125I Radioactive Seed Implantation for Patients with Primary Hepatic Carcinoma with Extrahepatic Metastases
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摘要: 目的:评价CT导向下125I粒子植入术治疗原发性肝癌及肝外转移瘤的临床价值及疗效。方法:本组病例31例,病灶总数为65个,平均直径为3.5cm,其中肝内病灶20个,肺转移瘤25个,淋巴结转移15个,骨转移瘤5个。全部病例经CT、MRI检查或病理穿刺活检证实。术前采用治疗计划系统(TPS)计算布源,术中将活度为0.8mCi的125I粒子在CT导向下植入肿瘤内。粒子按照0.5～1.0cm平面插植。肿瘤周边匹配剂量(MPD)100～150Gy。结果:2个月后CT复查,完全缓解(CR)4例;部分缓解(PR)18例;无变化(NC)3例;进展(PD)6例,总有效率71.1%(22/31),疼痛缓解率72.7%(8/11)。65个病灶中完全缓解(CR)18个;部分缓解(PR)35个;无变化(NC)8个;进展(PD)4个,局部控制率81.5%(53/65)。2例患者死于远处转移,3例死于肝功能衰竭。2个月随访过程中发现8颗粒子在肝脏内游走,5颗粒子迁徙至肺内;2例出现气胸,肺压缩在30%以下,术后2例患者出现轻度白细胞下降,白细胞计数≥3.0×109/L,经保守治疗后均恢复正常。所有手术均顺利完成,未见放射性肺炎、大出血、胆汁瘘、胰瘘等严重并发症。结论:125I粒子植入术治疗原发性肝癌及肝外转移瘤疗效确切,创伤小,并发症少。Abstract: Objective: To investigate the effect of CT- guided 125I radioactive seed implantation on primary hepatic carcinoma and extrahepatic metastases. Methods: Data from 31 patients with 65 total lesions (mean diameter of 3.5 cm) were collected. There were 20 lesions in the liver, 25 metastatic lesions in the lung, 15 lymph node metastases and 5 osseous metastases. The diagnosis of each of the 31 cases was verified by CT, MRI or biopsy.125I seeds of 0.8 mCi were implanted into the 65 lesions at an interval of 0.5- 1.0cm according to treatment plan system (TPS). Matching perimeter dosage (MPD) was 100- 150 Gy. Results: After 2 months, CT examination showed complete remission (CR) in 4 patients,partial remission(PR) in 18 patients, no change(NC) in 3 patients, and progressive disease(PD) in 6 patients. The response rate was 71.1%(22/31) and the rate of pain amelioration was 72.7%(8/11). Among the 65 lesions, we observed CR in 18, PR in 35, NC in 8, and PD in 4. The local control rate was 81.5%(53/65). Two patients died of metastasis and 3 patients died of liver failure. Two months after the operation, 8 seeds had migrated into the liver, and 5 seeds had migrated into the lung. Pneumothorax was seen in 2 cases, and the lung was compressed to less than 30% of its normal size. WBC count decreased slightly in 2 cases after the operation, but the count was still over 3.0× 109/L. Complications like radiation pneumonia, hemorrhoea, biliary fistula and pancreatic fistula were not observed. Conclu-sion: CT- guided 125I radioactive seed implantation has good clinical effects with minimal damage and few complications for treating primary hepatic carcinoma and metastatic hepatic carcinoma.
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Keywords:
- Primary hepatic carcinoma /
- Metastatic tumor /
- Brachytherapy /
- Radioactive particle
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患者男性，29岁，因腹胀、腹痛伴便秘2个月收住安徽医科大学第一附属医院。体检：腹软，右上腹压痛（+），移动性浊音（+），Murphy's征（+）。血清学检查：低蛋白血症，血清AFP正常。增强CT显示，腹盆腔多发大小不等混杂密度影，最大者约12.7 cm×10.1 cm×8.6 cm，边界尚清，大部分为囊性不均匀低密度灶，实性部分呈渐进式、不均匀明显强化，其内见迂曲的血管，考虑为腹腔恶性间皮瘤（图 1）。PET-CT检查显示，左中腹部及盆腔内囊实性肿块，实性部分代谢增高，SUVmax分别为5.0和8.9（图 2）。行腹腔探查+腹腔肿瘤减瘤术+大网膜切除术，术中见上腹部直径约15 cm质硬肿块，包膜完整，来源于大网膜，另见盆腔内直径约20 cm质硬包块，与腹壁及肠管粘连紧密，肠道及系膜间大量串珠样小瘤体。术后病理：灰褐色不规则组织，切面见部分囊性内含暗红色坏死样物质，表面见大量乳头状突起，镜下见疏松网状结构及S-D小体（图 3A）；免疫组织化学法检测显示，肿瘤细胞中AFP（图 3B）、CD117、CA34、CEA、CK（H）、EMA、HCG、GFAP、PLAP表达均为阴性。术后病理诊断为腹腔恶性卵黄囊瘤（yolk sac tumor，YST）。术后27天予博来霉素+依托泊苷+顺铂（BEP）化疗方案1次。术后100天因大量腹水，予抽腹水，腹腔顺铂灌洗1次。术后5个月因大量腹水、低蛋白血症、贫血、恶病质而死亡。
小结 YST好发于儿童和青少年性腺内，较为少见，性腺外YST罕见但可以发生在全身各个部位。大多数YST患者的血清AFP明显升高，是其诊断及随访的主要肿瘤指标。CT及MRI检查均表现为单发的实性或囊实性肿块，边界尚清，渐进式、不均匀强化，内部见丰富而迂曲的血管是其特征之一[1]。PET-CT检查中YST表现为高代谢，易于发现，尤其对于罕见部位、微小/隐匿的原发病灶及转移病灶的诊断及复发检测更具优势[2]。治疗上主要是手术+化疗，需要强调的是即使是Ⅰa期患者，术后不进行化疗也可能会出现复发或转移[3]。
本文报道了1例YST在PET-CT检查中的表现，由于YST可发生在全身多个部位，PET-CT的全身显像对于YST的诊断及复发检测具有优势。
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