysphagia score, improved significantly in bothgroups: MSI group, from 4.56 to 1.51 (P\0.01); and DITgroup, from 4.38 to 1.48 (p\0.01). There were no short-term complications. Late complications including hema-temesis (n = 3), migration (n = 12), and stent occlusiondue to tumor overgrowth (n = 5) were evenly distributedbetween the groups. In the DIT group chemotherapy-induced neutropenia and transient renal dysfunction weredetected in six patients, which improved after symptomaticmanagement. Mean survival time after the procedure was5.9 and 11.1 months for MSI and DIT, respectively(P\0.001). In conclusion, both MSI and DIT offereffective palliation for malignant gastroduodenal obstruc-tion, but DIT appears to offer superior survival over MSIalone. Ideally, a prospective randomized trial comparingthese two techniques should be carried out to validate thisresult.

Background: A poor prognosis associated with esophageal cancer leads to surgical resection not suitable formost patients. Nitinol stents loaded with 50% 5-fluorouracil (5-FU) or paclitaxel (PTX), functioning both as a stentand local chemotherapy, could provide a new therapy modality for these patients.Objective: To investigate esophageal tissue responses to nitinol stents loaded with 50% 5-FU or PTX implantedin the esophagus of healthy pigs.Design: Twenty-three healthy Bama mini-pigs were randomly divided into 4 groups for stent implantation: groupA (PTX stent, n Z 13), group B (5-FU stent, n Z 8), group C (blank film–covered stent, n Z 1), and group D(bare stent, n Z 1). Tissue responses were observed by endoscopy or pathologic analyses, and 5-FU or PTX con-centrations were measured in the esophagus at the stent implantation site at different time points.Setting: Animal laboratory.Interventions: Endoscopic placement of esophagus stent.Main Outcome Measurements: Endoscopic examination, histology, and drug concentration analysis.Results: Ingeneral,theesophagealtissueresponsesvariedaccordingtodifferentpartsof5-FUorPTXstent(middlepart [drug-containing part] and bare ends [drug-free part]). Severe tissue responses at the bare ends of the stentincludedinflammation,ulceration,andgranulation.However,thetissueresponsesweregreatlyreducedinthemid-dlepartofthestent.Thedrugconcentrationsintheesophagusthathadcontactwiththe5-FUstentorPTXstentwerevery high, especially for the first period after implantation, which did not cause obvious tissue damage.Limitation: Some subjects had incomplete follow-up because of unexpected deaths and stent migration.Conclusion: The nitinol stents loaded with 50% 5-FU or PTX did not cause severe esophageal tissue responses,although there was a large concentration of the drug in these tissues.

小陈（化名）今年33岁，是一名高级白领，平时工作繁忙。前不久公司体检，发现肾脏可疑肿瘤。这么年轻就得了肿瘤，让小陈惊慌失措，赶忙到我院进一步检查。结果让小陈吃了一颗定心丸，医生告诉小陈他得的是肾动脉瘤，并不是肾癌。医生告诉小陈，肾动脉瘤虽然不是恶性肿瘤，平时生活中可能也没有任何症状，但是肾动脉瘤可以称得上人体内的“定时炸弹”，一旦破裂将可能发生致命性大出血，马上危及生命。小陈刚平复的心马上又悬到了嗓子眼，问医生该如何处理。医生告诉小陈，可以通过微创介入的手段，来治疗肾动脉瘤，降低破裂的风险。于是，小陈来到我院介入科进一步诊治，事不宜迟，为最大程度保障小陈的生命安全，我们团队立刻完善了相关检查，并安排了微创介入手术—肾动脉瘤栓塞术。只需要在大腿上打一个1mm左右的针孔，就可以完成弹簧圈栓塞、达到治愈的效果。手术非常顺利，小陈第二天就可以下床行走，第三天就高兴的出院了。肾动脉瘤属于少见且发病隐匿的内脏动脉瘤，人群发病率为0.1%。多数肾动脉瘤患者无明显症状，常因其他原因行影像学检查时被诊断；由于肾脏血供丰富，动脉瘤一旦破裂将发生大出血、危及生命。目前采用的肾动脉瘤分型由Rundback等提出，分为3型，包括（1）位于近端肾动脉主干与大分叉处囊状的1型，（2）邻近二级分支处梭形的2型，（3）肾门动脉或实质内的3型。肾动脉瘤的瘤体形态、钙化程度与其生长速率无显著关系。肾动脉瘤的主要治疗目的在于治疗或预防肾动脉瘤破裂，缓解继发性高血压及保护肾脏功能。目前肾动脉瘤外科治疗指征包括：（1）瘤体最大直径≥2cm；（2）育龄期女性；（3）出现腰痛、背痛、血尿等临床症状；（4）伴有顽固性高血压相关的肾动脉狭窄、血栓栓塞、夹层、破裂风险；（5）合并肾动脉狭窄。开放性肾动脉瘤修复术是肾动脉瘤治疗的经典方式，包括补片成形术、动脉瘤夹闭术等，但因创伤较大已经逐渐被微创治疗技术取代。随着腔内治疗技术应用于肾血管疾病且其在肾动脉瘤治疗中发展迅速，目前已成国内肾动脉瘤首选治疗方式。合适的解剖结构是选择腔内治疗的首要条件。覆膜支架广泛应用于1型肾动脉瘤，而2型分支肾动脉瘤应用则较为受限。支架植入过程中，需权衡肾动脉瘤细小分支的隔绝是否会对肾功能造成较大损伤。多层血流调节器拓宽了支架在复杂形态肾动脉瘤中的应用，多层血流调节器可促进湍流向层流转化，诱发瘤腔内机化血栓形成、减少旁路分支血管的闭塞。弹簧栓塞法常用于3型肾动脉瘤或具有狭窄颈部的囊状肾动脉瘤。球囊或支架辅助弹簧栓塞术应用于宽短瘤颈的肾动脉瘤，使弹簧栓塞更适应动脉瘤形态，同时防止远端栓塞事件发生。

【摘要l影像引导下射频消融(砒’A)治疗是一种安全、近期疗效肯定、并发症少的微创介入治疗方法。觋已广泛应用于肝癌、肺癌、肾上腺恶性肿瘤、骨肿瘤及脾功能亢进的治疗。RFA与动脉栓塞化疗、化学消融或经皮穿刺椎体成形术等联合应用，是一种新型的综合性介入治疗肿瘤的方法。将会进一步提高肿瘤治疗的疗效。