RU2248188C1 - Method for treating the cases of locally disseminated malignant tracheal and/or bronchial tumors - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out argon plasma of tracheal and/or bronchial lumen recanalization by applying power of 60-90 W with argond discharge rate being 2.0-2.4 l/min large. Brachitherapy is applied next to it moving the source with 5 mm large step. Trajectory length is 5 to 20 cm large. Reference isodose depth is 10 mm far from the source with applicator moving above and below the tumor from 1 to 3 cm. Dose from 14 to 28 Gr is to be administered once a week in 7 Gr large portions.

EFFECT: enhanced effectiveness of treatment; reduced risk of complications; prolonged remission period.

Description

The invention relates to methods for treating cancer, namely malignant tumors of the central bronchi and trachea.

The most important task of modern clinical oncology is to improve the quality of life of patients with malignant neoplasms. These are both patients with advanced stages of the tumor process, and patients who underwent complex and combined treatment, suffering from various types of physical and psycho-emotional discomfort.

Lung cancer is one of the most common and usually characterized by an adverse cancer outcome. In frequency, it takes the second place among malignant tumors and the first (31%) among them in men (Merabishvili V.M., Dyatchenko O.T. Lung cancer statistics // Practical Oncology. - 2000. - No. 3. - P.3 -7; Chisov V.I., Starinsky V.V. Malignant neoplasms in Russia in 1998. - M., 1999. - 284 p.). According to various sources, only 10-20% of patients are detected at the stage when radical surgical treatment is possible (Davydov M.I., Polotsky B.E. Lung cancer. - M .: Medicine, 1984. - 160 s .; Trakhtenberg A.Kh. ., Daryalova S.L., Glagolev A.N. Combined treatment of lung cancer // Onkol. - 1987. - No. 1. - P.69-77; Orlov S.V. Symptomatology, diagnosis and staging of small-cell lung cancer // Practical Oncology. - 2000. - No. 3. - P.8-16; Dellafiore L., Tagliaferri B., Bianco R., Soldi S., Tentori A. High-resolution computerized tomography in diffuse forms of bron-chiolo-alveolar carcinoma. // Radiologia Medica. - 1996. - Vol. 92. - P. 709-712). The severity of the condition of inoperable patients is often caused by impaired patency of the central bronchi and trachea, and then the question arises of the need for their recanalization in order to increase the respiratory surface, as well as the elimination of the phenomena of obstructive pneumonia. The proactive effect on the tumor, which prevents obstruction of the bronchi, is also relevant.

The results of the use of chemoradiotherapy in this group of patients remain unsatisfactory. Attempts to improve the immediate results of treatment by improving the options for remote radiation exposure have been ineffective, since the increase in dose loading is limited by the tolerance of the surrounding healthy tissues and organs. Under these conditions, the advantages of intracavitary (contact) irradiation, which provides a significantly larger focal dose in the tumor than in adjacent tissues, become apparent. With the introduction into clinical practice of modern devices for brachytherapy with a walking radiation source, there are certain hopes for increasing the effectiveness of palliative treatment. The contingent of patients that may be subjected to intracavitary radiation therapy is limited, due to obturation, or a sharp narrowing of the lumen of the central bronchi, or trachea, which makes it impossible to deliver the applicator with a radioactive source to the tumor (Trakhtenberg A.Kh. Lung cancer. - M .: Medicine . - 1987. - 304 p .; Sokh JD, Byhardt RW Komaki R. The Role of Radiotherapy in Squamous, Large Cell and Adenocarcinoma of the lung // Seminars Oncol. - 1983. - Vol. 1. - P. 81-94 ; Sorensen JB Prognosis and prognostic factors in adenocarcinoma of the lung. // Dan. Med. Bull. - 1992. - Vol. 5. - P. 453-463; Feldman ER, Eagan RT, Schaid DJ Metastatic bronchioloalveolar carcinoma and metastatic adenocarcinoma of the lung : comparison of clinical manifestations, chemotherapeutic responses, and prognosis. // Mayo Clinic. Proc. - 1992. - Vol. 67. - P. 27-32 .. Analysis of published data showed the novelty of the “Method for the treatment of locally advanced malignant tumors of the central bronchi and / or trachea. ”

Closest to the proposed method are standard methods of high-frequency electrocoagulation. For these methods, a number of drawbacks were noted - the difficulty of controlling the depth of exposure, the limited degrees of freedom during application, the complexity and duration of manipulation, the contamination of the tip, carbonization of the tissue, smoke of the lumen of the bronchi and trachea (Rusakov M.A. Endoscopic surgery of tumors and cicatricial stenoses of the trachea and bronchi . - M.: Russian Scientific Center for Surgery RAMS, 1999. - S.20-37).

The technical result of the method is 1) a decrease in the tumor mass (cytoreduction), 2) a decrease in intoxication and pain. This is achieved by performing argon plasma recanalization of the bronchi and / or trachea (ERBE ARC-300 apparatus, registration number 98/1735 dated 12/28/98. Certificate No. 4418755) followed by brachytherapy.

In the clinic of the Petrov Scientific Research Institute of Oncology, a functional complex was used consisting of a control unit for argon supply, a high-frequency generator, and flexible electrode probes. In the functional complex there was software with the ability to select the optimal parameters of the generator power and argon flow rate, allowing precise control of the depth and volume of the impact. Argon plasma coagulation is a method of monopolar high-frequency electrosurgery, in which the energy of a high-frequency current is transmitted to the tissue in a non-contact manner by means of ionized argon. An argon plasma arc is formed between the electrode and the tissue site that has the least resistance. The resulting dehydration (desiccation) of the coagulated tissue increases its resistance, which leads to the displacement of the argon arc to the tissue site with less resistance, ensuring the homogeneity of the coagulation zone and the controllability of the exposure depth. The coagulation depth, depending on the power and duration of application of the electrode does not exceed 3 mm, reducing the risk of perforation. Typically, coagulation was carried out at a power of 60-90 W (average 70 W), with an argon flow rate of 2.0-2.4 L / min (average 2.2 L / min). One of the advantages of the method is coagulation in an oxygen-free medium, which allows you to affect the tissue without significant carbonization (carbonization).

We noted only two serious complications: rather heavy bleeding from damaged bronchial arteries, stopped by temporary tamponade and subsequent coagulation of the vessel with increased power of the argon plasma electrocoagulator.

Intraluminal brachytherapy was performed on a Microselectron HDR apparatus (Nucleotron) with a source of iridium-192, a high radiation dose rate with an activity of 5-10 Curie. The movement of the source was carried out with a step of 5 mm. The length of the path of the source is from 5 to 20 cm, the depth of the reference isodose is 10 mm from the source. For endocuritherapy, a standard applicator was used, installed under local anesthesia, through the instrument channel of the fibrobronchoscope so as to ensure the movement of the source to a distance including the tumor or the wall of the bronchus and trachea above and below the tumor from 1 to 3 cm. When irradiation was implemented, the principles of conformal radiotherapy were implemented, the purpose of which is to bring the maximum possible dose of radiation to the tumor and reduce the dose load in the region of adjacent organs and tissues, which allows to reduce the frequency of radiation damage during the treatment of primary tumors.

The study included data on 52 patients who from June 2000 to May 2003 in our clinic made a total of 74 sessions of argon plasma electrocoagulation followed by brachytherapy. 39 patients had a tumor with a tumor of one of the lobar bronchi with a transition to the main one, 5 had a lesion of both main bronchi with a transition to the trachea, 3 had an intermediate bronchus and 3 had a lesion of one of the lobar bronchi. In 2 cases, an isolated lesion of the trachea with subcompensated stenosis was observed with relapse of thyroid cancer. The morphological structure of the tumors was as follows: in 37 patients, squamous cell cancer was established, in 15 - adenocarcinomas.

Full recanalization was achieved in 40 (76.9%) patients and partial in 12 (23.1%) with significant peribronchial or peritracheal components. In all patients, the intervention was performed with a palliative purpose. Immediately after the recanalization, patients noted a subjective improvement in well-being, which was confirmed by objective data - physical examination, improvement of clinical, biochemical and gas blood counts, and radiological data.

Brachytherapy as the 2nd stage of treatment was carried out in the period from 1 to 3 weeks after recanalization. This time was necessary for the subsidence of reactive inflammation, scab discharge and rejection of necrotic parts of the tumor. The dose was adjusted from 14 Gy to 28 Gy in a regimen of 1 time per week for 7 Gy.

Of the 52 treated patients within 6 months, the need for repeated argon-plasma recanalization arose in 9 patients, in the period from 6 months to 1 year - in 12, and up to 1.5 years - in 15. By now, the process has died from generalization 33 patients. At the dispensary observation, 19 patients remain.

The inventive step of the proposed method is confirmed by the fact that in all cases completely (76.9%) or partially (23.1%) the patency of the bronchi and trachea was restored, an improvement in the function of external respiration, a decrease in intoxication and pain syndrome were noted. The average duration of the relapse-free period with complete clinical remission was 21 months (10-38 months), and with partial remission - 11 months (from 5 to 16 months), while with laser recanalization, the duration of the relapse-free period averaged 11 months, with standard high-frequency electrocoagulation - 9 months, and with chemoradiotherapy - 7 months.

As clinical examples and to confirm the condition of “industrial applicability”, we present the following clinical observations.

Example 1. Patient A.D.A., 15 years old. Complaints upon admission to shortness of breath at rest, severe weakness, fever up to 39-40 ° C, hemoptysis. Clinical diagnosis: Cancer of the right main bronchus with a transition to bifurcation, left main bronchus and trachea. Morphological examination (bronchobiopsy) - glandular cancer. Operations 16 and 22.06.2000. argon plasma coagulation of the tumor in the trachea and bronchi, complete recanalization is achieved. The duration of the operation is 30 and 60 minutes. 07 and 07/14/2000 brachytherapy up to SOD 14 Gy. With dynamic clinical, radiological and endoscopic observation, complete remission of 10 months.

Example 2. Patient S.S.A., 47 years old. Complaints upon admission for shortness of breath with slight physical exertion, weakness, fever up to 38-39 ° C, hemoptysis. Clinical diagnosis: Cancer of the right main bronchus with a transition to bifurcation. Morphological examination (bronchobiopsy) - squamous cell carcinoma. Operations on May 30 and August 22, 2001, argon plasma coagulation of the tumor, complete recanalization was achieved. The duration of operations is 25 and 45 minutes. July 08-18, 2001 brachytherapy up to SOD 21 Gy. During dynamic clinical, radiological and endoscopic observation, complete remission is 21 months.

Example 3. Patient Sh. I.S., 76 years old. Complaints upon admission for shortness of breath with slight physical exertion, weakness, fever up to 38-39 ° C, hemoptysis. Clinical diagnosis: Cancer of the right upper lobar bronchus with a transition to the main one. Morphological examination (bronchobiopsy) - squamous cell carcinoma. Operations 23.04. and on June 27, 2001, argon plasma coagulation of the tumor, complete recanalization was achieved. The duration of operations is 40 and 20 minutes. 06/29/15 July 2001 brachytherapy up to an SOD of 28 Gy. With dynamic clinical, radiological and endoscopic observation, complete remission is 37 months.

Claims (1)

A method for the treatment of locally advanced malignant tumors of the trachea and / or bronchi, characterized in that they perform argon plasma recanalization of the lumen of the trachea and / or bronchi, with a power of 60-90 W and an argon flow rate of 2.0-2.4 l / min followed by brachytherapy with a source trajectory length of 5–20 cm, a step of 5 mm and a reference isodose depth of 10 mm, ensuring the applicator moves above and below the tumor from 1 to 3 cm and applying a dose of 14 to 28 Gy in a regimen of 1 time per week for 7 Gy .