Thoracic tumor

Until today, there is no effective treatment for malignant pleural mesothelioma, but after some method of treatment, a small number of patients at home and abroad live more than 5 years, the oldest up to 22 years, most people think it may be related to the natural survival time and stage of the tumor. Malignant pleural mesothelioma was divided into four stages according to Butchart stages. According to the clinical findings, stage I epithelial malignant pleural mesothelioma is likely to survive for a long time, so radical pleuropneumonectomy is recommended for these patients. For the cases of epithelial type and other pathological types in stage Ⅱ, Ⅲ and Ⅳ, the survival curve was basically the same after treatment, whether radical or palliative surgery, chemotherapy and radiotherapy were used or not. The average survival time was 18 months, and about 10% of the cases survived for 3 years.

1. Palliative care

Pleural effusion in patients with malignant pleural mesothelioma reappears soon after aspiration. Chemical agents are injected into the pleural cavity, resulting in pleural adhesion. Pleural effusion is controlled in most patients. Therefore, pleuropexy should be considered if pleuropexy fails or if a diagnostic thoracotomy is to be performed.

Malignant pleural mesothelioma can spread along puncture holes, catheterization channels, and thoracotomy incisions, but the resulting subcutaneous deposits rarely cause symptoms and therefore do not require treatment. If the patient is treated, these subcutaneous nodules can also be used as an indicator of efficacy.

Chest pain in patients with malignant pleural mesothelioma is the most difficult symptom to manage, is particularly severe in the late stage, continues all day long, does not respond to radiotherapy, should be given sufficient sedative analgesics, including opiates to reduce the pain, to ease the last moments of life.

2. Surgical treatment

At present, there are various surgical measures for the treatment of malignant pleural mesothelioma, the first of which is extended pleuropneumectomy, that is, radical removal of the involved part of the chest wall, the whole lung, the diaphragm, the mediastinum and the pericardium. This procedure is only suitable for stage I functional epithelial malignant pleural mesothelioma. Serious cardiopulmonary damage is contraindicated for this procedure. A standard posterolateral thoracic incision is made in the fourth intercostal space. The tough and thickened parietal pleura is bluntly removed from the chest wall along with the tumor nodules. This procedure causes extensive bleeding and can be carefully and thoroughly hemostasis by compression, cauterization, and suture. Then, the mediastinal pleura is separated from the top of the pulmonary hilum and the paratraheal lymph nodes are removed. In the front, at the level of the lung apex, the intramastric arteries and veins are ligated, and all visible lymph nodes associated with these vessels and the pleura are removed from the front chest wall. At the back, the lymph nodes in the para-esophageal and tracheal carina were removed. Incision of the pericardium from the left posterior corresponding section. The decision to cut the lung or the diaphragm first depends on where the tumor has invaded and how far it has extended. The hilum of the lung is transected and the blood vessels and bronchus are treated as in any pericardium (enlarged) total pneumonectomy. The lower pleura is not as low as the diaphragm, and the diaphragm can be excised outside the lower pleural fold after freeing the pleura. For full exposure, a second incision is usually made between 8 and 10 ribs on the same side. Due to intraoperative placement of the patient in the lateral position, the liver tends to shift from the top to the mediastinum after the resection of the diaphragm, pressing on the inferior vena cava, resulting in heartbeat and blood flow disturbances. After resection of the diaphragm, the defect can be repaired by Maxlex mesh or polyester silicones, or by dura. No matter what material and technology is used, it must be tight and leakproof to prevent blood or pleural fluid from flowing into the abdominal cavity. A diaphragm replacement should be used to firmly suture the residual edge of the diaphragm, so that the abdominal organs cannot protrude or herniate into the chest. Chest closure should be connected to the chest tube suction suction device. The operative mortality rate of extended pleuropneumectomy is 10% ~ 25%, but the curative effect is not better than pleurotomy, so it is not recommended to be widely used.

The second surgical treatment is pleurotomy, which is non-radical because the tumor often affects the underlying lungs. This procedure does not improve the survival time of patients with malignant pleural mesothelioma, but seems to control pleural fluid 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, and in cases suspected of malignant pleural mesothelioma, a simultaneous pleural resection should be considered when performing a diagnostic open biopsy. Pleurotomy may also be considered in cases with a large amount of pleural fluid and chemical pleuropexy failure. As described above, pleurotomy is a palliative procedure with the aim of removing the parietal pleura and part of the visceral pleura to prevent recurrence of pleural effusion and relieve symptoms of chest pain. Usually, a posterolateral incision is made in the 6th intercostal space. The blunt or sharp free parietal layer and the visceral pleura partially involved by the tumor are separated from the chest wall and lungs, respectively, and then removed. This procedure may cause damage to the spinal cord or brachial nerve plexus due to heat conduction. In particular, it is necessary to carefully retain the nerves and blood vessels in the top of the thoracic cavity and the mediastinum, and remove the tumor tissue as much as possible to reduce its volume, which is conducive to postoperative radiotherapy and chemotherapy. Closed thoracic drainage and negative pressure aspiration were performed after surgery.

3. Chemotherapy

Anthracyclines are considered to be effective for malignant pleural mesotheloma, followed by cisplatin, mitomycin, cyclophosphamide, fluorouracil, methotrexate, vincristine, etc. At present, anthracycline-based comprehensive chemotherapy is commonly used. In recent years, statistics of doxorubicin-based chemotherapy regimen at home and abroad, the total effective rate is about 20%, among which the best is alcinine (CAO); The overall response rate of anthracycline-free regiments was 21%, with mitomycin plus cisplatin (MP) being the best. Chemotherapy with increased doses of cisplatin methotrexate continues until the disease does not worsen.

4. Radiation therapy

External radiotherapy is disappointing for malignant pleural mesothelioma, but extended external radiotherapy is considered effective for relieving chest pain and controlling chest fluid in some cases, but not for the disease itself. In vitro irradiation above 40Gy has a palliative effect, and the remission rate of 50 ~ 55Gy irradiation is 67%. A few patients survive for 5 years, but almost all patients still die from recurrence or metastasis.

There is a glimmer of hope that intracavitary radiotherapy has some response to a small number of malignant pleural mesothelioma patients, and a small number of patients have long-term efficacy. The main isotope used is radioactive gold, which has an affinity for cells covering the serosal lumen and is particularly suitable for the treatment of diffuse tumors, such as mesothelioma. Its main therapeutic effect is due to the radioactivity of the beta plasmid, which penetrates 2 ~ 3mm and is most effective against early tumors, but it is difficult to detect cases of early malignant pleural mesothelioma. In the early years, colloidal 198 gold was injected into the pleural cavity, and a few cases survived for more than 5 years, due to the difficulty of protection, it has been rarely used.

There was no long-term cure after combined treatment, intraoperative irradiation or implantation of 132I, 192Ir, 32P, and postoperative external radiotherapy plus chemotherapy.

5. Comprehensive treatment

In recent years, comprehensive treatment measures have been adopted, including chemotherapy after pleuropulmonary resection and CAP regimen. After operation, 55Gy in vitro irradiation was performed at the site of the original tumor or the site of the residual tumor. Analysis of 53 patients who received comprehensive treatment, the incidence of perioperative complications was 17%, and the operative mortality was 5.8%. The average survival time was 16 months (1-8 years). The 1-year, 2-year 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 patients with mixed and sarcomatous types were 45% and 7.5%, and none of them survived more than 25 months. The survival time of patients with local mediastinal lymph node metastasis is shorter than that of those without lymph node metastasis, and the 5-year survival rate of patients with epithelial mediastinal lymph node negative is 45%, so early treatment is very important.