The method of sclerotherapy for malignant focal liver lesions

 

(57) Abstract:

The invention relates to medicine, namely to surgery, and can be used for sclerotherapy of malignant focal liver lesions. 96% ethanol is injected through a fan-shaped punctures during forward movement of the needle from the periphery to the center of the hearth with the capture of the surrounding healthy liver tissue thickness of 1/2 the diameter of the hearth. Upon reaching the center of the hearth, stop the introduction of ethanol and needle with mandrin spend hearth down through the healthy parenchyma at a distance of 1/2 the diameter of the hearth. Then injected ethanol with a retrograde movement of the needle from the periphery to the center of the hearth. The minimum number of needle channels with the volume zone of 10-20 mm and no less than four. By increasing the area 1 cm add 2 puncture channel. The method prevents the dissemination of tumor cells outside the zone of necrosis by creating an ethanol unit around the hearth. This allows to reduce the number of recurrences and improves patient outcomes. 2 Il.

The invention relates to medicine and can be used in the clinic, where treatment of patients with focal lesions of the liver malignant origin.

During laboratory and instrumental about the W ill result of morphological verification of foci in the liver by biopsy under laparoscopic, ultrasound or x-ray control. After the results of cyto - histological examination (primary liver tumor or metastatic lesion) on the Council in the composition of the oncologist, the surgeon, therapist addressed the issue of the nature of the treatment: surgical or symptomatic.

The known method of sclerotherapy liver foci 96% R-rum of ethanol. In the preoperative period for this purpose, a series of puncture of the liver under ULTRASOUND control; during the operation, perform sclerotherapy under visual control of the surgeon. The saturation of the lesion in the liver is carried out through several puncture channels at the rate of 100 per cent of alcohol by volume of focal lesions, with the "capture" of the liver parenchyma around the hearth thickness of from 5 to 15 ml, depending on the size of the structure of the hearth. In some cases, alcohol injected, starting from the edge of the hearth with holding the needle to the borders of the lesion with subsequent saturation of the surrounding tissue during advancement of the needle; in other cases, the needle is introduced into the center of the hearth and, introducing the needle, saturate the hearth and the liver alcohol; and third, short needle a few millimeters to focus, begin to enter the alcohol and advance the needle to the lesion and outside at the same distance as before the introduction of 96% erventional ultrasound. Eur J Radiol 1998 May, 27 Supp 1. ; Livraghi T. Physical and chrmical locoregional therapy in liver metastasis Ann Jtal Chir 1996 Nov, 67161: 799-804).

The disadvantage of this method is that the process of introduction of the alcohol through the puncture needle into the lesion and the surrounding tissue of the liver is extremely variabelno, depending on the experience of the physician-operator. Thus, evidence-based programs the introduction of alcohol into the zone "liver-lesion-liver" in the available literature we have not met. This leads to the fact that the saturation of the tissues of the liver and hearth alcohol at the entrance puncture needle from the centre to the periphery and then the liver parenchyma causes extrusion of blood alcohol by capillaries at the periphery of the treatment area, which in turn carries the risk of spread of malignant cells in untreated alcohol the liver parenchyma and their further growth.

The method of sclerotherapy for malignant focal liver lesions by fan-shaped punctures is that ethanol is administered during forward movement of the needle from the periphery to the center of the hearth, capturing the surrounding tissue of the liver parenchyma thickness of 1/2 of its diameter, after reaching the center of the hearth, stop the introduction of ethanol, needle with mandrin conducted through the lesion and the liver at a distance of 1/2 diameter the number of needle channels must be at least four in the volume zone of 10-20 mm, if you increase the area 1 cm add 2 puncture channel.

The size of the processed alcohol section of the liver around the hearth of not less than 1/2 of its diameter is based on the basic mechanisms of growth of metastases in the liver (General Oncology: Hands-on for clinicians/edited by N. P. Napalkova. - L. : Honey. , 1989, S. 168-193).

The saturation of alcohol zone of tumor growth, including the surrounding liver in the direction from the periphery to the core of the center is based on the need of education "ethanol block between malignant cells and normal liver to prevent the dissemination of intact tumor cells when saturated with ethanol tissue lesion and liver.

The method is as follows: after identifying foci in the liver and their morphological verification with the establishment of a malignant nature carried out by a Board of doctors to determine further tactics of treatment. In the case of selection of the method of sclerotherapy 96% ethanol conduct targeted ULTRASOUND study of the RPF and liver around him. Determine the total volume of the entire treatment area with alcohol in mm, comprising: a lesion of the liver parenchyma on the radius distance of the lesion from its borders. Calculate the volume of the input is momentalnye data (CT, NMR, UST, PA) for the selection of the most optimal trajectories needle channels in all the departments of the zone.

The achievement of the hearth needle in two ways:

1) percutaneous, when used only minimally invasive instrumentation and visualization source needle (ultrasound, x-ray, laparoscopic);

2) open, when performed laparotomy and remove the primary tumor and visible metastases in the liver. Those lesions that cannot be removed operationally, is subjected to sclerotherapy. Sometimes, during operation, the lesions in the liver are not removed, and only treated with alcohol.

However, in these two ways the process of saturation with alcohol zone must be controlled by some method of visualization. In most cases ispolzuetsa ULTRASONIC tomography, or a combination of UST and visual inspection.

The movement of the needle and the introduction of alcohol consist of 3 stages.

STAGE 1: the needle with Madrina injected into the liver under ultrasound or by visual inspection, reach the border of the desired zone on the distance from the edge of the hearth to 1/2 of its diameter, clean madren of the needle and then advancing the needle, injected 96% ethanol at a rate of not less than 0.8 ml of ethanol at 10 mm stroke needle channel (STU insert madren and hold it through the entire lesion and the liver at a distance of 1/2 of the diameter from the edge of the hearth.

STAGE 3: remove needle madren and begin to enter the alcohol simultaneously with the retrograde movement of the needle. Needle "repeats" your way around the puncture channel, only changes the motion vector. Alcohol injected to the center point of the hearth, where we completed the introduction of alcohol on the 2nd stage. The needle is then removed from the hearth and body.

In Fig. 1 shows the liver 1 and focus 2. The minimum number of needle channels 4 when the volume of the zone of 10-20 mm With the increase in the volume zone 1 cm add two puncture channel. The saturation zone ethanol consists of the hearth 2 and the liver parenchyma, delimited by the points a and C, spaced from the edge of the hearth at a distance of 1/2 of its diameter. Puncture needle with a diameter of 0.8-1.2 mm promoted under the ULTRASOUND to the point A. Then begin the introduction of 96% alcohol syringe in the puncture needle 4 and, respectively, in the puncture channel and surrounding tissue. On the screen of the ULTRASONIC device a specific picture saturation alcohol 5. The movement of the needle is straight from point a to point C. the Introduction of alcohol carried out sequentially on the basis of the calculated volume of the zone, divided by the number of needle channels. Double control of the introduction of alcohol: the volume and size of the area of infiltration 5 on the screen of the ULTRASONIC device. Area is-IN)

(A1)-(A2)-(A3)

(A2)-(A3)-(A4)

(A3)-(A4)-(C1 -)

(A4-B)-(C1)-(C2)

(C1)-(C2)-(C3)

(C2)-(C3)-(C4)

(C3)-(C4)-(A1 -)

When reaching the puncture needle center of focus In the introduction of alcohol cease. The needle advancing to point C and then re-start the introduction of alcohol during retrograde movement of the needle from point C to In puncture channel. In the description of figures 1 and 2, points a and C were not subdivided into A1-A4 and C1-C4, as all the stages of the proposed method on all of these points are identical.

Under the optimal regime of the zone of infiltration, "overlapping" each other, reach a high level of saturation ethanol tissue lesion and liver around him, enough to complete necrosis of the cells, which is consistent with the requirements aplastic in surgical Oncology. The introduction of alcohol on the channel from s to stop In at the point C. Then the needle is removed from the center on the axis And through the fabric, already processed by the alcohol, from the point a and to the output of the needle from the tissue of a patient, the introduction of alcohol into the puncture channel in order to prevent the formation of implantation metastases according to the relevant procedure (application for invention 98121742/20 (023673) from 30.11.98,).

Example.

Patient L. , 43 years - in 1997, the ideological center in 1999 was revealed the progress of the disease (metastases to the liver). The objective of the study:

Postoperative scar without signs of recurrence. Regional lymph nodes are not enlarged. The abdomen is soft, moderately painful in the right hypochondrium. The liver is enlarged (3.0 cm from the edge of the costal arch on l. medioclav. ). Additional research methods:

Complete blood count: Erythrocytes-3, 810, leukocytes-710. Leukocyte formula without features. ESR-48 mm/h

General analysis of sputum + urinalysis - without features.

Biochemical blood test: total bilirubin - 28 Ámol/l, ALT-98 U/l, AST-120 U/l, alkaline phosphatase-165 U/l

Fluoroscopy OGK+GIT: without organic pathology.

ULTRASONIC tomography: VII, IV segments of the three hearth sizes 18, 25, 28 mm, DM, at a depth of from 10 to 30 mm from glassonby capsules.

Clinical diagnosis:

Breast cancer (condition after surgical treatment in 1997 ). The progress of the disease-Mts in the liver.

Started chemotherapy. Planned removal of the ovaries. In the preoperative period performed a biopsy of lesions in the liver - the diagnosis is confirmed. Twice a week during the month sclerotherapy with ethanol 3 foci in the liver. Two lesions (VII segment) was processed according to predlojennoi operated. During the examination zone of metastases in the first two identified areas of necrosis in the last metastasis (segment IV) on the periphery of the zone were revealed necrosis and areas of malignant cells. In the II and III segments had 4 podkapsulnaya metastasis to 5 mm in DM. They were sclerotic (fibrous) under visual control, and then (after 15 minutes) excised with "capture" unmodified liver around the hearth. 3 foci program sclerosing under the proposed method intact tumor cells have been identified. In one hearth at the border zone of coagulation and liver, where sclerotherapy was performed according to standard procedures, was identified group of cells adenocarcinoma without evidence of damage.

The proposed method is applied in 9 patients (7 patients with metastatic liver disease, 2 patients with primary liver cancer). The recurrence of malignant growth in the area of sclerotherapy in the period of clinical follow-up of 2 years have not been identified.

Thus, the proposed method sclerotherapy 96% ethanol focal liver lesions malignant Genesis avoids the danger of the spread of tumor cells outside the zone of necrosis, by creating "ethanol block" around the hearth with placesetting growth at the boundary of sclerotherapy and improve 1-3-5-year survival in these patients.

The method of sclerotherapy for malignant liver lesions 96% ethanol by fan-shaped punctures hearth, characterized in that ethanol is administered during forward movement of the needle from the periphery to the center of the hearth, capturing the surrounding tissue of the liver parenchyma thickness of 1/2 of its diameter, upon reaching the center of the hearth, stop the introduction of ethanol, needle with mandrin conducted through the lesion and the liver at a distance of 1/2 the diameter of the hearth and then injected ethanol with a retrograde movement of the needle from the periphery to the center of the hearth, the minimum number of needle channels must be at least four in the volume zone of 10-20 mm, if you increase the area 1 cm add 2 puncture channel.

 

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