Interventional medicine may be an unfamiliar department to the majority of patients, but nowadays, general municipal hospitals and even some good county hospitals have an interventional department, what kind of department is it? What kind of diseases can be seen? Here is a brief introduction for you.
“Interventional” is a foreign word, simplified from the “interventional radiology” (interventional radiology). Interventional Radiology was first introduced by Margulis in 1967. It is a marginal discipline that developed rapidly in the late 1970s. It is a series of techniques to diagnose and treat various diseases with the guidance of medical imaging equipment, based on diagnostic imaging and clinical diagnostics, combined with the principles of clinical therapeutics, using catheters, guidewires and other equipment. That is: under the guidance of imaging medicine (X-ray, ultrasound, CT, MRI), a specially designed catheter or device is inserted into the lesion site for diagnostic imaging and treatment through a percutaneous puncture route or through the body’s original orifice. Or tissue collection for cytology bacteriology and biochemical examination. Cheng Hongtao, Department of Radiology and Interventional Medicine, Henan Cancer Hospital
In the past, the Department of Radiology was mainly engaged in diagnostic imaging work, that is, the people often said to take films, watch films and so on. With the development and progress of medicine, the radiology department not only undertakes the task of diagnostic imaging, but also gradually and actively participates in the work of clinical treatment. In other words, under the guidance of X-ray fluoroscopy or CT scan and other imaging means, drugs are delivered directly to the lesion site by intubation or puncture, or narrow or occluded physiological ducts (such as esophageal stenosis, ureteral stenosis, bile duct stenosis, urethral stenosis, vascular stenosis, etc.) are reopened by means of balloon dilation or stent implantation under X-ray guidance, or the diagnosis of Puncture of an unknown solid mass and extraction of tissue for pathological diagnosis under a microscope are all interventional radiology techniques.
Which diseases are suitable for interventional therapy? As an oncologist, I would like to talk about the tumor-related diseases that are suitable for interventional treatment.
I. Chest.
1.Lung cancer.
Lung cancer is one of the most common malignant tumors. For early stage lung cancer, if the conditions for radical surgical resection are available, surgical resection is preferred, but if other concomitant diseases make it impossible to tolerate surgical treatment, then there is no need to be too nervous. With the development of modern medicine, more and more minimally invasive methods have been introduced into clinical application, such as radiofrequency ablation, microwave ablation, argon helium knife ablation, etc. If properly used, they can achieve clinical effects comparable to those of surgical resection. For single lung cancer that cannot be surgically resected, the aforementioned ablation equipment can be used. Under the guidance of CT or other imaging equipment, the radiofrequency knife or microwave knife can be inserted directly into the tumor, heating the tumor to a high temperature of more than 80 degrees to kill the tumor directly in the body. There is only one puncture eye in the skin after the operation, so there is almost no bleeding during and after the operation, few complications and fast recovery. Ar-He knife is similar in size to microwave and radiofrequency, but the principle is different. Ar-He knife freezes the tumor instantly to -175° for 10 minutes, and then heats the tumor to 20-40° rapidly, and the tumor undergoes solid necrosis after repeated freezing and thawing. For some advanced lung cancers that cannot be resected, such as large blood vessels near the hilum, which cannot be radically resected due to adhesion with large blood vessels, thermal ablation therapy such as microwave and radiofrequency can also be used to achieve the goal of complete necrosis of the tumor.
2.Esophageal cancer is also one of the high incidence tumors, and Henan Province is also a high incidence area for esophageal cancer. Early esophageal cancer should be preferred to radical esophageal cancer resection, but many patients are already in advanced stage when they are diagnosed and lose the chance of radical surgery. For esophageal cancer that cannot be removed surgically, especially squamous esophageal cancer, active radiotherapy combined with chemotherapy should be adopted, which has high efficiency and many patients can still survive for a long time or even be cured. For patients with recurrent esophageal cancer after surgery and failed radiotherapy, especially those with severe dysphagia, you will find another world if you visit the interventional department. For patients with recurrence after surgery, failed radiotherapy and severe dysphagia, esophageal stent implantation can be performed in the interventional department to reopen the dietary channel for patients, and even the esophageal stent with radioactive 125 iodine particles can be placed, which can not only rebuild the dietary channel, but also directly treat the tumor with continuous and uninterrupted radiation therapy. The effective radiation distance is about 1.7mm, and the damage to normal tissues is extremely slight, and there is almost no systemic toxic side effect. Recently, a team led by Prof. Teng Gaojun from CUH of Southeast University has achieved great success in the treatment of esophageal cancer by radioactive iodine particle stent implantation, and the results of a multicenter clinical trial organized by Prof. Teng have been published in one of the most authoritative medical journals in the world, “The Lancet – Oncology”. -The results of the study were published in one of the most authoritative medical journals in the world, “The Lancet–oncology”, which has an impact factor of 25.117 points.
For patients who have lost the chance of surgery and are not suitable for esophageal stent implantation (too close to the acoustic canal for stent placement), if they have severe dysphagia and have difficulty in eating, they are often malnourished and in poor general health condition, which makes it difficult for them to tolerate aggressive radiotherapy. For such patients, we can also use fluoroscopic percutaneous gastrostomy to establish dietary access so that the patient can receive adequate nutritional support and improve the patient’s overall basic condition, thus allowing the patient to regain access to radiotherapy. The gastrostomy tube will be removed after the tumor is effectively controlled and swallowing difficulties are restored.
Anastomotic stenosis after esophageal cancer surgery
1.Benign anastomotic stricture without tumor recurrence: balloon dilation treatment is preferred. If recurrent recurrence occurs after balloon dilation, and the recurrence interval is shorter than 2 months, esophageal stent placement is recommended.
2. Anastomotic stenosis due to tumor recurrence: permanent stent implantation, or radioactive iodine particle stent placement.
Tracheal stenosis.
For severe tracheal stenosis caused by tumor, which has caused severe respiratory distress, tracheal stent implantation should be performed as early as possible. Only after reconstruction of usual airway can the patient’s life be secured, and tracheal stent implantation can rapidly relieve respiratory distress caused by tracheal stenosis and maintain normal respiratory function, thus gaining valuable opportunities for treatment of primary diseases.
II. Abdomen
Liver cancer.
1. Arterial chemoembolization therapy: most hepatocellular carcinomas are developed from post-hepatitis cirrhosis, and most primary hepatocellular carcinomas are vascular-rich tumors, that is, there are abundant blood vessels inside the tumor, and tumor growth needs sufficient blood supply, and most of the blood supply arteries of hepatocellular carcinoma come from hepatic artery branches, and the hepatic artery branches inside the liver are like a small tree growing from the aorta, and the hepatic artery is the trunk, and the artery branches inside the liver are like The hepatic artery is the trunk of the tree, and the branches of the arteries in the liver are like branches. The hepatic artery enters the liver and divides into two branches, and then the branches become more and more thin. The principle of hepatic artery chemoembolization for liver cancer treatment is to use a small catheter to insert into the small branches of the tumor through the hepatic artery and inject a mixture of iodinated oil and chemotherapeutic drugs into the tumor directly, replacing the blood with drugs and blocking the blood supply to the tumor, so that the iodinated oil, which has the power to kill the tumor, accumulates in the tumor for a long time to kill the tumor while protecting the normal liver tissue. Whether it is single liver cancer or multiple liver cancers, this treatment method can achieve good efficacy, and the clinical effect of this treatment method has been recognized by domestic and foreign medical circles.
2.Ablation therapy.
Ablation therapy includes thermal ablation and cold ablation. Thermal ablation is a therapeutic measure of placing radio frequency or microwave directly into the tumor under the guidance of image, and heating up the tumor to over 80 degrees after connecting the high frequency radio frequency or microwave generator, thus causing rapid necrosis of the tumor. Cold ablation, on the other hand, is to freeze the tumor instantly to -175° for 10 minutes, and then to heat the tumor to 20-40° rapidly, so that the tumor is necrosed by cell consolidation after repeated freezing and thawing. For selected patients with liver cancer, through rigorous preoperative planning and precise intraoperative ablation, the liver cancer can be completely ablated in one go, which is a complete necrosis of the tumor, thus obtaining a radical clinical effect. More and more research results have confirmed that the long-term survival rate of liver cancer patients treated with radical ablation is comparable to surgical resection, with lower complication rate and shorter hospital stay.
(iii) Hepatic hemangioma.
Hepatic hemangioma is a relatively common benign tumor of the liver. Hemangioma is not a true tumor, but is caused by congenital malformation of the terminal blood vessels of the liver. During embryonic development, abnormal development of liver blood vessels causes abnormal proliferation of vascular endothelial cells to form hepatic hemangioma.
Hepatic hemangioma mostly has no obvious discomfort symptoms, but when the hemangioma increases to more than 5cm, the following symptoms may appear.
1. abdominal mass
2. Gastrointestinal symptoms
Indistinct pain and/or discomfort in the right upper abdomen, belching, bloating and fullness after eating, and other indigestion symptoms.
3. Compression symptoms
Large hemangioma may push and compress the surrounding tissues and organs. Compression on the lower esophagus – difficulty in swallowing; compression on the bile duct – obstructive jaundice; compression on the lungs – dyspnea and atelectasis; compression on the stomach and duodenum – postprandial fullness and discomfort.
4. Rupture and bleeding of hepatic hemangioma
Larger hepatic hemangiomas growing below the costal arch rupture and bleed due to external forces.
5. Kasabach-Merritt syndrome
Coagulation abnormalities caused by thrombocytopenia and massive depletion of coagulation factors.
Smaller hepatic hemangiomas generally do not cause clinical symptoms and grow slowly or even do not progress significantly throughout life. For asymptomatic hepatic hemangiomas under 5 cm, treatment is generally not needed, only regular review and size measurement is required. If the hemangioma does not increase in size after long-term review, no treatment is needed, or embolization can be considered if the hemangioma gradually increases in size. For larger hemangiomas that have developed clinical symptoms, transhepatic artery embolization is recommended for treatment. Therefore, if a catheter is inserted into the trophoblastic artery of hepatic hemangioma, embolic agents such as iodized oil or PVA particles or sodium alginate microspheres are injected directly into the hepatic hemangioma through the catheter to form thrombus in the malformed vessels of the hemangioma and completely block the trophoblastic vessels of the hemangioma. With time, the thrombus in the hemangioma mechanizes, fibrosis, and tissue dehydration gradually shrinks. The vast majority of hemangiomas can be completely de-vascularized and gradually atrophied after a single arterial embolization.
(C) Obstructive jaundice.
Jaundice caused by intrahepatic or extrahepatic bile duct stenosis or occlusion due to various reasons, resulting in the inability of bile to drain from the intrahepatic duct to the duodenum, is obstructive jaundice, except for obstruction caused by bile duct stones or pseudotumor of the head of the pancreas due to chronic pancreatitis, other causes of obstruction are mostly tumors, including intrahepatic tumors compressing or invading the bile duct, advanced gastrointestinal tumors directly invading the common bile duct, or metastasis of lymph nodes in the hilar region compression of extrahepatic bile duct, or invasion of pancreatic head cancer as compression of bile duct. Clinical symptoms include yellowing of skin and whites of eyes, dark yellow urine, white stools with white clay-like stools. Prolonged bile duct obstruction can easily induce biliary tract infection, which can form septic cholangitis and endanger life in severe cases. For severe obstructive jaundice, a percutaneous transhepatic bile duct puncture can be used to drain the bile accumulated in the intrahepatic bile ducts to the outside of the body, which not only rapidly reduces jaundice, but also prevents biliary tract infection or allows the infected bile ducts to be quickly controlled due to the usual drainage. As the saying goes, running water does not rot, and the household pivot is not worm-eaten. Biliary tract infections are often due to the presence of bile duct obstruction, so it is even more important to actively drain the already infected obstructed jaundice early. After the jaundice subsides, the original cause of the disease can be treated.
(D) Pancreatic cancer
The number of patients with pancreatic cancer is increasing significantly. Early stage pancreatic cancer lacks specific symptoms and is difficult to diagnose, therefore, most of the pancreatic cancer diagnosed clinically is advanced. After the initial diagnosis of pancreatic cancer, the mortality rate is as high as 80% within 1 year and 95% within 3 years. The median survival period for patients with metastasis is 3-6 months, and the median survival period for patients with locally advanced pancreatic cancer is 6-10 months. In China, the incidence of pancreatic cancer is on the rise, and in clinical practice about 80% of pancreatic cancer patients have metastases by the time they present with symptoms and seek medical attention. The radical resection rate is less than 20%. At present, there is still no most effective treatment for advanced pancreatic cancer.
For pancreatic cancer that cannot be surgically resected, there is a lack of effective clinical treatment, and conventional chemotherapy is ineffective with a short median survival. Although the application of gemcitabine, capecitabine and doxorubicin in pancreatic cancer chemotherapy has significantly improved the quality of survival and prolonged the survival of advanced pancreatic cancer to some extent, however, there is not much breakthrough in its median survival and 1-year survival rate.
Pain is the most common serious clinical symptom of advanced pancreatic cancer, and most patients’ pain is due to tumor invasion of the abdominal plexus including the autonomic nerve, causing severe pain in the abdomen as well as the back, which seriously affects patients’ diet and sleep, accelerates physical exertion, causes a series of poor prognosis, and is more difficult to treat.
In recent years, 125I particle inter-tissue implantation, as an emerging radiotherapy technique for tumors, has been widely used in the radiotherapy of various malignant tumors and has achieved encouraging results. 125I particle therapy for pancreatic cancer is also gradually increasing in clinical reports, and many clinical studies suggest that CT-guided implantation of 125I radioactive particles for pancreatic cancer has precise recent efficacy and good It is a safe, effective and minimally invasive treatment method with few complications.
Radioactive 125I particles are low-energy radioisotopes with a half-life of 59.6 days, and the continuous release of γ and X-rays can cause cell death by damaging DNA molecules, inducing apoptosis and inhibiting tumor cell proliferation, thus achieving therapeutic purposes. The relative biological effectiveness (RBE) of radiation is related to many factors, among which linear energy transfer (LET) and dose rate play a major role. 125I particles have an average photon energy of 28 keV, which is a low-energy radiation and theoretically has a high REB. The average photon energy of 125I particles is 28 keV, which is a low-energy radiation and theoretically has a high REB, so that a high relative biological effect can be obtained without a very high dose when using 125I particles for continuous low-dose irradiation, which can kill tumor cells by radiation, block the tumor cell cycle and inhibit tumor cell repair.
We have successfully carried out CT-guided percutaneous puncture 125I radioactive particle implantation for pancreatic cancer, and the patient’s pain symptoms were significantly reduced 2 days after radioactive iodine particle implantation, and the bile duct obstruction caused by pancreatic head cancer was restored to bile flow, with remarkable clinical effects. Due to the careful preoperative perioperative treatment, the complications were effectively prevented and no serious complications occurred in all cases. Radioactive iodine particles can be discharged 3-5 days after implantation.
(E) Kidney cancer.
For isolated kidney cancer, if it cannot tolerate surgery, it can be treated by cold and heat ablation such as argon helium knife or radiofrequency and microwave, just like liver cancer, which can obtain radical effect.
(F) Uterine fibroids.
Uterine fibroids are benign tumors and can be treated by surgical resection for symptomatic fibroids. However, for patients who have a desire to preserve the uterus or cannot tolerate surgical treatment, they can be treated by uterine artery embolization. The treatment principle is similar to chemoembolization for hepatocellular carcinoma, but fibroids do not require the use of chemotherapeutic drugs, and the use of particulate embolic agents alone can cause ischemia and consolidation necrosis of the fibroids.
(vii) Ureteral stenosis.
For ureteral stenosis caused by various reasons, percutaneous pelvic puncture can be used to place an endocannula, which is a soft plastic catheter curled into a pigtail shape at both ends, with side holes along its full length, and the pigtail at both ends of the endocannula is placed in the renal pelvis at one end and in the bladder at the other end, so that urine in the renal pelvis can flow smoothly into the bladder through the endocannula, thus reducing hydronephrosis and restoring renal function.