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
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摘要
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 chylothorax by thoracic duct extremity exploration.Methods Data of 34 LAM with chylothorax confirmed by pathology and clinical diagnosis were retrospectively analyzed.All patients underwent 99 Tcm-DX lymphoscintigraphy and CT lymphangiography(CTL).Thoracic duct lesion types of 99 Tcm-DX lymphoscintigraphy were typeⅠ(abnormal concentration pattern),typeⅡ(ectopic drainage pattern),and typeⅢ(without image or transient image pattern).The typeⅠand typeⅡ were diagnosed as thoracic duct abnormalities.Thoracic duct lesion types of CTL were typeⅠ(dilatation pattern),typeⅡ(distal obstruction pattern),typeⅢ(truck constriction pattern),typeⅣ(ectopic drainage pattern),and typeⅤ(no-display pattern).TypeⅠ—Ⅳ were diagnosed as thoracic duct abnormalities.Consistency of displaying thoracic duct abnormalities between 99 Tcm-DX lymphoscintigraphy and CTL was evaluated.Results The thoracic duct abnormalities in 99 Tc m-DX lymphoscintigraphy were 58.82%(20/34;typeⅠin 17,typeⅡin 3,type Ⅲ in 14),and in CTL were73.53%(25/34;typeⅠin 15,typeⅡin 3,typeⅢin 5,typeⅣin 2,typeⅤin 9).The consistency of CTL and 99 Tc m-DX lymphoscintigraphy for detecting thoracic duct abnormalities was good(Kappa=0.679).In CTL thoracic duct types,typeⅠandⅡwere operated by thoracic duct-venous anastomosis or thoracic duct extremity release operation,typeⅢ was operated by thoracic duct adhesion or compression band release operation,operative approach and method were chosen according to the abnormal thoracic duct flow path in typeⅣ,typeⅤ was took conservative treatment.Conclusion CTL is superior to 99 Tc m-DX lymphoscintigraphy,which can clearly display the type of thoracic duct lesion and provide imaging informations to choose operation methods in thoracic duct exploration treatment for LAM with chylothorax.
Objective To evaluate the value of imaging examinations in the treatment of lymphangioleiomyomatosis(LAM)with chylothorax by thoracic duct extremity exploration.Methods Data of 34 LAM with chylothorax confirmed by pathology and clinical diagnosis were retrospectively analyzed.All patients underwent 99 Tcm-DX lymphoscintigraphy and CT lymphangiography(CTL).Thoracic duct lesion types of 99 Tcm-DX lymphoscintigraphy were typeⅠ(abnormal concentration pattern),typeⅡ(ectopic drainage pattern),and typeⅢ(without image or transient image pattern).The typeⅠand typeⅡ were diagnosed as thoracic duct abnormalities.Thoracic duct lesion types of CTL were typeⅠ(dilatation pattern),typeⅡ(distal obstruction pattern),typeⅢ(truck constriction pattern),typeⅣ(ectopic drainage pattern),and typeⅤ(no-display pattern).TypeⅠ—Ⅳ were diagnosed as thoracic duct abnormalities.Consistency of displaying thoracic duct abnormalities between 99 Tcm-DX lymphoscintigraphy and CTL was evaluated.Results The thoracic duct abnormalities in 99 Tc m-DX lymphoscintigraphy were 58.82%(20/34;typeⅠin 17,typeⅡin 3,type Ⅲ in 14),and in CTL were73.53%(25/34;typeⅠin 15,typeⅡin 3,typeⅢin 5,typeⅣin 2,typeⅤin 9).The consistency of CTL and 99 Tc m-DX lymphoscintigraphy for detecting thoracic duct abnormalities was good(Kappa=0.679).In CTL thoracic duct types,typeⅠandⅡwere operated by thoracic duct-venous anastomosis or thoracic duct extremity release operation,typeⅢ was operated by thoracic duct adhesion or compression band release operation,operative approach and method were chosen according to the abnormal thoracic duct flow path in typeⅣ,typeⅤ was took conservative treatment.Conclusion CTL is superior to 99 Tc m-DX lymphoscintigraphy,which can clearly display the type of thoracic duct lesion and provide imaging informations to choose operation methods in thoracic duct exploration treatment for LAM with chylothorax.
引文
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[14]王圣应,王震寰,张荣新.颈段胸导管的临床应用解剖研究.淮海医药,2000,18(4):241-242.
[15]Munn LL,Padera TP.Imaging the lymphatic system.Microvasc Res,2014,96:55-63.
[16]Zhang F,Niu G,Lu G,et al.Preclinical lymphatic imaging.Mol Imaging Biol,2011,13(4):599-612.
[17]Guermazi A,Brice P,Hennequin C,et al.Lymphography:An old technique retains its usefulness.Radiographics,2003,23(6):1541-1558.
[2]Bearz A,Rupolo M,Canzonieri V,et al.Lymphangioleiomyomatosis:A case report and review of the literature.Tumori,2004,90(5):528-531.
[3]张奇瑾,张春燕,陈孝柏,等.CT淋巴管造影对淋巴管肌瘤病淋巴回流障碍的诊断价值.中华放射学杂志,2013,47(9):801-804.
[4]Johnson SR,Cordier JF,Lazor R,et al.European respiratory society guidelines for the diagnosis and management of lymphangioleiomyomatosis.Eur Respir J,2010,35(1):14-26.
[5]童冠圣,沈文彬,耿万德,等.淋巴显像评估妇科肿瘤治疗后下肢淋巴系统损伤.中华核医学杂志,2011,31(1):19-24.
[6]张春燕,陈孝柏,侯睿,等.直接淋巴管造影后MSCT诊断乳糜胸.中国医学影像技术,2012,28(2):206-210.
[7]魏海亮,陈孝柏,宋建美,等.CT淋巴管造影对乳糜尿的诊断价值.中国医学影像技术,2012,28(2):190-193.
[8]Kiyonaga M,Mori H,Matsumoto S,et al.Thoracic duct and cisterna chyli:Evaluation with multidetector row CT.Br J Radiol,2012,85(116):1052-1058.
[9]Johnson SR.Lymphangioleiomyomatosis.Eur Respir J,2006,27(5):1056-1065.
[10]Mccormack FX.Lymphangioleiomyomatosis:A clinical update.Chest,2008,133(2):507-516.
[11]Taveira-Dasilva AM,Stylianou MP,Hedin CJ,et al.Decline in lung function in patients with lymphangioleiomyomatosis treated with or without progesterone.Chest,2004,126(6):1867-1874.
[12]Hillerdal G.Chylothorax and pseudochylothorax.Eur Respir J,1997,10(5):1157-1162.
[13]Chen E,Itkin M.Thoracic duct embolization for chylous leaks.Semin Intervent Radiol,2011,28(1):63-74.
[14]王圣应,王震寰,张荣新.颈段胸导管的临床应用解剖研究.淮海医药,2000,18(4):241-242.
[15]Munn LL,Padera TP.Imaging the lymphatic system.Microvasc Res,2014,96:55-63.
[16]Zhang F,Niu G,Lu G,et al.Preclinical lymphatic imaging.Mol Imaging Biol,2011,13(4):599-612.
[17]Guermazi A,Brice P,Hennequin C,et al.Lymphography:An old technique retains its usefulness.Radiographics,2003,23(6):1541-1558.