1.Overview
Pancreatic cancer is one of the most malignant solid tumors, with a mortality to morbidity ratio of 0.99:1. Statistics from Beijing and Shanghai before 2006 show that its incidence rate is in the 9th place of malignant tumors and mortality rate is in the 6th place. The cause of pancreatic cancer is unknown and is related to genetic factors, high fat diet, intake of high animal protein, smoking, alcoholism, chronic pancreatitis, diabetes, excessive coffee consumption, and surgical resection of the stomach.
More than 2/3 of pancreatic cancer occurs in the head of the pancreas, about 1/4 occurs in the tail of the pancreatic body, and 1/10 in the whole pancreas. pancreatic cancer often has no obvious symptoms in the early stage, and when it is detected, it is already in the advanced stage, and the opportunity of surgical resection is lost. The tumor stage and KPS score are independent factors affecting the prognosis of pancreatic cancer. For pancreatic cancer that cannot be surgically resected, palliative treatment can be used. Studies have proved that transarterial infusion chemotherapy can achieve better therapeutic effects due to higher local drug concentration in the tumor than intravenous drugs, and has achieved impressive results in improving disease-related symptoms, prolonging survival, reducing liver metastasis and treatment after liver metastasis occurs. In the advanced stage of pancreatic head cancer, it may compress or invade the common bile duct and cause obstructive jaundice, and interventional treatment for obstructive jaundice is feasible at this time.
2.Indications and contraindications
2.1 Indications (1) Locally advanced pancreatic cancer that cannot be surgically removed. (2) Pancreatic cancer that has lost the chance of surgery due to medical reasons. (3) Pancreatic cancer with liver metastasis.
2.2 Contraindications
(1) Contraindication to angiography and contrast application.
(2) Large amount of ascites and multiple metastases in the body.
(3) Systemic failure, obvious malignancy, ECOG score >2, with multi-organ failure.
(4) Those with bleeding or coagulopathy that cannot be corrected, with significant bleeding tendency.
(5) Patients with poor liver and kidney function, exceeding 3 times the normal reference value.
(6) White blood cells <3.5×109/L and platelets <50×109/L.
The above (1)-(3) are absolute contraindications and (4)-(6) are relative contraindications.
3. Preoperative preparation
3.1 Patients were prepared for skin preparation at the puncture site, and fasted from food and water for 4 hours before surgery.
3.2 Laboratory tests are routinely performed for tumor markers (CA199, CEA, CA125, etc.), routine blood tests, liver and kidney function, coagulation system, electrolytes, electrocardiogram, and frontal and lateral chest views to understand the patient’s systemic and major organ conditions, to determine whether there are contraindications to treatment, and to facilitate postoperative observation and comparison.
3.3 Imaging examinations for first treatment and without pathological diagnosis, two or more imaging examinations must suggest imaging features of pancreatic cancer, and the scan should include all of the pancreas.
3.4 Pre-operative medicationAnti-emetic drugs should be given intravenously half an hour before perfusion chemotherapy, and no special treatment for the rest.
3.5 Sign the informed consent form before surgery
3.6 Medication method: If high-dose cisplatin (>100mg/time) is applied for perfusion chemotherapy, the possible nephrotoxicity should be relieved before perfusion of cisplatin, and usually saline or glucose solution 1000ml plus 15% potassium chloride 10ml is given intravenously 6 hours before arterial perfusion chemotherapy; 20% mannitol 125ml is given intravenously in a single drip before treatment and hydrated after surgery.
3.7 Instrument preparation includes puncture needle, super-slip guidewire, catheter sheath, catheter, chemotherapy drug box (used for subcutaneous chemotherapy drug box placement).
4. Operation method
4.1 Patient position The patient is in the supine position.
4.2 Operation steps Routine inguinal area disinfection towel, inguinal local anesthesia, modified selding method of puncturing the femoral artery, placement of arterial sheath, selective arterial cannulation. After removal of the catheter and arterial sheath, local compression was applied to stop bleeding. Refer to the guidelines for interventional treatment of malignant obstructive jaundice for patients with concomitant obstructive jaundice.
4.2.1 Selective arterial cannulation
4.2.1.1 The catheter is placed selectively in the celiac artery and superior mesenteric artery for imaging respectively (imaging is continued to the venous phase to observe the venous invasion), and if the tumor blood supplying vessels are visible, super-selective to the blood supplying arteries for perfusion chemotherapy.
4.2.1.2 If no tumor blood supply artery is seen, the target vessels should be determined according to the tumor site, invasion scope and blood supply. If the blood supply of intrahepatic metastases is rich, embolization therapy can be given, and the embolization agent can be super liquefied iodine oil or granular embolization agent.
4.3 Drug selection can be chosen from gemcitabine, fluorouracil, tetrahydrofolic acid, cisplatin, oxaliplatin, etc.
4.4 Drug administration can be intraoperative once-impact perfusion chemotherapy, or sustainable perfusion chemotherapy.
4.4.1 A single shock infusion chemotherapy can be completed intraoperatively at a recommended dose of gemcitabine 800-1000 mg/m2, fluorouracil 500-700 mg/m2, tetrahydrofolate 100 mg, cisplatin 60-80 mg/m2, oxaliplatin 100 mg/m2, alone or in combination. It can be repeated for 2-3 weeks, or when it recurs after pain treatment is relieved.
4.4.2 Continuous perfusion chemotherapy includes indwelling catheter continuous perfusion chemotherapy and subcutaneous perfusion cartridge system placement. Continuous perfusion chemotherapy can choose cell cycle-specific drugs and/or non-specific drugs, which are better than single-shock perfusion chemotherapy in terms of drug administration method, perfusion time and other planability and controllability, and the perfusion time is decided according to the characteristics of the drug, such as fluorouracil can be used 500-700mg/m2 continuous 5 days continuous perfusion chemotherapy, and repeat the cycle with the same shock perfusion chemotherapy.
5.Postoperative treatment
① Antibiotic treatment if necessary.
② Adequate rehydration, liver protection, and symptomatic treatment (antiemetic, antipyretic, etc.) for 3 to 5 days.
③Repeat liver and kidney function, blood routine, tumor markers, serum amylase, etc. within 1 week after surgery.
6.Common complications
6.1 Complications related to endovascular operation hematoma, arterial entrapment formation, arterial spasm, occlusion, etc.
6.2 Complications related to chemotherapy drugs nausea, vomiting, pain, fever, bone marrow suppression, liver function damage, kidney function damage, etc.
7. Efficacy evaluation and follow-up requirements
Monthly follow-up is recommended for quality of life evaluation (QOL, ECOG scoring system is recommended) and routine blood, liver and kidney function, tumor markers and imaging.