目的 探讨肺癌伴恶性胸腔积液(MPE)经肋间动脉灌注化疗的意义及多途径治疗方案。方法 共20例肺癌伴MPE患者, 置管引流后, 对2例肺不能复张者行胸膜剥脱术和病理检查, 其余18例肺复张后被随机分为三组, 每组6例, 分别将卡铂经支气管动脉、肋间动脉和肺动脉灌注化疗, 连续多时点测定新产生的胸腔积液中铂离子的浓度, 比较胸腔积液中铂(Pt)离子的浓度变化, 丝裂霉素和表阿霉素均经其他两条途径灌注, 然后统一进行高聚金葡素胸腔内灌注, 并观察临床疗效。结果 三种途径灌注后胸腔积液中铂离子浓度随时间变化趋势相似, 肋间动脉灌注组Pt离子浓度明显高于支气管动脉灌注组和肺动脉灌注组(P<0.05)。本组患者胸腔积液治疗有效率为94.4%, 肺部实体瘤有效率为50%, 副反应轻微, 治疗前后生活质量大幅度改善(P<0.05)。结论 对于肺癌伴MPE患者的介入化疗应注重肋间动脉灌注化疗。
Objective To study the mechanism and of interventional chemotherapy through the intercostal arteries and evaluate multiple treatment plans for malignant pleural effusion with pulmonary carcinoma.Methods 20 MPE cases totally.Pleurectomy are performed on 2 cases of them with trapped lung for pathological study.The rest 18 cases were divided into three groups,6 cases in each group:carboplatin was administrated through bronchial artery in groupⅠ,through intercostal artery in groupⅡ,and through pulmonary artery in groupⅢ.All patients were treated with small-bore catheter drainage system,interventional chemotherapy and HASL.The Pt concentration in pleural effusion of three groups were compared at different time after carboplatin administration and their clinical results,side effects and life quality improvement were observed.Results Pt concentration curves of the three groups were similar to each other,rose quickly after administration of carboplatin,reached a peak 1 hour or so later,and then began to decrease slowly,but still kept certain levels after 12 hours.Pt concentration of group Ⅱwas obviously higher than that of the other two groups (P<0.05).Pt concentration of groupⅠand group Ⅲ were low,and had no difference between the two groups (P>0.05).The side effects of 18 cases were insignificant.The rates of CR+PR for pleural effusion and pulmonary carcinoma were 94.4% and 50% respectively,and life quality improved significantly after the treatment(P<0.05).Pathological study found embolus of tumor cells in lymphatic vessels of parietal pleura.Conclusion MPE with lung cancer mainly caused by parietal pleura metastasis supplied by intercostal artery,thus we may lay particular emphasis on intercostal artery intervention chemotherapy for MPE with pulmonary carcinoma.The combined therapy of small-ball catheter drainage system,local administration of HASL in pleural cavity and multi interventional therapy is safe,effective and deserving of being widely used.
[1] Finley DJ,Rusch VW.Anatomy of the pleura[J].Thorac Surg Clin,2011,21(2):157-163.
[2] 俞森洋.胸膜和胸膜腔的解剖和生理功能的研究[J].中华结核和呼吸杂志,2001,24(1):14-15.
[3] Fysh ET,Waterer GW,Kendall P,et al.Indwelling pleural catheters reduce inpatient days over pleurodesis for malignant pleural effusion[J].Chest,2012,141(6):199-205.
[4] 王永武,张家裕,周永新,等.改良中心静脉导管置管引流系统治疗恶性胸腔积液47例[J].中国肺癌杂志 2003,6(5):395-396.
[5] Morel A,Mishra E,Medley L,et al.Chemotherapy should not be withheld from patients with an indwelling pleural catheter for malignant pleural effusion[J].Thorax,2011,66(5):448-449.
[6] MacEachern P,Tremblay A.Pleural controversy:pleurodesis versus indwelling pleural catheters for malignant effusions[J].Respirology,2011,16(5):747-754.
[7] Aydogmus U,Ozdemir S,Cansever L,et al.Bedside talc pleurodesis for malignant pleural effusion:factors affecting success[J].Ann Surg Oncol,2009,16(3):745-750.
[8] Davies HE,Mishra EK,Kahan BC,et al.Effect of an indwelling pleural catheter vs chest tube and talc pleurodesis for relieving dyspnea in patients with malignant pleural effusion:the TIME2 randomized controlled trial[J].JAMA,2012,307(22):2383-2389.
[9] Hunt BM,Farivar AS,Vallières E,et al.Thoracoscopic talc versus tunneled pleural catheters for palliation of malignant pleural effusions[J].Ann Thorac Surg,2012,62(7):448-449.
[10] Chen WJ,Yuan SF,Yan QY,et al.intrapleural chemo-and hyperthermotherapies for malignant pleural effusion:a randomized prospective study[J].Cancer Invest,2012,30(2):126-130.
