径向探头超声支气管镜引导支气管透壁肺活检术在外周肺病变诊断中的应用

doi:10.3877/cma.j.issn.1674-6902.2019.05.009

目的

探讨径向探头超声支气管镜引导支气管透壁肺活检术(R-EBUS-TBLB)在外周肺病变(PPLs)诊断中的价值及应用，评估其诊断成功率、影响因素及安全性。

方法

回顾性总结2017年8月至2019年1月在我科接受R-EBUS-TBLB检查的86例患者的临床资料，观察R-EBUS对病灶的定位能力，分析其诊断成功率及影响因素，观察有无并发症，进行安全性评估。

结果

R-EBUS病灶探及率为89.53%(77/86)，R-EBUS-TBLB在PPLs中的总诊断率为59.30%(51/86)，对直径≥2 cm、位于中下叶、距离肺门近、超声内部回声不均匀、边缘不连续的病灶确诊率均高于直径<2 cm、位于上叶、距离肺门远、超声内部回声均匀、边缘连续的病灶(P<0.05)；病灶包绕超声探头的诊断率为78.26%(36/46)，病灶边缘临近超声探头的诊断率为41.94%(13/31)，两组差异有统计学意义(P<0.05)。R-EBUS-TBLB对PPLs的诊断敏感性为59.30%，特异性为100%，阳性预测值以及阴性预测值分别为100%和42.22%。R-EBUS-TBLB的安全性较高，86例受检者中仅有7例需要镜下局部止血，其余均为少量出血，无需特殊处理，未见气胸等并发症的发生。

结论

R-EBUS-TBLB安全有效，对PPLs有重要的诊断意义和较高的应用价值。病灶大小、部位以及超声探头和病灶的位置关系是影响R-EBUS-TBLB诊断效能的主要因素。

关键词: 超声支气管镜, 外周肺病变, 支气管透壁肺活检, 测量技术

Objective

To explore the application and value of radial probe endobronchial ultrasound-guided bronchoscope for transbronchial lung biopsy (R-EBUS-TBLB) in the diagnosis of peripheral pulmonary lesions (PPLs) and to evaluate the diagnostic success rate, influencing factors and safety.

Methods

The clinical data of 86 patients with PPLs who received R-EBUS-TBLB in our hospital from August 2017 to January 2019 were retrospectively summarized. The ability of R-EBUS to locate the lesions was observed, the success rate of diagnosis and its influencing factors were analyzed, and the complications were observed for safety assessment.

Results

The detection rate of R-EBUS for lesions was 89.53% (77/86) and the total diagnosis rate of R-EBUS-TBLB in the patients with PPLs was 59.30% (51/86). The diagnosis rate of the lesions with the diameter ≥2 cm, being located in the middle or lower lobe, close to the hilum, with uneven echo inside the ultrasound, and with discontinuous edges was higher than that of the lesions with the diameter <2 cm, being located in the upper lobe, far from the hilum, with uniform echo inside the ultrasound, and with continuous edges (P<0.05). The diagnosis rate of the lesions wrapping the ultrasonic probe was 78.26% (36/46) and the diagnosis rate of the lesions whose edges were adjacent to the ultrasonic probe was 41.94 % (13/31). The difference between the two groups was statistically significant (P<0.05). The diagnostic sensitivity of R-EBUS-TBLB to PPLs was 59.30%, the specificity was 100%, and the positive predictive value and the negative predictive value were 100% and 42.22%, respectively. The safety of R-EBUS-TBLB was relatively high. Only 7 out of the 86 subjects needed local hemostasis under the microscope, and the rest with small amounts of bleeding needed no special treatment. No pneumothorax or other complications were observed.

Conclusion

R-EBUS-TBLB is safe and effective, which has an important diagnostic significance and a high application value for PPLs. The size and location of the lesions, the relationship between the ultrasonic probe, and the location of the lesions are the main factors affecting the diagnostic efficacy of R-EBUS-TBLB.

Key words: Endobronchial ultrasonography, Peripheral pulmonary lesions, Transbronchial lung biopsy, Measurement techniques

图1 正常R-EBUS超声图像呈暴风雪改变

图2 A：胸部CT示PPL(左肺上叶结节)；B：R-EBUS示超声探头位于病灶内；C：TBLB病理回报肺腺癌(HE ×100)

图3 A：胸部CT示PPL(右肺上叶密度增高影)；B：R-EBUS示超声探头位于病灶边缘；C：TBLB病理回报肺结核(HE ×100)

表1 R-EBUS-TBLB诊断率与超声探头位置、超声图像特征、病灶大小、病灶位置以及麻醉方式的关系比较

临床资料		例数	确诊例数(%)	χ²值	P值
超声探头位置
	在病灶内	46	36(78.26)	15.852	<0.001
	邻近病灶	31	13(41.94)
	未探及病灶	9	2(22.22)
超声图像边缘
	连续	41	20(48.78)	7.047	0.008
	不连续	36	29(80.56)
超声内部回声
	均匀	31	12(38.71)	12.188	<0.001
	不均匀	46	37(80.43)
病灶直径大小
	直径≥3 cm	19	16(84.21)	19.896	<0.001
	2 cm≤直径<3 cm	44	37(61.36)
	直径<2 cm	23	8(34.78)
病灶位置
	双上叶	21	7(33.33)	8.202	0.017
	右中叶	35	25(71.42)
	双下叶	30	19(63.33)
病灶与肺门距离
	距离肺门≥5 cm	41	18(43.90)	6.528	0.011
	距离肺门<5 cm	45	33(73.33)
麻醉方式
	局麻	23	12(52.17)	0.319	0.572
	全麻	63	39(61.90)

表1 R-EBUS-TBLB诊断率与超声探头位置、超声图像特征、病灶大小、病灶位置以及麻醉方式的关系比较

临床资料		例数	确诊例数(%)	χ²值	P值
超声探头位置
	在病灶内	46	36(78.26)	15.852	<0.001
	邻近病灶	31	13(41.94)
	未探及病灶	9	2(22.22)
超声图像边缘
	连续	41	20(48.78)	7.047	0.008
	不连续	36	29(80.56)
超声内部回声
	均匀	31	12(38.71)	12.188	<0.001
	不均匀	46	37(80.43)
病灶直径大小
	直径≥3 cm	19	16(84.21)	19.896	<0.001
	2 cm≤直径<3 cm	44	37(61.36)
	直径<2 cm	23	8(34.78)
病灶位置
	双上叶	21	7(33.33)	8.202	0.017
	右中叶	35	25(71.42)
	双下叶	30	19(63.33)
病灶与肺门距离
	距离肺门≥5 cm	41	18(43.90)	6.528	0.011
	距离肺门<5 cm	45	33(73.33)
麻醉方式
	局麻	23	12(52.17)	0.319	0.572
	全麻	63	39(61.90)

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