硝酸银与滑石粉产生胸膜固定术的效果比较及机制探讨
摘要
目的：比较硝酸银和滑石粉浆在大鼠自发性气胸模型中产生胸膜固定术的效果；探讨TNF-α、ICAM-1和NF-κB在硝酸银和滑石粉浆诱导的胸膜固定术中的作用及产生胸膜固定术的机制。
方法：健康成年雄性Sprague-Dawley大鼠66只，随机分为正常对照组(6只)、滑石粉T组(30只)和硝酸银A组(30只)。建立大鼠气胸模型，正常对照组胸腔内注入0.9％生理盐水，A组注入硝酸银(0.1％硝酸银1ml)，T组注入200mg／kg滑石粉+1.0ml 0.9％生理盐水。A组和T组分别在第1d、4d、7d、2w、4w时，进行剖胸探查收集标本，观察大鼠胸膜粘连积分、胸膜炎性积分、胸膜纤维化积分及检测肺组织中髓过氧化物酶(MPO)的活性；ELISA法检测24小时收集的血清和胸液中TNF-α的含量及各时点血清中TNF-α的含量；观察肺组织病理学改变及检测肺组织中NF-κB及ICAM-1的活性。
结果：滑石粉浆组产生胸膜粘连在初期较硝酸银组快，但从第二周开始，硝酸银组产生胸膜粘连效果好于滑石粉浆组，到第四周，滑石粉浆组粘连积分为1.8±0.1，而硝酸银组积分为3.3±0.2，显著高于滑石粉浆组；炎性积分和纤维化积分均为硝酸银组高于滑石粉浆组，两组肺组织内MPO活性随着注入硬化剂的时间延长而逐渐增加，其活性均在注入硬化剂后开始增高，第二周时达到高峰值，到第四周时降至正常水平。硝酸银组24小时胸液量多于滑石粉浆组；两组肺组织内ICAM-1和NF-κB活性表达随着注入硬化剂的时间延长而逐渐增加，其活性均在注入硬化剂后开始增高，第二周时达到高峰值，到第四周时降至正常水平，且肺组织内ICAM-1和NF-κB活性有明显的相关性。血清中各观察时点TNF-α的含量均为滑石粉浆组高于硝酸银组，但两组24小时胸液中TNF-α的含量均高于血清中的含量，且在硝酸银组中显著增高。
结论：0.1％硝酸银1ml产生胸膜固定术的效果好于200mg／kg滑石粉，具有临床使用价值。TNF-α是炎症前细胞因子，对滑石粉浆和硝酸银所致的胸膜粘连起关键性作用；NF-κB的激活和ICAM-1的表达增强了胸膜粘连的作用。胸膜固定
术的主要机制是无菌性炎症反应以及炎性细胞的豁附过程。
Objective: To study the mechanisms of experimental pleurodesis in rats induced by silver nitrate or talc, and the role of TNF- a, ICAM-1 and NF- kB in the mechanisms of experimental pleurodesis in rats induced by silver nitrate or talc. To compare the pleurodesis results from the intrapleural injection of silver nitrate and talc slurry over an observation period of one month in rats.
Methods: 66 Adult Sprague-Dawley rats underwent pleurodesis as follows: 6 rats received 1ml 0.9% Natrii Chloride solution; 30 rats received 1ml of 0.1% silver nitrate; and 30 rats received 200mg/kg of talc slurry in 1 ml intrapleurally. Six rats in each group were killed at day1, day4, day7, day 14 and day28 after intrapleural injection. The degree of gross pleurodesis, the amount of microscopic pleural fibrosis and inflammation were graded on a scale of 0 to 4. Pleural fluid at the first 24 hours, hisopathological alternation of experimental lung were observed. TNF-a in plasma and 24h pleural fluid were determined by ELISA. The NF-kB activation and ICAM-1 expression of the experimental lung tissues were examined by immunohistochemistry and image analysis. The accumulation of polymorphonuclear leukocytes in lung tissues was determined by the myeloperoxidase(MPO) assay.
Results: The mean+SEM gross pleurodesis score in the rats that received silver nitrate was 3.3+0.2, which was significantly higher than the score of 1.8+0.1 in the rats that received talc. The mean gross pleurodesis score was significantly higher at each of the observation times(P<0.05), except at the first seven days, in the rats that received silver nitrate. The NF- kB activation and ICAM-1 expression were both positive staining in the cytoplasm for each observation times of two groups. They began to increase at the dayl and peak at the week2, and then decreased gradually to the contrast level at the week4. The ICAM-1 expression was positively correlated with the NF- k B activation in lung tissues. The MPO activation began to increase at the dayl and peak at the week2, and then decreased gradually to the contrast level at the week4, and was significantly higher (P<0.05) in the rats that received silver nitrate at each of the observation times. So does the microscopic pleural fibrosis and inflammation grade
s. The volume of pleural fluid at 24h following silver nitrate administration were significant higher than
that of talc, while the TNF-a in plasma were on the contrary. The TNF-a in 24h plasma were significant lower in 24h pleural fluid at the same experimental group. Conclusion: The intrapleural injection of 1ml of 0.1% silver nitrate produces a better pleurodesis than does the intrapleural injection of 200mg/kg of talc slurry in rats. The up-regulation of NF- k B activation and ICAM-1 expression is important in the process of pleurodesis. TNF- a is important in the process of pleurodesis. The mechanisms responsible for the pleurodesis is that the inflammatory reaction to the administration of sclerosing agent. The efficacy of silver nitrate as a sclerosing agent in humans should be evaluated.
方法：健康成年雄性Sprague-Dawley大鼠66只，随机分为正常对照组(6只)、滑石粉T组(30只)和硝酸银A组(30只)。建立大鼠气胸模型，正常对照组胸腔内注入0.9％生理盐水，A组注入硝酸银(0.1％硝酸银1ml)，T组注入200mg／kg滑石粉+1.0ml 0.9％生理盐水。A组和T组分别在第1d、4d、7d、2w、4w时，进行剖胸探查收集标本，观察大鼠胸膜粘连积分、胸膜炎性积分、胸膜纤维化积分及检测肺组织中髓过氧化物酶(MPO)的活性；ELISA法检测24小时收集的血清和胸液中TNF-α的含量及各时点血清中TNF-α的含量；观察肺组织病理学改变及检测肺组织中NF-κB及ICAM-1的活性。
结果：滑石粉浆组产生胸膜粘连在初期较硝酸银组快，但从第二周开始，硝酸银组产生胸膜粘连效果好于滑石粉浆组，到第四周，滑石粉浆组粘连积分为1.8±0.1，而硝酸银组积分为3.3±0.2，显著高于滑石粉浆组；炎性积分和纤维化积分均为硝酸银组高于滑石粉浆组，两组肺组织内MPO活性随着注入硬化剂的时间延长而逐渐增加，其活性均在注入硬化剂后开始增高，第二周时达到高峰值，到第四周时降至正常水平。硝酸银组24小时胸液量多于滑石粉浆组；两组肺组织内ICAM-1和NF-κB活性表达随着注入硬化剂的时间延长而逐渐增加，其活性均在注入硬化剂后开始增高，第二周时达到高峰值，到第四周时降至正常水平，且肺组织内ICAM-1和NF-κB活性有明显的相关性。血清中各观察时点TNF-α的含量均为滑石粉浆组高于硝酸银组，但两组24小时胸液中TNF-α的含量均高于血清中的含量，且在硝酸银组中显著增高。
结论：0.1％硝酸银1ml产生胸膜固定术的效果好于200mg／kg滑石粉，具有临床使用价值。TNF-α是炎症前细胞因子，对滑石粉浆和硝酸银所致的胸膜粘连起关键性作用；NF-κB的激活和ICAM-1的表达增强了胸膜粘连的作用。胸膜固定
术的主要机制是无菌性炎症反应以及炎性细胞的豁附过程。
Objective: To study the mechanisms of experimental pleurodesis in rats induced by silver nitrate or talc, and the role of TNF- a, ICAM-1 and NF- kB in the mechanisms of experimental pleurodesis in rats induced by silver nitrate or talc. To compare the pleurodesis results from the intrapleural injection of silver nitrate and talc slurry over an observation period of one month in rats.
Methods: 66 Adult Sprague-Dawley rats underwent pleurodesis as follows: 6 rats received 1ml 0.9% Natrii Chloride solution; 30 rats received 1ml of 0.1% silver nitrate; and 30 rats received 200mg/kg of talc slurry in 1 ml intrapleurally. Six rats in each group were killed at day1, day4, day7, day 14 and day28 after intrapleural injection. The degree of gross pleurodesis, the amount of microscopic pleural fibrosis and inflammation were graded on a scale of 0 to 4. Pleural fluid at the first 24 hours, hisopathological alternation of experimental lung were observed. TNF-a in plasma and 24h pleural fluid were determined by ELISA. The NF-kB activation and ICAM-1 expression of the experimental lung tissues were examined by immunohistochemistry and image analysis. The accumulation of polymorphonuclear leukocytes in lung tissues was determined by the myeloperoxidase(MPO) assay.
Results: The mean+SEM gross pleurodesis score in the rats that received silver nitrate was 3.3+0.2, which was significantly higher than the score of 1.8+0.1 in the rats that received talc. The mean gross pleurodesis score was significantly higher at each of the observation times(P<0.05), except at the first seven days, in the rats that received silver nitrate. The NF- kB activation and ICAM-1 expression were both positive staining in the cytoplasm for each observation times of two groups. They began to increase at the dayl and peak at the week2, and then decreased gradually to the contrast level at the week4. The ICAM-1 expression was positively correlated with the NF- k B activation in lung tissues. The MPO activation began to increase at the dayl and peak at the week2, and then decreased gradually to the contrast level at the week4, and was significantly higher (P<0.05) in the rats that received silver nitrate at each of the observation times. So does the microscopic pleural fibrosis and inflammation grade
s. The volume of pleural fluid at 24h following silver nitrate administration were significant higher than
that of talc, while the TNF-a in plasma were on the contrary. The TNF-a in 24h plasma were significant lower in 24h pleural fluid at the same experimental group. Conclusion: The intrapleural injection of 1ml of 0.1% silver nitrate produces a better pleurodesis than does the intrapleural injection of 200mg/kg of talc slurry in rats. The up-regulation of NF- k B activation and ICAM-1 expression is important in the process of pleurodesis. TNF- a is important in the process of pleurodesis. The mechanisms responsible for the pleurodesis is that the inflammatory reaction to the administration of sclerosing agent. The efficacy of silver nitrate as a sclerosing agent in humans should be evaluated.
引文
1. Chen JS, Hsu HH, Kuo SW, et al. Effects of additional minocycline pleurodesis after thoracoscopic procedures for primary spontaneous pneumothorax. Chest. 2004 Jan;125(1):50-5.
2. Paull DE, Delahanty TJ, Weber FJ, Harostock MD. Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations. Surg Laparosc Endosc Percutan Tech. 2003 Oct;13(5):339-44.
3. Abid Q, Millner RW. Chylothorax following coronary bypass grafting: treatment by talc pleurodesis. Asian Cardiovasc Thorac Ann. 2003 Dec; 11(4):355-6.
4. Marchi E, Teixeira LR, Vargas F. Talc for pleurodesis: hero or villain? Chest. 2003 Jul;124(1):416; author reply 416-7.
5. Milanez Campos JR, Werebe EC, Vargas FS, et al. Respiratory failure because of insufflated talc. Lancet 1997;349:251-252
6. Milanez Campos JR, Vargas FS, Werebe EC, et al. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001; 119:801-806
7. Rehse DⅡ, Aye RW, Florence MG. Respiratory failure after talc pleurodesis. Am J Surg 1999; 177:437-440
8. Bouros D, Froudamkis M, Siafakas NM. Pleurodesis: everything flows. Chest 2000;118:577-579
9. Marcl M. Zrustova M. Stasny B. Light RW. The incidence of pleural effusion in a well-defined region: epidemiologic study in central Bohemia. Chest 1993;104:1486-1489
10. Ligher RW. Pleural diseases. 4th edition. Baltimore, MD: Lippincott, Williams & Wilkins; 2001
11. Lee YC, Baumann MH, Maskell NA, et al. Pleurodesis practice for malignant pleural effusions in five English-speaking countries: survey of pulmonologists. Chest. 2003 Dec; 124(6):2229-38.
12. Francisco S. Vargas, Lisete R. Teixeira, Leila Antonangelo, et al. Experimental pleurodesis in rabbits induced by silver nitrate or talc 1-year follow up. Chest 2001;119:1516-1520
13. Xie C, Teixeira LR, McGovem JP, et al. Systemic corticosteroids decrease the effectoveness of talc pleurodesis. Am J Respir Crit Care Med 1998;157:1441-1444
14. Cheng D-S, Rogers J, Wheeler A, et al. The effects of intrapleural polyclonal anti-tumor mecrosis factor Fab fragments on pleurodesis in rabbits. Lung 2000;178:19-30
15. Vargas FS, Teixeira LR, Silva LMMF, et al. Comparism of silver nitrate and tetracyline as tracycline as pleural sclerosing agents in rabbits. Chest, 1995,108:1080-1083
16. Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for malignant pleural effusions.Chest. 2003 Jun;123(6): 1895-8.
17. Kennedy L, Harley LA, Sahn SA, et al. Talc slurry pleurodesis: pleural fluid and histologic analysis. Chest 1995;107:1707-1712
18. Sahn SA, Good JT. The effect of common sclerosing agents on the rabbit pleura space. Am Rev Respir Dis 1981;124:65-67
19. Cotran R, Kumar V, Collins T. Robbins pathologic basis of disease. 6th ed. Philadelphia, PA: W.B. Saunders, 1999;89-134
20. Christaman JW, Sadikot RT, Blackwell TS. The role of nuclear factor-kB in pulmonary diseases. Chest, 2000, 117(5): 1482-1487
21. Fan H, Sun B, Gu Q, et al. Oxygen radicals trigger activation of NF-kappaB and AP-1 and upregulation of ICAM-1 in reperfused canine heart. Am J physiol Heart and circulation physiol, 2002, 282(5):H1778-1786.
22. Najmunnisa Nasreen, Daniel L.H, Kammal A.M, et al. Talc-induced expression of C-C and C-X-C cytokine and ICAM-1 in mesothelial cells. Am J Resp Crit Med, 1998;158:971-978
23. Mal H, Dehoux M, Sleiman C, et al. Early release of proinflammatory cytokines after lung transplantation. Chest, 1998, 113(3): 645-651.
24. Spooner CE, Markowitz NP, Saravolatz LD. The role of tumor necrosis factor in sepsis. Clinical Immunologu and Immunopathology, 1992; 62:S11
25. Cerami A. Inflammatory cytokines. Clinical immunology and immunopathology, 1992;62:S3
26. Vargas F.S, Teixeira LR, Silva LMMF, et al. Comparism of silver nitrate and tetracycline as tracycline as pleural sclerosing agents in rabbits. Chest,
1995,108:1080-1083
27. Marshall BC, Santana A, Xn QP, et at. Metalloproteinases and tissue inhibitor of metalloproteinases in mesothelial cells-cellular differentiation influences expression. J Clin Invest 1993,91:1792-1799
28. D'Agostino P, Camemi AR, Caruso R, et al. Matrix metalloproteinases production in malignant pleural effusions after talc pleurodesis. Clin Exp Immunol. 2003 Oct; 134(1): 138-42.
29. Enamitsu S, Matsukawa A, Ohkawara S, et al. Role of TNF-α, IL-1, and IL-1 ra in the mediation of leukocyte infiltration and increased permeability in rabbits with LPS-induced pleurisy. Clin Immunol Immunopathol, 1995,75:68-74
30. Menezes-de-lima-junior O, Werner-Barroso E, Cordeiro RS, et al. Effects of inhibitors of inflammatory mediators and cytokines in eosinophil and neutrophil accumulation induced by Mycobacterium bovis bacillus Calmettee-Guerin in mouse pleurisy. J Leukoc Biol, 1997,62:778-785.
31．程升东，谢灿茂，Richard W．Light。抗肿瘤坏死因子α多克隆抗体对滑石粉和多西环素胸膜固定术效果的影响。中华结核和呼吸杂志，2001，24(1)：25-28。
2. Paull DE, Delahanty TJ, Weber FJ, Harostock MD. Thoracoscopic talc pleurodesis for recurrent, symptomatic pleural effusion following cardiac operations. Surg Laparosc Endosc Percutan Tech. 2003 Oct;13(5):339-44.
3. Abid Q, Millner RW. Chylothorax following coronary bypass grafting: treatment by talc pleurodesis. Asian Cardiovasc Thorac Ann. 2003 Dec; 11(4):355-6.
4. Marchi E, Teixeira LR, Vargas F. Talc for pleurodesis: hero or villain? Chest. 2003 Jul;124(1):416; author reply 416-7.
5. Milanez Campos JR, Werebe EC, Vargas FS, et al. Respiratory failure because of insufflated talc. Lancet 1997;349:251-252
6. Milanez Campos JR, Vargas FS, Werebe EC, et al. Thoracoscopy talc poudrage: a 15-year experience. Chest 2001; 119:801-806
7. Rehse DⅡ, Aye RW, Florence MG. Respiratory failure after talc pleurodesis. Am J Surg 1999; 177:437-440
8. Bouros D, Froudamkis M, Siafakas NM. Pleurodesis: everything flows. Chest 2000;118:577-579
9. Marcl M. Zrustova M. Stasny B. Light RW. The incidence of pleural effusion in a well-defined region: epidemiologic study in central Bohemia. Chest 1993;104:1486-1489
10. Ligher RW. Pleural diseases. 4th edition. Baltimore, MD: Lippincott, Williams & Wilkins; 2001
11. Lee YC, Baumann MH, Maskell NA, et al. Pleurodesis practice for malignant pleural effusions in five English-speaking countries: survey of pulmonologists. Chest. 2003 Dec; 124(6):2229-38.
12. Francisco S. Vargas, Lisete R. Teixeira, Leila Antonangelo, et al. Experimental pleurodesis in rabbits induced by silver nitrate or talc 1-year follow up. Chest 2001;119:1516-1520
13. Xie C, Teixeira LR, McGovem JP, et al. Systemic corticosteroids decrease the effectoveness of talc pleurodesis. Am J Respir Crit Care Med 1998;157:1441-1444
14. Cheng D-S, Rogers J, Wheeler A, et al. The effects of intrapleural polyclonal anti-tumor mecrosis factor Fab fragments on pleurodesis in rabbits. Lung 2000;178:19-30
15. Vargas FS, Teixeira LR, Silva LMMF, et al. Comparism of silver nitrate and tetracyline as tracycline as pleural sclerosing agents in rabbits. Chest, 1995,108:1080-1083
16. Spiegler PA, Hurewitz AN, Groth ML. Rapid pleurodesis for malignant pleural effusions.Chest. 2003 Jun;123(6): 1895-8.
17. Kennedy L, Harley LA, Sahn SA, et al. Talc slurry pleurodesis: pleural fluid and histologic analysis. Chest 1995;107:1707-1712
18. Sahn SA, Good JT. The effect of common sclerosing agents on the rabbit pleura space. Am Rev Respir Dis 1981;124:65-67
19. Cotran R, Kumar V, Collins T. Robbins pathologic basis of disease. 6th ed. Philadelphia, PA: W.B. Saunders, 1999;89-134
20. Christaman JW, Sadikot RT, Blackwell TS. The role of nuclear factor-kB in pulmonary diseases. Chest, 2000, 117(5): 1482-1487
21. Fan H, Sun B, Gu Q, et al. Oxygen radicals trigger activation of NF-kappaB and AP-1 and upregulation of ICAM-1 in reperfused canine heart. Am J physiol Heart and circulation physiol, 2002, 282(5):H1778-1786.
22. Najmunnisa Nasreen, Daniel L.H, Kammal A.M, et al. Talc-induced expression of C-C and C-X-C cytokine and ICAM-1 in mesothelial cells. Am J Resp Crit Med, 1998;158:971-978
23. Mal H, Dehoux M, Sleiman C, et al. Early release of proinflammatory cytokines after lung transplantation. Chest, 1998, 113(3): 645-651.
24. Spooner CE, Markowitz NP, Saravolatz LD. The role of tumor necrosis factor in sepsis. Clinical Immunologu and Immunopathology, 1992; 62:S11
25. Cerami A. Inflammatory cytokines. Clinical immunology and immunopathology, 1992;62:S3
26. Vargas F.S, Teixeira LR, Silva LMMF, et al. Comparism of silver nitrate and tetracycline as tracycline as pleural sclerosing agents in rabbits. Chest,
1995,108:1080-1083
27. Marshall BC, Santana A, Xn QP, et at. Metalloproteinases and tissue inhibitor of metalloproteinases in mesothelial cells-cellular differentiation influences expression. J Clin Invest 1993,91:1792-1799
28. D'Agostino P, Camemi AR, Caruso R, et al. Matrix metalloproteinases production in malignant pleural effusions after talc pleurodesis. Clin Exp Immunol. 2003 Oct; 134(1): 138-42.
29. Enamitsu S, Matsukawa A, Ohkawara S, et al. Role of TNF-α, IL-1, and IL-1 ra in the mediation of leukocyte infiltration and increased permeability in rabbits with LPS-induced pleurisy. Clin Immunol Immunopathol, 1995,75:68-74
30. Menezes-de-lima-junior O, Werner-Barroso E, Cordeiro RS, et al. Effects of inhibitors of inflammatory mediators and cytokines in eosinophil and neutrophil accumulation induced by Mycobacterium bovis bacillus Calmettee-Guerin in mouse pleurisy. J Leukoc Biol, 1997,62:778-785.
31．程升东，谢灿茂，Richard W．Light。抗肿瘤坏死因子α多克隆抗体对滑石粉和多西环素胸膜固定术效果的影响。中华结核和呼吸杂志，2001，24(1)：25-28。