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Proton knife gives birth to a new era of nerve tumor treatment
The proton therapy system, the best equipment for treating whole-body tumors, which marks a new era of nerve tumor treatment, was put into operation in Zibo Wanjie Hospital. More than 200 experts and professors from the province's neuro-oncology medical field visited the proton therapy center of Zibo Wanjie Hospital and conducted in-depth discussions on the clinical application of the proton knife and other new advances in the treatment of neuro-oncology. Zibo Wanjie Hospital, as a center of tumor conformal radiotherapy, has a mature treatment for intracranial neural tumors Intracranial tumors are generally treated with conventional surgery and traditional radiation therapy. In 2002, Zibo Wanjie Hospital successfully introduced the most advanced proton therapy system in China and set up the first proton therapy center in China, so that China's tumor radiation therapy technology has reached the world's leading level. With the advantages of high energy and high accuracy, the proton therapy system can be used to reach tumors in any part of the human body, and it can hit the tumors in a targeted and shaped manner to destroy them. It can accurately hit the tumor and destroy the diseased tissues without damaging the normal tissues.
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The University of Texas Cancer Center invested $125 million to set up a proton therapy center to treat cancer patients with the most advanced technology, treating 3,500 patients with lung cancer, prostate cancer, head and neck cancer, and eye cancer each year.
Proton therapy is the state-of-the-art technology in radiation therapy, which differs from traditional X-ray radiation therapy in that proton rays release only a small amount of energy in the path they traverse, and only release a large amount of energy when they reach the depth of the treatment, so that the radiation has little effect on normal tissues.
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Speed up the construction of key healthcare projects. Construction of Nanhui and Fengxian central hospitals and 13 emergency sub-stations (points) construction projects, as well as 400 village health room renovation projects, guiding municipal high-quality medical resources to support suburban health care and improve the level of rural medical services in the suburbs. Promote the Shanghai Sixth People's Hospital outpatient medical and technical building and East China Hospital Citizen's Outpatient and Emergency Building renovation and other projects, and grasp the proton knife project preliminary work.
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096.Briefly explain the principle of stereotactic radiosurgery.
(1) Stereotactic radiation neurosurgery treatment of disease equipment required for linear gas pedal, γ-knife, cyclotron, and proximity remote control after loading machine. By the above devices to provide treatment for X-rays, γ-rays, electron beams, proton beams, heavy particle beams and isotopes used in interstitial radiotherapy; (2) with the help of high-precision stereotactic instrument, in the CT, MRI and DSA and other imaging technology, the implementation of accurate positioning of the target point of treatment, to determine the coordinates of the target point; (3) with the treatment planning system, to set out the treatment plan; (4) the three-dimensional target point of the coordinate parameters converted to the irradiation device. (4) The three-dimensional coordinate parameters of the target point are converted to the coordinate system of the irradiation device, and the radiation is gathered at the target point by controlling the direction of the incoming rays and their trajectory, so as to achieve the treatment of the target point.
097. Briefly describe the methods, applications, and complications of stereotactic therapy.
Stereotactic reflexology in recent years has given rise to many new methods of treatment technology, such as the use of 60Co or linear gas pedal as a source of radiation γ knife, X knife; heavy ion gas pedal as a source of radiation ion knife; radioactive isotopes as a source of radioactivity in the tumor mesenchymal arc intra-tumor cavity brachytherapy; via directional surgical lesions pre-positioning of catheters after loading treatment; intraoperative tumor bed radiotherapy. It is applied to cerebrovascular malformations, certain intracranial tumors and functional diseases. The main complications are radioactive cerebral necrosis, edema of brain tissue around the target site, hemorrhage of the lesion, and neurological dysfunction.
098.Briefly describe the method of stereotactic destruction of the target point.
(1) radiofrequency electrothermal destruction: 1. radiofrequency electrocoagulation: electrocoagulation temperature in 60 ℃ -80 ℃; the size of the destruction area with electrocoagulation time control, generally 5 s-30 s; 2. induction electrothermal (2) DC electrolysis; (3) mechanical cutting: with a special cutter knife in the target structure of the mechanical cutting; (4) drug injection : injection of neurodestructive drugs into the target area, alcohol is commonly used; (5) cryopreservation: a double-chambered brain needle is used, and liquid nitrogen is used as the coolant; (6) ultrasound; (7) radioactive destruction: 1. radionuclide intracerebral implantation; 2. heavy ion in vitro irradiation; 3. γ-knife, X-knife, and other means.
026.Briefly summarize the application of interventional radiotherapy in neurosurgery.
1. Treatment of cerebral aneurysms: the use of detectable detachable balloon and other endovascular embolization treatment, can be operated in a state of full consciousness of the patient, continuous monitoring of neurological function, so that most of the medium-large or huge shape of the surgery is difficult to complete the aneurysm can be treated by this technology; 2. Treatment of cerebral arteriovenous malformations: surgery is difficult to complete the main functional areas and the deep brain of the arteriovenous malformations are able to Treatment of arterial spasm and arterial stenosis: angioplasty can be effective for symptomatic vasospasm after subarachnoid hemorrhage when drug treatment is ineffective; 4. Preoperative embolization of external carotid artery for meningioma: it can reduce intraoperative bleeding, make the surgical field of vision clear, and make it easy to completely resect the tumor; 5. Selective or super-selective intra-arterial instillation of anticancer drugs for the treatment of cerebral gliomas: this method is better than the intravenous route of drug administration. Selective or super-selective intra-arterial infusion of anticancer drugs for glioma: this method is better than intravenous route of drug administration, which can reduce systemic reaction, increase local drug concentration and achieve better therapeutic effect; 6. Others: treatment of Galen's venous tumor, vascular malformation of spinal cord, thrombolytic therapy after cerebral embolism.
062.Briefly describe the principles and overview of photodynamic therapy of brain tumors.
Certain photosensitizers such as fluorescein, eosin, tetracycline, and stilbenes can be taken up by malignant tumor cells and accumulate in large amounts in the mitochondria of the cytoplasm. The amount of accumulation can be 5-20 times larger than that of normal tissue cells, and the accumulation time can be as long as 48 hours. Under the irradiation of light, the tumor cells containing photosensitive substances lose their vitality due to physical or chemical reactions and achieve the therapeutic purpose. However, most photosensitive substances cannot pass the blood-brain barrier, which greatly prevents the role of photodynamic therapy in brain tumors. In recent years, it has been found that hemazoin derivatives treated with acetic acid and sulfuric acid can not only pass the blood-brain barrier, but also enter the tumor cells. Therefore, using it to treat brain tumors not only has a reliable theoretical basis, but will greatly improve the efficacy of this therapy.
064.Introduction to boron neutron capture therapy.
Boron Neutron Capture Therapy (BNCT) is a treatment that destroys tumors by using atomic nuclear reactions that occur within the tumor cells. The patient is first injected with the stable isotope 10 boron (10B). 10B enters the body and rapidly concentrates in the cells of the tumor patient, and then the tumor is irradiated with high-energy thermal neutrons, and when irradiated, the 10B absorbs the neutrons and turns them into 11B atoms and immediately undergoes nuclear fission, releasing alpha particles; the alpha particles are high-energy-transmitting-density rays, which can effectively kill the tumor cells and are equally effective in the treatment of cells with anoxic cells and cells with an inter-dividing phase. The α-particle is a high energy density ray, which can effectively kill tumor cells, and is also effective for anaerobic treatment cells and interphase cells. α-particle has a short range of 10 um, equivalent to the diameter of one cell, so it can only kill tumor cells with nuclear reaction, and has no effect on the surrounding normal cells, so as to achieve the purpose of protecting the surrounding healthy tissues.
065.Briefly describe the concept and progress of brachytherapy for brain tumors.
Brachytherapy is named in response to conventional distant radiotherapy, which is a type of radiation therapy that irradiates a tumor by implanting a radioactive source directly into the tumor. It includes interstitial radiotherapy and intracavitary (capsule) radiotherapy. In recent years, with the application of CT and MRI, the location, size and shape of tumors have been determined more precisely. The combination of imaging methods with stereotactic and electronic computers can simulate the isotope dose curves before operation, and accurately deliver the predetermined radiation dose interstitially within the specific tumor boundaries; coupled with the improvement of the implantation methods of radioactive sources, such as post-catheter mounted radioactive source technology and intracavitary injection of isotope colloidal suspensions, it can be used for the treatment of tumors of various tissue compositions, and the indications are more enlarged, especially for the deep, functional areas and high malignant brain tumors. brain tumors.
066.What are the indications and surgical technique requirements for hearing preservation in auditory neuromas?
The indications for hearing preservation are: 1) small acoustic neuromas with normal or near-normal hearing; 2) cases originating from the vestibular nerve and located in the middle of the internal auditory canal; and 3) tumors with invasion of no more than 1.5 cm into the pontine cerebellar angle. When the brainstem auditory evoked potential waveform on the side of the tumor is essentially normal or the thermal response is reduced (suggesting that the tumor is likely to originate from the vestibular nerve), there is a high likelihood of hearing preservation, and hearing preservation is more likely with an acoustic neuroma with a diameter of less than 2 cm.
The technical requirements for hearing preservation are: 1. the bone window should be large enough; 2. cerebrospinal fluid release to reduce intracranial pressure; 3. abrasion of the posterior wall of the internal auditory canal (less than 12 mm); 4. intracapsular chunking of the tumor followed by resection of the cysticercus; 5. the application of a microscope; 6. bipolar electrocoagulation; 7. intraoperative monitoring of the brainstem auditory evoked potentials; and 8. the protection of the arteries supplying the 8th cranial nerve and the cochlear nerve.
068.What is the concept of stereotactic radiosurgery? How does it differ from general neurosurgery?
According to the principle of stereotacticity, the use of a large dose of narrow-beam ionizing rays on an intracranial target point to precisely gather irradiation, so as to produce focal damage to achieve the therapeutic destination is called stereotactic radiological neurosurgery. It is significantly different from general neurosurgery: 1. no craniotomy, no bleeding, surgical risk and fewer postoperative complications; 2. simple operation, accurate positioning, short treatment, less trauma, no general anesthesia, blood transfusion and the corresponding complications; 3. patients are not affected by age, physical condition and multiple operations, wide range of indications, general neurosurgery by the doctor's experience, surgical skills have a greater impact.
069. What are the applications of stereotactic radiosurgery?
1. Functional neurosurgical diseases: (1) malignant pain; (2) trigeminal neuralgia; (3) intractable psychosis; (4) extrapyramidal disorders: Parkinson's disease, other basal ganglia disorders such as torsion spasms, spasmodic trapezius, torsades de pointes; (5) epilepsy; (6) functional pituitary gland resection, mainly used for malignant pain caused by cancers, which may be associated with the suppression of endocrine function; 2. Non-functional neurosurgical diseases. Functional neurosurgical diseases: (1) intracranial tumors: meningiomas, saddle region tumors, pineal region tumors, acoustic neuroma, brain stem tumors, deep brain tumors, intracranial metastases; (2) cerebrovascular disease: arteriovenous malformations, aneurysms, vascular reticulocytomas, cavernous hemangiomas in the area of jugular venous foramen.
070.Briefly describe the biological staging of stereotactic radiosurgery.
Phase I: necrotic phase, when the absorbed dose in the center of the target site is 200Gγ, necrosis of the target site, acute degeneration and inflammatory reaction appear in the third and fourth weeks after irradiation; Phase II: absorptive phase, after the necrotic phase to one year after irradiation. A large amount of cellular debris is absorbed from the necrotic foci, and a glial scar begins to form, with proliferation of astrocytes around the necrotic area, chronic inflammatory reaction, vascular congestion, neocapillary formation, and thickening of vascular endothelial cells, which lasts for one year or more after irradiation; Phase III: late phase, starting one year after irradiation, a glial scar forms, and a series of changes in the early phase disappears, with complete elimination of the cellular debris and formation of a clear-cut glial scar. clear gelatinous scars.
071.What are the indications for stereotactic radiosurgery in the treatment of arteriovenous malformations?
The indications for stereotactic neurosurgery in the treatment of cerebral arteriovenous malformations are usually considered to be the following: 1. lesions less than 3 cm in diameter; 2. deep cerebral lesions, especially those located in the brainstem, thalamus, or basal ganglia, and other important functional areas; 3. old and frail patients, or patients who cannot tolerate the general anesthesia and the blows of craniotomy due to the combination of diseases of other organs; 4. patients with residual malformed vascular clusters after craniotomy; and 5. patients with a large amount of blood vessels in the brain. After craniotomy, there is still a malformation of the vascular mass; 5. Embolization therapy failed; 6. The patient refuses to general anesthesia craniotomy.
074. How to rationally use γ-knife and Χ-knife in clinical practice?
1. Brain tumors or arteriovenous malformations smaller than 30mm are preferred to γ-knife; 2. Deep lesions, lesions located in the brainstem are preferred to γ-knife; 3. Multiple small lesions, such as multiple gliomas, multiple arteriovenous malformations are preferred to γ-knife; 4. Small nasopharyngeal cancers are preferred to Χ-knife; 5. Small nasopharyngeal cancers are preferred to Χ-knife. γ-knife is preferred; 5. γ-knife is preferred for functional neurosurgical diseases; 6. Χ-knife should be preferred for malignant gliomas unless they are small in size and show clear borders on MRI; 7. Χ-knife is preferred for 36mm-50mm diameter lesions; 8. Χ-knife is preferred for lesions requiring Χ-knife is preferred for lesions larger than 40mm; 9. Χ-knife is required for tumors in the neck that are difficult to localize
075. What are the advantages of γ-knife compared to Χ-knife?
1. The effect of γ-knife is reliable; 2. Wider range of use than γ-knife, which can be extended to the base of the skull, neck, spine and other parts of the body and is easy to use; 3. Applicable to tumors of different sizes and irregularities and cerebral vascular malformations, etc.; 4. The caliber of the collimator ranges from 4mm-50mm or larger; 5. More than γ-knife, the cost-effectiveness is high. -knife with high economic benefits, requiring less investment and cost; 6. Χ-knife stereotactic positioning device installation is simpler than γ-knife; 7. Dynamic and segmental are matched with suitable collimator; 8. There is no γ-knife application for 5 years needing to replace the 60Co and handling of the Problems of radioactive waste.
076.Briefly describe the indications, points of attention, and major complications of gamma knife treatment of pituitary adenoma.
Indications: 1. Pituitary adenomas (especially functional microadenomas) with a distance from the optic nerve greater than 5 mm; 2. Pituitary adenomas with surgical failure or residual tumors or tumors of sudden onset; 3. Advanced age, poor health, inability to tolerate surgery; 4. Refusal to undergo surgery or inability to undergo transsphenoidal surgery. In order to obtain good results of Gamma Knife, the following aspects should be paid attention to: 1. precise positioning; 2. selecting the appropriate irradiation dose, especially the marginal (minimum) dose received by the tumor is an important factor; 3. knowing the size of the tumor, the relationship between the tumor and the surrounding structures, and what type of tumor it is before treatment. Practice confirms that ACTH, GH, PRL functional adenomas have better results.
Major complications: the incidence of pituitary hypoplasia is around 10-33%, generally related to imprecise localization and overdose, and most of the short-term underfunctioning manifestation occurs from 2 months to 6 months after treatment.
077.Briefly describe the diagnostic value of single photon emission CT scanner (SPECT) in the treatment of craniocerebral injuries.
SPECT can provide a certain objective diagnostic basis for the diagnosis of patients with concussion and head trauma syndrome, which cannot be determined by objective indexes at present, and it is more sensitive than CT or MRI to some extent for patients with cerebral contusion and intracranial hematoma, and it can find the lesions earlier in time and more in number than CT or MRI, and it can find the lesions in a wider range than CT, which can respond to the clinical condition of patients and predict the outcome of craniocerebral injury. It can more accurately respond to the patient's clinical condition and predict the progression and prognosis of the disease. Therefore, combining the anatomical information provided by SPECT is conducive to further improving the diagnostic accuracy of craniocerebral injury and guiding clinical treatment.
078.Briefly describe the working principle of ultrasonic surgical suction.
The ultrasonic surgical attractor (CUSA) utilizes a magnetically controlled ultrasonic oscillator to convert electrical energy into mechanical motion, i.e., by varying the current of the electromagnetic field, it produces 23,000 vibrations per second. This extremely high speed vibration is amplified through the connector and transmitted to the surgical probe (titanium tube), which produces a corresponding longitudinal motion. The probe comes into contact with the tumor tissue and crushes it. At the same time, an appropriate amount of saline overflows around the probe, mixes with the tumor debris to emulsify it, and is suctioned off by the suction device on the probe. It can be seen that the ultrasonic surgical suction device has the three functions of oscillation crushing, rinsing emulsification and suction.
079.Introduction to the use of lasers in neurosurgery.
1. Intracranial tumors and intraspinal tumors: CO2 laser surgery. Choose low power (1w-5w) non-focused light coagulation tumor cytomembrane, make it crumple, surface vascular coagulation, and then use high power (5w-100w) beam line tumor cytomembrane excision, and finally use low power (1w-10w) beam to gradually excise the tumor cytomembrane and the small piece of residue. Tumor resection with laser is more thorough, with less bleeding, sterile, accurate, and less damage to surrounding tissues, because the vascular and lymphatic vessels have been occluded, which can avoid the spread of tumor cells; 2. Cerebrovascular disease: laser can make the thrombosis in the aneurysm, while it has less effect on the tumor-carrying arteries and the adjacent perforating branches, and the laser can make the foci of arteriovenous malformations to be coagulated; 3. Functional neurosurgery: treating the chronic pains caused by various reasons, controlling the trigeminal neuralgia, vascular headache, and the pain in the heart. Trigeminal neuralgia, vascular headache and tension headache; 4. Microvascular anastomosis.
080.Briefly describe advances in the treatment of brain tumors.
1. Skull base surgery with large bone flap craniotomy and full exposure as the basic feature is maturing: the improvement of microsurgical techniques, neuroimaging and neuroradiology have promoted the development of skull base surgery including brain stem tumors. Intraoperative monitoring such as brainstem evoked potentials, the application of lasers, the rate of total tumor resection has been greatly improved, and the surgical mortality rate and disability rate have been significantly reduced; 2. Microinvasive neurosurgery has risen to prominence: the rapid development of neurosurgery assisted by neuroendoscopic technology, stereotactic surgery and endoscopy has resulted in less traumatic operations, lighter reactions and better results; 3. Navigation technology has become a boutique neurosurgical surgical instrument: with the help of this system, the intracranial Precise positioning of lesions, selection of optimal surgical access and optimal surgical plan, reducing or avoiding damage to normal tissues and important structures; 4. Genetic engineering of gliomas has shown a bright spot: the development of molecular biology and genetic engineering technology has provided brand-new means and ideas for the understanding of the pathogenesis of neurosurgical diseases and their treatment.
081.Briefly describe the current status and considerations of microsurgical treatment of brainstem tumors.
Status: 1. The forbidden zone of surgery has been broken through: the brainstem division of arousal, respiratory and circulatory centers, which was regarded as the forbidden zone of surgery, has been broken through since the 1990s; 2. Domestic is at the leading level in the world.
Note: 1. Preoperative positioning should be accurate; 2. Surgical access design should be reasonable; 3. Microsurgery must be performed; 4. Intraoperative close observation of vital signs and neurophysiological monitoring; 5. Intramedullary resection of the tumor should be performed from the part of the tumor that is closest to the surface of the brainstem, and the operation should be gentle and delicate; 6. Operation at the upper and lower 4mm of the fontanelle of the medulla oblongata should be performed with a high degree of vigilance against respiratory disorders; 7. Postoperative admission to the ICU for close monitoring; 8. ICU close monitoring; 8. Active prevention and treatment of postoperative respiratory disorders and stress ulcers, and ventilator-assisted respiration if necessary.
084. What is the cytoknife? Why has the cytoknife become a popular treatment for Parkinson's disease (PD) in recent years?
The so-called cytoknife is the application of stereotactic technology, based on the anatomical localization of CT, MRI, and microelectrode extracellular recording electrophysiological technology to record the target electrical signals, so as to achieve the functional localization, and then the implementation of radiofrequency destruction. The cytoknife makes the surgical localization more accurate, safe and with fewer complications. Stereotactic surgery for the treatment of PD began in the 1940s, mainly using pallidum and thalamus disfigurement, and remained an important means of treating PD with good results until the 1960s. It was then neglected due to the advent of levodopa. The reasons why it has become popular again in recent years are: 1. Decreased efficacy and severe side effects after long-term use of levodopa; 2. Animal experiments with 1-methyl-phenyl-tetrahydropyridine (MPTP) suggest that PD leads to slowness of movement, possibly due to abnormal discharge of the pallidocellular cells; 3. The development of imaging technology (CT, MRI) and microelectrode technology has led to more accurate target localization and safer surgery.
085.What are the surgical indications for cytoknife treatment of Parkinson's disease (PD)?
1. First of all, the patient must be diagnosed with primary PD without damage to the cerebellum and the pyramidal tract system, and secondary Parkinson's disease and PD superimposed syndrome are excluded; 2. The patient must have been treated with a comprehensive and complete pharmacological therapy (mainly levodopa preparations), with significant efficacy to levodopa but with markedly diminished efficacy and side effects such as symptomatic fluctuations (end-of-agent or on-off phenomena) and/or anisotropic signs. Or) side effects, such as the symptomatic fluctuation (end-of-agent or switch phenomenon) and ( or) the isokinetic sign; 3. The patient's ability to take care of themselves is significantly reduced, and the patient's condition is moderate or severe, and the HOHEN and HAHR classification is three grades or more; 4. There is no obvious dementia and psychiatric symptoms, and there is no serious brain atrophy on CT scanning of the brain or MRI examination; 5. Selected patients are able to cooperate with the doctor well in the operation.