2017年 · 第97卷第31期

tumor ablation is a non-vascular interventional therapy, which is a local therapy that directly applies chemicals or energy to a tumor lesion to eradicate or substantially destroy the tumor: including chemical ablation and energy-based ablation. The former mainly uses absolute ethanol, acetic acid, etc. to destroy tumors, while the latter includes radio-frequency ablation (RFA), microwave ablation (MWA), cryoablation (Cryo-A), laser ablation (LA), ultrasound ablation (ultrasound ablation) and irreversible electroporation (IRE) that inactivates tumors by non-thermal effects^[1,2]。

The International Society for Medical Shockwave Treatment (ISMST) held an enlarged meeting of ISMST Standing Committee members in Naples, Italy on October 12, 2016, and once again focused on updating and revising the indications and contraindications of extracorporeal Shockwave, which became a weather vane to guide the clinical application of ISMST members' Shockwave technology in the new era, and laid an important foundation for China to expand the application scope and operating specifications of Shockwave technology. We interpret this revision accordingly, in order to promote the clinical application and popularization of shock wave technology.

Primary liver cancer is one of the common malignant tumors in China, and the liver is also the second most common metastatic organ of tumors in other parts of the body. The treatment methods of liver tumors include surgical resection, liver transplantation, local ablation, transcatheter hepatic artery chemoembolization (TACE), radiotherapy, etc. In recent years, with the promotion of minimally invasive concept, local ablation methods represented by radiofrequency ablation (RFA) have developed rapidly. Because of its advantages such as positive therapeutic effect, few complications and low cost, local ablation has gradually been widely used in the treatment of liver tumors. In order to standardize the clinical application of tumor ablation technology, the National Health and Family Planning Commission of the People's Republic of China has formulated the Technical Management Standards for Tumor Ablation Treatment (2017 edition) (hereinafter referred to as the Standards), which makes specific requirements for medical institutions and personnel qualifications, technical management and personnel training that carry out tumor ablation, so as to ensure the quality and medical safety of ablation treatment. This article discusses the standardized application of ablation technique in surgical treatment.

Tumor ablation technique refers to the local treatment technique that directly destroys the tumor by physical methods, including radiofrequency, microwave, freezing, ultrasound, laser, irreversible electroporation, etc^[1]Therapeutic approaches include percutaneous, laparoscopic and open surgery under direct vision. After decades of development and exploration, tumor ablation has been paid more and more attention by clinicians, and has become another important means for treating solid tumors besides surgical treatment, radiotherapy and chemotherapy. Although the tumor ablation treatment technology has exact safety and effectiveness, it is still in the initial stage of treatment for many solid tumors due to its late start, and it has high requirements for the service ability of medical institutions and the technical level of medical staff. Therefore, it belongs to the medical technology that needs limited conditions. At the same time, at present, medical institutions at all levels in China are carrying out or planning to carry out clinical and scientific research on tumor ablation treatment, but the development level of each institution is uneven, and a unified standardized management model has not yet been formed.

Thermal ablation of liver tumors refers to a local treatment method for in situ inactivation of liver tumors by thermal effects, including radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (Cryo-A), laser ablation (LA), ultrasound ablation, and the like. Percutaneous puncture is mostly performed under the guidance of images, which has the advantages of simple operation, minimally invasive, precise and accurate curative effect. It can also be performed under laparoscopy or open surgery, and its clinical application is increasingly widespread. Tumor ablation is a medical technology with limited clinical application in China. In order to standardize the operation of thermal ablation technology for liver tumors and ensure medical safety, the National Health and Family Planning Commission entrusted the Chinese Medical Doctors Association to organize multidisciplinary experts in the field of tumor ablation treatment in China to participate and carefully discuss, and finally form this consensus. This consensus is represented by radiofrequency ablation, which is also suitable for microwave ablation, and can provide reference for other ablation treatment methods.

The quality control indicators of clinical application of tumor ablation therapy technology are as follows.

In order to standardize the clinical application of tumor ablation treatment technology and ensure medical quality and medical safety, the National Health and Family Planning Commission organized domestic experts in the field of tumor ablation treatment and set up an expert group headed by Professor Zheng Jiasheng to formulate this specification. This specification is the minimum requirement for medical institutions and their medical staff to carry out tumor ablation treatment technology. The tumor ablation treatment technology mentioned in this specification refers to the local treatment technology that directly damages the tumor by physical methods, including radio frequency, microwave, freezing, ultrasound, laser, irreversible electroporation and other treatment technologies. The treatment approaches include percutaneous, endoscopic and open surgery.

The patient was a 45-year-old female. He was admitted to hospital in August 2016 with paroxysmal headache for more than 1 month as the main complaint. One month ago, the patient developed paroxysmal headache without obvious trigger, which was dull pain. One week ago, the pain worsened, and I went to a local hospital. CT of the head showed a space-occupying lesion at the top of the left forehead. I came to the First Affiliated Hospital of Zhengzhou University for further diagnosis and treatment. Physical examination: There was no obvious abnormality in nerve reflex, and the muscle strength was normal. Brain MRI: Plain scan showed that the space-occupying lesions at the left frontal top were found in T₁Mixed slightly lower signal on WI (FIG. 1A), at T₂There was mixed high signal on WI, with thick vascular flow empty signal shadows around it, and small patches of higher signal necrosis areas inside it (FIG. 1B), DWI high b value (b =1 000 s/mm²) showed a slightly higher signal (Figure 1C), the lesion showed uneven and obvious enhancement on enhancement scan, and the dura mater immediately adjacent to the lesion was compressed and showed linear enhancement (Figure 1D), the lesion pushes the surrounding brain parenchyma. CT of the brain showed a mixed isodensity mass at the top of the left forehead, with a maximum cross-sectional diameter of about 8.0 cm ×5.9 cm, and multiple calcified high-density shadows, with a CT value of 460 HU (Figure 1E，Figure 1F), the boundary of the mass is clear, the bone of the adjacent skull is destroyed, and a ring-shaped bone-like density shadow can be seen around the mass. Surgical and pathological findings: The left frontal and roof space-occupying lesion was resected under general anesthesia. During the operation, it was seen that the tumor had eroded part of the skull to the whole thickness subcutaneously. The tumor was located outside the dura, gray-red, soft in texture and rich in blood supply. The tumor and its attached dura were removed in blocks. Immunohistochemistry: Cytokeratin (CK), epithelial membrane antigen (EMA), glial fibrillary acidic protein (GFAP), S-100 protein, B lymphocytoma gene (Bcl-2), signaling and transcriptional activator (STAT6), smooth muscle actin (SMA), CD117, DOG-1, oligo-2, PR, CD99 negative, cell proliferation index (Ki-67) (about 20%), Vimentin, CD31, CD34, ERG, F-VIII positive. The pathological diagnosis was: epithelioid hemangioendothelioma (Figure 2)。

The pathophysiological basis of hypoxia is diffuse alveolar infiltration, and the causes of hypoxia are diverse, including right-to-left shunt, disproportionate ventilatory blood flow, and diffusion disorders. Right-to-left shunt includes intracardiac shunt and intrapulmonary shunt^[1]。 Intracardiac right-to-left shunt is mainly patent foramen Ovale (PFO)^[2]。 Intrapulmonary shunt includes anatomical shunt and functional shunt, which in turn includes physiological anatomical shunt and open arteriovenous short circuits and dilated capillaries under pathological conditions. Functional shunt mainly refers to capillary shunt and shunt-like effects. Whether it is intracardiac shunt or intrapulmonary shunt, after insufficiently oxygenated blood enters the left heart, it will lead to hypoxemia, and hypoxemia itself will promote the formation and progression of intracardiac shunt and intrapulmonary shunt; On the contrary, right-to-left shunt will aggravate hypoxemia, and the two interact and promote each other^[3]Forming a vicious circle. It can be seen that assessing the presence of shunt in patients is crucial to the overall condition assessment and prognosis of patients. Critical ultrasound technology, due to its non-invasive, safe and convenient, is widely used in the evaluation of critically ill patients. Combined cardiopulmonary ultrasound can be used for rapid differential diagnosis of hypoxemia^[4], combined with saline microbubble angiography experiments, can help assess the presence of shunt in patients^[5]。

long QT syndrome (LQTS) is a group of clinical syndromes caused by the reduction of the number of functional potassium ion channels on the cell membrane, which causes the abnormal repolarization of action potential stage III due to the weakening of IKr. There are many reasons for LQTS caused by weakening IKr, mainly including two categories: one is acquired long QT syndrome (aLQTS), which causes aLQTS: electrolyte disorder, hypoxia and different drugs blocking HERG potassium channels. In the past, many approved marketed drugs have been eliminated or their application has been restricted due to the risk of TdP caused by aLQTS, such as probucol, terfenadine, astemizole, etc. This not only greatly increases the cost of drug development, but also increases the risk and burden of serious adverse reactions for patients^[1]； The other type is hereditary long QT syndrome (hLQTS), which is mostly caused by gene mutations. It has been confirmed that most HERG gene mutations mainly affect the protein transport process, and some aLQTS can also cause LQTS due to abnormal HERG potassium channel transport. Therefore, the research on abnormal HERG potassium channel transport has attracted more and more attention.

repetitive transcranial magnetic stimulation (rTMS) is a non-invasive neuroelectrophysiological technique developed on the basis of transcranial magnetic stimulation (TMS). Because of its non-invasive, safe and simple operation, it is widely used in the research and treatment of depression, schizophrenia, Parkinson's disease, epilepsy and other mental and neurological diseases. The research status of rTMS in the treatment of depression in recent years is reviewed.