Introduction
DiffuseMalignant pleural mesotheliomaIt used to be called malignant mesothelioma. Malignant mesothelioma is a malignant tumor that originates in the pleura and is highly invasive. Malignant pleural mesothelioma is the most common type of pleural primary tumor. Clinical manifestations are associated with invasive behavior, which usually locally invades the pleural cavity and surrounding structures. If left untreated, the median survival is 4 to 12 months.
Cause
The causes and mechanisms of the disease are still not fully understood and may be related to the following factors:
1. Long-term exposure to asbestos
All kinds of asbestos fibers are almost related to the pathogenesis of mesothelioma, but the risk of each fiber is not the same. The most dangerous is exposure to crocidolite, and the least dangerous is exposure to yellow asbestos. The incubation period for the first exposure to asbestos is generally 20 to 40 years, and the incidence of mesothelioma is directly proportional to the time and severity of exposure to asbestos. Evidence of asbestos-induced pleural mesothelioma:
(1) animal experiment asbestos fluid can induce pleural mesothelioma;
(2) Asbestos fibers are found in malignant mesothelioma;
(3) Asbestos workers, especially those who work for 20 to 40 years, found that the incidence of mesothelioma was as high as 3.1%.
2. Other non-asbestos causes
Exposure to natural mineral fibers, chronic infection of the pleural cavity (tuberculous pleurisy), and repeated lung infections. Cases of pleural mesothelioma after exposure to radiation have also been reported, ranging from exposure to radiation to the discovery of pleural mesothelioma for 7 to 36 years, with an average of 16 years.
3. Rickets 40SV40 (infection)
30% to 50% of patients without a history of asbestos exposure may be associated with SV40 infection. Millions of Americans in the polio epidemic may be infected with SV40 by vaccination with the Salk vaccine. Recently, SV40 was isolated in patients with brain tumors and mesothelioma. Carbone and colleagues isolated SV40 fragments in 60% of patients with mesothelioma and successfully induced mesothelioma after intrathoracic injection of SV40 in rats.
symptom
Abnormal signs found in patients with malignant mesothelioma during physical examination include percussion dullness, weakened breath sounds during auscultation, and bilateral chest asymmetry. Early and mid-stage lesions are often limited to the unilateral chest. The most common sites of metastases include the mediastinal and hilar lymph nodes, the contralateral pleura, the lungs, and the chest. Liver, bone, and brain metastases are less common. Locally extensively advanced lesions often cause death, often due to respiratory failure or heart failure.
diagnosis
Patients with exudative pleural effusion, especially those with a history of exposure to asbestos, should consider the diagnosis of malignant pleural mesothelioma. Chest CT can determine the diagnosis, chest CT can determine whether pleural calcification or bone structure is damaged. When the tumor invades the diaphragm and chest wall, the magnetic resonance imaging is better than CT. Although pleural effusion, thoracic pleural biopsy, and pleural effusion cell sections can be used for malignant diagnosis, pleural metastatic adenocarcinoma and malignant mesothelial fistula cannot be identified.
treatment
Palliative treatment
The pleural effusion of patients with malignant pleural mesothelioma will appear soon after puncture and aspiration, injected into the pleural cavity with chemicals, causing pleural adhesions. Most patients have pleural effusion control, so if pleurodesis fails or is diagnosed Patients with thoracotomy should be considered for pleural stripping.
Malignant pleural mesothelioma can be spread along the puncture, the channel of the thoracic duct and the open thoracic incision, but the subcutaneous deposits caused by the seldom cause symptoms, so there is no need to treat it. If the patient is treated, these subcutaneous nodules can also be used as Observe the indicators of efficacy.
Chest pain in patients with malignant pleural mesothelioma is the most difficult symptom to treat. It is particularly severe in the late stage. It persists throughout the day and does not respond to radiotherapy. It should be given adequate sedative painkillers, including opioids to relieve pain, and the end of life. time.
2. Surgical treatment
There are various surgical measures for the treatment of malignant pleural mesothelioma. The first is enlarged pleural resection, which is the part of the chest wall, the whole lung, the diaphragm, the mediastinum and the pericardium that are involved in radical resection. This procedure is only applicable to patients with stage I functional epithelial malignant pleural mesothelioma. Severe cardiopulmonary dysfunction is a contraindication to this procedure. A standard posterolateral thoracotomy in the fourth intercostal space, together with the tough and thickened parietal pleura and tumor nodules, bluntly stripped from the chest wall, this operation can cause extensive bleeding, oppression, electrocautery and suture Drain carefully and completely stop bleeding. The mediastinal pleura is then separated from the top of the hilum and the paratracheal lymph nodes are removed. In the front, at the tip of the lung, the internal mammary artery and vein are ligated, and all visible lymph nodes along with these blood vessels and pleura are removed from the anterior chest wall. Later, the lymph nodes of the esophageal and tracheal bulges are removed. Cut the happy bag from the corresponding part on the left side. At this point, it is decided to cut the lungs first or remove the diaphragm first. The order depends on the location of the tumor and the extent of its extension. Transect the hilar and blood vessels and bronchi, as in any pericardial (expanded) pneumonectomy. The lower part of the pleura is not as low as the diaphragm, and the diaphragm can be removed in the lower part of the pleura after the pleura. For adequate exposure, a second incision is generally made between the 8 to 10 ribs on the same side. Because of the intraoperative placement of the patient in the lateral position, after removal of the diaphragm, the liver tends to shift from the superior mediastinum, compressing the inferior vena cava, leading to heartbeat and blood flow disorders. After removal of the diaphragm, the defect can be repaired with Maxlex mesh or polysilicon material, and some people use the dura repair. Regardless of the use of any materials and techniques, it must be kept tight to prevent blood or pleural effusion from flowing into the abdominal cavity by the thoracic farmer; the continuous suture method should be used to firmly suture the residual edge of the diaphragm to make the abdominal organs impossible. Invade or break into the chest. Before closing the chest, connect the chest tube to the suction of the suction device. The operative mortality rate of extended pleural pneumonectomy is 10% to 25%, but the effect is not better than pleural resection, so it is not recommended for widespread use.
The second surgical treatment is pleural resection, which is non-radical, as the tumor is often tired of the lungs below it. This surgery does not improve the survival time of patients with malignant pleural mesothelioma, but it seems to control pleural effusion and improve the quality of life of patients. In addition, chest pain caused by malignant pleural mesothelioma can sometimes be relieved after removal of the pleura. For cases suspected of malignant mesothelioma, a diagnostic thoracotomy should be considered for pleural resection. A large number of pleural effusions, as well as cases of chemical pleurodesis failure, may also be considered for pleural resection. From the above, pleural resection is a palliative operation, the purpose of which is to remove the parietal pleura and part of the visceral pleura to prevent recurrence of pleural effusion and reduce the symptoms of chest pain. Generally, the posterior lateral incision is performed in the sixth intercostal space. The blunt or sharp free wall layer and part of the visceral pleura involved in the tumor are removed from the chest wall and the lungs respectively. This operation may cause the spinal cord or arm nerve due to heat conduction. The plexus is damaged, and it is best to use a high-frequency argon knife when the tumor is removed at the side of the spine and at the top of the thoracic cavity. In particular, be careful to retain the nerves and blood vessels in the top of the chest and in the mediastinum, remove the tumor tissue as much as possible, reduce its volume, and facilitate postoperative radiotherapy and chemotherapy. After the operation, the thoracic closed drainage was used for negative pressure suction.
3. Chemotherapy
Anthracyclines are considered to be effective for malignant pleural mesothelioma, followed by cisplatin, mitomycin,CyclophosphamideFluorouracil,Methotrexate, vinca alkaloids, etc., currently more than the use of anthracycline-based comprehensive chemotherapy. In recent years, statistics on doxorubicin-based chemotherapy at home and abroad have a total effective rate of about 20%, of which alkaloids (CAO) are better; the total effective rate of various treatments without anthracyclines It is 21%, of which mitomycin and cisplatin (MP) are preferred. Cisplatin increased dose of methotrexate chemotherapy until the condition is not exacerbated.
4. Radiation therapy
External radiotherapy is very disappointing for malignant pleural mesothelioma, but extended in vitro radiotherapy is considered effective, can relieve chest pain and control pleural fluid in some cases, but has no effect on the disease itself. In vitro irradiation of more than 40Gy has a palliative effect, the response rate of 50 ~ 55Gy irradiation is 67%, a small number of patients survived for 5 years, but almost all patients still die of recurrence or metastasis.
Intracavitary radiotherapy has some response to a few malignant pleural mesothelioma, and a small number of patients with long-term efficacy, there seems to be a glimmer of hope. The main isotope is radioactive gold, which has affinity with cells covering the serosal cavity and is particularly suitable for the treatment of diffuse tumors such as mesothelioma. The main therapeutic effect is due to the radioactivity of the beta plasmid, which has a penetration of 2 to 3 mm, which is most effective for early tumors, but it is difficult to find cases of early malignant pleural mesothelioma. In the early years, the application of colloidal 198 gold into the pleural cavity, a few cases that have survived for 5 years, has been rarely used due to protection difficulties.
In the comprehensive treatment and surgery, the irradiation or isotope 132I, 192Ir, 32P implantation in the cavity and postoperative radiotherapy plus chemotherapy, no long-term cure.
5. Comprehensive treatment
In recent years, comprehensive treatment measures have been used, after pleural pneumonectomy and CAP regimen chemotherapy. After surgery, 55 Gy of external irradiation was performed at the site of the original tumor or the location of the residual tumor. Analysis of 53 patients who underwent comprehensive treatment had a perioperative complication rate of 17% and a operative mortality rate of 5.8%. The average survival time is 16 months (1 to 8 years). The 1-, 2-, and 3-year survival rates of 31 patients with epithelial type were 7%, 50%, and 2%, respectively. The 1- and 2-year survival rates of mixed and sarcoma patients were 45% and 7.5%. After 25 months. Local mediastinal lymph node metastasis, survival time is shorter than no lymph node metastasis, epithelial mediastinal lymph node negative, its 5-year survival rate is 45%, so early treatment is very important.
prevention
The study found an average of 19 months (5 to 51 months) from surgery to first recurrence. The most common recurrence of surgery is the ipsilateral thoracic cavity, and distant metastases are rarely seen. Of the patients with first recurrence, 35% had local recurrence, 26% had abdominal, 17% had contralateral thoracic cavity, and 8% had distant metastasis.
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