表现为间质性肺炎的肺腺癌15例临床分析

Clinical analysis of 15 cases of lung adenocarcinoma presenting as interstitial pneumonia

目的提高对肺腺癌临床表现及影像学多样性的认识,减少误诊。方法回顾性分析2012-07~2015-05收治的15例表现为肺间质性肺炎的肺腺癌临床资料及诊治经过,总结其临床特点、影像学表现及与间质性肺炎的差异,提出诊断线索和方法。结果 15例患者中,男8例,女7例,年龄在44-78岁,平均(56.8±8.2)岁。临床表现为不同程度咳嗽、咳痰、进行性呼吸困难,6例患者发热,体温在37.8-38.8℃。13例肺部可闻及爆裂音。14例患者部分肿瘤标志物增高。15例肺功能弥散功能下降,14例患者血气分析为Ⅰ型呼吸衰竭。胸部CT表现为磨玻璃影,实变、小结节影,网格影。15例患者经抗感染治疗无效。12例患者进行性呼吸困难给予甲强龙治疗,咳嗽,呼吸困难好转,肺部爆裂音减少,动脉血氧分压上升至70-80 mmHg,但胸部CT无明显吸收。经皮肺活检病理诊断为肺腺癌。5例患者拒绝治疗出院,随访3例死亡,生存期2-3个月,2例失访。8例患者给予化疗(GP,DP方案),患者病情好转,后随访8例患者死亡,生存期8-10月。2例EGFR基因突变患者给予化疗(GP方案)及吉非替尼治疗,患者病情明显好转,肺部病变明显吸收,随访3年,病情稳定。结论肺腺癌临床、影像学无特异性,表现形式呈多样性,尤其是部分肺腺癌临床与影像学类似间质性肺炎,易造成误诊。提高对这类型表现的肺腺癌的认识,在临床诊疗过程中发现肺癌的诊断线索,积极行经皮肺活检病理检查,明确诊断。

Objective To improve the understanding of the clinical manifestation and radiologic imaging diversity of lung adenocarci- noma and reduce misdiagnosis. Methods Clinical and imaging data of 15 cases of lung adenocarcinoma presenting as interstitial pneumonia were retrospectively analyzed. The data were collected form Army General Hospital from July 2012 to May 2015. Results All the 15 cases （ 8 males and 7 females, aged 47 - 77 years old, mean 57.5 ± 8. 2 years old） had the symptoms of cough, expectoration and dyspnea in varying degrees. Six cases of them had fever（ 37. 8-38.8 ℃ ）. Coarse crackles was heard in one or two lung fields of 13 patients. Blood tumor markers were elevated in 13 patients. Monoxide diffusion function was reduced in 15 patients. Blood gas analysis presented type I respiratory failure in 14 patients. Chest computed tomography showed ground glass opacities, consolidation with air bronchograms, small nodules shadows and reticulation shadow in two lung fields. The patients all were treated with broad-spectrum anti- biotics and the symptoms were not improved. Among 15 patients, 12 patients with progressive dyspnea received corticosteroid therapy, and then the dyspnea of the patients was improved and the crackles of lung was reduced. Arterial oxygen partial pressure of the patients raised to 70 - 80 mmHg, but the pulmonary lesion of chest CT scan was not absorbed. The patients all were diagnosed as lung adenocar- cinoma by percutaneous lung biopsy. Five patients refused chemotherapy and discharged. Three patients died after 2 - 3 months from the onset and two patients were lost for follow up. Eight patients received chemotherapy and survived for 8 - 10 months. Two patients with EGFR gene mutation were treated with chemotherapy combined with epidermal growth factor receptor inhibitor-gefitinib and still sur- vived after three-year follow-up. Conclusion Clinical manifestation and imaging of lung adenocarcinoma are diverse and non-specif- ic, and even some of them present as interstitial pneumonia. Clinicians must improve the understanding of the lung adenocarcinoma and obtain actively pathologic diagnosis by precutaneous lung biopsy.