外周型孤立性肺结节的诊断和外科治疗

Diagnosis and surgical treatment of peripheral solitary pulmonary nodules

目的探讨外周型孤立性肺结节(solitary pulmonary nodule,SPN)的诊断方法和外科治疗策略。方法回顾性分析北京友谊医院胸外科2002年至2009年手术治疗的90例外周型SPN的临床病理资料。结果(1)SPN的术前诊断:在各种诊断方法中,CT引导肺穿刺活检诊断肺癌的准确度达85.7%,Kappa值为0.711;SPECT检查的准确度达93.3%,Kappa值为0.842。(2)外科治疗方法:全部病例先采用胸腔镜辅助下病灶楔形切除,行术中快速冰冻病理检查。如为恶性,则行肺叶切除和纵隔淋巴结清除术。(3)术后病理报告:良性病变和肺癌各占50.0%(45/90)。45例肺癌中,肺腺癌占60.0%(27/45),肺泡细胞癌占28.9%(13/45),其中31.1%(14/45)合并纵隔淋巴结转移(N1),已非早期肺癌。结论SPECT检查是鉴别外周型SPN良恶性的首选无创诊断方法,对可疑肺癌的SPN应积极手术治疗。胸腔镜辅助、术中快速冰冻病理指导下的微创手术,是符合专家共识意见的、外周型SPN的主要治疗策略。

Objective To investigate the diagnosis and surgical treatment procedure of the peripheral solitary pulmonary nodules（SPN）.Methods From 2002 to 2009,ninety patients with peripheral SPNs were operated in the Department of Thoracic Surgery,Beijing Friendship Hospital.Their clinical and pathological data were retrospectively analyzed.Results（1）Among several diagnostic tests,the diagnostic accuracy and Kappa value for CT-guided pulmonary needle biopsy and SPECT were 85.7%,93.3% and 0.711,0.842,respectively.（2）The operative procedures were as follows： firstly,wedge-excision of SPN by video-assisted thoracoscopic surgery,then,intraoperative frozen section diagnosis,immediately followed by lobectomy and excision of the mediastinal lymph nodes if SPN was malignant.（3） Both benign and malignant SPNs accounted for 50 percent in postoperative pathological results.Of 45 malignant SPNs,27 were adenocarcinoma（60.0%）,and 13 were bronchoalveolar cell carcinoma（28.9%）.Fourteen patients with malignant SPNs（31.1%） were found to have mediastinal lymph node metastasis（N1）,which meant that their disease was at advanced stages and was not early.Conclusion SPECT scan is a preferred noninvasive test for identifying a malignant SPN.Surgical operation is necessary for suspected malignant SPN.Thoracoscopy and intraoperative pathological examination of frozen section are frequently used in clinical practice and are the optimal choice,which is consistent with specialist consensus.