孤立性肺结节早期诊治的临床策略

Early Diagnosis and Treatment of Solitary Pulmonary Nodules

目的 探讨孤立性肺结节（solitary pulmonary nodule，SPN）早期诊治的临床策略，明确肿瘤标志物、术前CT引导下亚甲蓝联合Hookwire针穿刺定位技术及电视胸腔镜手术（video-assisted thoracoscopic surgery，VATS）在孤立性肺结节早期诊治中的意义。方法回顾性分析2011年1月至2014年2月泰兴市人民医院胸外科70例孤立性肺结节患者的临床资料，其中男33例、女37例，年龄32～87（59．74±2．04）岁。收集病史，术前行心肺、肝肾功能、痰细胞学和支气管镜等常规检查，联合检测肺癌血清肿瘤标志物进行初步的良恶性诊断，并作手术风险评估。对孤立性肺结节直径小于1cm或肺内小结节预计术中无法准确定位者，术前半小时行常规CT引导下亚甲蓝与Hookwire联合定位；对肺结节较大预计术中可准确定位者，可直接行VATS肺结节及周围肺组织的楔形切除术。术中快速冰冻病理检查，如病理检查为恶性病变则行规范肺叶切除或肺段切除加系统性淋巴结清扫术，如病理检查为良性病变则结束手术。对孤立性肺结节患者特别是早期肺癌患者作长期的随访。结果住院期间无死亡，无支气管胸膜瘘发生，并发肺部感染2例、气胸3例、切口感染1例，经对症治疗后均治愈或好转出院。本组70例患者中有11例术前行肺穿刺获得病理诊断；59例患者中有12例肺结节偏中央型，术中穿刺活检，47例患者在VATS下行肺结节切除术，病理诊断结果为：腺癌19例，鳞癌9例，细支气管肺泡癌3例，腺鳞癌2例，炎I生假瘤11例、肺结核球4例，肉芽肿5例，硬化性血管瘤2例，乳腺癌肺转移1例，结肠癌肺转移1例，甲状腺癌肺转移1例，胃癌肺转移1例。随访70例（100％），随访时间2～34个月，无死亡，1例右肺上叶腺癌患者术后18个月发生脑转移，目前在接受放疗中，其余患者生存质量良好。结论对孤立性肺结节患者采用上述诊治策略诊断率高、创伤小、患者恢复快，近期效果满意。

Objective To explore clinical strategies of early diagnosis and treatment of solitary pulmonary nodules （SPN）, and define the importance of biological tumor markers, preoperative CT-guided localization with the combination of methylene blue and hookwire system, and video-assisted thoracoscopic surgery （VATS） for early diagnosis and treatment of SPN. Methods We retrospectively analyzed clinical records of 70 SPN patients in Department of Thoracic Surgery of Taixing People＇s Hospital from January 2011 to February 2014. There were 33 male and 37 female patients with their age of 32-87 （59.74±2.04） years. Preoperatively, patients＇ medical history, heart, lung, liver and kidney function, spu- turn cytology and bronchoscopic biopsy results were combined with biological tumor markers to make a preliminary dif- ferential diagnosis between benign or malignant SPN and surgical risk evaluation. For SPN less than 1 cm or too small for accurate intraoperative localization, CT-guided localization with the combination of methylene blue and hookwire system was routinely performed half an hour before the operation. For SPN large enough for accurate intraoperative localization,wedge resection of SPN and surrounding lung tissue was directly performed with VATS. Intraoperative frozen-section examination of resected lung specimens was preformed. If the pathological diagnosis was malignant, conventional VATS lobectomy/segmentectomy and lymphadenectomy were performed. If the pathological diagnosis was benign, the operation was then completed. Long-term follow-up was performed for SPN patients, especially patients with early-stage lung cancer. Results There was no in-hospital death or postoperative bronchopleural fistula in this study. Postoperatively, there were 2 patients with pneumonia, 3 patients with pneumothorax and 1 patient with wound infection, who were all cured or improved after proper treatment. Among the 70 patients, 11 patients acquired pathological diagnosis via preoperative lung needle bi- opsy. Among the other 59 patients, 12 patients with eccentric SPN acquired pathological diagnosis via intraoperative biop- sy, and 47 patients underwent SPN resection with VATS. Pathological diagnosis included adenocarcinoma in 19 patients, squamous cell carcinoma in 9 patients, bronchioloalveolar carcinoma in 3 patients, adenosquamous carcinoma in 2 patients, inflammatory pseudotumor in 11 patients, tuberculoma in 4 patients, granuloma in 5 patients, sclerosing hemangioma in 2 patients, lung metastasis from breast cancer in 1 patient, lung metastasis from colon cancer in 1 patient, lung metastasis from thyroid cancer in 1 patient, and lung metastasis from stomach cancer in 1 patient. All the 70 patients （100%） were followed up for a mean duration of 2-34 months, and there was no late death during follow-up. One patient with adenocar- cinoma of the right upper lobe had cerebral metastasis 18 months after operation, and had been receiving radiotherapy. All the other patients had a good quality of life. Conclusion Above clinical strategies are accurate for early diagnosis and minimally invasive treatment of SPN with good postoperative recovery and short-term outcomes.