结节病的弥漫性肺实质病变及病理诊断过程分析

Analysis of the parenchymal lung lesions in sarcoidosis and the pathological diagnostic procedures

目的提高对结节病肺实质病变的认识,强调其在病理诊断过程中的意义。方法回顾性病例分析。收集有病理证据的结节病伴肺实质病变病例,分析一般临床特征、影像表现和病理学标本的获取方法。结果符合要求病例26例,其中男5例,女21例;中位数年龄51岁。全部病例胸片均显示不同程度的肺实质病变,即都属于Ⅱ期以上,其中9例(9/26,34.6%)属于Ⅲ期。有CT资料者24例,22例显示肺门纵隔淋巴结肿大(22/24,91.7%),肺野表现以弥漫微小结节影(19/24,79.2%)和多发片状阴影(13/24,54.2%)最常见;大多数病例(20/24,83.3%)同时具有至少2种类型的影像表现,只有4例以1种类型为主。影像诊断中常拟诊的疾病是肺癌、结核和肺间质纤维化。病理标本的获取方法中,21例进行了支气管黏膜和/或经支气管肺活检,总计18例阳性(18/21,85.7%)。3例阴性和其余5例未行支气管镜活检的病例分别接受其他活检,包括电视胸腔镜(VATS)肺活检和纵隔淋巴结活检。结论多种类型的肺实质病变同时存在是结节病肺部病变的特征,最容易误诊为肺癌和结核。支气管镜检查并活检是效益风险比最佳的病理诊断手段。

Objective To improve the recognition of the parenchymal lesions in sarcoidosis and to emphasize its significance in the pathological diagnostic process. Methods Retrospective analysis was performed. Pathologically confirmed cases of sarcoidosis with lung parenchymal lesions were enrolled. Clinical features, radiologic manifestations and pathologic diagnostic procedures were analyzed. Results Twenty-six cases of sarcoidosis confirmed by pathologic study were enrolled. Chest X ray showed parenchymal lung lesions of different degree in all cases,of which 9 （9/26,34.6%） were categorized as stage Ⅲ and the remaining as stage Ⅱ .Lung CT was performed in 24 cases, in which mediastinal and hilar lymphadenopathy were found in 22 cases （22/24, 91.7% ）. Diffuse micro-nedular changes （ 19/24, 79.2% ） and mutifocal patchy infiltration （ 13/24, 54.2% ） were the most common parenchymal CT patterns, while the majority of the cases （20/24, 83.3% ） showed at least two different patterns. Lung malignancy, tuberculosis and interstitial fibrosis were the most commonly misdiagnosed entities by radiologists. For methods used to obtain pathological specimens, bronchoscopic examination with mucosal biopsy and/or transbronchial lung biopsy （TBLB） were performed in 21 cases, of which 18 （18/21,85.7%） achieved positive yield. 3 cases with a negative yield via bronchoscopic biopsy and the 5 cases without bronchoscopic biopsy received other biopsy procedures including video-assisted thoracoscopic surgery （VATS） and mediastinal lymph nede biopsy. Conclusions The concurrence of different patterns of parenchymal disease is a feature of lung involvement in sarcoidosis which is prone to be misinterpreted as malignancy and tuberculosis. Bronchoscopic examination and biopsy with the best efficiency to risk ratio is the optimal choice for a pathologic diagnosis.