1、I125放射性粒子植入术对晚省略辅助三维模型设计及植入方法的研究IulLZI一uubLzjl!nc: I川川zputzpt!uu mitN I1。e6叫 卒择仲映琴冷修:择丫升I Q,禅醉二布辑面乍升丫钾丫I1:环琳P T吟孵诩择玲译叼碑蔚咨釜咨:K22a攀征:今签x-l幸不即班摹让WI郸 U少丫6 f-律用 Ell华苯中d%工困卿7?峭非举业卿0 0即以歌哪击招业琴毕裂墙绍咪邝翼那豁草柑栩叩蒂俘W涯长塑坏田耳即们余阳日稗拜扣家?f即T-N早讨拐中业柯导任但 if 1W小丫Wff律日藉票坚卒傣通拜幸丫乐合独猖合土?k具即血摹工袜丁肛抬卯班琴卒击。艳年壑郑眯工军中V D.111 1 E霹那翻里水
2、米qll燮lll-N41幸丫Ice, g)3现否落wrvX晋绍#RNF-V-17 r?体络萃谭剧.汗单幽 耻典言匡吉咪中文摘要（1）英文摘要（4）英文缩略词汇表（9）前言（10）论文正文（12）第一部分 I125放射性粒子植入计划的三维模型设计及植入方法的研究材料与方法（13）结果（22）讨论（24）第二部分 术中 I125放射性粒子植入治疗晚期胰腺癌的疗效分析材料与方法（28）结果（41）讨论（56）结论（62）参考文献（63）文献综述（72）攻读学位期间发表文章情况（82）致 谢（83）- 1 -I125放射性粒子植入术对晚期胰腺癌的姑息治疗：植入计划的辅助三维模型设计及植入方法的研究中
3、文 摘 要本课题拟通过对无法切除的晚期胰腺癌患者进行术前三维数字模型的建立，来制定放射性粒子I125的肿瘤内植入计划并对粒子植入的方法进行研究，同时进行双旁路手术（胆肠、胃肠吻合）以解决患者目前存在的症状如疼痛、黄疸、胃排空障碍或术后可能出现的上述问题。胰腺癌预后很差，外科切除手术是唯一有可能治愈胰腺癌的治疗方式,但只有5%22%的患者可以接受根治性切除手术，无法行根治性切除的晚期胰腺癌病人只能接受各种各样的姑息性治疗。肿瘤内放射性粒子I125植入术是其中一种有效的治疗方法，我们通过综合分析文献及预实验后发现改进放射性粒子植入的方法，即最大程度地按照肿瘤的立体形状，将粒子均匀植入在肿瘤空间内可
4、以提高患者的生存时间。同等条件下植入粒子越彻底、越精准，越能延长患者的生存时间。并且通过预实验我们发现部分患者能获得与根治性切除手术相同的手术效果与生存时间，故本研究的主要内容是如何提高晚期胰腺癌患者的生存时间，次要研究内容是如何改善此类患者的症状和生活质量。目的：本课题分为两个部分，第一部分从植入计划的辅助三维模型设计及植入方法着手，运用三维软件系统完成粒子植入手术的三维植入模型的设计，预期达到粒子完全覆盖肿瘤，没有盲点、冷点，同时又不伤及周围组织、器官及血管的目的。第二部分按照我们设计的粒子植入方法，对晚期胰腺癌患者进行粒子植入手术，通过对患者生存期、生活质量的病例总结，分析可行性与安全性
5、，评估其临床价值。方法：根据相关纳入标准，运用飞特图盟公司自主研发的FitMe DICOMviewer 0.15.1 三维重建软件系统（以下简称FitMe），对在解放军总医院肝胆外科2009年1月至2013年12月收治的47例晚期胰腺癌患者，进行胰腺肿瘤与周围血管、组织、器官的三维重建，根据肿瘤立体空间位置的测算，计算粒子需要植入的数量，布控针道，模拟粒子植入的过程。手术中严格按照术前设计方案进行，对可能存在的盲点进行粒子的“补种”。随后就其影像学资料、- 2 -治疗结果、随访情况等方面作一综合性分析及研究。并将我院同期行姑息性手术治疗的78例晚期胰腺癌患者作为对照组，将两组患者之间的临床资料
6、进行对比分析。结果：1、研究期间，我科共对47例晚期胰腺癌患者实施粒子植入术，其中男性29例，女性18例。年龄36-87岁，平均年龄57.612.0岁。2、运用FitMe三维重建软件系统对粒子植入进行术前三维模型的设计，进行胰腺肿瘤与周围血管、组织的三维重建，进行肿瘤立体空间位置的测算，计算粒子需要植入的数量，布控针道，模拟粒子植入的过程。3、所有患者均行术中I125植入术，粒子植入数为16粒-116粒，平均53.119.8粒，其中5例患者同时行胃肠吻合术、10例患者同时行胆肠吻合术、13例患者同时行胆肠吻合加胃肠吻合术、19例患者仅行粒子植入术。4、粒子组患者术后发生胃瘫11例、胆瘘1例、菌
7、血症1例，9例患者出现胰瘘，分级为A级8例、B级1例，1例患者术后第12天发生腹腔出血，经保守治疗后好转，并发症Clavien分级I级10例，II级13例，无围手术期死亡患者。粒子组术后并发症的总发生数要明显高于对照组患者，因此该组术后住院时间也要长于对照组患者。但粒子植入术并没有增加严重并发症（Clavien分级II级）的发生率、无围手术期死亡患者。粒子植入组患者胰瘘和胃瘫的发生率要高于对照组患者。25例首发症状以腹痛前来就诊患者，术后出院时仍有腹痛患者8例，分为轻度5例，重度3例，腹痛缓解率为88%（22/25）。本组资料中术后共11例患者出现胃瘫综合征，经统计分析考虑，术后胃瘫的发生与是
8、否行胃肠吻合，以及行胃肠吻合的同时是否行粒子植入术密切相关。5、粒子组47例患者中42例得到随访，随访率为89.4%，获得随访患者的1月、半年、1年、2年的生存率分别为97.6%、62.4%、25.8%、14.3%，平均生存时间为13.01.2个月。对照组78例患者中72例得到随访，随访率为92.3%，获得随访患者的1月、半年、1年、2年的生存率分别为98.6%、41.7%、9.8%、3.3%，平均生存时间为6.60.2个月。明显差于粒子组患者。结论：1、对于不能行根治性切除的晚期胰腺癌患者，放射性粒子植入术是一种- 3 -安全有效的治疗手段。2、放射性粒子植入术并不会增加患者的死亡风险，是安
9、全可行的，其能明显延长晚期胰腺癌患者的生存时间，提高患者的生活质量。3、采用术前三维模拟粒子植入的方法，即最大程度地按照肿瘤的空间立体形态将粒子均匀地植入肿瘤内，能最大限度地延长患者的生存时间，甚至部分患者能获得与根治性切除手术相同的效果。关键词：晚期胰腺癌；I125粒子；外科治疗；生存时间；生活质量- 4 -Intra-operative implantation with I125seeds in the treatment ofadvanced pancreatic cancer: The assistant design of 3D modeland the research of i
10、mplantation wayAbstractIn this study, we through the establishment of unresectable advancedpancreatic cancer patients with preoperative three-dimensionaldigital model, research to develop radioactive seeds implantation ofI125planning and implantation method. At the same time through doublebypass ope
11、ration (biliary obstruction, gastrointestinal anastomosis)to solve patients present symptoms, such as pain, jaundice, gastricemptying and so on. Pancreatic cancer is very poor, surgical operationis the only cure method for the treatment of pancreatic cancer, butonly 5% to 22% of patients can accepte
12、d radical resection operation,the other patients can only accept expectant treatment. RadioactiveI125seeds implantation is an effective method in the treatment of theimproved pancreatic cancer. We found that radioactive seedsimplantation through a comprehensive literature analysis andpre-experiment
13、can improve the survival time of the patients. That isto say the maximum implantation according to the three-dimensionalshape of the tumor, in this case, we can prolong the survival time ofpatients. And through pre-experiment we found that some patients canobtain the same survival time with radical
14、resection operation. So thisarticle targets are to improve the survival time of patients andimprove the quality of life of patients.Objective: The purpose of this paper is divided into two parts, thefirst part starts from the 3D model design and implantation method.The design of 3D software system f
15、or the preoperative 3D model ofparticle implantation, is expected to fully cover the tumor and noblind spot, while not harming the surrounding tissues and the bloodvessels. The second part according to the seeds implantation method.According to the quality of life, survival period of patients, thefe
16、asibility analysis of safety to evaluate its clinical value.Methods: According to the inclusion criteria, using FitMe 3Dreconstruction software system, 47 patients with advanced pancreaticcancer in PLA General Hospital from 2009 January to 2013 December inour hospital department of hepatobiliary sur
17、gery. We finished 3Dreconstruction of pancreatic tumor and surrounding blood vessels,- 5 -tissue, and according to the calculation of three-dimensional spaceposition of the tumor, calculate the number of seeds neededimplantation, and simulation of seed implantation. Operation in strictaccordance wit
18、h the preoperative design, particle on the possibleexistence of blind spot. Analysis and research of imaging data,treatment, follow-up results etc. And in our hospital underwentpalliative operation treatment of 78 patients with advanced pancreaticcancer as the control group, the clinical data betwee
19、n the two groupsof patients were compared and analyzed.Result.1. During the study period, a total of 47 cases of advanced pancreaticcancer patients with seeds implantation, including 29 cases of male,female 18 cases. Ages were 36-87 years old, and the average age was57.612 years old.2. The design of
20、 FITME 3D reconstruction software system forpreoperative 3D model of seed implantation, 3D reconstruction ofpancreatic tumor and surrounding blood vessels, tissue, calculatetumor stereo space position, calculate the number of seeds neededimplantation, and simulate the process of particle implantatio
21、n.3. All patients underwent intraoperative I125 implantation,implantation for 16 -116 seeds, with an average of 53.119.8 seeds,5 of them underwent gastrointestinal anastomosis, 10 cases underwentbiliary-enteric anastomosis, 13 cases underwent biliary-entericanastomosis and gastrointestinal anastomos
22、is, 19 patients onlyreceived seeds implantation.4. Seed group of patients with postoperative gastroparesis in 11 cases,1 case of biliary fistula, 1 case of bacteremia, 9 patients hadpancreatic fistula, 8 cases of Grade A, 1 case of Grade B, 1 patientoccurred intraperitoneal hemorrhage at twelfth day
23、s after operationand cured by conservative therapy. Complications contains 10 cases ofClavien grade I, II grade of 13 cases, no peri-operation period deathpatients. Postoperative complications of seed group occurredsignificantly higher than the total number of patients in the controlgroup, and the p
24、ostoperative hospitalization time was longer thancontrol group patients. But seed implantation did not increase severecomplications (Clavien grade II) incidence, no peri-operation perioddeath patients. Seed implantation in patients of pancreatic fistulaand gastroparesis incidence was higher than tha
25、t of the control groupof patients. The first symptom of 25 cases with abdominal pain topatients, postoperative abdominal pain patients was 8 cases, divided- 6 -into 5 mild cases, 3 severe cases, the remission rate of abdominal painwas 88%(22/25). The data of 11 patients with postoperativegastropares
26、is, through statistical analysis and consideration, theoccurrence of postoperative gastroparesis is closely related towhether gastrointestinal anastomosis, and at the same time for seedimplantation.5. S eed group of 47 patients, 42 cases were followed up, thefollow-up rate was 89.4%. The one month,
27、half of year, one year, andtwo year survival rates of particle group were 97.6%, 62.4%, 25.8% and14.3%, the average survival time was 13.01.2 months. The survivalrates and time were significantly higher than control group(P0.05).Conclusion:1. For cant radical resection patients with advanced pancrea
28、ticcancer, radioactive seeds implantation is a safe and effectivetreatment method.2. Radioactive seeds implantation did not increase the risk of deathin patients, is safe and feasible, which can obviously prolong thesurvival time of patients with advanced pancreatic cancer, improve thequality of lif
29、e of patients.3. By using the method of preoperative three-dimensional simulationof particle implantation, namely the maximum according to thethree-dimensional shape of tumor implantation, could prolong thesurvival time of patients, and even some patients can obtain treatmentas the radical operation
30、.Keywords: Advanced pancreatic cancer; I125seed; Surgical treatment;Survival time; Quality of life- 7 -英文缩略语词表英文缩写 英文全称 中文全称TPS theraphy planning system计算机立体定位计划系统MSv milliSievert 毫西弗TACE transarterial chemoembolization 经导管动脉化疗栓塞RFA radiofrequency ablation 射频消融术Gy Gray 戈瑞CR Complete Response 完全缓解PR Partial Response 部分缓解I125 Iodine-125 碘-125CT Computed Tomography 计算机断层扫描SD S
