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treatment of metastatic pleural tumors, what to do with metastatic pleural tumors, medications for metastatic pleural tumors

treatment of metastatic pleural tumors, what to do with metastatic pleural tumors, medications for metastatic pleural tumors

Knowledge of diagnosis and treatment of metastatic pleural tumors

Treatment department: Cardiothoracic Surgery Oncology Department Treatment costs: different hospitals have different charging standards, the city's top three hospitals are about (50,000-100,000 yuan) Cure rate: Treatment cycle: Treatment methods: chemotherapy, drug treatment General treatment of metastatic pleural tumors

One, treatment

The treatment of pleural metastases includes the treatment of primary tumors and the treatment of pleural metastases. The former should be given corresponding anti-tumor treatments according to different primary tumor properties. The latter can be based on the extent of pleural metastases and the amount of malignant pleural effusion. At the same time as the primary tumor is treated, video-assisted thoracoscopy is used to remove pleural metastases, exclude malignant pleural effusion, inject anticancer drugs into the pleural cavity, and make the pleura. Fixation is used to reduce or eliminate the generation of malignant pleural effusion, relieve the patient's chest symptoms, and prolong the patient's survival period.

To treat patients with malignant pleural effusion, first clarify the nature of the primary tumor. The appearance of malignant pleural effusion indicates that it has been spread throughout the body, and the only treatment that can be selected is systemic chemotherapy. In patients with breast cancer metastasized to the pleura, 40% of the cases disappeared after systemic chemotherapy. For small cell lung cancer, the pleural effusion was not controlled by systemic chemotherapy.

75% of patients with malignant pleural effusion have primary tumors from the lung, breast or lymphoma, and most of the other primary tumors come from the abdominal cavity. . When the diagnosis of malignant pleural effusion is unknown, CT examination of the chest and abdomen, mammography and pelvic examination should be performed. If the clues of the primary lung tumor cannot be found after these examinations, no other examinations are necessary. The survival time of patients with malignant pleural effusion is limited, and there is no need for long-term hospitalization and multiple examinations to find the primary tumor. About 6% of patients have never found the primary tumor.

Chemical pleural fixation: For patients who are not suitable for systemic chemotherapy or systemic chemotherapy is ineffective, chemical pleural fixation should be considered. The purpose is to eliminate the pleural cavity to prevent pleural fluid from accumulating, rather than to make the tumor smaller. Therefore, this surgery is only suitable for patients with symptoms caused by pleural fluid. If the patient is asymptomatic, there is no need to increase the patient's pleural fluid to eliminate it. The patient is in a dying state due to the spread of the tumor, and there is no need to place a chest drainage. For patients with symptoms caused by pleural effusion, the symptoms are relieved after pleural puncture, so Qing considers pleurodesis. Before doing pleurodesis, evaluate the mediastinal displacement. If the mediastinum moves to the side of the effusion, it means that the ipsilateral lung can no longer expand normally, and the negative pressure of the ipsilateral thoracic cavity will rise, and there will be no contact, so pleurodesis should not be performed.

Chemical pleural fixation is to inject a certain medicine into the pleural cavity, causing a violent chemical reaction, causing the parietal and visceral layers to fuse and stick, so that the pleural cavity is closed and no pleural fluid is accumulated. Before this operation, a chest tube should be placed for drainage and pleural fluid should be drained to make the wall layer and the visceral pleura adhere to each other after injection of the sclerosing agent.

The choice of sclerosing agent: At present, there are a variety of sclerosing agents to choose from, such as anti-cancer drugs mustard, bleomycin and radioisotopes, A's talcum powder, tetracycline and Corynebacterium parvum. Animal experiments have shown that tetracycline is the most effective sclerosing agent. Adipin has a poor long-term effect. Injecting talcum powder into the pleural cavity can cause severe pneumonia. Anticancer drugs can cause systemic chest pain and fever, and the effect is not good.

Operating technique: Before performing chemical pleural fixation for the patient, a closed drainage of the chest cavity should be installed to drain the pleural fluid as much as possible. If the lungs still do not expand after 24 hours of closed drainage with a water-sealed bottle, and then use negative pressure suction and rapid drainage, patients with chronic pleural effusion may be complicated by re-expanding pulmonary edema. If chest tube drainage can cause lung recruitment, it is contraindicated to perform pleurodesis for the patient. Otherwise, it will only thicken the visceral pleura and further damage the lungs under the pleura.

Once the lungs are fully recruited, try to do pleurodesis. It is not necessary to postpone the operation until the thoracic drainage is stopped. In view of the severe pain caused by the injection of sclerosing agent, a local or systemic pain agent should be given before the injection of tetracycline. For local anesthesia, 150mg lidocaine can be converted into 50ml solution and injected into the thoracic cavity during 10 to 15 minutes after the injection, so that the patient can change the position frequently so that all the pleura can be in contact with the anesthetic. Based on 20mg of tetracycline per kilogram of body weight

Calculate, dilute it into 50ml solution and inject it into the pleural cavity through the chest tube. Then 15ml of normal saline was injected through the chest tube to flush out the tetracycline residual liquid.

After injecting tetracycline, immediately clamp the chest tube for 2 hours to make the patient change position; supine, prone, left and right positions and sitting position, make tetracycline contact all the surface of the pleura, then open the chest tube and connect the negative pressure -1.47~- 1.96kPa (-15~-20cmH2O) continuous suction for at least 48h, until the chest drainage is less than 150ml/d. The function of tetracycline is that it causes a severe inflammatory reaction, makes the visceral layer and parietal pleura adhere to each other, and eliminates the pleural cavity.

In appropriately selected cases, chemical pleurodesis can achieve a success rate of 80% to 90%. Cases where pleurodesis fails are those patients whose mediastinum moves to the side of the effusion and the lung cannot be expanded after drainage through the chest tube. .

Thoracic puncture: A series of intermittent therapeutic pleural puncture fluids have limited efficacy in patients with malignant pleural effusion, and pleural fluid reappears within 1 to 3 days after therapeutic pleural puncture. In addition, repeated chest punctures will consume protein. According to calculations, pumping out 2000ml of pleural fluid (400g/L) will cause the patient to lose 80g of protein. Repeated chest puncture causes pleural fluid separation, which makes it difficult to perform pleural fixation in the future. Therefore, therapeutic thoracic puncture is more suitable for those advanced cases, and its purpose is only to reduce the symptoms caused by thoracic pressure. Patients who cannot re-expand the lung should not undergo pleurodesis can also be considered for therapeutic thoracic drainage.

Pleuroplasty: The following conditions should be considered for pleurectomy: ① For patients who are highly suspected of malignant pleural effusion but the diagnosis is not clear, parietal pleural resection may be considered when diagnostic thoracotomy is planned. ②The malignant disease has been identified. In order to prevent the reappearance of malignant pleural fluid, the parietal pleura should also be removed. ③Patients with persistent pleural effusion causing symptoms and collapsed lungs on the same side should be stripped of the visceral pleura that collapsed the lungs and the parietal pleura should be removed. In 90% of cases, pleuriectomy can effectively control pleural effusion, but the surgical mortality rate is about 10%. The general situation is good, the primary tumor is slower or has been controlled, and only patients with symptoms caused by pleural fluid are suitable for visceral pleural exfoliation and parietal pleuraectomy.

2. Prognosis

Metastatic pleural tumors often cause exudative malignant pleural effusion, suggesting that the patient has systemic metastatic disease, and the prognosis is extremely poor. Chernow reported 96 patients. The average survival time after diagnosis was 3.1 months, 54% died within 1 month, and the 6-month mortality rate was 84%. The average survival time of 30 lung cancer patients was only 2.2 months, and the average survival time of 13 breast cancer patients was 73 months. At present, there are no effective measures to prolong the life of patients

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