肺癌伴恶性胸腔积液经皮导管引流后致肺不张的预测分析

doi:10.3877/cma.j.issn.1674-6902.2026.01.004

目的

分析肺癌伴恶性胸腔积液(malignant pleural effusion, MPE)患者超声引导经皮导管引流(percutaneous catheter drainage, PCD)后发生肺不张的危险因素及对预后的影响。

方法

回顾性选择2021年6月至2024年3月我院收治的因MPE行超声引导PCD肺癌患者114例为对象。根据PCD后肺部扩张情况分组，肺不张18例为观察组，未发生肺不张96例为对照组。比较两组临床资料、影像学结果、总生存期(overall survival, OS)，通过回归分析发生肺不张危险因素。

结果

观察组患者乳酸脱氢酶(lactate dehydrogenase, LDH)[828.30(694.24，909.56)]、胸腔积液-血清LDH比值[1.88(1.38，4.00)]、支气管内病变[9(50.00)]、MPE确诊至PCD时间[7.00(5.00，11.00)]、引流量[850.00(600.00，1 000.00)]较对照组LDH[547.30(460.20，669.50)]、胸腔积液-血清LDH比值[1.18(0.47，2.21)]、支气管内病变[20(20.83)]、MPE确诊至PCD时间[4.00(2.00，7.00)]、引流量[1 215.00(950.00，1 535.00)](P<0.05)。Logistic回归分析显示，胸腔积液-血清LDH比值(OR＝2.228，95%CI：1.359~3.652)、支气管内病变(OR＝5.076，95%CI：1.488~17.317)及MPE确诊至PCD时间(OR＝1.108，95%CI：1.010~1.215)为肺癌伴MPE患者发生肺不张的危险因素(P<0.05)。受试者工作特征曲线(receiver operating characteristic, ROC)预测肺癌伴MPE患者PCD后发生肺不张曲线下面积(area under the curve, AUC) 0.833(95%CI：0.716~0.949)，Hosmer-Lemeshow检验P＝0.564。截至随访结束，生存者27例(23.68%)，死亡者87例(76.32%)，观察组OS 79.0(IQR：56.4~103.8)d短于对照组99.2 (IQR：73.1~142.7)d(log rank＝5.491，P＝0.019)。COX回归分析显示，ECOG-PS≥2、远处转移、血清CRP、胸腔积液-血清LDH比值及肺不张为肺癌伴MPE患者死亡的危险因素(P<0.05)。

结论

胸腔积液-血清LDH比值、支气管内病变及MPE确诊至PCD时间可预测肺不张发生。肺不张影响肺癌伴MPE患者PCD治疗后总生存期。

关键词: 支气管肺癌, 恶性胸腔积液, 经皮导管引流, 肺不张, 预后

Objective

To analyze the relevant clinical factors associated with atelectasis following ultrasound-guided percutaneous catheter drainage (PCD) in lung cancer patients complicated with malignant pleural effusion (MPE), and to evaluate the impact of atelectasis on patient prognosis.

Methods

A retrospective selection was made of 114 lung cancer patients with malignant pleural effusion (MPE) who underwent ultrasound-guided percutaneous catheter drainage (PCD) in our hospital from June 2021 to March 2024 as the subjects. They were grouped according to the lung expansion status after PCD: 18 cases with atelectasis were included in the observation group, and 96 cases without atelectasis were included in the control group. The clinical data, imaging results, and overall survival of the two groups were compared, and the risk factors for atelectasis were analyzed by regression analysis.

Results

In the observation group, the lactate dehydrogenase( LDH) level [828.30(694.24, 909.56)], pleural fluid-to-serum LDH ratio [1.88 (1.38, 4.00)], endobronchial lesions [9 cases(50.00%)], time from diagnosis of MPE to PCD [7.00 (5.00, 11.00)] days, and drainage volume [850.00 (600.00, 1 000.00)]ml showed statistically significant differences compared with the control group, which had LDH [547.30(460.20, 669.50)], pleural fluid-to-serum LDH ratio [1.18 (0.47, 2.21)], endobronchial lesions 20 cases(20.83%), time from MPE diagnosis to PCD [4.00 (2.00, 7.00) ]days, and drainage volume [1 215.00 (950.00, 1 535.00)]ml (P<0.05). Logistic regression analysis revealed that the pleural fluid-to-serum LDH ratio (OR=2.228, 95%CI: 1.359~3.652), endobronchial lesions (OR=5.076, 95%CI: 1.488~17.317), and time from MPE diagnosis to PCD (OR=1.108, 95%CI: 1.010~1.215) were risk factors for atelectasis in lung cancer patients with MPE (P<0.05). The receiver operating characteristic AUC for predicting post-PCD atelectasis in lung cancer patients with MPE was 0.833 (95%CI: 0.716~0.949), with a Hosmer-Lemeshow test P-value of 0.564. By the end of follow-up, 27 patients (23.68%) were alive and 87 patients (76.32%) had died. The overall survival in the observation group was 79.0 days (IQR: 56.4~103.8 days), which was shorter than that in the control group (99.2 days, IQR: 73.1~142.7 days) (log rank=5.491, P=0.019). COX regression analysis indicated that ECOG-PS ≥ 2, distant metastasis, serum CRP, pleural fluid-to-serum LDH ratio, and atelectasis were risk factors for death in lung cancer patients with MPE (P<0.05).

Conclusion

The pleural effusion-serum LDH ratio, endobronchial lesions, and the time from MPE diagnosis to PCD can predict the occurrence of atelectasis. Atelectasis affects the overall survival of lung cancer patients with MPE after PCD treatment.

Key words: Bronchogenic carcinoma, Malignant pleural effusion, Percutaneous catheter drainage, Atelectasis, Prognosis

表1 两组肺癌伴MPE患者的临床资料结果比较

临床资料	观察组(n＝18)	对照组(n＝96)	Z/t/χ²	P值
吸烟史[n(%)]	12(66.67)	40(41.67)	3.819	0.051
ECOG-PS≥2[n(%)]	4(22.22)	19(19.79)	0.056	0.814
未接受过化疗[n(%)]	14(77.78)	72(75.00)	0.063	0.802
远处转移[n(%)]	7(38.89)	43(44.79)	0.215	0.643
实验室检测指标[M₅₀(Q₂₅，Q₇₅)]
NLR	3.27(2.25，4.48)	3.01(2.29，4.40)	0.307	0.759
血清CRP(mg/dl)	2.73(1.33，15.45)	2.10(0.69，18.86)	0.896	0.370
LDH(U/L)	828.30(694.24，909.56)	547.30(460.20，669.50)	4.259	0.000
CEA(ng/ml)	18.04(6.24，34.33)	8.92(2.99，43.18)	0.964	0.335
胸腔积液/血清蛋白质比值	0.66(0.59，0.72)	0.65(0.60，0.70)	0.089	0.935
胸腔积液/血清LDH比值	1.88(1.38，4.00)	1.18(0.47，2.21)	3.451	0.000
组织学类型[n(%)]			1.788	0.618
肺腺癌	14(77.78)	73(76.04)
鳞状细胞癌	1(5.56)	12(12.50)
大细胞癌	0(0.00)	2(2.08)
小细胞癌	3(16.67)	9(9.38)
MPE确诊至PCD时间[d，M₅₀(Q₂₅，Q₇₅)]	7.00(5.00，11.00)	4.00(2.00，7.00)	2.774	0.006
引流量[ml，M₅₀(Q₂₅，Q₇₅)]	850.00(600.00，1 000.00)	1 215.00(950.00，1 535.00)	2.565	0.010

表1 两组肺癌伴MPE患者的临床资料结果比较

临床资料	观察组(n＝18)	对照组(n＝96)	Z/t/χ²	P值
吸烟史[n(%)]	12(66.67)	40(41.67)	3.819	0.051
ECOG-PS≥2[n(%)]	4(22.22)	19(19.79)	0.056	0.814
未接受过化疗[n(%)]	14(77.78)	72(75.00)	0.063	0.802
远处转移[n(%)]	7(38.89)	43(44.79)	0.215	0.643
实验室检测指标[M₅₀(Q₂₅，Q₇₅)]
NLR	3.27(2.25，4.48)	3.01(2.29，4.40)	0.307	0.759
血清CRP(mg/dl)	2.73(1.33，15.45)	2.10(0.69，18.86)	0.896	0.370
LDH(U/L)	828.30(694.24，909.56)	547.30(460.20，669.50)	4.259	0.000
CEA(ng/ml)	18.04(6.24，34.33)	8.92(2.99，43.18)	0.964	0.335
胸腔积液/血清蛋白质比值	0.66(0.59，0.72)	0.65(0.60，0.70)	0.089	0.935
胸腔积液/血清LDH比值	1.88(1.38，4.00)	1.18(0.47，2.21)	3.451	0.000
组织学类型[n(%)]			1.788	0.618
肺腺癌	14(77.78)	73(76.04)
鳞状细胞癌	1(5.56)	12(12.50)
大细胞癌	0(0.00)	2(2.08)
小细胞癌	3(16.67)	9(9.38)
MPE确诊至PCD时间[d，M₅₀(Q₂₅，Q₇₅)]	7.00(5.00，11.00)	4.00(2.00，7.00)	2.774	0.006
引流量[ml，M₅₀(Q₂₅，Q₇₅)]	850.00(600.00，1 000.00)	1 215.00(950.00，1 535.00)	2.565	0.010

图1 肺癌伴MPE患者肺不张风险预测列线图注：MPE为恶性胸腔积液；PCD为经皮导管引流；LDH为乳酸脱氢酶

表2 肺癌伴MPE患者肺不张多因素Logistic回归分析

影响因素	β	SE	Walds值	OR(95%CI)	P值
LDH(连续变量，每增加1 U/L)	0.001	0.001	3.224	1.001(1.000~1.003)	0.073
积液-血清LDH比值(连续变量，每增加1个单位)	0.801	0.252	3.176	2.228(1.359~3.652)	0.001
支气管内病变(0＝否，1＝是)	1.624	0.626	2.594	5.076(1.488~17.317)	0.009
MPE确诊至PCD时间(连续变量，每增加1 d)	0.102	0.047	2.170	1.108(1.010~1.215)	0.030
引流量(连续变量，每增加1 ml)	0.002	0.001	3.116	0.998(0.997~1.000)	0.078

表2 肺癌伴MPE患者肺不张多因素Logistic回归分析

影响因素	β	SE	Walds值	OR(95%CI)	P值
LDH(连续变量，每增加1 U/L)	0.001	0.001	3.224	1.001(1.000~1.003)	0.073
积液-血清LDH比值(连续变量，每增加1个单位)	0.801	0.252	3.176	2.228(1.359~3.652)	0.001
支气管内病变(0＝否，1＝是)	1.624	0.626	2.594	5.076(1.488~17.317)	0.009
MPE确诊至PCD时间(连续变量，每增加1 d)	0.102	0.047	2.170	1.108(1.010~1.215)	0.030
引流量(连续变量，每增加1 ml)	0.002	0.001	3.116	0.998(0.997~1.000)	0.078

表3 肺癌伴MPE患者预后COX回归分析

影响因素	单因素					多因素
影响因素	β	SE	Walds值	HR(95%CI)	P值	β	SE	Walds值	HR(95%CI)	P值
ECOG-PS≥2(0＝否，1＝是)	0.550	0.219	6.292	1.733(1.128~2.664)	0.012	0.489	0.226	4.694	1.631(1.048~2.538)	0.030
远处转移(0＝否，1＝是)	0.627	0.221	8.097	1.873(1.216~2.886)	0.004	0.811	0.317	6.539	2.250(1.208~4.188)	0.011
NLR	0.049	0.023	4.636	2.610(1.004~3.008)	0.035	0.033	0.017	3.682	1.033(0.999~1.069)	0.055
血清CRP	0.259	0.120	4.690	3.095(2.000~4.637)	0.030	0.311	0.140	4.935	3.888(2.113~5.143)	0.042
LDH	0.138	0.055	6.315	1.008(1.001~1.017)	0.022	0.118	0.211	0.311	1.125(0.744~1.701)	0.577
积液-血清LDH比值	0.062	0.016	15.734	1.044(1.032~1.067)	0.009	0.101	0.023	19.233	2.435(1.177~3.038)	0.016
肺不张(0＝否，1＝是)	0.800	0.301	7.048	2.225(1.233~4.015)	0.008	1.028	0.375	7.522	2.367(1.380~5.044)	0.006

表3 肺癌伴MPE患者预后COX回归分析

影响因素	单因素					多因素
影响因素	β	SE	Walds值	HR(95%CI)	P值	β	SE	Walds值	HR(95%CI)	P值
ECOG-PS≥2(0＝否，1＝是)	0.550	0.219	6.292	1.733(1.128~2.664)	0.012	0.489	0.226	4.694	1.631(1.048~2.538)	0.030
远处转移(0＝否，1＝是)	0.627	0.221	8.097	1.873(1.216~2.886)	0.004	0.811	0.317	6.539	2.250(1.208~4.188)	0.011
NLR	0.049	0.023	4.636	2.610(1.004~3.008)	0.035	0.033	0.017	3.682	1.033(0.999~1.069)	0.055
血清CRP	0.259	0.120	4.690	3.095(2.000~4.637)	0.030	0.311	0.140	4.935	3.888(2.113~5.143)	0.042
LDH	0.138	0.055	6.315	1.008(1.001~1.017)	0.022	0.118	0.211	0.311	1.125(0.744~1.701)	0.577
积液-血清LDH比值	0.062	0.016	15.734	1.044(1.032~1.067)	0.009	0.101	0.023	19.233	2.435(1.177~3.038)	0.016
肺不张(0＝否，1＝是)	0.800	0.301	7.048	2.225(1.233~4.015)	0.008	1.028	0.375	7.522	2.367(1.380~5.044)	0.006

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Clinical predictive factors and prognosis analysis of atelectasis after percutaneous catheter drainage in patients with lung cancer complicated with malignant pleural effusion

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Clinical predictive factors and prognosis analysis of atelectasis after percutaneous catheter drainage in patients with lung cancer complicated with malignant pleural effusion