Wu Qing, Wu Xueyong , Feng Jianping
Department of Oncology , Jing'an Elder People Hospital , Shanghai
(Abstract) objects: to eveluate the clinical application of cryocare
surgery system (Argon - Helium Scalpel) in the treatment for rearperitoneum
leiomyoma's recurrence after operation, observe its effectiveness
as well as its influences on the prognosis. Methods: Using local anesthesia,under
B-ultrasonography or computer tomography monitoring,6 patients were
treated by targeted Ar-He cryoablation. Results: The operation is
simple and safe, no mortality. All of the six cases are appeasement
refrigeration. After the following-up of more than six months, the
range of the refrigeration is over 75%. The effectiveness is significant,
the clinical symptom has been improved and the quality of the patients'
life has been elevated. Conclusion: if the resecting is not need again,
Targeted Cryoablation is a feasible and effective method for treating
rear peritoneum leiomyoma's recurrence after operation.
(Key Words) rear peritoneum leiomyoma, Cryocare surgery system, Targeted
Cryoablation
Concerning rear peritoneum leiomyom, operation is still the main treatment
method on clinical oncology; however, the recurrence rate is high
after operation, the ratio of resecting again cases is very small
as well as the effectiveness of radiation or chemical treatment is
very poor. The authors applied the Cryocare surgery system, ultra
low temperature refrigeration (namely Ya-He Targeted Cryoablation)
during the period between March and August of 2000 to treat six cases,
which have no need to resect the cancer again, and have made preliminary
effectiveness. The details are presented as following:
1 Clinical Data
⑴General Information：Four male cases, two female cases with the age
between 60 and 75 years old (the aeverage age is 68 years old). Among
which, four cases are right-middle-up abdomen ones and two are left-middle
abdomen ones. The six cases are all the recurrence cases after operation
among which two cases are the second time recurrence after twice operations,
one case can not accept the second resecting, because the gut and
the cancer are conglutinated together and the vessels on the cancer's
surface are congested, two cases' cancer has influenced the veins
of below cavity, as well as one case's cancer has penetrated into
cavity main artery, spleen artery and pancreas with pressing the duodenum,
which causes the incomplete ileus. The shortest recurrence time is
three months and the longest is 8 months. Six cases have been proved
as Peritoneum Leiomyoma by operation and all have the symptoms of
stomachache, weight losing etc. According to the CT examination, the
size of the smallest cancer is 8×7×5cm3, and the largest is 14.7×14×10.5cm3.
All six cases are not suitable for accepting the resecting operations
once more.
⑵ The Anaesthesia Method: De to relatively older ages of the cases,
the consistent anaesthesia outside the scirrhus is adopted.
⑶The preparation and the simulated orientation: CT examination identifies
the size and the surroundings of the cancer. If the cancer has penetrated
into the organs, the range of refrigeration should be controlled strictly.
The CT simulated orientation is adopted before the operation. According
to the cancer's shape and the surroundings detected by CT as well
as the specifications of the targeted cryoablation, the multiple-scalpel
operation plan should be designed, as the reference for the authentic
operation, to specify the number of the cryoprob, directions, angles,
depth, distances, ranges etc to avoid hurting other organs , to provide
reference for the ultra B short wave inducing during the operation
as well as to avoid the serious syndrome. Diagram 1 indicates the
CT simulated orientation refrigeration designing blueprint before
the operation. Because the cancer has penetrated into the intestine
and can not be separated, the refrigeration is conducted from the
center of the cancer to the peripheral to ensure that the surface
of intestine will not be frozen dead. Altogether, four cryoprob are
used including three 3mm ones and one 2mm. The operation spot is marked
on the skin as the reference of the operation. Since one week before
the operation, the TPN supporting shall be given to the patient to
rectify the negative nitrogen balance and the electrolyte balance
as well as to supply vitmin K1 in order that the patient can elevate
his endurance of the operation.
⑷ The Method of the Operation(1-2): Cutting from the abdomen, separating
abundantly and exposing the cancer. During the operation, using the
ultra B short wave to detect the size of the cancer as well as the
surroundings of the cancer together with pre-operation CT orientation's
result. Under the ultra B short wave's inducing, the puncture is conducted
with a thin cannulation. After arriving the aimed spot, dilate with
a steel wire and insert the cryoprobs to fix temporarily. After re-examination,
cryocare surgery system should be started off. The cycles of "refrigeration-calefaction-
refrigeration-calefaction" should be finished then. Each time,
the refrigeration duration is about 15 minutes. The first calefaction
temperature is 0-5℃，as well as the second calefaction temperature
is about 15℃左右。As soon as the frozen cancer becomes flexible, the
scalpel can be withdrawn. The lowest frozen temperature is approximate‐150℃.
If the cancer is very huge, the second time refrigeration can be conducted
after withdrawing the cryoprob 3-3.5 cm till the cancer thoroughly
becomes a huge ice-ball. The ultra B short wave indicates the boundary
of the ice-ball clearly and this can be used to judge the effective
refrigeration range primarily. After withdrawing the scalpel, the
specialized hemostatic gauze should be used to jam the wound to avoid
the bleeding. After the hemostasia, drainage should be conducted and
no clean out needed. After the operation, measures should be conducted
to diminish inflammation Also, some immunity treatments are needed
like thymus peptide and bcg vaccine. If necessary, the chemical treatment
and artery intervention treatment could be adopted.
2 The Results
In all the 6 cases, no mortality appears during the operation or due
to the syndrome. One case had incomplete ileus due to the cancer's
oppression. After the operation, large abscess occurred and the hemostasia
was not successful. The patient refused a second time operation and
died of exhaustion four months later. Other five cases, after more
than six months' following-up, their stomachache has got lysis significantly
,the quality of their lives has been improved and their weights have
increased 1-3 Kg. According to the re-examination, the caner neither
grows nor transfers. All the cases have got fever after the operation
with a temperature between 38-39℃, which lasts approximate one week.
One case, with huge cancer, had been getting fever for two weeks.
The fever is often related to the refrigeration range and the necrotic
tissues. The refrigeration ranges of all the six cases have not reached
100% with a maximum of 90% and a minimum of 60%. Diagram indicates
the cancer dies after refrigeration and forms a low-density area in
CT picture, whose CT numerical value has decreased from 72Hu to 1～
10Hu.
3 Discussion
The size of the effective refrigeration range is closely related to
the results. Theoretically, all the cancer should be frozen and the
range of the refrigeration should be 1～1.5cm surpassing the brim of
the cancer to ensure the zero rudimental cancer. However, in the actual
practice, due to the limitation of connections between the cancer
and other important organs, doctors have to consider more about the
security and the ideal refrigeration range can not be attained. Especially
in cases of recrudescent cancers, the refrigeration operation has
more difficulties. Therefore what refrigeration range is really effective
is an issue requires research(3-5). According to our preliminary observation,
if the range is more than 85%, the effectiveness is significant and
if the range is less than 60%, the effectiveness is insignificant.
Hence, the rudimental rate should be as low as possible with the security
as the premise. Research result indicates that no rudimental cancer
cleaning out can stimulate the immunity response and is helpful for
shrinking the cancer as well as controlling the transferring.（1）One
case with huge cancer 14.7×14×10.5cm3，as indicated by diagram 1 and
2, adopts "four croprobs combination" and "two withdrawing",
totally 6 refrigeration circles. Therefore, a huge ice column forms
in the celio-cavity; however, the no ice-crystal forms on the surface
of the cancer. And the intestine is not hurt by refrigeration. After
the operation, the recovery goes smoothly. According to the CT's reexamination,
it indicates that the refrigeration range has reached approximate
75%. After the operation, absolute alcohol, HCPT and DDP are injected
into the cancer and the left kidney artery intervention chemical treatments
are conducted twice. Based on the seven months' following up, tumidness
has been significant released, the healthy condition has been improved
as well as the weight has increased 2Kg. Presently, we are still continuing
to follow up this case. Concerning the refrigeration of the main vessels,
the author holds the cautious attitude. The animal experiments indicate
that if the diameter of the vessel is beyond 4mm, due to the fast
speed of the blood stream, the temperature transmission is fairly
quick, namely the "warm pool" effect, and after refrigeration
the embolism and blood stream block may not happen.（2）Also, experiments
indicate that the fiber content of main artery is more than that of
the vein, therefore the artery's endurance ability of refrigeration
is better than the vein. Though the author has conducted the refrigeration
on important vessels and no negative effects occurred after the operation;
however, the author still does not advocate the refrigeration on main
vessels, such as the abdomen main artery and the below cavity vein.
Currently, no systematical parameter is available. At the same time,
it may cause angioma, which will threaten the patient's life. For
the Rear Peritoneum Leiomyoma's Recurrence cases, which can not be
cut, there is not effective treatment available. The targeted Argon
and Helium cryoablation treatment under the inducing of ultra B short
wave has the advantage of simplicity, less bleeding and less hurt,
as well as no more cancer tissues are needed to be dissociated. Combine
CT orientation before the operation with the ultra B short wave inducing
during the operation, the border of the cancer as well as the nearby
tissues can be indicated. During the process of the operation, the
temperature detecting probe is adopted, which can avoid hurting or
frostbite of the vessels and organs successfully. The operation is
relatively safe, the recovery period is short as well as there is
less syndrome. After the operation, the immune system is strengthened.
Therefore, this is a new treatment for cancer patients(6).
Based on out preliminary observation, the operation is safe and feasible
with decent effectiveness. However, the number of the surveyed cases
is limited, the following-up time is relatively short, the effectiveness
needs further observation and the comparison research of its influences
on the patients' life-span is not abundant. .
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( Paper was accepted at March, 2001) |
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