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中华肺部疾病杂志(电子版)

中华肺部疾病杂志(电子版) ›› 2019, Vol. 12 ›› Issue (05) : 585 -590. doi: 10.3877/cma.j.issn.1674-6902.2019.05.010

论著

外科肺活检诊断弥漫性实质性肺疾病的临床分析
张娟娟1, 邱玉英1,†(), 张英为1   
  1. 1. 210008　南京，南京大学医学院附属鼓楼医院呼吸与危重症医学科
  • 收稿日期:2019-04-18 出版日期:2019-10-20
  • 通信作者: 邱玉英
  • 基金资助:
    南京市卫生科技发展项目资助(YKK17068)

Efficacy and safety of surgical lung biopsy in diagnosis of diffuse parenchymal lung disease

Juanjuan Zhang1, Yuying Qiu1,†(), Yingwei Zhang1   

  1. 1. Department of Respiratory and Critical Care Medicine, Affiliated Drum Tower Hospital, Medical School, Nanjing University, Nanjing 210008, China
  • Received:2019-04-18 Published:2019-10-20
  • Corresponding author: Yuying Qiu
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张娟娟, 邱玉英, 张英为. 外科肺活检诊断弥漫性实质性肺疾病的临床分析[J]. 中华肺部疾病杂志(电子版), 2019, 12(05): 585-590.

Juanjuan Zhang, Yuying Qiu, Yingwei Zhang. Efficacy and safety of surgical lung biopsy in diagnosis of diffuse parenchymal lung disease[J]. Chinese Journal of Lung Diseases(Electronic Edition), 2019, 12(05): 585-590.

目的

评价外科肺活检诊断弥漫性实质性肺疾病的有效性和安全性。

方法

回顾性分析南京鼓楼医院呼吸与危重症医学科2006年1月至2018年9月54例行外科肺活检的弥漫性实质性肺疾病患者的临床资料。

结果

54例患者中，37例接受了电视辅助胸腔镜手术，17例接受了开胸肺活检，术后最常见的病理诊断是机化性肺炎，48例(88.9%)患者术后获得明确的诊断，术后38例(70.4%)患者根据诊断结果调整了治疗方案。术前接受小创伤肺活检未明确诊断的患者，接受外科肺活检后96%确诊。按术后有无并发症分为并发症组和无并发症二组。15例(27.8%)患者术后出现并发症，其中9例(16.7%)气胸，5例(9.3%)肺部感染，3例(5.6%)脱机困难，3例(5.6%)呼吸衰竭，1例(1.9%)术后再次插管，1例(1.9%)术后出血，1例(1.9%)进行气管切开。术后30 d病死率为1.9%，死亡原因主要是呼吸衰竭。术后并发症组和无并发症组在性别、年龄、FVC% pre、FEV1%pre、DLCO% pre、术前PaO2、术前激素使用情况和手术方式之间的差异没有统计学意义(P>0.05)。

结论

对于结合临床病史、胸部高分辨率CT、实验室检查及小创伤肺活检资料仍诊断不明的弥漫性实质性肺疾病的患者，外科肺活检可作为最后一项有意义的检查方法，其诊断率为88.9%。外科肺活检是一项相对安全且可靠的诊断弥漫性实质性肺疾病的手段，但基础情况较差的患者，术后出现并发症的可能性较高，此类患者应尽量避免外科肺活检。

关键词: 弥漫性实质性肺疾病, 外科肺活检, 诊断
Objective

To evaluate the efficacy and safety of surgical lung biopsy in the diagnosis of diffuse parenchymal lung disease (DPLD).

Methods

We retrospectively analyzed the clinical data of 54 consecutively-suspected DPLD cases who received surgical lung biopsy in the Department of Respiratory and Critical Care Medicine of Nanjing Drum Tower Hospital during January 2006 to September 2018.

Results

Among the 54 cases, the lung biopsy was performed by video-assisted thoracoscopic surgery in 37 cases and by open lung biopsy in 17 cases. The most common postoperative pathological diagnosis was organized pneumonia, and a definite diagnosis was obtained in 48 patients after the procedure. The therapeutic schedule was changed in 38 cases according to the diagnosis after surgery. The patients who accepted minimally invasive lung biopsy without definite diagnosis were mostly (96%) confirmed after surgical lung biopsy. Surgical complication occurred in 15 cases out of the 54 cases, with the morbidity of 27.8%, including pneumothorax in 9 cases, pulmonary infection in 5, delayed weaning ventilator (>48 h after surgery) in 3, respiratory failure in 3, re-intubation in 1, postoperative bleeding in 1, and tracheotomy in 1. The 30-day postoperative mortality was 1.9%, mostly due to respiratory failures. There was no statistical significant difference in sex, age, the preoperative percentage of the forced vital capacity (FVC%pre), the preoperative percentage of the forced expiratory volume in one second (FEV1%pre), the preoperative percentage of the diffusing capacity of the lungs for carbon monoxide (DLCO%pre), the preoperative partial pressure of oxygen in artery (PaO2), the preoperative steroids use and the operation methods (P>0.05) between the complication group and the non-complication group.

Conclusion

For the patients with undiagnosed DPLD after combination with clinical history, high-resolution CT (HRCT) of the chest, laboratory examination and data of minimally invasive lung biopsy, surgical lung biopsy can be used as the last meaningful examination method, with a diagnosis rate of 88.9%. Surgical lung biopsy is a relatively safe and reliable method for the diagnosis of DPLD, but the patients with poor basic conditions are more likely to suffer from postoperative complications. Such patients should avoid surgical lung biopsy as far as possible.

Key words: Diffuse parenchymal lung disease, Surgical lung biopsy, Diagnosis
表1 术后48例确诊患者的病理结果
病理结果 例数
普通型间质性肺炎 3
肺泡蛋白沉积症 3
PLCH 3
PLCH和NSIP 1
矽肺和NSIP 1
NSIP，继发细支气管肺炎，血管炎 1
NSIP 4
机化性肺炎 6
机化性肺炎，尘肺，肺气肿 1
肺腺癌 2
脱屑性间质性肺炎合并肺腺癌 1
良性转移性平滑肌瘤 1
原发性血管内大B细胞淋巴瘤 1
肺MALT型边缘区B细胞淋巴瘤 1
Castleman病 1
淋巴瘤样肉芽肿病(Ⅰ级) 1
结节性肉芽肿性病变 1
先天性囊性腺瘤样畸形 1
肺泡微石症 1
滤泡性细支气管炎 2
呼吸性细支气管炎 1
巨细胞性间质性肺炎 1
过敏性肺炎 1
尘肺 2
血管炎 1
弥漫性小叶中心性肺气肿 1
肺结核 2
细支气管非特异性炎症伴纤维组织增生 1
外源性异物吸入致末端小支气管纤维化病变 1
小气道碳沫沉着伴反应性纤维组织增生 1
图1 囊状影
图2 网状实变影
图3 网状实变影、结节影
图4 病例1肺组织病理学诊断肺朗格汉斯细胞组织细胞增生症；注：A ：(HE×10)肺组织病理示大量朗格汉斯组织细胞、少量嗜酸性粒细胞和淋巴细胞浸润；B：(HE×40)肺组织病理示朗格汉斯细胞核呈卵圆形、肾形(黑箭)，可见明显核沟，少量嗜酸性粒细胞浸润；C：免疫组化示朗格汉斯组织细胞膜CD1a阳性(棕色)表达；D：免疫组化示朗格汉斯组织细胞S-100阳性(棕色)表达；E：免疫组化示朗格汉斯组织细胞膜CD68阴性表达；F：免疫组化示朗格汉斯组织细胞Langerin阳性(棕色)表达
图5 病例2多数区域肺泡间隔纤维组织增生、慢性炎症细胞浸润。肺组织病理学诊断机化性肺炎(HE×10)
图6 病例3小气道周围、胸膜下、小叶间隔周围淋巴组织结节状增生伴淋巴滤泡形成，淋巴组织间纤维组织增生，组织学可符合castleman病累及小气道和肺实质(HE×10)
表2 术后6例未确诊患者的病理结果
病理结果 例数
机化性肺炎，脱屑性肺炎，细支气管炎 1
机化性肺炎伴间质纤维化 1
NSIP，慢性小气道炎症，过敏性肺炎 1
终末气道中心性纤维化伴肺气肿 1
慢性阻塞性肺疾病 1
间质性肺炎 1
表3 比较术后并发症组和无并发症组临床资料的差异
临床资料 并发症组(n＝15) 无并发症组(n＝39) χ2/t值 P值
性别，男(%) 10(66.7) 19(48.7) 1.404 0.24
年龄(岁) 41.9±16.3 43.3±13.3 0.328 0.74
FVC% pre(%) 71.3±22.4 76.5±15.0 1.002 0.32
FEV1%pre(%) 73.9±22.5 77.6±17.6 0.627 0.53
DLCO% pre(%) 63.6±32.0 68.3±19.8 0.644 0.52
术前PaO2(mmHg) 80.5±21.7 87.5±17.4 1.223 0.22
术前使用激素[n(%)]        
  有 4(26.7) 6(15.4) 0.319 0.57
  无 11(73.3) 33(84.6)    
手术方式[n(%)]        
  VATS 9(60.0) 28(71.8) 0.259 0.61
  OLB 6(40.0) 11(28.2)    
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