超声支气管镜引导下电刀辅助开窗活检钳活检在纵膈疾病诊断中的临床应用

doi:10.3877/cma.j.issn.1674-6902.2020.05.003

目的

探索在超声支气管镜引导下使用高频电针刀在气管壁开窗，形成通向纵膈病变的孔道，再使用活检钳取样这一新的纵膈活检取样方法对纵膈淋巴结肿大病因的诊断价值，并评估其安全性。

方法

纳入2018年11月至2019年11月我院收治的纵膈疾病患者，先后实施超声支气管镜引导下经支气管针吸活检(EBUS-guided transbronchial needle aspiration, EBUS-TBNA)和超声支气管镜引导下电刀辅助开窗活检钳活检(EBUS-guided cautery-assisted transbronchial forceps biopsy, EBUS-caTBFB)，样本送病理检查，进而比较这两种方法的诊断效能和安全性。

结果

共纳入纵膈疾病患者15例，明确诊断12例，其中恶性肿瘤8例，包括肺腺癌3例、肺鳞癌2例、肺小细胞癌2例和未分型癌1例；良性4例，包括炎性假瘤1例，结核3例，另有病因不明慢性肉芽肿性炎3例。EBUS-TBNA和EBUS-caTBFB样本病理学诊断率分别为53.3%(8/15)和86.7% (13/15)，EBUS-caTBFB组的病理诊断率具有高于EBUS-TBNA组的趋势(P＝0.054)。病因诊断率分别为50% (6/12)和83.3% (10/12)，但两组之间无统计学差异(P＝0.097)。联合两种方法对于纵膈疾病的病理学诊断率和病因诊断率分别为93.3%(14/15)和91.7%(11/12)。所有患者均未出现严重出血、气胸、感染等并发症。

结论

EBUS-caTBFB是一项安全可靠的、可有效诊断纵膈疾病的方法。EBUS-caTBFB与EBUS-TBNA的联合应用可能进一步提高纵膈疾患的诊断率。

关键词: 纵膈疾病, 超声支气管镜, 电刀辅助活检钳活检, 经支气管针吸活检

Objective

To evaluate the diagnostic yield and safety of a novel method, endobronchial ultrasound-guided cautery-assisted transbronchial forceps biopsy (EBUS-caTBFB) to discriminate the etiologies of mediastinal lymphadenopathy.

Methods

Patients admitted in Xinqiao Hospital with mediastinal lymphadenopathy between December 2018 and December 2019 were included in this study. For each of them, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and EBUS-caTBFB were sequentially performed to acquire specimens for pathologic diagnosis. Diagnostic yield and the incidence of complications were compared between the two methods.

Results

15 patients with 8 of malignant cases (3 of adenocarcinoma cases, 2 of squamous carcinoma cases and 1 of unclassified case), 4 of benign cases (1 of inflammatory pseudotumor case and 3 of tuberculosis cases) and 3 of unclear chronic granulomatous inflammation were included. The EBUS-caTBFB tend to has a better pathological diagnostic yield than EBUS-TBNA, with respective rate of 86.7%(13/15)and 53.3%(8/15)(P=0.054). Among the 12 cases diagnosed with definite etiologies, the EBUS-caTBFB also seemed to have a higher etiological diagnostic yield than EBUS-TBNA as the rate was 50.0% (6/12) versus 83.3% (10/12) but without significant difference. The overall diagnostic yield of the two methods was 93.3%(14/15)in pathology and 91.7% (11/12) in etiology. Complications including pneumothorax, severe bleeding and infections were not encountered.

Conclusion

EBUS-caTBFB may be a safe and effective method compared to EBUS-TBNA to obtain specimens for mediastinal adenopathy diagnosis. Furthermore, the combination of the two methods may further improve the overall diagnostic yield.

Key words: Lymphadenopathy, Endobronchial ultrasound, Cautery-assisted transbronchial forceps biopsy, Transbronchial needle aspiration

表1 两种方法病理诊断率比较

疾病诊断		例数	病理诊断率(%)		P值
疾病诊断		例数	EBUS-TBNA	EBUS-caTBFB	P值
肉芽肿性炎		6	50.0	83.3	0.273
	结核	3	33.3	66.7
	不明	3	66.7	100.0
炎性假瘤		1	0.0	100.0
肺癌		8	62.5	87.5	0.285
	鳞状细胞癌	3	66.7	100.0
	腺癌	2	50.0	50.0
	小细胞癌	2	50.0	100.0
未分型		1	100.0	100.0
总　计		15	53.3	86.7	0.054

表1 两种方法病理诊断率比较

疾病诊断		例数	病理诊断率(%)		P值
疾病诊断		例数	EBUS-TBNA	EBUS-caTBFB	P值
肉芽肿性炎		6	50.0	83.3	0.273
	结核	3	33.3	66.7
	不明	3	66.7	100.0
炎性假瘤		1	0.0	100.0
肺癌		8	62.5	87.5	0.285
	鳞状细胞癌	3	66.7	100.0
	腺癌	2	50.0	50.0
	小细胞癌	2	50.0	100.0
未分型		1	100.0	100.0
总　计		15	53.3	86.7	0.054

表2 两种方法病因诊断率比较

疾病诊断		例数	病因诊断率(%)		P值
疾病诊断		例数	EBUS-TBNA	EBUS-caTBFB	P值
良性疾病		4	25.0	75.0	0.243
	结核	3	33.3	66.7
	炎性假瘤	1	0.0	100.0
肺癌		8	62.5	87.5	0.285
	鳞状细胞癌	3	66.7	100.0
	腺癌	2	50.0	50.0
	小细胞癌	2	50.0	100.0
	未分型	1	100.0	100.0
总　计		12	50.0	83.3	0.097

表2 两种方法病因诊断率比较

疾病诊断		例数	病因诊断率(%)		P值
疾病诊断		例数	EBUS-TBNA	EBUS-caTBFB	P值
良性疾病		4	25.0	75.0	0.243
	结核	3	33.3	66.7
	炎性假瘤	1	0.0	100.0
肺癌		8	62.5	87.5	0.285
	鳞状细胞癌	3	66.7	100.0
	腺癌	2	50.0	50.0
	小细胞癌	2	50.0	100.0
	未分型	1	100.0	100.0
总　计		12	50.0	83.3	0.097

1	Nin Carlos Schüler, Valério Silveira de Souza Vinícius, Holderbaum do Amaral Ricardo, et al. Thoracic lymphadenopathy in benign diseases: A state of the art review[J]. Respir Med, 2016，112: 10-17.
2	Gaddey Heidi L, Riegel Angela M. Unexplained Lymphadenopathy: Evaluation and Differential Diagnosis[J]. Am Family Phys, 2016, 94(11): 896-903.
3	Ferlay J, Colombet M, Soerjomataram I, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods[J]. Int J Cancer, 2019, 144(8): 1941-1953.
4	Gamliel Z. Mediastinal staging in non-small cell lung cancer[J]. Surg Oncol Clin N Am, 2016, 25(3): 493-502.
5	Hegde PV, Liberman M. Mediastinal staging: endosonographic ultrasound lymph node biopsy or mediastinoscopy[J]. Thorac Surg Clin, 2016, 26(3): 243-249.
6	Bousema JE, van Dorp M, Noyez VJJM, et al. Unforeseen N2 disease after negative endosonography findings with or without confirmatory mediastinoscopy in resectable non-small cell lung cancer: A systematic review and Meta-analysis[J]. J Thoracic Oncol, 2019, 14(6): 979-992.
7	Divisi D, Zaccagna G, Barone M, et al. Endobronchial ultrasound-transbronchial needle aspiration (EBUS/TBNA): a diagnostic challenge for mediastinal lesions[J]. Annals Translat Med, 2018, 6(5): 92-92.
8	Detterbeck FC, Lewis SZ, Diekemper R, et al. Executive summary[J]. Chest, 2013, 143(5): 7S-37S.
9	Wahidi MM, Herth F, Yasufuku K, et al. Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration[J]. Chest, 2016, 149(3): 816-835.
10	Herth F J F, Schuler H, Gompelmann D, et al. Endobronchial ultrasound-guided lymph node biopsy with transbronchial needle forceps: a pilot study[J]. Eur Respir J, 2012, 39(2): 373-377.
11	Jun Zhu, Zhang Hai-Ping, Jian Ni, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing mediastinal lymphadenectasis: a cohort study from a single center[J]. Clin Respir J, 2017, 11(2): 159-167.
12	Navani Neal, Brown James M, Nankivell Matthew, et al. Suitability of endobronchial ultrasound-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer: a multicenter study of 774 patients[J]. Am J Respir Crit Care Med, 2012, 185(12): 1316-1322.
13	Righi L, Franzi F, Montarolo F, et al. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)-from morphology to molecular testing[J]. J Thorac Dis, 2017, 9(Suppl 5): S395-S404.
14	Medford A, Pillai A. Cytotechnician rapid on-site evaluation for cytology for transbronchial needle aspiration[J]. J Bronchol Intervent Pulmonol, 2013, 20(2): 189-190.
15	Vilmann P, Clementsen P, Colella S, et al. Combined endobronchial and esophageal endosonography for the diagnosis and staging of lung cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline, in cooperation with the European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS)[J]. Endoscopy, 2015, 47(6): c1.
16	Bramley K, Pisani MA, Murphy TE, et al. Endobronchial Ultrasound-Guided Cautery-Assisted Transbronchial Forceps Biopsies: Safety and Sensitivity Relative to Transbronchial Needle Aspiration[J]. Ann Thorac Surg, 2016, 101(5): 1870-1876.
17	Ray AS, Li C, Murphy TE, et al. Improved Diagnostic Yield and Specimen Quality With Endobronchial Ultrasound-Guided Forceps Biopsies: A Retrospective Analysis[J]. Ann Thorac Surg, 2020, 109(3): 894-901.
18	Medford AR, Bennett JA, Free CM, et al. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): applications in chest disease[J]. Respirology, 2010, 15(1): 71-79.
19	Yarmus L, Akulian J, Gilbert C, et al. Optimizing endobronchial ultrasound for molecular analysis. How many passes are needed? [J]. Ann Am Thoracic Society, 2013, 10(6): 636-643.
20	Cheng G, Mahajan A, Oh S, et al. Endobronchial ultrasound-guided intranodal forceps biopsy (EBUS-IFB)-technical review[J]. J Thorac Dis, 2019, 11(9): 4049-4058.
21	Zhu J, Zhang HP, Ni J, et al. Endobronchial ultrasound-guided transbronchial needle aspiration for diagnosing mediastinal lymphadenectasis: a cohort study from a single center[J]. Clin Respir J, 2017, 11(2): 159-167.
22	Luo Gy, Cai Pq, He Jh, et al. Application of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Management of Mediastinal and Hilar Lymphadenopathy Without Intrapulmonary Mass: Experience from the Largest Cancer Center of Southern China[J]. Cell Biochem Biophys, 2013, 67(3): 1533-1538.
23	Tyan CC, Machuca T, Czarnecka K, et al. Performance of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Isolated Mediastinal and Hilar Lymphadenopathy[J]. Respir, 2017, 94(5): 457-464.
24	Tertemiz KC, Alpaydin AO, Karacam V. The role of endobronchial ultrasonography for mediastinal lymphadenopathy in cases with extrathoracic malignancy[J]. Surg Endosc, 2017, 31(7): 2829-2836.
25	Dhooria S, Aggarwal AN, Gupta D, et al. Utility and Safety of Endoscopic Ultrasound With Bronchoscope-Guided Fine-Needle Aspiration in Mediastinal Lymph Node Sampling: Systematic Review and Meta-Analysis[J]. Respir Care, 2015, 60(7): 1040-1050.
26	Osinka KZM, Korczyński P. Impact of Endobronchial Ultrasound Guided Transbronchial Needle Aspiration on Diagnostic Yield of Bronchoscopy in Patients with Mediastinal Lymph Node Enlargement[J]. Oxygen Transport to Tissue XXXIII, 2016, 911: 33-43.
27	Ernst AAD, Eberhardt R. Diagnosis of Mediastinal Adenopathy-Real-Time Endobronchial Ultrasound Guided Needle Aspiration versus Mediastinoscopy[J]. J Thorac Oncol, 2008, 3(6): 577-582.
28	Sakata K, Midthun D, Mullon J, et al. Comparison of Programmed Death Ligand-1 Immunohistochemical Staining Between Endobronchial Ultrasound Transbronchial Needle Aspiration and Resected Lung Cancer Specimens[J]. Chest, 2018, 154(4): 827-837.
29	Agarwal R, Aggarwal AN, Gupta D. Efficacy and safety of conventional transbronchial needle aspiration in sarcoidosis: a systematic review and meta-analysis[J]. Respir Care, 2013, 58(4): 683-693.
30	Franke KJ, Bruckner C, Szyrach M, et al. The contribution of endobronchial ultrasound-guided forceps biopsy in the diagnostic workup of unexplained mediastinal and hilar lymphadenopathy[J]. Lung, 2012, 190(2): 227-232.
31	芸　等，李　晓，潘　马. 经气管镜超声引导活检钳活检术在纵隔和肺门病变诊断中的初步应用[J]. 中国微创外科杂志，2019, 19(12): 1066-1069.

[1]	李慧, 曹敏, 徐庆庆, 黄妹, 李蕤, 苗立云, 肖永龙, 孟凡青, 蔡后荣, 代静泓. 超声支气管镜引导下针吸活检术与常规支气管镜活检术对结节病诊断价值的比较[J]. 中华医学超声杂志（电子版）, 2016, 13(02): 144-149.
[2]	王旖旎, 汤玲一, 黄赞胜, 陈慧, 张明周, 王苹, 王爽, 周培花, 范晔, 赵静, 边巴多杰, 张春兰. 超声支气管镜引导下经支气管纵膈冷冻活检术的操作难度及安全性[J]. 中华肺部疾病杂志(电子版), 2023, 16(01): 11-14.
[3]	刘颖, 张业, 颜晶晶, 刘政. 经引导鞘超声支气管镜对肺外周结节的诊断意义[J]. 中华肺部疾病杂志(电子版), 2021, 14(06): 794-796.
[4]	明宗娟, 张德信, 李维, 史红阳, 和平, 杨侠, 方萍, 谢梅, 吕洁, 黎萌, 杨拴盈. 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[J]. 中华肺部疾病杂志(电子版), 2019, 12(05): 579-584.
[5]	顾兴, 颜西刚, 王琰, 周艳敏, 谢永宏, 金发光, 张红军. 全身麻醉下行EBUS-TBNA诊断纵隔病变的临床经验[J]. 中华肺部疾病杂志(电子版), 2017, 10(02): 137-140.
[6]	韩茜, 崔江禹, 唐纯丽. 经支气管针吸活检模拟教学方法比较[J]. 中华临床实验室管理电子杂志, 2022, 10(04): 251-255.
[7]	隋锡朝, 赵辉, 周足力, 李晓, 李剑锋, 李运, 姜冠潮, 王俊. 支气管内超声引导针吸活检术在非小细胞肺癌术前分期中的临床应用[J]. 中华胸部外科电子杂志, 2014, 01(01): 13-17.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

EBUS-guided cautery-assisted transbronchial forceps biopsy in mediastinal disease

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

EBUS-guided cautery-assisted transbronchial forceps biopsy in mediastinal disease