氩氦刀联合中药治疗原发性肺癌的临床研究

【作者】 祁佳；

【导师】 胡凯文；

【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2009， 硕士

【摘要】 【目的】观察氦刀联合中药治疗原发性肺癌的安全性、可行性、近期及远期疗效,总结治疗前、后中医证候变化规律。为氩氦刀治疗原发性肺癌提供一定的指导作用,并为手术前、后中医药辅助治疗提供证候学依据。探索一种肺癌,尤其是老年中晚期肺癌临床治疗的新模式,以丰富肺癌的临床治疗手段,提高临床疗效。【方法】采用前瞻性与回顾性相结合的研究方法,观察2003年9月至2008年12月在东方医院肿瘤科接受氩氦刀冷冻术联合中药治疗的原发性肺癌患者88例,分析氩氦刀冷冻术的安全性、可行性、临床疗效,以及氩氦刀联合中药对肺癌患者临床症状、行为状况、生活质量、中医证候、生存期等的影响。【结果】1.影像学评价:(1)术中影响学评价88名患者,可评价目标病灶97个,术中CT影像监测显示,冷冻消融区域病灶CT值均见明显降低至负值,与非冷冻区有明显的界限。冰球彻底覆盖瘤灶达其边缘外1cm者30个,占30.93%;冰球覆盖瘤灶范围80%～100%之间者59例,占60.82%;冰球覆盖瘤灶范围60%～80%之间者6例,占5.15%;冰球覆盖瘤灶范围60%以下者(病灶巨大或是位置较靠近大动脉)2例占2.06%。总有效率达91.75%。②氩氦刀联合中药疗效评价参照实体瘤疗效评价标准(RECIST)进行评价。统计有效率(CR+PR)及临床获益率(CR+PR+SD)。术后1～2周左右85.57%的瘤灶体积增大,但CT影象显示冷冻区域密度减低,CT值(增强后)均低于20HU,部分可见蜂窝空洞形成,表明肿瘤细胞已崩解坏死;术后3个月有效率为54.64%,临床获益率达73.20%;6个月有效率58.70%,临床获益率83.70%;术后12个月有效率47.62%,临床获益率仍达到73.81%:术后2年、3年有效率及临床获益率分别为14.29%和33.33%、0%和25.00%。2.行为状况及生活质量变化术后1～6个月生活质量及KPS评分较术前有明显改善(P＜0.05),但术后12个月生活质量及KPS评分降至与术前相当的水平,证明氩氦刀联合中药治疗能明显改善肺癌患者的近期行为状况及生存质量,而远期(术后12个月及以后)生活质量没有明显改善。3.临床症状变化术后14天咳嗽、咯痰、咯血、胸痛、气短乏力、胸闷憋气等症状较术前均有所改善,其中咳嗽、胸闷憋气、气短乏力缓解尤为明显(P＜0.05);术后1～3月咳嗽、咯痰、气短乏力、胸闷憋气4项症状与术前比较有显著改善(P＜0.05),咯血及胸痛程度亦向轻度转化;术后6个月,死亡病例4人,有效病例79例,咳嗽、气短乏力、胸闷憋气等症状较术前好转仍理想(P＜0.05),但咯痰略有增加。总体来看,术后3个月至6个月,患者疾病得到有效控制,各项症状变化均无显著差异(P＞0.05),病情相对稳定。4.中医证候学变化分析气虚、血瘀、痰热、痰湿、阴虚、阳虚、血虚、热毒、气滞、湿热10个单证在本组88例肺癌患者术前、术后的分布情况,结果:术前证型以气虚、阴虚、血瘀、痰湿、痰热5型最多见,氩氦刀术后仍存在痰、虚、瘀证。术后1周气虚程度明显减轻(P＜0.05),痰热证有所增加,但无统计学意义,阴虚、血瘀、痰湿无明显改善(P＞0.05);术后3月各项证候分布情况较术前均没有显著差异。5.生存期、生存率(1)术后生存期88例患者术后生存时间均超过3个月,术后6月、12月、2年、3年、4年的生存率分别为95.19%、46.75%、25.35%、12.50%、8.89%。术后生存时间最短3.5个月,最长已超过59个月。术后中位生存时间15.8个月。(2)总生存期88例患者,6月、12月、2年、3年、4年、5年的总生存率分别为:96.47%、69.62%、27.03%、14.52%、12.50%、12.90%。总生存期最短4.5个月,最长已超过96个月。中位生存时间19.2个月。6.手术安全性88例患者均顺利完成手术,手术完成率100%。刺激性咳嗽、疼痛、气胸是氩氦刀术中常见不良反应,部分患者出现一过性心动过速、心律不齐、血压升高、寒战等,经对症治疗后均不影响手术进行。术后不良反应主要包括咳嗽、咯痰、胸痛、咯血、发热、肺部感染、气胸等,经积极治疗后一般在2周内缓解。结论:(1)氩氦刀靶向冷冻消融技术疗效确切,具有良好可控性,可以精确控制冷冻范围,是治疗肿瘤的有效方法。(2)氩氦刀靶向冷冻技术创伤小,副作用少,更适合体制较弱,耐受性差的晚期肿瘤患者。(3)气虚、阴虚、血瘀、痰证是患者氩氦刀术前、术后的主要证候。中药具有“扶正”、“减毒”、“增效”作用,对于改善患者整体状况,减轻手术不良反应,延长肿瘤患者的生存期等方面有着现代医学无法替代的优势。长期使用,能够稳定瘤灶,抑制复发转移。(4)“氩氦刀联合中药”是现代技术局部治疗优势与传统中医药整体治疗优势的有机结合,安全性及有效性可靠,是一种值得推广的治疗肺癌新方案。更多还原

【Abstract】 Objective:Using Argon-helium cryoablation combined with Traditional Chinese Medicine(TCM) treated primary lung cancer,and to observe the safety,feasibility, short-term and long-term efficacy.Meanwhile search for the changes of Chinese medical syndrome between preoperative and postoperative.The study tried to find out a new therapy of lung cancer,especially for the elderly and advanced patients, which could attain better outcome.The result may offer some help with the clinic application of Argon-helium cryoablation and TCM.Methods:Using prospective and retrospective research method,we select 88 primary lung cancer patients who had been treated by Argon-helium cryoablation combining with TCM during 2003.9 to 2008.12.The states of behavior,quality of life,clinical symptom,life span and TCM syndrome have been analyzed.Results:1.The evaluation of CT(1) CT monitoring during surgeryCT values about the ablated area of 97 tumors focus on 88 patients were obviously decreased.And there were markedly boundaries around the areas.Thirty tumors were covered by cryosurgery ice ball more than 1 cm to the tumor edge,which could consider to be dispersed completely,account for 30.93%.There are 59 tumor focus of 80%to 100%ice covered tumor account for 60.82%;6 tumor focus of 60%to 80%ice covered tumor account for 5.15%;in addition,2 lesions of less than 60%ice covered due to excessive size or close to aorta.Total effective rate in 88 cases is 91.75%.(2) Curative effect evaluationAccording to the Response Evaluation Criteria In Solid Tumor(RECIST).About 85.57%lesions increased in 1 to 2 weeks after the operation,but the value of CT decreased,and cavitations were found in some tumors.These lesions have already mortified.The effective rate and clinical benefit rate after 3 months,6 months,12 months,24 months and 36 months was 54.64%and 73.20%,58.70%and 83.70%, 47.62%and 73.81%,14.29%and 33.33%,0%and 25.00%.2.Quality of life and Karnofsky gradeDuring 1～6months after cryosurgery,the two evaluation improved obviously. However,after 6months,the improvement rate began to reduce and descend to the level as preoperative in 12 mouths after operation.3.The symptoms of cough,stethocatharsis,hemoptysis,thoracalgia,dispnea, shortness breath and lack of strength were palliated after 14 days.Especially, cough,dispnea,shortness breath and lack of strength had remarkable relief than preoperative(P＜0.05).After 1month to 3months,the improvements of cough, stethocatharsis,dispnea,shortness breath and lack of strength were still satisfying, other symptoms also decreased.All symptoms did not aggravate after 6months except stethocatharsis.4.The TCM syndrome of lung cancer contains sthenic zheng and deficiency zheng. There are five syndromes,as Qi asthenia,Yin deficiency,blood stasis,phlegmatic hygrosis and phlegmatic heat,can be found more frequently in the patients who did not undertake the cryotherapy.During the first week after the treatment,the level of Qi asthenia in those patients descended,but phlegmatic heat ascended. After cryotherapy three months,the TCM syndrome of patients was same as preoperative,there was no different from statistical degree.5.Survival time evaluation(1) The survival time evaluation after cryotherapyAll of the patients were alive in the 3 months after the operation.The survival rate after 6 months,12 months,24 months,36 months and 48 months was 95.19%、46.75%、25.35%、12.50%and 8.89%,respectively.The shortest postoperative survival time was 3.5 months in these 88 patients,and the longest time was more than 59 months.The postoperative median survival time was 15.8 months.(2)Total survival timeThe total survival rate of these 88 patients in 6 months,12 months,24 months,36 months,48 months and 60 months was 96.47%、69.62%、27.03%,14.52%,12.50% and 12.90%,respectively.The shortest and longest survival times were 4.5 months and 96 months.The median survival time reach 19.2 months.6.Completion rate of cryotherapy was 100%.There were not severe adverse reactions during and after the operation.Some complications as cough,pain, pneumothorax,frostbite and fever could relieve in two weeks.Conclusion1.Cryotherapy ablation is a effective treatment with desirable controllability and safety.2.Cryotherapy ablation is a minimally invasive operation without severe side effects.Therefore,the therapy seems more suitable for elderly and advance lung cancer patients than other treatments.3.Qi asthenia,Yin deficiency,phlegm zheng and blood stasis syndrome were the main TCM syndrome before and after cryosurgery in primary lung cancer patients. TCM can supporting body resistance,reduce the side reaction and increase efficiency of cryotherapy.As a follow-up treatment,it can inhibit tumors recurrence and metastasis;as well the survival time could be extended.4.Cryotherapy ablation combine with TCM is a new way that integrates focal treatment and systemic treatment.Its safety and efficacy have through the test. Therefore,this method is worthy to promote in the clinical treatment for primary lung cancer.更多还原