影像学检查在胸导管末端探查术治疗淋巴管肌瘤病合并乳糜胸术式选择中的价值

Value of imaging examinations in treatment of lymphangioleiomyomatosis with chylothorax by thoracic duct extremity exploration

目的探讨影像学检查在胸导管末端探查术治疗淋巴管肌瘤病(LAM)合并乳糜胸术式选择中的诊断价值。方法回顾性分析经临床和/或病理证实的34例LAM合并乳糜胸患者的临床和影像学资料。所有患者均接受放射性核素99 Tcm-右旋糖酐(DX)淋巴显像和CT淋巴管造影(CTL)检查。根据99 Tcm-DX淋巴显像对胸导管分型:Ⅰ型为异常浓聚型;Ⅱ型为异位引流型;Ⅲ型为未显影或一过性显影型,Ⅰ型和Ⅱ型为胸导管异常。根据CTL对胸导管分型:Ⅰ型为扩张型;Ⅱ型为末端梗阻型;Ⅲ型为主干缩窄型;Ⅳ型为异位引流型;Ⅴ型为未显示型。以Ⅰ~Ⅳ型为胸导管异常。评价2种方法显示胸导管病变的一致性。结果99 Tcm-DX淋巴显像显示Ⅰ型17例,Ⅱ型3例,Ⅲ型14例。58.82%(20/34)的LAM合并乳糜胸病例存在胸导管病变。CTL显示Ⅰ型15例,Ⅱ型3例,Ⅲ型5例,Ⅳ型2例,Ⅴ型9例,73.53%(25/34)的LAM合并乳糜胸病例存在胸导管病变。2种方法显示胸导管是否存在病变的一致性较好(Kappa=0.679)。CTL胸导管分型中,Ⅰ型和Ⅱ型多采用胸导管—静脉吻合术或胸导管末端松解术解除梗阻,Ⅲ型多采用胸导管末端压迫带/粘连松解术解除梗阻,Ⅳ型根据胸导管异常回流路径来选择手术入路和手术方式,Ⅴ型多采取保守治疗。结论 CTL优于99 Tcm-DX淋巴显像,能准确显示胸导管的病变情况,为胸导管末端探查术治疗LAM合并乳糜胸的术式选择提供影像学依据。

Objective To evaluate the value of imaging examinations in the treatment of lymphangioleiomyomatosis （LAM） with ehylothorax by thoracic duct extremity exploration. Methods Data of 34 LAM with chylothorax confirmed by pathology and clinical diagnosis were retrospectively analyzed. All patients underwent 99Tcm-DX lymphoscintigraphy and CT lymphangiography （CTL）. Thoracic duct lesion types of 99 Tcm-DX lymphoscintigraphy were type I （abnormal concen- tration pattern）, type II （ectopic drainage pattern）, and type III （without image or transient image pattern）. The type I and type II were diagnosed as thoracic duct abnormalities. Thoracic duct lesion types of CTL were type I （dilatation pat- tern）, type II （distal obstruction pattern）, type II （truck constriction pattern）, type IV （ectopic drainage pattern）, and type V （no-display pattern）. Type I -IV were diagnosed as thoracic duct abnormalities. Consistency of displaying tho- racic duct abnormalities between 99Tcm-DX lymphoscintigraphy and CTL was evaluated. Results The thoracic duct abnor- malities in 99Tcm-DX lymphoscintigraphy were 58.82% （20/3; type I in 17, type II in 3, type III in 14）, and in CTL were 73. 53% （25/34; type I in 15, type II in 3, type III in 5, type IV in 2, type V in 9）. The consistency of CTL and 99 Tcm-DX lym- phoscintigraphy for detecting thoracic duct abnormalities was good （Kappa= 0. 679）. In CTL thoracic duct types, type I and II were operated by thoracic duct-venous anastomosis or thoracic duct extremity release operation, type III was operated by thoracic duct adhesion or compression band release operation, operative approach and method were chosen according to the abnormal thorac- ic duct flow path in type IV, type V was took conservative treatment. Conclusion CTL is superior to 99Tcm-DX lymphoscintigra- phy, which can clearly display the type of thoracic duct lesion and provide imaging inforrnations to choose operation methods in tho- racic duct exploration treatment for LAM with chylothorax.