经皮介入方法在肺癌诊治中的应用2

•完全性消融–肺部原发肿瘤消融的适应证手术切除单发病灶，肿瘤最大径≤3cm，且无其–肺部转移性肿瘤消融的适应证•单侧单发转移瘤，最大直径≤3cm•姑息性消融–减轻肿瘤负荷–缓解症状和改善生活质量–适应证较完全性消融适当放宽引起的难治性疼痛，可对肿瘤局完全消融与不完全消融的评价标准•完全消融(出现下列表现任何一项)–病灶消失–完全形成空洞–病灶纤维化，可为疤痕–实性结节缩小或无变化，但CT扫描无造影剂强化征象–肺不张，肺不张内的病灶CT扫描无造影剂强化征象•不完全消融(出现下列表现任何一项)–空洞形成不全，有部分实性或液性成分，且CT扫描有造影剂强化–部分纤维化，病灶部分纤维化仍存有部分实性成分，且实性部分CT扫描–实性结节，大小无变化或增大，且伴CT扫描造影剂有强化征象氩氦刀冷冻治疗实例(完全性消融)时术后影像学改变(CT)•早期改变(1周内)–病灶内可出现蜂窝状或空洞样低密度影，消融肿瘤周边为不同衰减程度的同心圆包围，称为“帽徽”(capbadge)征象(此征象在消融后24h-48h更加明显)–CT值减低，病灶较消融前增大，周边呈现GGO样反应带GGOmm可达到术后影像学改变(CT)•中期改变(1周-3月内)可持续增大，其周边可能出现环绕清晰锐利的强化环，称为“蛋壳”(eggshell)征象•后期改变(3月后)–与基线(一般以病灶消融后1个月时的CT表现为基线)比消融区在以后的CT随访过程中病灶区域有几种不同、结节、肺不张、消失等素+cm++++++Modality1-yearLC2-yearOSCommontoxicitiesRelativecontraindicationsLobectomyorsublobarresection85-95%80-85%infection,airleak,myocardialinfarction,respiratoryfailuresevereCOPD(FEV1orDLCO<40%predicted)SBRT80-95%65-75%pneumonitis,chestwallpain/ribfracturecentraltumorsneartrachea,mainstembronchi,hilum,oresophagus60-75%60-80%pneumothorax,pneumonia,pleuraleffusion,post-procedurepaintumorsnearmajorbloodvessels,esophagus,trachea,mainstembronchi,or>3cm%5%pneumothorax,pneumonia,pleuraleffusion,hemoptysis,post-procedurepaintumorsnearesophagus,trachea,mainstembronchi85-95%~80%pneumothorax,hemorrhage,bronchospasmhemoptysis,pneumonitis,skinburnstumors>3cmCenterNumberofpatients(stageIA/IB)Patientage(y)Tumorsize(cm)Follow-upperiod(mo)ToxicitiesSurvivalYamanashiMedicalUniversityinJapan35(15/20)78*33**Nograde≥3toxicities2-yearOSandCSS58%and83%KyotoUniversityinJapan45(32/13)77*forstageIAand73*forstageIB<4.030*forstageIAand22*forstageNograde≥3pulmonarytoxicities5-yearOSandDFSforstageIA:83%72%5-yearOSandDFSforstageIB:72%and71%TechnicalUniversityinGermany30(5/25)60–69(n=10)70–79(n=14)≥80(n=6)18*foralivepatientsNograde5or4toxicitiesandgrade3pneumonitis:3%1-/2-yearOS:80%/75%SahlgrenskaUniversityinSweden45(18/27)74*3.5**43*Nograde5toxicitiesandnograde≥2radiationpneumonitis5-yearOSandCSS:30%and41%medianOSandCSS:39moand55moIndianaUniversityin70(35/35)70*Grade5toxicities:9%(includingpneumonia[6%],pericardialeffusion[1%],hemoptysis[1%])andgrade3or4toxicities:11%2-yearOS:55%andmedianOS:33moMulticenterinJapan257(164/93)74*2.8*38*Nomortalityandgrade≥3pulmonarytoxicities:5%5-yearOSandCSS:47%and73%MulticenterinSweden,Norway,andDenmark57(40/17)75*2.5*35*Nograde5toxicitiesandgrade4/3toxicities:2%/28%,respectively3-yearOSandCSS:60%and88%medianOS:41moYamanashiMedica+A2:G11lUniversityinJapan35(15/20)78*33**Nograde≥3toxicities2-yearOSandCSS:58%and83%KyotoUniversityinJapan45(32/13)77*forstageIAand73*forstageIB<4.030*forstageIAand22*forstageIBNograde≥3pulmonarytoxicities5-yearOSandDFSforstageIA:83%and72%5-yearOSandDFSforstageIB:72%and71%TechnicalUniversityinGermany30(5/25)60–69(n=10)70–79(n=14)≥80(n=6)18*foralivepatientsNograde5or4toxicitiesandgrade3pneumonitis:3%1-/2-yearOS:80%/75%CenterNumberofpatients(stageIA/IB)Patientage(y)Tumorsize(cm)Follow-upperiod(mo)ToxicitiesSurvivalSahlgrenskaUniversityinSweden45(18/27)74*3.5**43*Nograde5toxicitiesandnograde≥2radiationpneumonitis5-yearOSandCSS:30%and41%medianOSandCSS:39moand55moIndianaUniversityinUS70(35/35)70*NAGrade5toxicities:9%(includingpneumonia[6%],pericardialeffusion[1%],hemoptysis[1%])andgrade3or4toxicities:11%2-yearOS:55%andmedianOS:33moMulticenterinJapan257(164/93)74*2.8*38*Nomortalityandgrade≥3pulmonarytoxicities:5%5-yearOSandCSS:47%and73%MulticenterinSweden,Norway,andDenmark57(40/17)75*2.5*35*Nograde5toxicitiesandgrade4/3toxicities:2%/28%,respectively3-yearOSandCSS:60%and88%medianOS:41moIndianaUniversityinUS70(34/36)NANA50*Grade5toxicities:7%(includingpneumonia[4%],hemoptysis[1%],andrespiratoryfailure[1%])andgrade4/3toxicities:1%/9%3-yearOS/CSS:43%/82%,medianOS:32moOSforstagesIAandIB:39moand25moUniversityofTorinoinItaly62(43/19)74*2.4*28*Nograde5toxicitiesandgrade≥3radiationpneumonitis:3%3-yearOS,CSS,andDFS:57%,73%,and55%MulticenterinUSandCanada55(44/11)72*≤5.034*Nograde5toxicitiesandgrade4/3toxicities:4%/13%,respectively3-yearOS/DFS:56%/48%medianOSandDFS:48moand34moMulticenterinJapan87(64/23)74*.1*forstageIAand3.9*forstageIB55*Nograde5toxicities,grade3pulmonarytoxicities:1%,andoverallgrade3toxicities:9%5-yearOS/CSS:70%/76%5-yearOSforstagesIAandIB:72%and63%VUUniversityMedicalCenterinNetherlands177(106/71)76*2.6*32*Nograde5toxicitiesandgrade≥3radiationpneumonitis:2%5-yearOS:51%medianOS:62moMulticenterinJapan180(128/52)77*2.7*36*Nograde5toxicitiesandgrade3radiationpneumonitis:1%5-yearOS:52%3-yearOS/CSSforstagesIAandIB:88%and69%WashingtonUniversityinUS151(110/41)74**2.6**23*NA5-yearOSandDFS:25%and19%CenterNumberofpatients(stageIA/IB)Patientage(y)Tumorsize(cm)Follow-upperiod(mo)ToxicitiesSurvivalYamanashiMedicalUniversityinJapan35(15/20)78*33**Nograde≥3toxicities2-yearOSandCSS58%and83%KyotoUniversityinJapan45(32/13)77*forstageIAand73*forstageIB<4.030*forstageIAand22*forstageNograde≥3pulmonarytoxicities5-yearOSandDFSforstageIA:83%72%5-yearOSandDFSforstageIB:72%and71%TechnicalUniversityinGermany30(5/25)60–69(n=10)18*foraliveNograde5or4toxicitiesandgrade3pneumonitis:3%1-/2-yearOS:80%/75%70–79(n=14)≥80(n=6)patientsSahlgreny3.5*nograde≥25-yearOSandCSS:30%and41%medianOSandCSS:39moand55moIndianaUniversityin7%,%,9pneumonia[6%],pericardial4toxicities:11%effusionrade3or2-yearOS:55%andmedianOS:33moenterinJapan257(164/93)74*2.8*38*Nomortalityandgrade≥3putoxicities:5%lmonary5-yearOSandCSS:47%and73%MulticenterinSweden0/1775*2.5*35*Nograde5toxicitiesandgrade4/3toxicities:2%/28%,respectively3-yearOSandCSS:60%and88%medianOS:41moYamanashiMedica+A2:G11lUniversityinJapan35(15/20)78*33**Nograde≥3toxicities2-yearOSandCSS:58%and83%KyotoUniversityinJapan45(32/13)77*forstageIAand73*forstageIB<4.030*forstageIAand22*forstageIBNograde≥3pulmonarytoxicities5-yearOSandDFSforstageIA:83%and72%5-yearOSandDFSforstageIB:72%and71%TechnicalUniversityinGermany30(5/25)60–69(n=10)70–79(n=14)≥80(n=6)18*foralivepatientsNograde5or4toxicitiesandgrade3pneumonitis:3%1-/2-yearOS:80%/75%CenterNumberofpatients(stageIA/IB)Patientage(y)Tumorsize(cm)Follow-upperiod(mo)ToxicitiesSurvivalSahlgrenskaUniversityinSweden45(18/27)74*3.5**43*Nograde5toxicitiesandnograde≥2radiationpneumonitis5-yearOSandCSS:30%and41%medianOSandCSS:39moand55moIndianaUniversity死inUS死7070*NAGrade5toxicities:9%(includingpneumonia[6%],pericardialeffusion[1%],hemoptysis[1%])andgrade3or4toxicities:11%2-yearOS:55%andmedianOS:33moMulticenteJapanrin257(164/93)74*2.8*38*Nomortalityandgrade≥3pulmonarytoxicities:5%5-yearOSandCSS:47%and73%MulticenteSweden,Norway,aDenmark肺rin肺nd57752.5*35*Nograde5toxicitiesandgrade4/3toxicities:2%/28%,respectively3-yearOSandCSS:60%and88%medianOS:41moIndianaUniversity70NANA50*Grade5toxicities:7%(includingpneumonia[4%],hemoptysis[1%],andrespiratoryfailure[1%])andgrade4/3toxicities:1%/9%3-yearOS/CSS:43%/82%,medianOS:32moOSforstagesIAandIB:39moand25moUniversityTorinoinI引流taly62(43/19)74*2.4*28*Nograde5toxicitiesandgrade≥3radiationpneumonitis:3%3-yearOS,CSS,andDFS:57%,73%,and55%MulticenteUSandCarinnada55(44/11)72*≤5.034*Nograde5toxicitiesandgrade4/3toxicities:4%/13%,respectively3-yearOS/DFS:56%/48%medianOSandDFS:48moand34moMulticenteJapan严rin严87(64/23)74*IAand3forstagetage*IB55*Nograde5toxicities,grade3pulmonarytoxicities:1%,andoverallgrade3toxicities:9%5-yearOS/CSS: