【作者】 张超；

【导师】 顾春东；

【作者基本信息】 大连医科大学 ， 外科学（专业学位）， 2018， 硕士

【摘要】 目的:评估电视辅助胸腔镜手术(video-assisted thoracic surgery,VATS)术前CT引导下Hook-wire定位穿刺技术在肺双病灶同期定位中的安全性、有效性。并且分析与定位穿刺操作有关的并发气胸的危险因素,评估肺部小结节发生恶性病变的影像学危险因素。方法:本研究收集了大连医科大学附属第一医院2015年1月—2017年7月期间电视辅助胸腔镜手术(video-assisted thoracic surgery,VATS)术前行CT引导下Hook-wire定位患者共500人(男性患者218人,女性患者282人,年龄24岁—86岁,平均年龄56.3±11.2岁)568个肺结节(p GGO 208例,m GGO259例,实性结节101例)的临床及病理资料,500例患者中有97人因不同程度的咳嗽,咳痰,胸闷不适等症状于门诊就诊,行胸部CT检查提示肺部小结节,其中76人经系统抗炎治疗后复查胸部HRCT示病灶无明显变化,其余患者无明显自觉症状,健康体检时发现肺部小结节,500例患者中有36例既往有肿瘤病史并接受手术治疗,其中肺癌患者23例,甲状腺癌术后4例,乳腺癌术后7例,肾癌术后1例,直肠癌术后1例。500例患者中A组(双病灶患者)68人(其中男性患者27人,女性患者41人)136个结节,B组(单病灶患者)432人(其中男性患者191人,女性患者241人)432个结节,评估与Hook-wire定位穿刺操作有关的气胸发生率,并用多因素logistic回归分析定位穿刺过程中与穿刺操作有关的并发气胸的危险因素。同时对HRCT影像学表现如:病灶类型、病灶最大径、病灶形态等与术后病理的关系进行单因素分析,而后再用logistic回归分析筛选出肺部小结节发生恶性病变的影像学危险因素。结果:VATS术前肺双病灶同期定位的136个结节均成功定位,无严重并发症的发生,其中有12根穿刺针脱落,但是根据术中穿刺针的插入位置及肺脏层胸膜表面的出血点,这12个病灶均成功切除,而且136个结节最终都获得了病理学诊断。与B组相比较,A组的平均穿刺定位时间明显更长(P<0.001),气胸的发生率更高(发生率为33.8%,P=0.003),单因素分析示:定位针插入次数(P=0.006),体位改变(P=0.023)及病灶部位(P=0.003)是可能导致肺双病灶同期定位中气胸发生率相对较高的危险因素,多因素logistic回归分析表明,定位过程中发生体位改变(OR:2.632,P=0.023)和双病灶均位于同侧肺(OR:9.387,P<0.001)是肺双病灶同期定位中并发气胸的独立危险因素。在肺部结节临床影像学表现与术后病理关系单因素分析中发现病灶类型(P<0.001)、病灶直径≥8mm(P<0.001)、血管穿入(P<0.001)及中心高密度(P<0.001),具有这些影像学特征的病灶为恶性的可能性相对较高,而后行多因素logistic回归分析表明:混合性磨玻璃病灶(OR:1.632,P=0.014)、病灶直径≥8mm(OR:4.316,P=0.002),有血管穿行(OR:3.927,P=0.001)及中心高密度病灶(OR:12.516,P<0.001)为肺部小结节恶性病变的影像学危险因素。结论:(1)Hook-wire定位穿刺技术在肺双病灶中的应用是安全有效的,穿刺操作过程中体位改变和病灶位于同侧肺是并发气胸的独立危险因素。(2)影像学表现为混合性磨玻璃病灶、病灶直径≥8mm,有血管穿行及中心高密度病灶为肺部小结节恶性病变的影像学危险因素。更多还原

【Abstract】 Objective: To evaluate the safety and efficacy of preoperative CT-guided Hookwire localization puncture in the simultaneous localization of both lung lesions before the performance of video-assisted thoracic surgery(VATS)resection.Meanwhile,to analyze the risk factors of pneumothorax associated with the localization puncture procedure and to evaluate the imaging risk factors of malignant lesions in the pulmonary nodules.Methods: This study collected the clinical and pathological data of 568 pulmonary nodules from 500 patients(218 males and 282 females aged 24 to 86 with an average age of 56.3 ±11.2 years)who underwent CT-guided Hook-wire localization before the performance of VATS between January 2015 and July 2017 in the first Affiliated Hospital of Dalian University.Of all the 500 patients,97 patients were go to see a doctor because of varying degrees of cough,expectoration,chest distress and other symptoms.Chest CT examination revealed pulmonary nodules.After systemic anti-inflammatory therapy,76 patients showed no obvious changes in chest HRCT.The other patients had no obvious symptoms,and the pulmonary nodules were found at the time of physical examination.Of all the 500 patients,36 had a history of cancer and received surgical treatment,including 23 cases of lung cancer,4 cases of thyroid cancer,7 cases of breast cancer,1 case of renal carcinoma and 1 case of rectal cancer.Among them,group A which represent double lesions include 136 nodules in 68 patients and group B which represent single lesions include 432 nodules in 432 patients.The incidence of pneumothorax associated with Hook-wire puncture in group A and B was calculated.The risk factors of pneumothorax associated with localization procedure was evaluated by multivariate logistic regression analysis.Meanwhile,The imaging features of HRCT which include type of lesion,maximum lesion size,lesion morphology and clinical data which include gender,age,etc were evaluated by univariate analysis and then the imaging risk factors of malignant pulmonary nodules were evaluated by logistic regression analysis.Results: All 136 thoracic nodules were successfully located before the performance of VATS and no serious complications occurred.Among them,twelve puncture needles were detached,but all the twelve lesions were successfully resected according to the location of the puncture needle during the operation and the bleeding point on the surface of the lung pleura and 136 nodules eventually acquired pathological diagnosis.Compared with group B,the average puncture location time of group A was significantly longer(P<0.001),the incidence of pneumothorax was higher(incidence rate was 33.8%,P=0.003),and univariate analysis showed that the number of positioning needle insertion(P=0.006),posture change(P=0.023)and lesion location(P=0.003)are risk factors that may lead to a relatively high incidence of pneumothorax in the simultaneous positioning of lung lesions.Multivariate logistic regression analysis showed that posture changes during the positioning process(OR: 2.632,P = 0.023)and bilateral lesions located in the same side of the lung(OR: 9.387,P<0.001)were the independent risk factors of pneumothorax.In the univariate analysis of clinical imaging findings and postoperative pathology of pulmonary nodules,the type of lesion(P<0.001),maximum diameter greater than or equal to 8 mm(P<0.001),with vascular access(P <0.001)and central high density(P <0.001),the possibility of malignant lesions with these imaging features is relatively high.Multivariate logistic regression analysis showed that: hybrid ground glass lesions(OR: 1.632,P = 0.014),lesion maximal diameter ≥ 8 mm(OR: 4.316,P = 0.002),with vascular access(OR: 3.927,P=0.001)and central high-density lesions(OR: 12.516,P<0.001)were imaging risk factors for malignant nodules of the lungs.Conclusions:(1)CT-guided Hook-wire localization in the simultaneous localization of two lung lesions before the performance of VATS is safe and effective.Postural changes and double lesions located in the ipsilateral lung are independent risk factors for pneumothorax in the simultaneous localization of two lung lesions.(2)Imaging features mixed ground glass lesions,lesion maximum diameter ≥ 8 mm,with vascular access and central high-density lesions were imaging risk factors for malignant nodules of the lungs.更多还原