阅读说明：本技术 膀胱黏膜下注射吉西他滨在治疗膀胱癌中的应用 (Use of sub-mucosal injection of gemcitabine into the bladder for the treatment of bladder cancer ) 是由 傅广波 傅韬 于 2021-08-24 设计创作，主要内容包括：本发明公开了一种膀胱黏膜下注射吉西他滨在治疗膀胱癌中的应用,该方法是：建立操作SOP,在注射用尿道膀胱内镜辅助下,采用可控注射针在膀胱肿瘤基底部黏膜下注射吉西他滨；注射后,等候一段时间,再进行膀胱肿瘤电切术；膀胱肿瘤电切术后,正常按计划规律行吉西他滨膀胱内灌注化疗。本发明在膀胱肿瘤电切术前采用膀胱黏膜下注射吉西他滨,使肿瘤呈漂浮状态浸润在高浓度药液中,降低电切术肿瘤残余率,减少肿瘤复发,提高膀胱肿瘤患者术后生存率。(The invention discloses an application of gemcitabine for sub-mucosal injection in bladder in treating bladder cancer, which comprises the following steps: establishing operation SOP, and adopting a controllable injection needle to inject gemcitabine under the mucosa of the bladder tumor basal part under the assistance of a urethra-bladder endoscope for injection; after injection, waiting for a period of time, and performing bladder tumor electrostomy; after electrosectomy of bladder tumor, gemcitabine is normally infused intravesically according to a planned rule for chemotherapy. The invention adopts the sub-mucosal injection of gemcitabine in the bladder before the bladder tumor electrostomy to ensure that the tumor is infiltrated in high-concentration liquid medicine in a floating state, thereby reducing the residual rate of the tumor in the electrostomy, reducing the recurrence of the tumor and improving the postoperative survival rate of patients with bladder tumor.)

1. The application of the gemcitabine injected under the urinary bladder mucosa in the treatment of bladder cancer is characterized by comprising the following steps: establishing operation SOP, and adopting a controllable injection needle to inject gemcitabine liquid medicine under the submucosa of the bladder tumor base under the assistance of a urethra-bladder endoscope for injection; after injection, waiting for a period of time, and performing bladder tumor electrostomy; after electrosectomy of bladder tumor, gemcitabine is normally infused intravesically according to a planned rule for chemotherapy.

2. The use of subcutaneously injected gemcitabine of the bladder of claim 1 for the treatment of bladder cancer, wherein: injecting under an endoscope, injecting gemcitabine under the mucosa within the range of 1.5-2.5 cm at the basal part of the bladder tumor by using a controllable injection needle with the injection needle point length of 4-6 mm, wherein the depth is not more than 6mm, and injecting at 4-6 points.

3. The use of subcutaneously injected gemcitabine of the bladder of claim 1 for the treatment of bladder cancer, wherein: the gemcitabine is injected at a concentration of 1.0-2.5 mg/ml and an injection amount of 20-200 mg.

4. The use of subcutaneously injected gemcitabine of the bladder of claim 1 for the treatment of bladder cancer, wherein: after the sub-mucosal injection of gemcitabine into the bladder, the patient waits for 0.5 hour or more before performing the bladder tumor electrostomy.

5. The use of subcutaneously injected gemcitabine of the bladder of claim 1 for the treatment of bladder cancer, wherein: when in electrostomy, normal saline with the volume of 150-200 ml is perfused into the bladder.

6. The use of subcutaneously injected gemcitabine of the bladder of claim 1 for the treatment of bladder cancer, wherein: injecting under the mucosa of the basal part of the bladder tumor, and locally bulging the pedicle of the bladder tumor after injection to ensure that the injection is injected under the mucosa of the bladder to prevent the tumor from entering the outside of the bladder, wherein the tumor is in a floating state and is infiltrated in high-concentration liquid medicine.

Technical Field

The invention relates to a treatment method of bladder cancer, in particular to application of bladder submucosal injection gemcitabine in treatment of bladder cancer.

Background

Bladder cancer (BLADDER cancer, BCa) is a malignant tumor originating in the urothelium of the bladder and is classified as non-muscle invasive bladder cancer (NMIBC: Tis, Ta, T)₁) And muscle-invasive bladder cancer (MIBC: t is₂、T₃、T₄). Of these, NMIBC accounts for approximately 75%, and the histology is mostly low grade, transurethral resection of bladder tumor (TURBT) is currently recommended clinically, but TURBT alone does not solve the problem of high recurrence and progression rates, with 10-67% of patients relapsing within 12 months after surgery and 24-84% within 5 years. Therefore, post-operative bladder instillation therapy is very necessary, and TURBT in combination with post-operative chemotherapy drugs or immunomodulator bladder instillation is the standard protocol for the treatment of NMIBC. Although the recurrence rate of NMIBC can be reduced by bladder perfusion chemotherapy after TURBT operation, the recurrence rate of patients after operation can still reach 30-60%, 10-20% of patients with recurrence progress to MIBC, the 5-year survival rate is obviously reduced, and the clinical treatment difficulty is caused. Patients with MIBC often need total cystectomy and urinary diversion, and the postoperative survival quality of the patients is poor.

Recent studies suggest that tumor recurrence and metastasis depend on the intrinsic properties of tumor cells and the tumor microenvironment. The tumor microenvironment, i.e., the internal environment of tumor cell generation and life, includes not only the tumor cells themselves, but also the surrounding fibroblasts, immune and inflammatory cells, glial cells, etc., and also includes the intercellular substance, the microvasculature in the nearby area, and the biomolecules infiltrated therein. Bladder cancer is mainly characterized by lymphatic metastasis in the early stage, and the inherent layer of the bladder mucous membrane is rich in blood vessels and lymphatic vessels, so that when tumors invade the inherent layer of the mucous membrane, the risk of early lymph node metastasis is greatly increased. Meanwhile, the TURBT postoperative is accompanied by tumor tissue residues with different degrees, particularly middle and high grade graded bladder cancer at T1 stage, and the first postoperative tumor residue rate can reach 33.8-36% according to literature reports. Tumor cells remaining after TURBT surgery and lymphatic vessel infiltration of tumor cells are the root cause of early relapse after tumor resection. The treatment of secondary electrosection of bladder tumor, immediate postoperative intravesical perfusion chemotherapy and the like is recommended clinically to reduce the recurrence rate of bladder cancer and improve the survival rate of patients, and the effect is not satisfactory.

In 1988 Shafik a reported a clinical study for the treatment of progressive bladder cancer by sub-rectal submucosal injection of methotrexate. Animal experiments of Wu Rong et al in 1993 prove that after 5-FU and thiotepa are injected under the mucous membrane of the bladder, the 5-FU and the thiotepa can infiltrate the whole bladder wall and are linearly distributed along the drainage areas of the perivesical, the external iliac, the total iliac and the lumbar lymph nodes, and the animal experiments prove that the chemotherapeutic drugs can kill residual or regenerated tumor cells in the epithelium of the mucous membrane of the bladder and have definite killing or inhibiting effect on cancer cells transferred to the lymphatic drainage area around the bladder, so that the recurrence and recurrence time of the tumor are prolonged. A special stainless steel and certain-toughness bladder injection needle is inserted into a cystoscope operation hole for aged and the like, 20mg of pirarubicin is diluted into 80ml of injection water to be used for intravesical injection and combined with electrotomy to treat bladder cancer, the average follow-up visit lasts for 38 months, and the recurrence rate of an injection group is 11.8% (8/68). The injection of chemotherapeutic medicine under the urinary bladder mucosa is an effective method for treating bladder cancer, and no serious complications are found clinically. There are many clinical reports that submucosal injection of antineoplastic drugs (mitomycin, thiotepa, pirarubicin, 5-fluorouracil, doxorubicin, hydroxycamptothecin, etc.) after standard TURBT is a more effective method for reducing the recurrence of superficial tumors. The injection of the anti-tumor medicine under the mucous membrane of the bladder tumor can directly act on a tumor microenvironment and also can act on tumor cells transferred by a lymphatic channel and the environment thereof through absorption of the lymphatic channel. However, the clinical research does not study the concentration and action time of the injected medicament in detail, the recurrence rate is still high, and the short-term recurrence (3-6 months) of the tumor, namely the local tumor residue problem, cannot be well controlled.

Gemcitabine is a novel deoxycytidine analogue, belongs to pyrimidine antimetabolites, and has broad-spectrum antitumor activity. Gemcitabine has antitumor activity only when being transported into cells through channel proteins and converted into phosphorylated metabolites in cells, so that the antitumor effect of gemcitabine has obvious cell cycle specificity, mainly acts on a DNA synthesis phase, can block cell proliferation in an S phase and a G1 phase, and has no effect on a G2 phase and a M phase. Gemcitabine systemic chemotherapy has definite curative effect on advanced bladder cancer, is the first choice chemotherapy scheme for metastatic bladder cancer at present, and has adverse reactions such as bone marrow suppression, gastrointestinal reaction and the like. Di Lorenzo G et al given gemcitabine (2000mg) infusion therapy to patients who relapsed after 1 course of BCG infusion therapy, the rate of relapse was 52.5% in the gemcitabine infusion group and 87.5% in the BCG infusion group compared to the group that still received BCG infusion therapy. There was no significant statistical difference in tumor recurrence rate (28% vs 39%) and tumor progression rate (11% vs 18%) in patients after intravesical gemcitabine infusion compared to mitomycin. Gemcitabine, however, significantly reduced the incidence of chemical cystitis (dysuria, hematuria) (38.8% vs 72.2%, P ═ 0.02). Multiple phase II and III clinical trials also prove that the gemcitabine infused in the bladder has better curative effect on middle/high-risk NMIBC, mitomycin and BCG (bacillus calmette guerin) patients who fail to infuse. Gemcitabine, because of its low toxicity, is widely used in BCa systemic and intravesical local chemotherapy. However, the experience of local injection of gemcitabine into the bladder is still insufficient.

Disclosure of Invention

The purpose of the invention is: the application of the gemcitabine injected under the bladder mucosa in treating bladder cancer is provided, and the gemcitabine injected under the bladder mucosa is adopted before the bladder tumor electrostomy, so that the tumor residual rate of the electrostomy is reduced, the operation effect is improved, and the tumor recurrence is reduced.

The technical solution of the invention is as follows: use of sub-mucosal gemcitabine for bladder injection in the treatment of bladder cancer, the method comprising: establishing operation SOP, and adopting a controllable injection needle to inject gemcitabine liquid medicine under the submucosa of the bladder tumor base under the assistance of a urethra-bladder endoscope for injection; after injection, waiting for a period of time, and performing bladder tumor electrostomy; after electrosectomy of bladder tumors, gemcitabine is normally administered as planned by intravesical perfusion chemotherapy.

More optimally, the method comprises the following steps: accurate injection under the scope is adopted, a controllable injection needle with an injection needle point length of 4-6 mm is used, gemcitabine is injected under the mucosa within the range of 1.5-2.5 cm at the basal part of bladder tumor, the depth is not more than 6mm, and the gemcitabine is injected at 4-6 points.

More optimally, the method comprises the following steps: the gemcitabine is injected at a concentration of 1.0-2.5 mg/ml and an injection amount of 20-200 mg.

More optimally, the method comprises the following steps: after injection, the patient waits for 0.5 hour or more before bladder tumor electrostomy is performed.

More optimally, the method comprises the following steps: when in electrostomy, normal saline with the volume of 150-200 ml is perfused into the bladder.

More optimally, the method comprises the following steps: injecting under the mucosa of the basal part of the bladder tumor, and locally bulging the pedicle of the bladder tumor after injection to ensure that the injection is injected under the mucosa of the bladder to prevent the tumor from entering the outside of the bladder, wherein the tumor is in a floating state and is infiltrated in high-concentration liquid medicine.

The invention has the advantages that: the gemcitabine is injected under the bladder mucosa before the bladder tumor electrosurgery so that the tumor is infiltrated in high-concentration liquid medicine in a floating state, the tumor residue of the electrosurgery is reduced, the operation method is simple, the bleeding is less, the pain of a patient is not increased, the recurrence after the NMIBC electrosurgery is effectively prevented, and the postoperative survival rate of the patient with the bladder tumor is improved.

Drawings

FIG. 1 is a photograph of a rat open bladder submucosal injection drug absorption pathway test;

FIG. 2 is a photograph of an endoscopic sub-vesical submucosal injection test of a radiopharmaceutical in a female dog;

FIG. 3 is a graph of bladder capacity versus bladder wall thickness variation;

FIG. 4 is a photograph of drug sensitivity test of bladder tumor tissue;

FIG. 5 is a photograph of a Meilan lymphatic channel test and a blood concentration test of gemcitabine drug injected submucously into the bladder of a patient with bladder cancer;

FIG. 6 is a photograph of endoscopic cysteaminoclastine gemcitabine injection combined with transurethral plasmatic bladder cancer electrostomy;

FIG. 7 is a flow chart of a clinical study of patients with bladder cancer.

Detailed Description

The technical scheme of the invention is further described in the following with reference to the attached drawings, but the technical scheme is not to be construed as being limited, and the adaptive improvement on the technical scheme belongs to the protection scope of the invention.

Test example 1: rat open sub-mucosal injection drug absorption pathway test 3 experimental SD rats were injected with 99Tc-DX105 under the urinary bladder. The results show that the 99Tc-DX105 has good imaging in the rat lymph node, and the nuclide concentration at the iliofencoinal groin of the rat can be seen 5min after the injection. As time goes on, nuclide further moves in lymphatic vessels and lymph nodes along with lymphatic drainage, and nuclide development appears in the liver at 35min, as shown in figure 1, because the nuclide is injected in a relatively narrow range under the mucous membrane of the urinary bladder of a rat, the lymph nodes are in a supersaturated state when the injection volume is large, and liquid medicine flows back through the lymphatic vessels and finally enters blood circulation.

Test example 2: a test of injecting radioactive drugs under urinary bladder submucosa of a female dog takes a 3-year old female dog, performs PET/CT detection after injecting radioactive labeled drugs under the urinary bladder submucosa of a child under the general anesthesia of an endotracheal tube. The results showed that the injected nuclides dispersed on the bladder wall with time and nuclide imaging occurred in the chest cavity at 40min after injection, as shown in fig. 2, it was known that the drug migrated in the lymphatic vessels and lymph nodes by lymphatic drainage and the drug solution returned through the lymphatic vessels and finally entered the blood circulation.

Test example 3: screening for appropriate bladder perfusion Capacity at electrocision

And selecting 7 patients with the satisfied conditions, and performing color ultrasound to measure the bladder wall thickness. As the bladder capacity was multiplied, the thickness of the bladder wall became thinner and the bladder capacity versus bladder wall thickness varied as shown in figure 3. When the bladder is filled with physiological saline with the capacity of 150-200 ml, the bladder is good in filling, the thickness of the bladder wall is moderate, and the submucosal injection and the bladder cancer electrotomy treatment are facilitated. 200ml of liquid is perfused into the bladder, 20ml of normal saline is injected under the mucosa around the bladder tumor base under the direct vision of an endoscope, the thickness of the bladder wall after injection is 10.3 +/-1.3 mm, the average thickness is increased by 63.5 percent, and the safety of the tumor during electroexcision can be fully ensured.

Test example 4: drug sensitivity test for bladder tumor tissue

Taking 0.5-1cm of the bladder after partial excision or radical total cystectomy³Treating the tumor tissue according to the operation flow of drug sensitivity test to prepare tumor single cell suspension. As shown in figure 4, mitomycin, hydroxycamptothecin, pirarubicin, epirubicin, gemcitabine are added into 5-7 dose groups respectively to analyze sensitive drugs for bladder cancer. According to the drug susceptibility test: the side reaction of mitomycin is large; 10 cases of Pirarubicin injection, 4 cases of relapse in short term, the effect is poor; the results of the 10 cases of gemcitabine injections were determined to be betterClinical studies were initiated with gemcitabine.

Test example 5: the melan lymph channel test of the bladder cancer patient and the blood concentration detection of the gemcitabine medicament injected under the bladder mucosa are carried out by cystoscope examination and MRI examination before operation, 2 cases of bladder cancer patients with muscle layer infiltration are selected, and the MRI examination shows that tumor cells invade the muscle layer to carry out radical total cystectomy. During the operation, the paraneoplastic methylene blue solution in the bladder is injected under the mucosa, and the results are observed by naked eyes after 15 min: the plasma layer of the bladder and the surrounding adipose tissue of the bladder corresponding to the injection points showed methylene blue accumulation and were located along the perivesical, extrailiac, and intra-iliac/obturator lymph node sections. In addition, 20mg of gemcitabine with a concentration of 1.0mg/ml is injected around the tumor under an endoscope after anesthesia for 3ml at different time points, and blood metabonomics detection is performed, as shown in fig. 5, the drug concentration reaches a peak value after about 1 hour after injection, and the peak value is consistent with the animal experiment result.

Example (b): the combination of post-injection cysteamine gemcitabine with transurethral plasma electrosurgery of bladder cancer is shown in fig. 6, and the operation steps are as follows:

(1) after intraspinal anesthesia or general anesthesia of a patient succeeds, taking a lithotomy position, inserting a urethra-bladder endoscope through a urethra, and filling 150-200 ml of normal saline into a bladder;

(2) injecting gemcitabine under the mucosa within the range of 1.5-2.5 cm at the basal part of the bladder tumor by using a controllable injection needle with the injection needle tip length of 4-6 mm, wherein the depth is not more than 6mm, and injecting by 4-6 points; wherein, the injection amount of the gemcitabine is four groups of 20mg, 50mg, 100mg and 200mg respectively, and the concentration of the gemcitabine is 1.0 mg/ml-2.5 mg/ml; injecting under the mucosa of the basal part of the bladder tumor, wherein the pedicle part of the bladder tumor is locally raised after injection, so that the injection is ensured to be injected under the mucosa of the bladder, the tumor is prevented from entering the outside of the bladder, is in a floating state and is infiltrated in high-concentration liquid medicine; according to the design, the patient needs to wait for half an hour or more for the electric excision after injection;

(3) replacing a plasma resectoscope, wherein the resectoscope energy is 200J, the electrocoagulation energy is 100J, completely resecting the tumor at a position which is about 2cm away from the bottom of the tumor and reaches the superficial muscular layer of the bladder wall, and performing electrocoagulation hemostasis on the wound surface;

(4) after the operation, the catheterization is kept, the bladder is continuously flushed by normal saline, and the bladder is perfused with gemcitabine for chemotherapy within 24 hours;

(5) the repeated diagnosis is performed every 3 months and the cystoscopy is performed in parallel.

The above-described specific cases of combined transurethral plasmacytoma electrostomy after injection of submucosal gemcitabine in bladder were summarized in categories as follows:

1. test by injecting distilled water

91 cases of non-muscle invasive bladder cancer are diagnosed and divided into 46 cases of a treatment group and 45 cases of a control group; treatment groups (20ml of medical distilled water injected submucosally) patients successfully completed one-time complete tumor resection after the injection of the bladder tumor basilar submucosa; the control group was subjected to conventional bladder tumor resection. Patient baseline data are shown in table 1, indicating that baseline differences were not statistically significant in both groups of patients. The results are shown in table 2 and show that submucosal injection is helpful in reducing tumor recurrence after bladder tumor resection, but is not helpful for short-term (3 months) recurrence, i.e., is not effective in patients with tumor tissue residue on the wound surface after electrocision.

TABLE 1 clinical basic data of the subjects

TABLE 2 comparison of complications and prognosis between treatment and control groups

2. Gemcitabine 20mg test with sub-mucosal injection concentration of 1.0mg/ml for bladder

101 cases of non-muscle invasive bladder cancer hospitalized were selected and divided into two groups: the sub-mucosal injection concentration of the bladder is 1.0mg/ml gemcitabine, 20mg (20ml) + the resected group, the conventional tumor resected group, the two groups of baseline conditions are shown in Table 3, and the two groups of baseline conditions have different ages.

TABLE 3 Sudeck injection and common electrotomy data

No bladder perforation in none of the medians; no obturator reflex appears in the operation of the lymphatic channel administration group, and 8 obturator nerve reflexes in the common electrostomy group have statistical significance (P is less than 0.05). Postoperative complications (hematuria, urinary infection, urethral stricture, bladder neck contracture, liver and kidney function impairment, etc.) had no statistical significance for the differences (P >0.05), as shown in table 4.

TABLE 4 comparison of intraoperative and postoperative conditions of two groups of cases [ n (%) ]

Compared with the two groups, although the number of relapse cases is small in the bladder submucosa injection and tumor electrocision group, the problem of relapse of tumor electrocision wounds (relapse within 3 months) cannot be solved by injecting 20mg (20ml) of gemcitabine under the bladder submucosa, and the difference has no statistical significance, so that a clinical treatment scheme needs to be further optimized.

3. The sub-mucosal injection concentration of the bladder is 1.5mg/ml gemcitabine 50mg, and the test is performed by electrotomy after waiting for half an hour

284 cases of non-muscle invasive bladder cancer hospitalized in months 1 to 2020 and 8 in 2018 were divided into 58 cases of SIOG (50mg/1.5mg/ml, waiting half an hour after injection) + turbo group (treatment group) and 215 conventional turbo group (control group). The two general cases are shown in Table 5. Study results analysis used a 1:2 bias match, 58 in the treatment group and 116 in the control group. The clinical curative effect is shown in table 6, the recurrence of the bladder cancer of the treatment group is obviously lower than that of the control group, no recurrence is seen within 3 months, no serious adverse reaction is found, the hematuria of the treatment group is heavier than that of the control group, and the analysis of the complication is detailed in table 7.

Table 5–Comparison of preoperative demographic and postoperative pathological characteristics in the study groups before and after 1:2 PS matching.

Table 6–Comparison of postoperative oncological outcomes in the 1:2 matched cohorts.

Table 7–Comparison of adverse events in the 1:2 matched cohorts.

4. The injection concentration of gemcitabine 2.0mg/ml 100mg waiting for a half hour test

More than 5 multiple bladder tumors are generated, 7 patients and families strongly require bladder retention or cannot tolerate total cystectomy due to physical conditions, gemcitabine is injected in multiple points, the prepared drug concentration is 2.0mg/ml, the total amount of the drug is 100mg, 1 hour of post-injection is waited for electrostomy, the bladder is perfused and followed up periodically after the operation, 5 patients relapse after the operation, the relapse time is 6-40 months after the operation, and the median time exceeds 12 months. 4 people have gastrointestinal tract and hematuria reactions of different degrees and have no serious adverse reaction.

5. The concentration of gemcitabine is 200mg at 2.5mg/ml once every two weeks for 3 times of gemcitabine test concentration 2.5mg/ml 200mg once every 2 weeks, and after 3 times of injection, the bladder treatment is retained by the combination of local radiotherapy. 2 male patients, age 55 and age 67, had multiple invasive bladder cancer, were physically reluctant to total cystectomy, had severe gastrointestinal tract reaction and severe hematuria in postoperative patients, and had tumor recurrence at 12 and 23 months after surgery, which was a single tumor.