【作者】 李波；

【导师】 李月川；

【作者基本信息】 天津医科大学 ， 内科学， 2015， 硕士

【摘要】 目的:目前支气管肺癌是最常见的肺部原发恶性肿瘤,严重威胁人类的健康和生命。只有病理学结果被认为是诊断各种肿瘤包括支气管肺癌诊断的金标准,同时可靠的病理结果也是临床医生选择治疗方案及判断预后的关键依据。随着医学科学的进步,支气管肺癌病理确诊率得到大幅度提高,但对支气管腔外的中央型肺癌和早期周围型肺癌的病理诊断率仍不让人满意。CT引导下经皮肺穿刺活检术可以依靠后期影像重建技术的帮助,对于病灶定位较准确、易于操作,对于特殊部位的操作(例如心脏后方、贴近胸壁等),较其他的检查方式具有一定的优势。但其所获得的的病理标本与肺内病变的实际情况是否相符,能否代表病灶全貌,却少有研究报道。本次研究的目的就是比较CT引导下经皮肺穿刺活检术与外科手术所获得的病理标本结果是否一致。方法:选择2003年1月至2013年12月,我院影像学检查发现肺部肿物,经痰液细胞学、支气管镜的涂片细胞学或活检组织学等检查,均未能明确诊断的肺部病变患者。经CT引导下经皮肺穿刺活检术取得病理标本(涂片细胞学和/或活检组织学),共计192例;其中明确诊断支气管肺癌(非小细胞肺癌),再行手术切除肺部病灶获得病理标本共91例,其中男性∶女性=99∶93,年龄38~77岁,平均(52.33±11.24)岁。所有患者年龄和体质量符合正态分布,并且符合研究所设置的纳入标准及剔除标准。将CT引导下经皮肺穿刺获得的病理结果(涂片细胞学、活检组织学、涂片细胞学+活检组织学)与手术病理结果进行比较,再使用统计学方法进行分析。结果:经CT引导下经皮肺穿刺活检术取得病理标本,穿刺之后手术切除病灶的患者共192例。肺穿刺活检取材成功率达100%。其中诊断良性病变88例;发现肿瘤细胞,未能明确分型13例;发现肿瘤细胞,并明确病理分型的支气管肺癌患者91例,均为非小细胞肺癌,其中鳞癌35例,腺癌51例,腺鳞癌5例。已经由经皮肺穿刺活检确定诊断并明确病理类型的91例支气管肺癌患者,与手术所得病理结果的符合率为86.81%(79例/91例),诊断的假阳性率为0%。其中CT引导下经皮肺穿刺活检涂片细胞学病理诊断与手术病理结果的符合率60.00%(6/10),CT引导下经皮肺穿刺活检组织学病理诊断与手术病理结果的符合率81.48%(22/27),CT引导下经皮肺穿刺活检两种方法(涂片细胞学+活检组织学)同时诊断支气管肺癌的病理结果与手术病理结果的符合率为94.44%(51/54)。CT引导下经皮肺穿刺活检的病理结果确诊为支气管肺癌的患者,不同病理类型与手术病理分型结果符合率不尽相同。肺穿刺活检的病理结果为鳞癌的患者,与手术病理结果的符合率为88.57%(31/35)。肺穿刺活检的病理结果为腺癌的患者,与手术病理结果的符合率为86.27%(44/51)。肺穿刺活检的病理结果为腺鳞癌的患者,与手术病理结果的符合率为80.00%(4/5)。手术后明确病理诊断的91例患者,除1例诊断多形性癌以外,均为非小细胞癌。腺癌、鳞癌、腺鳞癌通过CT引导下经皮肺穿刺活检术检出率分别为100%、93.94%、30.77%。术前穿刺病理为腺癌,经手术病理诊断为鳞癌的2例患者,术前血肿瘤标志物有1例CYFRA21-1升高,2例患者CEA均未见升高。手术病理为腺鳞癌的9例患者,术前穿刺病理有5例是腺癌,4例是鳞癌;穿刺病理为腺癌的患者血肿瘤标志物CEA、CYFRA21-1同时升高的有3例,穿刺病理为鳞癌的患者血肿瘤标志物CEA、CYFRA21-1同时升高的有3例。此次研究全部192例CT引导下经皮肺穿刺活检患者中,出现并发症的共有32例,发生率为16.7%;其中发生出血的患者8例,发生率仅为4.2%,均未予止血处理,24小时内症状消失;气胸24例,发生率仅为12.5%,需胸穿闭式引流患者3例,所有患者72小时复查胸片肺组织均完全复张。CT引导下经皮肺穿刺三种途径(涂片细胞学、活检组织学、涂片细胞学+活检组织学)获得病理结果与手术病理结果获得的病理结果符合率的比较,经χ2检验,P<0.05有统计学差异。结论:1、CT引导肺穿刺活检术并发症少且轻微,是一种安全的检查手段。2、CT引导肺穿刺活检术成功率高,对支气管肺癌的定性诊断确诊率高,假阳性率低。3、单一类型的支气管肺癌通过CT引导下经皮肺穿刺活检方法,检出率均较高,结果较为可靠,但复合型支气管肺癌检出率偏低,结果不让人满意。4、CT引导下经皮肺穿刺活检术的三种途径(涂片细胞学、活检组织学、涂片细胞学+活检组织学)获得的病理结果与手术病理结果符合率的比较,有统计学差异。5、不同病理类型的非小细胞肺癌,经过CT引导下经皮肺穿刺活检诊断的准确率无差别,准确率都较高。6、不同病理类型的非小细胞肺癌(鳞癌、腺癌、腺鳞癌)通过3种方式(涂片细胞学、活检组织学、涂片细胞学+活检组织学)获得的病理结果与手术病理结果的比较,因样本含量较小,无法比较。7、CT引导下经皮肺穿刺活检术病理结果与外科手术病理结果符合率高。8、血肿瘤标志物对支气管肺癌具有一定的辅助诊断作用。更多还原

【Abstract】 Objective: At present, lung cancer is the most common primary malignancy of the lung, a serious threat to human health. Pathology results is the gold standard for diagnosis of lung cancer, The pathologic result reliable is also the key foundation that a doctor to select treatment plan and prognosis. With the progress of medicine, bronchial lung cancer pathological diagnosis rate has been greatly improved, but the pathological diagnosis of central type of lung cancer and early peripheral lung cancer on the bronchial cavity outside the rate is still low. computed tomography guided percutaneous lung biopsy is accurate and intuitive, by the help of image reconstruction technique, and it has irreplaceable advantages, Especially for the operation of special cardiac site, such as close to the rear, paravertebral pleuraor chest wall. But the pathological specimens is consistent with the lung lesions ? It will be representative of the whole lesions, there is little literature reports. The purpose of this study want to find the differences in lung cancer specimens pathological results with computed tomography guided percutaneous lung biopsy and surgical operationMethods: Select 2003 January to 2013 December, imaging examination showed that pulmonary masses, by bronchoscopy, sputum cytology smear cytology or biopsy histology examination, pulmonary lesions of patients with the diagnosis was not clear. By CT guided percutaneous puncture biopsy of the lung pathology specimens were obtained(smear and / or biopsy), a definite diagnosis of bronchial lung cancer(NSCLC), it is 192 cases, re operation resection of lung lesions obtained the pathological specimens a total of 91 cases, including male: female =99: 93, age 38 ~ 77 years old, average(52.33 + 11.24) years old. All the patients age and body quality accords with the normal distribution. All of the age of the patients with normal distribution, and in line with the study of the set inclusion criteria and exclusion criteria. Will receive percutaneous lung puncture pathology results(smear cytology and biopsy and smear + biopsy) were compared with operative and pathological findings, and then use statistical methods to analyze.Result: After CT guided percutaneous puncture biopsy of the lung pathology specimens were made after operation excision, puncture in patients with a total of 192 cases. Lung puncture biopsy success rate was 100%. The diagnosis of benign lesions in 88 cases; the tumor cells were found, not clearly divided into type 13 cases; the tumor cells were found in 91 patients with lung cancer, bronchial and clear pathological types of cases, are non-small cell lung cancer, including 35 cases of squamous cell carcinoma, 51 cases of adenocarcinoma, 5 cases of adenosquamous carcinoma. Already by percutaneous lung puncture biopsy to confirm the diagnosis and 91 patients with lung cancer confirmed pathological types, and operation income rate in line with pathological results was 86.81%(79 /91 cases), the false positive rate of diagnosis was 0%. The CT guided 60% compliance rate of percutaneous lung biopsy smear cytology pathological diagnosis and operation pathology result(6/10), CT guided percutaneous 81.48% coincidence rate of pathology diagnosis and operation pathology results of percutaneous lung puncture biopsy(22/27), CT guided percutaneous lung puncture biopsy of two methods(smear cytology + biopsy pathology results at the same time) diagnosis of bronchogenic carcinoma with operation pathology results the coincidence rate was 94.44%(51/54). Patients with CT guided percutaneous biopsy of pulmonary pathology results confirmed the diagnosis of bronchial lung cancer of different pathological types, pathological types and operation with the results of different. Pathological lung biopsy results for squamous cell carcinoma patients with operation pathology results, the coincidence rate was 88.57%(31/35). Pathological lung biopsy results for adenocarcinoma of patients with the results of operation and pathology, the coincidence rate was 86.27%(44/51). Pathological lung biopsy results for adenosquamous carcinoma patients with operation pathology results, the coincidence rate was 80%(4/5). In 91 cases after operation in patients with definite pathological diagnosis, except for the diagnosis of 1 cases of pleomorphic carcinoma, small cell lung cancer were. Adenocarcinoma, squamous cell carcinoma, adenosquamous carcinoma by CTguided percutaneous puncture biopsy of the lung were detected in 100%, 93.94%, 30.77%. Preoperative biopsy for adenocarcinoma, confirmed by operation and pathology of 2 cases of squamous cell carcinoma patients, preoperative serum tumor markers CYFRA21-1 elevated in 1 cases, 2 patients showed no increased CEA. Operation and pathology 9 cases adenosquamous carcinoma patients, preoperative puncture pathology in 5 cases were adenocarcinoma, 4 cases were squamous cell carcinoma; pathology of adenocarcinoma patients blood tumor markers CEA, CYFRA21-1 also increased in 3 cases, biopsy for patients with squamous cell carcinoma of the blood tumor markers CEA, CYFRA21-1 and the rise of there are 3 cases. The study of all 192 cases of CT guided percutaneous lung biopsy in patients with postoperative complications occurred in 32 cases, common, the incidence rate was 16.7%; of which 8 cases of hemorrhage patients, the incidence rate was 4.2%, have not been hemostatic treatment, symptoms disappeared within 24 hours; pneumothorax in 24 cases, the incidence rate was 12.5%, need wear a chest closed drainage in 3 patients, all patients 72 hours check sternum lung tissue were completely re expansion. CT guided percutaneous lung biopsy in three ways(smear, biopsy, smear + biopsy) obtained the pathological results with the results of operation and pathology results obtained pathological coincidence rate comparison, the χ2 test, no significant difference in P <0.05.Conclusion: 1.CT guided puncture biopsy of the lung complications were few and mild, is a safe means of inspection. 2.CT guided percutaneous pulmonary biopsy with high success rate, the qualitative diagnosis of bronchial lung cancer rate is high, the false positive rate is low. 3.A single type of bronchial lung cancer by CT guided percutaneous lung biopsy method, the detection rate is higher, the result is more reliable, but the composite type of bronchial lung cancer detection rate is relatively low, the result is not satisfactory. 4.Three ways of percutaneous lung puncture biopsy guided by CT(smear, biopsy, smear + biopsy pathology) coincidence rate of results obtained with operation bypathological results, has significant difference. 5. Non small cell lung cancer of different pathological types has no differenced in diagnosis accuracy rate of, by CT guided percutaneous lung biopsy, the accurate rate is high. 6.Non small cell lung cancer of different pathological types(squamous cell carcinoma, adenocarcinoma, adenosquamous carcinoma)by 3 ways(smear,biopsy,smear+biopsy) compare the results obtained with the results of operation and pathology, because of the small sample size, no comparison. 7.CT guided percutaneous lung biopsy pathology results and surgical operation pathology results in line with the high rate of. 8. The blood tumor markers for lung cancer is helpful for assistant diagnosis.更多还原