经支气管镜针吸活检在纵隔及肺部疾病中的诊断价值
|
摘要
研究目的：探讨经支气管镜针吸活检术(TBNA)在纵隔及肺部疾病中的诊断价值。
研究方法：山东省立医院呼吸内科2005年3月至2006年10月期间，对89例胸部CT检查提示纵隔淋巴结肿大、肺部占位性病变、常规支气管镜检查未见管腔内明显病变患者行经支气管镜针吸活检术，观察其诊断阳性率。其中男59例，女30例，年龄15～78岁。根据胸部薄层强化CT，按照WANG氏定位法确定穿刺部位、角度和深度。采用OLYMPUS BF-240电子支气管镜，WANG氏穿刺针。
患者常规术前准备、局部麻醉后，将电子支气管镜经鼻、声门插入气管，按支气管树顺序检查，观察腔内有无可视性病变。确定穿刺部位，将WANG氏针沿气管镜活检通道插入气道，采用推进法结合猛刺法、咳嗽法穿透支气管壁，刺入纵隔淋巴结、腔外病变内，抽取标本。将穿刺物用力推出，涂片、固定，送细胞或病理检查。每一部位至少进行2个点穿刺，以提高阳性率。TBNA完成后，再于支气管相应病变部位反复进行刷检，同样涂于玻片，固定，送检。
结果：
1．常规支气管镜检查结果：
89例患者的气道粘膜均结构完整，未见新生物，未见溃疡及糜烂，未见活动性出血，刷检阳性率12.36％(11／89)。
22例单纯纵隔淋巴结肿大患者，13例气管镜检查无气管粘膜及管腔内改变，9例气管呈轻度外压性改变；
49例肺部占位性病变合并纵隔淋巴结肿大患者，窥见支气管管腔外病变的间接征像29例，13例病灶区域(穿刺部位)有支气管粘膜充血、水肿，余7例管腔结构无异常：
8例单纯支气管管腔外压性狭窄患者管腔闭锁2例，半阻塞性狭窄9例，管腔轻度狭窄7例。
2．TBNA检查结果：
89例患者均行TBNA检查，共穿刺251次，确诊74例，诊断阳性率83.15％(74／89)。
对22例单纯纵隔淋巴结肿大患者行纵隔淋巴结穿刺，确诊18例，诊断阳性率为81.82％；49例肺部占位性病变合并纵隔淋巴结肿大患者TBNA确诊42例(占病例总数的85.71％)；18例支气管管腔外占位患者确诊14例，诊断阳性率77.78％。
结论及意义：①TBNA在单纯纵隔病变的诊断及肺癌分期方面有独特优势，敏感性高，并可进行病理分型，可部分代替纵隔镜检查。②对影像学提示支气管管腔狭窄的外压性病变、管腔内基本正常的患者，由于常规气管镜的活检手段如钳检及毛刷等不能较好地获取标本，经支气管镜针吸活检术作为一种独特的检查和诊断方法，在此类病例的诊断中同样发挥了重要的作用，使大部分病例的诊断得以明确。③TBNA相对于对纵隔镜、经皮肺活检和剖胸探查术等手段而言，是一种简单、安全、经济、实用、无严重并发症的检查技术，有较大发展前途，适合广泛推广及普及。
Objective: To evaluate the value of transbronchial needle aspiration (TBNA) in the diagnosis of mediastinum and pulmonary diseases.
Methods: 89 consecutive patients (59 males and 30 females) referred to the Department of Pulmonary Medicine, Shandong Provincial Hospital, between March 2005 and October 2006 with mediastinal lymphadenectasis, extrabronchial occupying lesions on CT, were included in this study. The age range was 15～78 yrs. We have not included any cases with concomitant endobronchial lesions.
TBNA was performed with Wang needle, using electronic bronchoscope (BF-240;Olympus).
Following local anesthesia (lidocaine 2%), introduced the electronic bronchoscope transnasally. After a careful examination of the bronchial, provided no endobronchial lesions were identified, the mediastinal lymphaden or extrabronchial lesion was approached first by TBNA and then by brush. Inserted the WANG needle in the retracted position through the work channel of the bronchoscope, reached the lesion by pushing the needle into the corresponding segmental bronchus, then applied suction. Direct smear technique was used for preparation of TBNA specimens. Specifically, needle content was coated on a glass slide and fixed, for cytologic examination. TBNA procedures were repeated at least 2 times every lesion to increase the positive rate. Results:
1. The results of routine bronchoscopy:
The tunica mucosa bronchiorum were integrated in all the 89 cases, neoplasm, ulcer ,erosion and active hemorrhage were not found;the positive rate of the brush was 12.36%(11/89).
Of the 22 patients with simple mediastinal lymphadenectasis, the tunica mucosa bronchiorum and lumens were completely normal in 13 cases;lightly compressed changes of the bronchus were found in 9 cases.
During the 49 patients with combined lung disease and mediastinal lymphadenectasis,29 cases showed indirect signs of extrabronchial lesions, 13 cases found bronchial mucosa swollen, hyperemic, 7 cases did not find any abnormal signs.
18 cases of extrabronchial dieases, the lumens were locked in 2 cases, half-locked in 9 cases, low-degree stenosis in 7 cases.
2. The results of TBNA:
74 of 89 cases reached the final diagnosis by TBNA, the diagnostic yield was 83.15% (74/89) .
18 of the 22 patients with simple mediastinal lymphadenectasis, reached the final diagnosis, the diagnostic yield was 81.82%; 42 of 49 patients with combined lung disease and mediastinal lymphadenectasis, reached the final diagnosis, the diagnostic yield was 85.71%; 18 cases of extrabronchial dieases, 14 cases got final diagnosis, the diagnostic yield was 77.78%.
Conclusions:
(1) TBNA has its own unique superiority in the diagnosing of simple mediastinal lymphadenectasis and in the staging of lung cancer, has high sensitivity, can partly take the place of the mediastinoscopy. (2) TBNA could get the final diagnosis of most of extrabronchial lesions which
routine bronchoscopy( brush smear,biopsy) can not even get the specimen. (3) TBNA is generally more convenient, less risky, and less expensive for diagnosing lung diseases.
研究方法：山东省立医院呼吸内科2005年3月至2006年10月期间，对89例胸部CT检查提示纵隔淋巴结肿大、肺部占位性病变、常规支气管镜检查未见管腔内明显病变患者行经支气管镜针吸活检术，观察其诊断阳性率。其中男59例，女30例，年龄15～78岁。根据胸部薄层强化CT，按照WANG氏定位法确定穿刺部位、角度和深度。采用OLYMPUS BF-240电子支气管镜，WANG氏穿刺针。
患者常规术前准备、局部麻醉后，将电子支气管镜经鼻、声门插入气管，按支气管树顺序检查，观察腔内有无可视性病变。确定穿刺部位，将WANG氏针沿气管镜活检通道插入气道，采用推进法结合猛刺法、咳嗽法穿透支气管壁，刺入纵隔淋巴结、腔外病变内，抽取标本。将穿刺物用力推出，涂片、固定，送细胞或病理检查。每一部位至少进行2个点穿刺，以提高阳性率。TBNA完成后，再于支气管相应病变部位反复进行刷检，同样涂于玻片，固定，送检。
结果：
1．常规支气管镜检查结果：
89例患者的气道粘膜均结构完整，未见新生物，未见溃疡及糜烂，未见活动性出血，刷检阳性率12.36％(11／89)。
22例单纯纵隔淋巴结肿大患者，13例气管镜检查无气管粘膜及管腔内改变，9例气管呈轻度外压性改变；
49例肺部占位性病变合并纵隔淋巴结肿大患者，窥见支气管管腔外病变的间接征像29例，13例病灶区域(穿刺部位)有支气管粘膜充血、水肿，余7例管腔结构无异常：
8例单纯支气管管腔外压性狭窄患者管腔闭锁2例，半阻塞性狭窄9例，管腔轻度狭窄7例。
2．TBNA检查结果：
89例患者均行TBNA检查，共穿刺251次，确诊74例，诊断阳性率83.15％(74／89)。
对22例单纯纵隔淋巴结肿大患者行纵隔淋巴结穿刺，确诊18例，诊断阳性率为81.82％；49例肺部占位性病变合并纵隔淋巴结肿大患者TBNA确诊42例(占病例总数的85.71％)；18例支气管管腔外占位患者确诊14例，诊断阳性率77.78％。
结论及意义：①TBNA在单纯纵隔病变的诊断及肺癌分期方面有独特优势，敏感性高，并可进行病理分型，可部分代替纵隔镜检查。②对影像学提示支气管管腔狭窄的外压性病变、管腔内基本正常的患者，由于常规气管镜的活检手段如钳检及毛刷等不能较好地获取标本，经支气管镜针吸活检术作为一种独特的检查和诊断方法，在此类病例的诊断中同样发挥了重要的作用，使大部分病例的诊断得以明确。③TBNA相对于对纵隔镜、经皮肺活检和剖胸探查术等手段而言，是一种简单、安全、经济、实用、无严重并发症的检查技术，有较大发展前途，适合广泛推广及普及。
Objective: To evaluate the value of transbronchial needle aspiration (TBNA) in the diagnosis of mediastinum and pulmonary diseases.
Methods: 89 consecutive patients (59 males and 30 females) referred to the Department of Pulmonary Medicine, Shandong Provincial Hospital, between March 2005 and October 2006 with mediastinal lymphadenectasis, extrabronchial occupying lesions on CT, were included in this study. The age range was 15～78 yrs. We have not included any cases with concomitant endobronchial lesions.
TBNA was performed with Wang needle, using electronic bronchoscope (BF-240;Olympus).
Following local anesthesia (lidocaine 2%), introduced the electronic bronchoscope transnasally. After a careful examination of the bronchial, provided no endobronchial lesions were identified, the mediastinal lymphaden or extrabronchial lesion was approached first by TBNA and then by brush. Inserted the WANG needle in the retracted position through the work channel of the bronchoscope, reached the lesion by pushing the needle into the corresponding segmental bronchus, then applied suction. Direct smear technique was used for preparation of TBNA specimens. Specifically, needle content was coated on a glass slide and fixed, for cytologic examination. TBNA procedures were repeated at least 2 times every lesion to increase the positive rate. Results:
1. The results of routine bronchoscopy:
The tunica mucosa bronchiorum were integrated in all the 89 cases, neoplasm, ulcer ,erosion and active hemorrhage were not found;the positive rate of the brush was 12.36%(11/89).
Of the 22 patients with simple mediastinal lymphadenectasis, the tunica mucosa bronchiorum and lumens were completely normal in 13 cases;lightly compressed changes of the bronchus were found in 9 cases.
During the 49 patients with combined lung disease and mediastinal lymphadenectasis,29 cases showed indirect signs of extrabronchial lesions, 13 cases found bronchial mucosa swollen, hyperemic, 7 cases did not find any abnormal signs.
18 cases of extrabronchial dieases, the lumens were locked in 2 cases, half-locked in 9 cases, low-degree stenosis in 7 cases.
2. The results of TBNA:
74 of 89 cases reached the final diagnosis by TBNA, the diagnostic yield was 83.15% (74/89) .
18 of the 22 patients with simple mediastinal lymphadenectasis, reached the final diagnosis, the diagnostic yield was 81.82%; 42 of 49 patients with combined lung disease and mediastinal lymphadenectasis, reached the final diagnosis, the diagnostic yield was 85.71%; 18 cases of extrabronchial dieases, 14 cases got final diagnosis, the diagnostic yield was 77.78%.
Conclusions:
(1) TBNA has its own unique superiority in the diagnosing of simple mediastinal lymphadenectasis and in the staging of lung cancer, has high sensitivity, can partly take the place of the mediastinoscopy. (2) TBNA could get the final diagnosis of most of extrabronchial lesions which
routine bronchoscopy( brush smear,biopsy) can not even get the specimen. (3) TBNA is generally more convenient, less risky, and less expensive for diagnosing lung diseases.
引文
[1] Manser RL, Ievirg LB, Bymes G, Abamson MJ, et al.Screening for lung cancer: a systematic review and meta-analysis of controlled trials[J].Thorax,2003,58(9):784～789.
[2] 董碧落，何萍．从循证医学角度谈早期肺癌的筛查[J]．中国循证医学杂志，2004，4(6)：419-422．
[3] Killian G.. Ueber directe Bronchoscopie. MMW, 1898, 27: 844～847.
[4] 李强．呼吸内镜学[M]．上海：上海科学技术出版社，2004．126-127．
[5] Wang KP,Terry PB, Marsh B.Bronchoscopic needle aspiration biopsy of paratracheal tumors[J]. Am Rev Respir Dis, 1978,118:17～21
[6] Wang KP,Brower, R, Haonik EK,et al. Flexible transbronchial needle aspiration for staging of bronchogenic carinoma[J]. Chest, 1983,84:571～576
[7] 张捷，王长利．支气管镜发展史[J]．中华医史杂志，2006，36(2)：96～99．
[8] Suter M, Meyer A. A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe? [J].Surg Endosc,2001,15(10): 1187～1192
[9] Wang KP. Staging of brochogentic carcinoma by brochoscopy [J] Chest,1994,106:588～593.
[10] 贾龑婷，杨艳娜，王西艳，等．经支气管镜针吸活检术在纵隔及肺部疾病诊断中的价值[J]．山东医药，2006，47(5)：39～40．
[11] 王瑞，王增林，陈宇，等．经气管镜针吸活检对肺癌的诊断价值[J]．中国内镜杂志，2000，6(8)：3～4．
[12] 王瑞，韩建京，姚计方，等．经气管镜针吸活检在肺癌分期中的作用[J]冲国肺癌杂志，2002，5(4)：284～2861．
[13] Arita T, Matsumoto T, Kuramitsu T, et al. Is it possible to differentiate malignant mediastinal nodes from benign nodes by size? Reevaluation by CT, transesophageal echocardiography and nodal specimen[J]. Chest, 1996, 110:1004～1008.
[14] Takeshi A, Tatsuya K, Mitsutoshi M. Bronchogenic carcinoma: incidence of metastases to normal sized lymph nodes[J]. Thorax, 1995, 50:1267～1269.
[15] Lahde S, Paivansalo M, Rainio P. CT for predicting the resectability of lung cancer. A prospective study[J]. Acta Radiol, 1991, 32:449～454.
[16] Gould MK, Kuschner WG, Rydzak CE, et al. Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer[J]. Ann Intern Med, 2003, 139:879～892.
[17] Rami Porta R. Surgical exploration of the mediastinum by mediastinoscopy, parasternal mediastinotomy and remediastinoscopy: indications, technique and complications[J]. Ann Ital Chir,1999, 70:867～872.
[18] Hujala KT, Sipila JI, Grenman R. Mediastinoscopy: its role and value today in the differential diagnosis of mediastinal pathology[J]. Acta Oncol, 2001,40:79～82.
[19] Detterbeck FC, DeCamp MM Jr, Kohman LJ, et al. Lung cancer. Invasive staging: the guidelines[J].Chest, 2003,123(1 Suppl): 167～75S.
[20] Shure D. Fiberoptic bronchoscopy: diagnostic applications[J]. Clin Chest Med, 1987,8:1～13.
[21] Toloza EM, Harpole L, Detterbeck F, et al. Invasive staging of non-small cell lung cancer: a review of the current evidence[J]. Chest, 2003,123(1 Suppl):157～66S.
[22] 王国忠．经纤维支气管镜针吸活检在肺部疾病诊断中的应用[J]．浙江医学，2002，24(9)：563～564
[23] 吴琦，董丽霞，谢巍，等．经纤维支气管镜针吸活检对纵隔肿大淋巴结的诊断价值[J]．实用癌症杂志，2003，18(1)：95．
[24] 李玉光，张罗献，王凯，等．经纤维支气管镜针吸术对纵隔淋巴结肿大及支气管腔外肺肿瘤的诊断意义[J]．中国综合临床，2005，2l(2)：118～119
[25] Dasgup ta A, Jain P, Minai OA, et al. Utility of transbronchial needle aspiration in the diagnosis of endobronchial lesions[J]. Chest, 1999, 115(5): 1237～1241.
[26] Fritscher Ravens A, Sriram PV, Bobrowski C, et al. Mediastinal lymphadenopachy, in patients with or without previous mali gnancy:EUS-FNA based differential cytodiagoosis in 153 patients[J]. Am J Gastoenterol,2000,95(9): 2278.
[27] 孙思予，王孟春，王彩霞，等．超声内镜引导下细针穿刺活检对上消化道肿大淋已结的诊断[J]．世界华人消化杂志，2000，8(11)：1319．
[28] Hawes R, Gress F, Kesler K, et al. Endoscopic ultrasound versus CT in the evaluation of the mediastinum in patients with no small cell lung cancer[J].Endoscopy, 1994,26:784～787.
[29] Potepan P, Meroni E, Spagnoli L, et al. Non-small cell lung cancer: detection of mediastinal lymph node metastases by endoscopic ultrasound and CT[J]. Eur Radiol, 1996,6:19～27.
[30] Hasegawa N. Niwa Y, Arisawa T,et al. Preoperativc staging of superficial esophageal. carcinoma: comparison of an ultrasound probe and standard endoscopic ultrasonography[J]. Gastrointest Endose, 1996, 44:388.
[31] 王云喜，孙玉鹤．腔内超声在肺癌诊断中的应用[J]．中华外科杂志，1998，6(2)：86．
[32] J-E C Holty, W G Kuschner, M K Gould. Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis[J]. Thorax 2005,60:949～955.
[1] 滕洪，马富锦，曲家骐等．X线、CT和B超联合检查诊断纵隔肿瘤和囊肿的临床应用价值[J]．综合临床医学，1991，7(2)：74～76．
[2] 蔡曙波，徐阳，周婕．CT扫描在纵隔占位性病变中的诊断价值[J]．实用医技杂志，2006，13(3)：335～336．
[3] Lewis JMJr, Pearlberg JL, Beute GH, et al. Can computed tomography of chest stage lung cancer? yes and no[J]. Ann Thorac Surg, 1990, 49 (6): 591～596.
[4] Suzuki K, Nagai K, Yoshida J, et al. Clinical predictors of N2 disease in the setting of a negative computed tomographic scan in patients with lung cancer[J]. J Thorac Cardiovasc Surg,1999,177(3): 593～598.
[5] 于红，李惠民，肖湘生．纵隔病理性淋巴结的CT研究现状[J]．国外医学临床放射学分册，2004，7(5)：303～307．
[6] Mukaida N, Zachariae CCO, Gusella GI, et al. Dexam ethasone inhibits the induction of monocyte chemotactic activating factor production by JL-1 or tumor necrosis factor[J]. J Immunol, 1991, 146:1212～1215.
[7] Kim Y, Lee KS, Yoo J H, et al. Middle mediastinal lesions: imaging findings and pat hologic correlation[J]. Eur J Radiol, 2000,35(1): 30～38.
[8] Kerry M,Lawrence J,James C,et al.Magnetic resonance imaging of the mediastinum[J].Journal of Thoracic Imaging, 1993,8(1):34.
[9] 卢光明，苏学曾．磁共振成像诊断纵隔肿块的价值[J]．中国医学影像技术，1991，7(4)：69～70．
[10] Koganemaru M, Fujimoto'K, Nishimuta H, et al. Hilar and mediastinal lymph node metastases from lung cancer: detection with CT and MR imaging [J].Rinsho Hoshasen, 1990,35(7):811～819.
[11] Crisci R, Di Cesare E, Lupattelli L, et al. MR study of N_2 disease in lung cancer: contrast-enhanced method using Gadolinium-DTPA[J]. Eur J cardiothorac Surg, 1997,11(2):214～217.
[12] Yokoi K, Kamiya N, Matsuguma H, et al. Detection of brain metastases in potentially operable non-small cell lung cancer: a comparion of CT and MRI[J]. Chest, 1999,115(3)714～719.
[13] Deslauners J, Gregoire J. Clinical and surgical staging of non-small cell lung cancer[J]. Chest,2000,117(4):96～103.
[14] Grover FL. The role of CT and MRI in staging of the mediastinum [J].Chest, 1994,106(6):391～396.
[15] Bonemo L, Ciccotosto C, Guidotti A, et al. Lung cancer staging: The role of computed tomography and magnetic resonance imaging[J]. Eur J Radiol, 1996,23(1):35～45.
[16] 虞登高，吕晓波，牛汝朴．隐匿性肺癌及其纵隔转移的MRI诊断[J]．实用医学影像杂志，2001，2(1)：22～24．
[17] 安宁豫，高元桂，蔡幼锉，等．增强MRI在原发性支气管肺癌分期中的价值[J]．中华放射学杂志，1998，32(4)：323～327．
[18] 王瑞，王增林，陈宇，等．经气管镜针吸活检对肺癌的诊断价值[J]．中国内镜杂志，2000，6(8)：3～4．
[19] 王瑞，韩建京，姚计方，等．经气管镜针吸活检在肺癌分期中的作用[J]．中国肺癌杂志，2002，5(4)：284～286．
[20] 蒋捍东，程兆忠，刘淑红，等．经气管镜针吸活检诊断纵隔疾病的价值[J]．山东医药，2004，44(7)：9～10．
[21] Wang KP. Brower R. Haponnrk EF. et al. Flexiblc trans-bronchial needle aspirtion for bronchogenic carcinoma [J]. Chest,1983,84 (5):571～576.
[22] Shure D. Fedullo PF. The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma[J]. Chest, 1984,86(5):693～696
[23] 朱纯儒，周谦让，刘邦荣，等．经支气管针吸活检对肺癌术前TNM分期与术后分期的对比分析[J]．安徽医学，2005，26(3)：168～170．
[24] Toloza EM, Harpole L, Detterbeck F, et al. Invasive staging of non-small cell lung cancer: a review of the current evidence[J]. Chest, 2003,123(1 Suppl): 157～66S.
[25] J-E C Holty, W G Kuschner, M K Gould, Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis[J]. Thorax, 2005,60:949～955.
[26] Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial[J]. Chest,2004,125(1):322～325.
[27] Fritscher Ravens A, Sriram PV, Bobrowski C, et al. Mediastinal lymphadenopachy, in patients with or without previous mali gnancy:EUS-FNA based differential cytodiagoosis in 153 patients[J]. Am J Gastoenterol, 2000,95(9): 2278.
[28] 孙思予，王孟春，王彩霞，等．超声内镜引导下细针穿刺活检对上消化道肿大淋已结的诊断[J]．世界华人消化杂志，2000，8(11)：1319．
[29] Hawes R, Gress F, Kesler K, et al. Endoscopic ultrasound versus CT in the evaluation of the mediastinum in patients with no small cell lung cancer[J].Endoscopy, 1994,26:784～787.
[30] Potepan P, Meroni E, Spagnoli L, et al. Non-small cell lung cancer: detection of mediastinal lymph node metastases by endoscopic ultrasound and CT[J]. Eur Radiol, 1996,6:19～27.
[31] Hasegawa N. Niwa Y, Arisawa T,et al. Preoperativc staging of superficial esophageal. carcinoma: comparison of an ultrasound probe and standard endoscopic ultrasonography[J]. Gastrointest Endose, 1996,44:388.
[32] 王云喜，孙玉鹤．腔内超声在肺癌诊断中的应用[J]．中华外科杂志，1998，36(2)：86．
[33] Weng E, Tran I, Rege S. Accuracy and clinical impact of mediastinal lymph node staging with FDG-PET imaging in potentially respectable lung cancer[J]. Am J Clin Oncol,2000,23 (1):47～52.
[34] Vansteenkiste JF. PET scan in the staging of non-small cell lung cancer[J]. Lung Cancer,2003,42(suppll):s27～37.
[35] Gupta NC, Graeber GM, Bishop HA. Comparative efficacy of positron emission tomography with fluorodeoxyglucose in evaluation of small(＜1cm), intermediate (1 to3 cm), and large (＞3 cm) lymph-node lesion[J]. Chest,2000, 117: 773～778.
[36] Vansteenkiste JF, Stroobants SG, De Leyn PR, et al. Lymph node staging in non small2cell lung cancer with FDG-PET scan: a prospective study on 690 lymph node staging from 68 patients[J].J Clin Ocol, 1998, 16: 2142～2149.
[37] 支修益，刘宝东，许庆生，等．CT和正电子发射计算机断层摄影显像对确定非小细胞肺癌纵隔淋巴结转移的临床价值[J]．中华医学杂志，2005，85(29)：2026～2029．
[38] Venissac N, Alifano M,Mouroux J Video-Assisted Mediastinoscopy: Experience From 240 Consecutive Cases[J]. Annn Yhorac Surg, 2003, 76:208～212.
[39] 傅尧箕．纵隔镜检查术[J]．中华外科杂志，1965，13：760～761
[40] 刘向阳，张大为，张汝刚，等．纵隔镜在纵隔肿物诊断中的临床价值[J]．中华肿瘤杂志，2000，22：238～240．
[41] 赵辉，王俊，刘军，等．纵隔镜检查在胸部疾病诊断及肺癌分期中的价值[J]．中国胸心血管外科杂志，2003，10：131～133
[42] 王欣，黄植蕃，戎铁华，等．纵隔镜的诊断价值及在肺癌分期中的应用[J]．中华肿瘤杂志，2002，24：74～77
[43] Venissac N, Alifano M, Mouroux J. Video-Assisted Mediastinoscopy: Experience From 240 Consecutive Cases[J]. Annn Thorac Surg, 2003, 76:208～212.
[44] 王俊，赵辉．纵隔镜术及其在肺癌分期中的应用价值[J]．中华胸心血管外科杂志，2002，18：190～191．
[45] Hazelrigg Y, Landreneau M. Minimal Access Cardiothracic Surgery[J]. Philadelphia:W.B. Saunders Company,2002,169～174.
[46] Potepan P, Meroni E, Spagnolil, et al. Non-small-cell lung cancer: detection of mediastinal lymph node metastases by e doscopic ultrasound and CT[J].Eur Radiol, 1996,6:19.
[47] Wang KY, Lin CY, Kuo-Tai J, et al. Use of transesophageal echocardiography for evaluation of respectability of lung cancer[J]. Acta Anaesthesiol Sin,1994,32: 255.
[48] Lynch M, Balk MA, Lee RB, et al. Role of transesophageal echocardiography in the management of patients with bronchogenic carcinoma invading the left atrium[J]. Am J Cardiol,1995,76:1101.
[49] Suriani R, Konstadt S, Camunas J, et al. Transesophageal echocardiographic detection of left atrial involve ment of lung tumor[J].J Cardiothorac Vasc Anesth, 1993,7:73.
[50] Bressler EL, Kirkham JA, Mediastinal masses: alternative approaches to CT—guided needle biopsy[J]. Radiology, 1994, 191 (2): 391～396.
[51] 王欣，高桂芬，刘晓杰．纵隔肿块CT导向经皮穿刺活检的精确性和安全性[J]．哈尔滨医科大学学报，2005，39(1)：82～84．
[52] Watanabc M,Takagi T,Aoki T,et al. A comparison of biopsy through a parastemal anterior mediastinotomy under local ancsthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors[J]. Surg Today, 1998,28(10): 1022～1026.
[53] Belfiore C, Camera L, Moggio C,et al. Middle mediastinum lesions: preliminary experience with CT-guided fine-needle aspiration biopsy with asuprasternal approach[J].Radiology, 1997, 202 (3): 870～873.
[55] Li H,Bioselle PM. Diagnostic accuracy and safety of CT guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules[J] .A JR, 1996,167:105.
[56] Watanabc M,Takagi T,Aoki T,et al. A comparison of biopsy through aparast ernal anterior mediastinotomy under local ancsthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors[J]. Surg Today, 1998, 28(10): 1022～1026.
[57] 廖锦堂，黄渊金，肖萤等．超声引导下经皮纵隔肿瘤穿刺自动活检的应[J]．中国医师杂志，2003，5(8)：1038～1039．
[58] Vansteenkiste JF. PET scan in the staging of non-small cell lung cancer[J].Lung Cancer,2003,42(suppll):s27～37.
[2] 董碧落，何萍．从循证医学角度谈早期肺癌的筛查[J]．中国循证医学杂志，2004，4(6)：419-422．
[3] Killian G.. Ueber directe Bronchoscopie. MMW, 1898, 27: 844～847.
[4] 李强．呼吸内镜学[M]．上海：上海科学技术出版社，2004．126-127．
[5] Wang KP,Terry PB, Marsh B.Bronchoscopic needle aspiration biopsy of paratracheal tumors[J]. Am Rev Respir Dis, 1978,118:17～21
[6] Wang KP,Brower, R, Haonik EK,et al. Flexible transbronchial needle aspiration for staging of bronchogenic carinoma[J]. Chest, 1983,84:571～576
[7] 张捷，王长利．支气管镜发展史[J]．中华医史杂志，2006，36(2)：96～99．
[8] Suter M, Meyer A. A 10-year experience with the use of laparoscopic cholecystectomy for acute cholecystitis: is it safe? [J].Surg Endosc,2001,15(10): 1187～1192
[9] Wang KP. Staging of brochogentic carcinoma by brochoscopy [J] Chest,1994,106:588～593.
[10] 贾龑婷，杨艳娜，王西艳，等．经支气管镜针吸活检术在纵隔及肺部疾病诊断中的价值[J]．山东医药，2006，47(5)：39～40．
[11] 王瑞，王增林，陈宇，等．经气管镜针吸活检对肺癌的诊断价值[J]．中国内镜杂志，2000，6(8)：3～4．
[12] 王瑞，韩建京，姚计方，等．经气管镜针吸活检在肺癌分期中的作用[J]冲国肺癌杂志，2002，5(4)：284～2861．
[13] Arita T, Matsumoto T, Kuramitsu T, et al. Is it possible to differentiate malignant mediastinal nodes from benign nodes by size? Reevaluation by CT, transesophageal echocardiography and nodal specimen[J]. Chest, 1996, 110:1004～1008.
[14] Takeshi A, Tatsuya K, Mitsutoshi M. Bronchogenic carcinoma: incidence of metastases to normal sized lymph nodes[J]. Thorax, 1995, 50:1267～1269.
[15] Lahde S, Paivansalo M, Rainio P. CT for predicting the resectability of lung cancer. A prospective study[J]. Acta Radiol, 1991, 32:449～454.
[16] Gould MK, Kuschner WG, Rydzak CE, et al. Test performance of positron emission tomography and computed tomography for mediastinal staging in patients with non-small-cell lung cancer[J]. Ann Intern Med, 2003, 139:879～892.
[17] Rami Porta R. Surgical exploration of the mediastinum by mediastinoscopy, parasternal mediastinotomy and remediastinoscopy: indications, technique and complications[J]. Ann Ital Chir,1999, 70:867～872.
[18] Hujala KT, Sipila JI, Grenman R. Mediastinoscopy: its role and value today in the differential diagnosis of mediastinal pathology[J]. Acta Oncol, 2001,40:79～82.
[19] Detterbeck FC, DeCamp MM Jr, Kohman LJ, et al. Lung cancer. Invasive staging: the guidelines[J].Chest, 2003,123(1 Suppl): 167～75S.
[20] Shure D. Fiberoptic bronchoscopy: diagnostic applications[J]. Clin Chest Med, 1987,8:1～13.
[21] Toloza EM, Harpole L, Detterbeck F, et al. Invasive staging of non-small cell lung cancer: a review of the current evidence[J]. Chest, 2003,123(1 Suppl):157～66S.
[22] 王国忠．经纤维支气管镜针吸活检在肺部疾病诊断中的应用[J]．浙江医学，2002，24(9)：563～564
[23] 吴琦，董丽霞，谢巍，等．经纤维支气管镜针吸活检对纵隔肿大淋巴结的诊断价值[J]．实用癌症杂志，2003，18(1)：95．
[24] 李玉光，张罗献，王凯，等．经纤维支气管镜针吸术对纵隔淋巴结肿大及支气管腔外肺肿瘤的诊断意义[J]．中国综合临床，2005，2l(2)：118～119
[25] Dasgup ta A, Jain P, Minai OA, et al. Utility of transbronchial needle aspiration in the diagnosis of endobronchial lesions[J]. Chest, 1999, 115(5): 1237～1241.
[26] Fritscher Ravens A, Sriram PV, Bobrowski C, et al. Mediastinal lymphadenopachy, in patients with or without previous mali gnancy:EUS-FNA based differential cytodiagoosis in 153 patients[J]. Am J Gastoenterol,2000,95(9): 2278.
[27] 孙思予，王孟春，王彩霞，等．超声内镜引导下细针穿刺活检对上消化道肿大淋已结的诊断[J]．世界华人消化杂志，2000，8(11)：1319．
[28] Hawes R, Gress F, Kesler K, et al. Endoscopic ultrasound versus CT in the evaluation of the mediastinum in patients with no small cell lung cancer[J].Endoscopy, 1994,26:784～787.
[29] Potepan P, Meroni E, Spagnoli L, et al. Non-small cell lung cancer: detection of mediastinal lymph node metastases by endoscopic ultrasound and CT[J]. Eur Radiol, 1996,6:19～27.
[30] Hasegawa N. Niwa Y, Arisawa T,et al. Preoperativc staging of superficial esophageal. carcinoma: comparison of an ultrasound probe and standard endoscopic ultrasonography[J]. Gastrointest Endose, 1996, 44:388.
[31] 王云喜，孙玉鹤．腔内超声在肺癌诊断中的应用[J]．中华外科杂志，1998，6(2)：86．
[32] J-E C Holty, W G Kuschner, M K Gould. Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis[J]. Thorax 2005,60:949～955.
[1] 滕洪，马富锦，曲家骐等．X线、CT和B超联合检查诊断纵隔肿瘤和囊肿的临床应用价值[J]．综合临床医学，1991，7(2)：74～76．
[2] 蔡曙波，徐阳，周婕．CT扫描在纵隔占位性病变中的诊断价值[J]．实用医技杂志，2006，13(3)：335～336．
[3] Lewis JMJr, Pearlberg JL, Beute GH, et al. Can computed tomography of chest stage lung cancer? yes and no[J]. Ann Thorac Surg, 1990, 49 (6): 591～596.
[4] Suzuki K, Nagai K, Yoshida J, et al. Clinical predictors of N2 disease in the setting of a negative computed tomographic scan in patients with lung cancer[J]. J Thorac Cardiovasc Surg,1999,177(3): 593～598.
[5] 于红，李惠民，肖湘生．纵隔病理性淋巴结的CT研究现状[J]．国外医学临床放射学分册，2004，7(5)：303～307．
[6] Mukaida N, Zachariae CCO, Gusella GI, et al. Dexam ethasone inhibits the induction of monocyte chemotactic activating factor production by JL-1 or tumor necrosis factor[J]. J Immunol, 1991, 146:1212～1215.
[7] Kim Y, Lee KS, Yoo J H, et al. Middle mediastinal lesions: imaging findings and pat hologic correlation[J]. Eur J Radiol, 2000,35(1): 30～38.
[8] Kerry M,Lawrence J,James C,et al.Magnetic resonance imaging of the mediastinum[J].Journal of Thoracic Imaging, 1993,8(1):34.
[9] 卢光明，苏学曾．磁共振成像诊断纵隔肿块的价值[J]．中国医学影像技术，1991，7(4)：69～70．
[10] Koganemaru M, Fujimoto'K, Nishimuta H, et al. Hilar and mediastinal lymph node metastases from lung cancer: detection with CT and MR imaging [J].Rinsho Hoshasen, 1990,35(7):811～819.
[11] Crisci R, Di Cesare E, Lupattelli L, et al. MR study of N_2 disease in lung cancer: contrast-enhanced method using Gadolinium-DTPA[J]. Eur J cardiothorac Surg, 1997,11(2):214～217.
[12] Yokoi K, Kamiya N, Matsuguma H, et al. Detection of brain metastases in potentially operable non-small cell lung cancer: a comparion of CT and MRI[J]. Chest, 1999,115(3)714～719.
[13] Deslauners J, Gregoire J. Clinical and surgical staging of non-small cell lung cancer[J]. Chest,2000,117(4):96～103.
[14] Grover FL. The role of CT and MRI in staging of the mediastinum [J].Chest, 1994,106(6):391～396.
[15] Bonemo L, Ciccotosto C, Guidotti A, et al. Lung cancer staging: The role of computed tomography and magnetic resonance imaging[J]. Eur J Radiol, 1996,23(1):35～45.
[16] 虞登高，吕晓波，牛汝朴．隐匿性肺癌及其纵隔转移的MRI诊断[J]．实用医学影像杂志，2001，2(1)：22～24．
[17] 安宁豫，高元桂，蔡幼锉，等．增强MRI在原发性支气管肺癌分期中的价值[J]．中华放射学杂志，1998，32(4)：323～327．
[18] 王瑞，王增林，陈宇，等．经气管镜针吸活检对肺癌的诊断价值[J]．中国内镜杂志，2000，6(8)：3～4．
[19] 王瑞，韩建京，姚计方，等．经气管镜针吸活检在肺癌分期中的作用[J]．中国肺癌杂志，2002，5(4)：284～286．
[20] 蒋捍东，程兆忠，刘淑红，等．经气管镜针吸活检诊断纵隔疾病的价值[J]．山东医药，2004，44(7)：9～10．
[21] Wang KP. Brower R. Haponnrk EF. et al. Flexiblc trans-bronchial needle aspirtion for bronchogenic carcinoma [J]. Chest,1983,84 (5):571～576.
[22] Shure D. Fedullo PF. The role of transcarinal needle aspiration in the staging of bronchogenic carcinoma[J]. Chest, 1984,86(5):693～696
[23] 朱纯儒，周谦让，刘邦荣，等．经支气管针吸活检对肺癌术前TNM分期与术后分期的对比分析[J]．安徽医学，2005，26(3)：168～170．
[24] Toloza EM, Harpole L, Detterbeck F, et al. Invasive staging of non-small cell lung cancer: a review of the current evidence[J]. Chest, 2003,123(1 Suppl): 157～66S.
[25] J-E C Holty, W G Kuschner, M K Gould, Accuracy of transbronchial needle aspiration for mediastinal staging of non-small cell lung cancer: a meta-analysis[J]. Thorax, 2005,60:949～955.
[26] Herth F, Becker HD, Ernst A. Conventional vs endobronchial ultrasound-guided transbronchial needle aspiration: a randomized trial[J]. Chest,2004,125(1):322～325.
[27] Fritscher Ravens A, Sriram PV, Bobrowski C, et al. Mediastinal lymphadenopachy, in patients with or without previous mali gnancy:EUS-FNA based differential cytodiagoosis in 153 patients[J]. Am J Gastoenterol, 2000,95(9): 2278.
[28] 孙思予，王孟春，王彩霞，等．超声内镜引导下细针穿刺活检对上消化道肿大淋已结的诊断[J]．世界华人消化杂志，2000，8(11)：1319．
[29] Hawes R, Gress F, Kesler K, et al. Endoscopic ultrasound versus CT in the evaluation of the mediastinum in patients with no small cell lung cancer[J].Endoscopy, 1994,26:784～787.
[30] Potepan P, Meroni E, Spagnoli L, et al. Non-small cell lung cancer: detection of mediastinal lymph node metastases by endoscopic ultrasound and CT[J]. Eur Radiol, 1996,6:19～27.
[31] Hasegawa N. Niwa Y, Arisawa T,et al. Preoperativc staging of superficial esophageal. carcinoma: comparison of an ultrasound probe and standard endoscopic ultrasonography[J]. Gastrointest Endose, 1996,44:388.
[32] 王云喜，孙玉鹤．腔内超声在肺癌诊断中的应用[J]．中华外科杂志，1998，36(2)：86．
[33] Weng E, Tran I, Rege S. Accuracy and clinical impact of mediastinal lymph node staging with FDG-PET imaging in potentially respectable lung cancer[J]. Am J Clin Oncol,2000,23 (1):47～52.
[34] Vansteenkiste JF. PET scan in the staging of non-small cell lung cancer[J]. Lung Cancer,2003,42(suppll):s27～37.
[35] Gupta NC, Graeber GM, Bishop HA. Comparative efficacy of positron emission tomography with fluorodeoxyglucose in evaluation of small(＜1cm), intermediate (1 to3 cm), and large (＞3 cm) lymph-node lesion[J]. Chest,2000, 117: 773～778.
[36] Vansteenkiste JF, Stroobants SG, De Leyn PR, et al. Lymph node staging in non small2cell lung cancer with FDG-PET scan: a prospective study on 690 lymph node staging from 68 patients[J].J Clin Ocol, 1998, 16: 2142～2149.
[37] 支修益，刘宝东，许庆生，等．CT和正电子发射计算机断层摄影显像对确定非小细胞肺癌纵隔淋巴结转移的临床价值[J]．中华医学杂志，2005，85(29)：2026～2029．
[38] Venissac N, Alifano M,Mouroux J Video-Assisted Mediastinoscopy: Experience From 240 Consecutive Cases[J]. Annn Yhorac Surg, 2003, 76:208～212.
[39] 傅尧箕．纵隔镜检查术[J]．中华外科杂志，1965，13：760～761
[40] 刘向阳，张大为，张汝刚，等．纵隔镜在纵隔肿物诊断中的临床价值[J]．中华肿瘤杂志，2000，22：238～240．
[41] 赵辉，王俊，刘军，等．纵隔镜检查在胸部疾病诊断及肺癌分期中的价值[J]．中国胸心血管外科杂志，2003，10：131～133
[42] 王欣，黄植蕃，戎铁华，等．纵隔镜的诊断价值及在肺癌分期中的应用[J]．中华肿瘤杂志，2002，24：74～77
[43] Venissac N, Alifano M, Mouroux J. Video-Assisted Mediastinoscopy: Experience From 240 Consecutive Cases[J]. Annn Thorac Surg, 2003, 76:208～212.
[44] 王俊，赵辉．纵隔镜术及其在肺癌分期中的应用价值[J]．中华胸心血管外科杂志，2002，18：190～191．
[45] Hazelrigg Y, Landreneau M. Minimal Access Cardiothracic Surgery[J]. Philadelphia:W.B. Saunders Company,2002,169～174.
[46] Potepan P, Meroni E, Spagnolil, et al. Non-small-cell lung cancer: detection of mediastinal lymph node metastases by e doscopic ultrasound and CT[J].Eur Radiol, 1996,6:19.
[47] Wang KY, Lin CY, Kuo-Tai J, et al. Use of transesophageal echocardiography for evaluation of respectability of lung cancer[J]. Acta Anaesthesiol Sin,1994,32: 255.
[48] Lynch M, Balk MA, Lee RB, et al. Role of transesophageal echocardiography in the management of patients with bronchogenic carcinoma invading the left atrium[J]. Am J Cardiol,1995,76:1101.
[49] Suriani R, Konstadt S, Camunas J, et al. Transesophageal echocardiographic detection of left atrial involve ment of lung tumor[J].J Cardiothorac Vasc Anesth, 1993,7:73.
[50] Bressler EL, Kirkham JA, Mediastinal masses: alternative approaches to CT—guided needle biopsy[J]. Radiology, 1994, 191 (2): 391～396.
[51] 王欣，高桂芬，刘晓杰．纵隔肿块CT导向经皮穿刺活检的精确性和安全性[J]．哈尔滨医科大学学报，2005，39(1)：82～84．
[52] Watanabc M,Takagi T,Aoki T,et al. A comparison of biopsy through a parastemal anterior mediastinotomy under local ancsthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors[J]. Surg Today, 1998,28(10): 1022～1026.
[53] Belfiore C, Camera L, Moggio C,et al. Middle mediastinum lesions: preliminary experience with CT-guided fine-needle aspiration biopsy with asuprasternal approach[J].Radiology, 1997, 202 (3): 870～873.
[55] Li H,Bioselle PM. Diagnostic accuracy and safety of CT guided percutaneous needle aspiration biopsy of the lung: comparison of small and large pulmonary nodules[J] .A JR, 1996,167:105.
[56] Watanabc M,Takagi T,Aoki T,et al. A comparison of biopsy through aparast ernal anterior mediastinotomy under local ancsthesia and percutaneous needle biopsy for malignant anterior mediastinal tumors[J]. Surg Today, 1998, 28(10): 1022～1026.
[57] 廖锦堂，黄渊金，肖萤等．超声引导下经皮纵隔肿瘤穿刺自动活检的应[J]．中国医师杂志，2003，5(8)：1038～1039．
[58] Vansteenkiste JF. PET scan in the staging of non-small cell lung cancer[J].Lung Cancer,2003,42(suppll):s27～37.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |