循环灌注热化疗与高频热疗机化疗治疗恶性胸腔积液疗效对比分析

目的比较采用胸腔镜辅助下胸内循环灌注热化疗与体外高频热疗机灌注化疗治疗恶性胸腔积液的疗效。方法 2006年12月~2013年4月共收治102例恶性胸腔积液患者,治疗组54例采用胸腔镜辅助下胸内循环灌注热化疗治疗,对照组48例采用体外高频热疗机灌注化疗。两组灌注抗癌药均为顺铂注射液。比较两组患者胸水疗效、临床症状改善率、生活质量改善率及毒性不良反应。结果治疗组恶性胸水治疗总有效率优于对照组(100%VS 81.25%,P<0.05),生活质量改善率亦高于对照组(96.30 VS 72.92%,P<0.01)。而两组临床症状改善率、毒性不良反应率比较均无统计学差异(P>0.05)。结论胸腔镜辅助下胸内循环灌注热化疗治疗恶性胸腔积液的综合治疗效果较体外高频热疗机化疗效果更优越,具有热化疗疗效确切,患者生活质量改善率高的明显优势,值得临床推广运用。     

胸腔内高温灌注化学治疗恶性胸腔积液

目的总结电视胸腔镜辅助下胸腔内高温灌注化学治疗恶性病变引起的胸腔积液的方法和效果。方法1999年2月至2005年3月，将58例恶性胸腔积液患者随机分为治疗组（30例）和对照组（28例），治疗组在全身麻醉电视胸腔镜下行胸膜活检术，并用人工心肺机恒温43℃，生理盐水3000ml加顺铂300mg灌注1h；对照组予以胸腔引流，胸腔内灌注顺铂60～80mg。比较两组治疗前、后胸水量的变化、胸水中癌胚抗原（CEA）、细胞角蛋白K19片段（CYFRA21—1）、神经元特异性烯醇化酶（NSE）浓度变化和毒副作用。结果治疗组、对照组有效率分别为100.0％和53，6％，差异有统计学意义（x^2=3．863，P〈0.05）；治疗组治疗后较治疗前胸水中CEA，CYFRA21—1，NSE浓度明显下降（t=2．562，P〈0.05），治疗后治疗组较对照组明显降低（P〈0.05）；两组各种毒副反应比较差异无统计学意义（P〉0.05）。结论电视胸腔镜辅助下胸腔内高温灌注化学治疗恶性胸腔积液安全有效，具有创伤小、视野大、活检准确方便、便于确诊的优点。     

胸腔循环热灌注化疗治疗恶性胸腔积液的护理体会

目的探讨恶性胸腔积液在胸腔循环热灌注化疗期间的护理体会及要点。方法对恶性胸腔积液患者行胸腔热灌注化疗,分析治疗期间出现的不良反应、护理体会及临床疗效。结果热灌注化疗治疗恶性胸腔积液总有效率为76.9%,不良反应中胃肠道反应发生率(84.6%)较高。3个月后完全消失。结论热灌注化疗是一种有效治疗恶性胸腔积液的手段,加强化疗期间的护理措施,可提高患者的生存质量。较少化疗各种不良反应。     

中心静脉置管行胸腔积液引流的护理

通过对照实验的方法采用射频透热治疗恶性胸腔积液,并与传统的胸腔灌注治疗恶性胸腔积液进行对比分析.结果表明,射频透热治疗治疗组总有效率94.9%,单纯灌注治疗组总有效率69.6%,两组疗效对比有明显差异(P＜0.005)其优点,射频透热治疗能使胸水充分吸收,达到治疗目的.它是一种简单有效、安全、可靠、绿色、患者容易接受的一种方法.值得推广.     

胸腺肽联合顺铂胸腔灌注治疗恶性胸腔积液效果观察

目的观察胸腺肽联合顺铂胸腔灌注治疗恶性胸腔积液的效果。方法随机将68例晚期肺癌伴恶性胸腔积液患者分为2组,每组34例。胸腔闭式引流后对照组经引流管缓慢将顺铂注射液20 mg注入胸腔,夹闭引流管48 h。观察组联合胸腺肽200mg胸腔灌注。比较2组近期疗效、治疗期间不良反应及治疗前后Karnofsky功能状态评分(KPS)。结果观察组总有效率和治疗后KPS评分均明显高于对照组,差异有统计学意义(P0.05)。2组不良反应发生率比较差异无统计学意义(P0.05)。结论胸腺肽联合顺铂胸腔灌注治疗恶性胸腔积液,能有效抑制胸腔积液的生成,改善患者生活质量。     

射频透热配合化疗治疗恶性胸腔积液的疗效观察与护理

通过对照实验的方法采用射频透热治疗恶性胸腔积液,并与传统的胸腔灌注治疗恶性胸腔积液进行对比分析.结果表明,射频透热治疗治疗组总有效率94.9%,单纯灌注治疗组总有效率69.6%,两组疗效对比有明显差异(P＜0.005)其优点,射频透热治疗能使胸水充分吸收,达到治疗目的.它是一种简单有效、安全、可靠、绿色、患者容易接受的一种方法.值得推广.     

循环胸腔热灌注治疗肺癌胸水的麻醉

肺癌胸水循环胸腔热灌注(简称热灌注)治疗法是向胸腔内循环灌注43℃温生理盐水60min治疗肺癌胸水的一种方法[1],在治疗期间因胸腔及体温升高可能导致患者的病理生理改变,本文就该治疗术麻醉中的一些经验进行初步总结。资料与方法一般资料选择ASAⅠ～Ⅲ级肺癌患者58例,男42例,女     

顺铂联合香菇多糖治疗恶性胸腔积液32例疗效观察

目的 探讨顺铂联合香菇多糖治疗恶性胸腔积液的疗效及机制。方法 将64例恶性胸腔积液患者随机分为观察组(32例)和对照组(32例)。观察组32例患者放尽胸水后经胸腔内注入顺铂加香菇多糖进行治疗；对照组32例患者放尽胸水后经胸腔内注入顺铂进行治疗。结果 观察组有效率(84．4％)高于对照组(50.0％)具有显著性差异(P＜0．05)。结论 顺铂联合香菇多糖治疗恶性胸腔积液患者有确切疗效。明显提高化疗药敏感性，提高患者生存期及生活质量。     

电视胸腔镜手术诊治恶性胸腔积液

目的:探讨电视胸腔镜手术(VATS)诊治恶性胸腔积液的安全性和效果。方法:自2001年6月至2002年6月对7例胸腔病人实施了VATS诊治。均行胸腔活检、滑石粉喷洒胸腔固定术。结果:6例获得明确的病理诊断,4例为癌胸膜转移,2例为恶性间皮细胞瘤。1例未明确诊断,无术后严重并发症和死亡。随访1～8个月,胸腔积液均得到控制,未见复发。结论:电视胸腔镜手术在诊治恶性胸水方面有明显的优点。     

奈达铂胸腔灌注治疗恶性胸腔积液的临床观察

目的观察胸腔内注射奈达铂治疗恶性胸腔积液的临床疗效及安全性。方法 59例恶性胸腔积液患者,应用1次性单腔中心静脉导管行胸腔穿刺置管和闭式引流术排尽胸水后,行胸腔内药物注射。随机分治疗组和对照组：治疗组34例奈达铂100mg/次,0.9氯化钠注射液40mL稀释;对照组25例,顺铂80mg/次,0.9氯化钠注射液40mL稀释注入胸腔。1周后再次注药,共计不超过3次。结果治疗组CR12例,PR14例,有效率为76.5;对照组CR4例,PR9例,有效率为52.0。两组比较差异有统计学意义（P〈0.05）。两组患者腔内治疗均无气胸、胸腔感染、胸壁种植等严重并发症发生。结论胸腔置管闭式引流后注入奈达铂,是一种治疗恶性胸腔积液有效、安全的方法。     

Comparison of nucleolar organiser regions and DNA flow cytometry in the evaluation of pleural effusion.

BACKGROUND--In conventional cytological diagnosis of pleural effusions the assessment of morphological features plays an important part. However, false negative and false positive results may occur. In this study conventional cytology was compared with flow cytometric DNA analysis and the argyrophil staining technique for nucleolar organiser regions (AgNOR) to characterise benign and malignant effusions. METHODS--Pleural effusions from 71 patients (38 with benign lung disease, 33 with proven adenocarcinoma of lung) were studied by conventional cytology, flow cytometric DNA analysis, and the AgNOR technique. Tumour cell ploidy was determined by flow cytometry. In an attempt to detect the cell proliferative state, flow cytometric S phase fraction and the AgNOR technique were used. The correlations among conventional cytology, flow cytometric DNA ploidy, S phase fraction analysis, and nucleolar organiser regions were investigated. RESULTS--All the 38 benign pleural effusions were diploid. There were 17 (52%) aneuploid and 16 (48%) diploid malignant pleural effusions. Based on these results this type of DNA analysis had a sensitivity of 52% and a specificity of 100%. The mean (SD) numbers of flow cytometric S phase fractions of benign and malignant cases were 5.32 (1.67)% and 12.45 (3.93)% respectively. The mean numbers of S phase fractions of diploid malignant cases were higher than diploid benign cases. In each case the number of AgNORs was counted in 100 cells. The mean number of AgNOR dots per nucleus was 12.57 (3.64) for malignant pleural effusion cells and 3.96 (1.39) for benign pleural effusion cells. The mean number of AgNOR dots was 14.45 (3.36) for aneuploid malignant pleural effusion cells and 10.57 (2.82) for diploid malignant pleural effusion cells. The AgNOR numbers were higher in diploid malignant cells than in diploid benign cells. There was a significant correlation between the S phase fraction determined by flow cytometry and the mean number of AgNORs per nucleus in malignant cases. CONCLUSIONS--Both flow cytometry and the AgNOR methods provide comparable measurements in the diagnosis of pleural effusion. The study also indicates that the AgNOR method, which is rapid and easy to perform, may be a useful adjunct to flow cytometry, S phase fraction analysis and conventional cytology in the routine diagnosis of malignant pleural effusion.     

实时荧光定量RT-PCR检测胸、腹腔积液和癌胚抗原mRNA表达的临床意义

目的　探讨良、恶性胸腔腹腔积液中癌胚抗原 (CEA)mRNA表达的临床意义。　方法收集明确病理学诊断的恶性肿瘤 (5 8例 )及良性疾病患者 (76例 )的胸腔、腹腔积液 ,采用实时荧光定量RT PCR法检测其CEAmRNA的表达水平 ,并与脱落细胞学检查结果比较。　结果　 5 8例肿瘤患者胸、腹腔积液中 ,脱落细胞学检查有 19例 (32 8% )找到癌细胞 ,而CEAmRNA阳性 (>1CN)者为 4 6例 (79 3% ) ,二者阳性率差异具有极显著性意义 (χ2 =2 1 82 ,P =0 0 0 0 )。 76例良性疾病患者的胸、腹腔积液中CEAmRNA阳性 (>1CN)者为 19例 (2 5 0 % ) ,良性疾病与恶性肿瘤患者胸腔腹腔积液中CEAmRNA的表达水平差异有极显著性意义 (χ2 =38 85 ,P =0 0 0 0 )。　结论　采用实时荧光定量RT PCR法可定量检测胸、腹腔积液中CEAmRNA表达 ,其敏感性优于脱落细胞学检查 ,且有助于胸、腹腔积液良、恶性的鉴别。     

Vascular endothelial growth factor (VEGF) in inflammatory and malignant pleural effusions

BACKGROUND: Investigation and management of pleural effusions is an important clinical problem yet the pathogenesis of pleural fluid accumulation is poorly understood. Vascular endothelial growth factor (VEGF) is a potent inducer of capillary permeability that is produced by both malignant and inflammatory cells. A study was undertaken to determine whether VEGF has a potential pathogenic role in the development of pleural effusions and whether VEGF receptors are present on human pleural mesothelial cells. METHODS: Normal and inflamed pleura were examined immunohistochemically for the presence of FLT-1 (the fms-like tyrosine kinase receptor of VEGF). VEGF levels were measured by ELISA in 78 consecutive patients presenting with undiagnosed unilateral pleural effusions and the levels were correlated with the aetiology of the effusions. RESULTS: Immunohistochemical staining of normal and diseased pleura demonstrated the presence of the FLT-1 VEGF receptor on human mesothelial cells. Median VEGF levels were 2500 pg/ml in the malignant group and 305 pg/ml in the non-malignant group (median difference 1397.5 pg/ml (95% CI 851 to 2693), p<0.005). Median VEGF levels varied according to tumour histology. VEGF levels were also significantly raised compared with transudates (median 36.5 pg/ml) in empyema (4651 pg/ml (95% CI 833 to 10 000), p<0.001) and parainfectious effusions (360 pg/ml (95% CI 46 to 597), p<0.005). CONCLUSIONS: This first report of VEGF receptors on pleural mesothelial cells has indicated a potential mechanism for the biological activity of VEGF on pleural tissue. VEGF levels are raised in the majority of exudative effusions, implying a pathogenic role for this molecule in the development of pleural effusions.     

Induction of apoptosis by intrapleural perfusion hyperthermo-chemotherapy for malignant pleural mesothelioma.

PURPOSE: Despite extensive clinical research, no effective therapy for advanced malignant pleural mesothelioma has been established. In this study, we induced apoptosis in patients with this disease, using intrapleural perfusion hyperthermo-chemotherapy, a new procedure developed in our surgical department. We then measured the tumorcidal effect. MATERIAL AND METHODS: Our study included 6 consecutive patients with malignant pleural mesothelioma (stage III: 5; stage IV: 1). Because of the advanced stage of the disease, none of the patients underwent tumor resection or pleurectomy. All patients, however, received perfusion treatment. Tumor cells collected from pleural effusions pre-and at 0, 24, and 48 h postperfusion were examined using an immunocytochemical stain to determine apoptosis. The percentage of positively stained cells was expressed as the apoptotic index. RESULTS: Preperfusion, the apoptotic index was 3.8%+/-2.0%, indicating spontaneous apoptosis of untreated tumor cells. Postperfusion, the apoptotic index at 0, 24, and 48 h was 22.8%+/-5.15%, 63.8%+/-8.2%, and 47.8%+/-6.9%, respectively. The patients had a median survival time of 30 months. No patient morbidity was associated with the perfusion treatment. CONCLUSION: In patients with malignant pleural mesothelioma, intrapleural perfusion hyperthermo-chemotherapy induced potent apoptosis of tumor cells, increasing immediately postperfusion and peaking at 24 h.     

Value of DNA analysis in addition to cytological testing in the diagnosis of malignant pleural effusions.

BACKGROUND--Aneuploidy appears to be a highly specific marker for cancer, and measurement of cellular DNA content by flow cytometry is rapid and reliable. This study was undertaken to determine if the addition of DNA analysis improved the sensitivity of cytological diagnosis of malignancy in pleural fluid. METHODS--Pleural effusions from 92 patients were studied by cytological examination and flow cytometry. RESULTS--In 41 patients the final diagnosis was malignancy, there were 40 cases of benign effusions including 22 with pleural tuberculosis, and in the remaining 11 patients with biopsy proven cancer the presence of malignant cells was not found by cytological and histological means in the pleural fluid. Aneuploidy and cytological malignancy were found in 14 samples. There were seven cases with abnormal flow cytometry and negative cytological results. In 12 patients the cytological test results were positive but DNA analysis was normal. Thirty six samples of fluid were both diploid and cytologically negative. Of the 22 tuberculous effusions seven contained aneuploid cells. The sensitivity of DNA and cytological analysis was 51.2% and 63.4%, respectively. The specificity of DNA analysis was 74.5%. CONCLUSIONS--DNA analysis of cells in malignant pleural effusions is both less sensitive and specific than the cytological diagnosis. Flow cytometric analysis is not recommended for routine use in the diagnosis of pleural effusions.     

Tumor type M2-pyruvate-kinase levels in pleural fluid versus plasma in cancer patients: a further tool to define the need for invasive procedures.

OBJECTIVE: Pleural effusion is a common diagnostic problem and a challenge to the thoracic surgeon. The analysis of serum and body fluids for tumor markers is an established diagnostic procedure. Among various markers, tumors are linked to the overexpression of a glycolytic isoenzyme, M2-pyruvate-kinase (M2-PK). This preliminary study evaluated this enzyme as a tumor marker to differentiate malignant from benign pleural effusion. METHODS: The tumor M2-PK concentration was measured in the EDTA-plasma and pleural fluid of 34 patients with an established diagnosis of cancer, either primary of the chest (18) or secondary to chest (16) and in 34 controls with benign effusion. The concentration was quantitatively determined by an enzyme-linked immunosorbent assay. The cut-off level between negative and positive values of the tumor M2-PK was defined as the benign group's mean+2SD (95% percentile). True-positives, false-positives, true-negatives, and false-negatives, were determined with 'positive' referring to histologically proven malignant effusion and 'negative' referred to as nonmalignant effusions. Sensitivity, specificity, positive predictive value, and negative predictive value were assessed. RESULTS: The cut-off value was established at 7.61 U/ml for plasma and 32.9 U/ml for pleural fluid. Both plasma and pleural fluid levels of tumor M2-PK were significantly higher in patients with known chest malignancy, either primary or metastatic, compared to nonmalignant effusions (p<0.001). Sensitivity in pleural fluid was significantly higher compared to plasma (85.7% vs 76.2%; p<0.01). Moreover, negative predictive value was higher for pleural fluid compared to plasma (79.4% vs 70.8; p<0.01) CONCLUSIONS: Tumor M2-PK marker is useful in differentiating malignant from benign pleural effusions. Moreover, its sensitivity and NPV in pleural fluid are significantly higher compared to plasma. The usefulness of such a test is not strictly diagnostic but aims at excluding poorly performing patients from further invasive procedures. Thus, the inclusion of M2-PK within a panel of well-known tumor markers such as CEA, MCA, Ca 125 and Ca 19-9, may help in increasing the overall sensitivity and specificity.     

Experimental and clinical studies on intrapleural instillations of interleukin-2 (IL-2) in patients with malignant pleural effusion

The author investigated the anti-tumor effect of lymphokine-activated killer (LAK) cell induced by culture in IL-2 and performed intrapleural instillation of IL-2 in patients with malignant pleural effusion on the original protocol. The original protocol had been designed to keep high concentration of IL-2 in the effusion. The mean LAK activity in advanced esophageal cancer patients was not depressed as compared with other disease of patients and normal individuals. LAK cells expressed the surface markers of OKIa1, Leu7, and OKT8. Clinically pleural effusions and malignant cells in the effusion disappeared in all of the 12 pleural cavities in 10 patients. Therefore the validity of this therapy was 100% (CR: 3 cases, PR: 7 cases). Mean survival time from the initial administration of IL-2 was 9.0 months. Fever and eosinophilia were the main side effects of instillation of IL-2, but the symptoms were temporary and not so serious. The results suggested that intrapleural instillations of IL-2 should be highly recommended for patients with malignant pleural effusion. It seems that cytotoxic LAK cells derived from Tumor Infiltrating Lymphocytes (TIL) in the effusion with high concentration of IL-2 might be effective to eliminated malignant cells.     

What is the best treatment for malignant pleural effusions?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether chemical pleurodesis is superior to catheter drainage or pleuroperitoneal shunts (PPS) in the management of patients with pleural effusions. Overall 161 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that chemical pleurodesis is superior to chronic catheter drainage and PPS in terms survival length and mortality rates but in patients with trapped lung syndrome chronic intrapleural catheter placement is indicated. Six studies reported patient outcomes after treatment with chemical pleurodesis. They report high success rates (89.4%) and low mortality rates (2%) without any need to convert to open thoracotomy. Mean hospital stay of 2.33 days, complication rates of 16.5% and mean survival length of 23.8 ± 16.3 months were observed. Five studies managed malignant pleural effusions (MPEs) using chronic indwelling catheters. They reported mean survival length of 126 days. Symptomatic relief was achieved in 94.2% of patients. There was a significant reduction in the Medical Research Council dyspnoea score (3.0-1.9, P < 0.001) and despite complication rates of 22%, comparable mortality rates (7.5%) were observed. Even in patients with trapped lung syndrome, mean survival length was 125 days with symptomatic improvement being achieved in 90.9% of patients. Three studies treated MPEs using PPSs. Mean hospital stay was 6.2 days (range 2-26) with a mean survival length of 11 months. Pleurodesis success rates varied from 57.1% to 95% with a complication rate of 14.8%. PPSs were shown to produce lower success rates (57.1% vs. 92.3%), shorter survival lengths (4.3 ± 1.9 vs. 6.7 ± 2.1 months) and higher complication rates (14.3% vs. 2.8%) than talc pleurodesis. Overall, chemical pleurodesis is the optimal treatment option for MPE with use of chronic intrapleural catheters reserved in cases where talc pleurodesis is not possible.     

Pleuroperitoneal shunt for recurrent malignant pleural effusions.

The therapeutic options available for the management of malignant pleural effusions associated with a restricting malignant cortex remain unsatisfactory. The efficacy of pleuroperitoneal shunts was evaluated in 16 patients with recurrent malignant effusions. There were no operative deaths; one patient died on the third postoperative day as a result of lymphangitis carcinomatosa. The median hospital stay was five (range 3-21) days. Palliation was obtained in all but one of the other 15 patients. There was no appreciable reaccumulation of pleural fluid as judged by radiography. Two patients developed occlusion of the shunt. In one case this was due to blood clots in the pleural catheter and necessitated insertion of a new shunt. The other shunt was removed because of obstructing infected fibrin debris, and a rib resection was performed. There were eight deaths related to the underlying malignancy after a mean interval of 7.3 (range 1.5-23) months. The other six patients are still alive, with a mean survival of 11.0 (range 5-20) months, and have achieved good symptomatic relief. The insertion of a pleuroperitoneal shunt can offer effective palliation for patients with recurrent malignant pleural effusions.     

Talc pleurodesis in recurrent pleural effusions

Background and aims: The treatment of recurrent malignant pleural effusions is known to be difficult and varies from observation in asymptomatic patients to pleurectomy with varying results. This prospective study presents the efficacy and the limits of iodized talc pleurodesis in patients with malignant and non-malignant recurrent pleural effusions. Methods: In a prospective trial talc pleurodesis was performed in 50 patients with recurrent pleural effusions (malignant effusions: n = 36, non-malignant effusions: n = 14). After insertion of a chest tube and complete re-expansion of the lung, 5 mg of talc and 3 mg of thymol iodine were installed with 0.5 ml of 1% xylocaine/kg body weight and 30 ml 0.9% saline solution. The chest tube was removed after an average time of 4 days and chest radiographs were performed 1 month after instillation to evaluate the efficacy of pleurodesis. Results: Successful therapy was achieved in 31 of 33 patients (94%) with malignant effusions within a follow-up period of 7 months. Three patients died within 1 month after therapy due to progressive malignant disease. The treatment was successful in all cases of non-malignant effusions and complications did not occur in either group. Conclusions: These results indicate that pleurodesis with iodized talcum slurry is a simple and inexpensive method with high efficacy in controlling malignant and non-malignant pleural effusions. Received: 23 October 1997