TBNA在支气管腔外病变中的诊断价值
摘要
目的由于支气管腔外病变多未侵犯支气管粘膜,因而常规气管镜检查难以获取有效病变标本,诊断阳性率较低。经支气管针吸活检术(transbronchial needle aspiration,TBNA)可通过特制的带有可弯曲导管的穿刺针,穿透气道壁对气管、支气管腔外病变(如结节、肿块、肿大的淋巴结等)进行针刺吸引,获取细胞或组织标本进行细胞学或病理学检查,从而获得诊断。本文通过对87例胸部CT扫描发现纵隔及肺内肿块、结节、阻塞性炎症或肺不张,常规气管镜检查示支气管管腔正常或仅见外压性狭窄的患者行TBNA检查,TBNA术毕,每例患者均行刷检及活检,并对TBNA,刷检及活检的阳性率进行统计学分析,从而探讨经支气管针吸活检技术(TBNA)对支气管腔外病变的诊断价值。
方法
1、术前准备术前4小时禁饮水饮食,常规行心电图、血常规、凝血五项、病毒系列、测血压检查,上述检查符合条件者签署知情同意书。2%利多卡因鼻腔及声门麻醉成功后,嘱患者去枕平卧于操作床上,常规吸氧,持续检测血氧饱和度。
2.操作步骤持支气管镜经鼻孔进入气道,结合胸部薄层CT扫描结果及镜下所见确定穿刺部位、角度和深度,穿刺针沿活检通道进入气道,使其与气管壁接近90。,采用推进法结合猛刺法、咳嗽法用力将穿刺针刺入预定位置,穿透气管壁刺入病变组织,镜下见穿刺针完全刺入气管壁内(刺入深度1.0～1.5cm)时拔出针芯,将60mL注射器连接在穿刺针尾端,抽吸并持续30-40 s。在确保穿刺针不脱出气道粘膜的情况下,操作者从不同方向来回抽动穿刺针以增加获取标本的机率。每例患者行TBNA 1～3个部位,穿刺2-3次。解除负压,拔出穿刺针,将穿刺物直接涂片,送细胞学检查。TBNA术毕,常规行刷检及活检。
3.统计学方法采用x2检验方法进行统计分析.
结果
1.常规气管镜检查结果43例患者管腔可见不同程度受压狭窄(如图3-4所示)。27例管腔及粘膜未见明显异常；17例局部粘膜可见充血水肿。
2.TBNA穿刺结果87例患者共穿刺167个位点,获阳性诊断82例,阳性率94.3%。其中恶性肿瘤75例(86.2%),分别为腺癌32例(如图5所示)。小细胞未分化癌20例(如图6所示)。鳞癌11例、大细胞未分化癌5例、淋巴瘤2例,难以分类的恶性肿瘤5例；良性病变7例,分别为结节病5例,结核病2例；非特异性炎症5例。
3.刷检结果87例患者中获阳性诊断4例,阳性率4.60%。分别为鳞癌3例；结核病1例；
4.活检结果87例患者中21例患者示慢性炎症,余66例均为正常支气管粘膜组织。
5.统计学分析结果：三种方法比较,TBNA组阳性率显著高于刷检和活检组(p<0.01).
6.并发症：8例患者穿刺部位少量出血,未行特殊处理；未见感染、纵隔气肿等并发症发生；所有患者均可良好耐受。结论TBNA操作简单,创伤小,诊断率高,是诊断支气管腔外病变的一项安全、高效、可靠的方法,值得临床推广。
Objective Due to most extra bronchial lesions haven't violated bronchial mucosa, it is difficult for Conventional Bronchoscope to obtain effective specimens. So the positive rate for Conventional Bronchoscope is relatively low. Transbronchial needle aspiration (TBNA) is available in penetrating the airway wall of trachea through a special flexible puncture needle with a catheter, acupuncturing and aspirating the lesions(e.g. nodules, masses、swollen lymph nodes etc.) to acquire cell or tissue specimens for cytology or pathology examination. In this paper,87patients with CT scan showed mediastinal or lung mass, nodules, obstructive inflammation or atelectasis, conventional bronchoscopy showed a normal bronchial lumen or only stenosis by external pressure were given TBNA. Followed TBNA, each patient has Brushing and Biopsy examination. We explored the diagnostic value of TBNA in extra bronchial lesions by making statistical analysis for the positive rate of the three operation mentioned above.
Methods
1.Preoperative preparations Drink and food were forbidden for 4 hours before operation; Examinations such as:electrocardiogram, blood test,blood coagulation, the virus family, blood pressure measure are essential. Patients with normal check results mentioned above were asked to sign in the informed consent form.After successful anesthesia with 2% Lidocaine, requested patients to lie on the operation bed, give oxygen inhalation and continuous blood oxygen saturation(SaO2) monitor.
2. Operation procedure
Introduced the Bronchoscope into airway via nasal route; Identified the puncture site,angle and depth according to the CT scan and direct vision by Bronchoscope, then the needle was introduced into the working channel,when it arrived at the intended position, penetrated it vertically into the lesion employing pushing method combining with jabbing and cough method(piercing depth of 1.0-1.5cm),making sure the needle be completely imbedded. Then pulled out the needle core. Applying suction at the proximal suction port, the negative pressure produced allowed cell or tissue to be trapped inside the needle chamber.Keeping aspiration for 30-40s. Twitch-ed back and forth from different directions to increase the opportunity of specimen's acquiring under the condition of ensuring the needle not get out of the bronchial wall. Each patients underwent TBNA 1-3 sites, puncturing 2-3 times per site. With the elimination of negative pressure, withdrawned the needle completely from the bronchoscope. Smeared the specimens directly, and then sent the smears to cytology laboratory for examination. After TBNA, Brsuing and Biopsy examination were given for each patient.
3. Statistical Methods Using x 2 test for statistical analysis.
Results
1. The results of conventional bronchoscope 43 patients had different degrees of lumen stenosis by external pressure(Figure 3-4); 27 patients showed normal bronchial lumen and mucosa; 17 cases had congestion and edema in local mucosal.
2. Results of TBNA 87 patients underwent TBNA in 167 sites in total,82 patients (94.3%) cases obtained positive diagnosis.75 cases (86.2%) had proven malignant tumor, in which adenocarcinoma had 32 cases (Figure 5),20 cases with Small cell undifferentiated carcinoma (Figure6),11 cases with squamous cell carcinoma,5 cases with large cell undifferentiated carcinoma, lymphoma in 2 cases,5 patients with malignant tumors difficult to classify; Benign lesions in 7 cases, as five cases of sarcoidosis,2 cases with tuberculosis; Non-specific inflammation in 5 cases.
3. Results of Brushing examination Of 87 patients, only 4 cases (4.60%)had positive results. Among which,3 cases showed squamous cell carcinoma,1 case showed tuberculosis.
4. Results of Biopsy examination Only 21cases showed chronic inflammation; the rest 66 cases showed normal bronchial mucosa.
5. Statistical analysis Results:Comparison of the three methods, the positive rate of TBNA group was significantly higher than brushing and biopsy group (p<0.01).
6. Complications:Except eight cases had minor bleeding in the puncture site without special treatment, no infection, mediastinal emphysema and other complications occurred; All patients can well tolerate TBNA.
Conclusion TBNA is a safe, simple and effective way for diagnosing extra bronchial lesions with a high diagnostic rate and minor injuries. It is worthy to be popularized in clinic work.
方法
1、术前准备术前4小时禁饮水饮食,常规行心电图、血常规、凝血五项、病毒系列、测血压检查,上述检查符合条件者签署知情同意书。2%利多卡因鼻腔及声门麻醉成功后,嘱患者去枕平卧于操作床上,常规吸氧,持续检测血氧饱和度。
2.操作步骤持支气管镜经鼻孔进入气道,结合胸部薄层CT扫描结果及镜下所见确定穿刺部位、角度和深度,穿刺针沿活检通道进入气道,使其与气管壁接近90。,采用推进法结合猛刺法、咳嗽法用力将穿刺针刺入预定位置,穿透气管壁刺入病变组织,镜下见穿刺针完全刺入气管壁内(刺入深度1.0～1.5cm)时拔出针芯,将60mL注射器连接在穿刺针尾端,抽吸并持续30-40 s。在确保穿刺针不脱出气道粘膜的情况下,操作者从不同方向来回抽动穿刺针以增加获取标本的机率。每例患者行TBNA 1～3个部位,穿刺2-3次。解除负压,拔出穿刺针,将穿刺物直接涂片,送细胞学检查。TBNA术毕,常规行刷检及活检。
3.统计学方法采用x2检验方法进行统计分析.
结果
1.常规气管镜检查结果43例患者管腔可见不同程度受压狭窄(如图3-4所示)。27例管腔及粘膜未见明显异常；17例局部粘膜可见充血水肿。
2.TBNA穿刺结果87例患者共穿刺167个位点,获阳性诊断82例,阳性率94.3%。其中恶性肿瘤75例(86.2%),分别为腺癌32例(如图5所示)。小细胞未分化癌20例(如图6所示)。鳞癌11例、大细胞未分化癌5例、淋巴瘤2例,难以分类的恶性肿瘤5例；良性病变7例,分别为结节病5例,结核病2例；非特异性炎症5例。
3.刷检结果87例患者中获阳性诊断4例,阳性率4.60%。分别为鳞癌3例；结核病1例；
4.活检结果87例患者中21例患者示慢性炎症,余66例均为正常支气管粘膜组织。
5.统计学分析结果：三种方法比较,TBNA组阳性率显著高于刷检和活检组(p<0.01).
6.并发症：8例患者穿刺部位少量出血,未行特殊处理；未见感染、纵隔气肿等并发症发生；所有患者均可良好耐受。结论TBNA操作简单,创伤小,诊断率高,是诊断支气管腔外病变的一项安全、高效、可靠的方法,值得临床推广。
Objective Due to most extra bronchial lesions haven't violated bronchial mucosa, it is difficult for Conventional Bronchoscope to obtain effective specimens. So the positive rate for Conventional Bronchoscope is relatively low. Transbronchial needle aspiration (TBNA) is available in penetrating the airway wall of trachea through a special flexible puncture needle with a catheter, acupuncturing and aspirating the lesions(e.g. nodules, masses、swollen lymph nodes etc.) to acquire cell or tissue specimens for cytology or pathology examination. In this paper,87patients with CT scan showed mediastinal or lung mass, nodules, obstructive inflammation or atelectasis, conventional bronchoscopy showed a normal bronchial lumen or only stenosis by external pressure were given TBNA. Followed TBNA, each patient has Brushing and Biopsy examination. We explored the diagnostic value of TBNA in extra bronchial lesions by making statistical analysis for the positive rate of the three operation mentioned above.
Methods
1.Preoperative preparations Drink and food were forbidden for 4 hours before operation; Examinations such as:electrocardiogram, blood test,blood coagulation, the virus family, blood pressure measure are essential. Patients with normal check results mentioned above were asked to sign in the informed consent form.After successful anesthesia with 2% Lidocaine, requested patients to lie on the operation bed, give oxygen inhalation and continuous blood oxygen saturation(SaO2) monitor.
2. Operation procedure
Introduced the Bronchoscope into airway via nasal route; Identified the puncture site,angle and depth according to the CT scan and direct vision by Bronchoscope, then the needle was introduced into the working channel,when it arrived at the intended position, penetrated it vertically into the lesion employing pushing method combining with jabbing and cough method(piercing depth of 1.0-1.5cm),making sure the needle be completely imbedded. Then pulled out the needle core. Applying suction at the proximal suction port, the negative pressure produced allowed cell or tissue to be trapped inside the needle chamber.Keeping aspiration for 30-40s. Twitch-ed back and forth from different directions to increase the opportunity of specimen's acquiring under the condition of ensuring the needle not get out of the bronchial wall. Each patients underwent TBNA 1-3 sites, puncturing 2-3 times per site. With the elimination of negative pressure, withdrawned the needle completely from the bronchoscope. Smeared the specimens directly, and then sent the smears to cytology laboratory for examination. After TBNA, Brsuing and Biopsy examination were given for each patient.
3. Statistical Methods Using x 2 test for statistical analysis.
Results
1. The results of conventional bronchoscope 43 patients had different degrees of lumen stenosis by external pressure(Figure 3-4); 27 patients showed normal bronchial lumen and mucosa; 17 cases had congestion and edema in local mucosal.
2. Results of TBNA 87 patients underwent TBNA in 167 sites in total,82 patients (94.3%) cases obtained positive diagnosis.75 cases (86.2%) had proven malignant tumor, in which adenocarcinoma had 32 cases (Figure 5),20 cases with Small cell undifferentiated carcinoma (Figure6),11 cases with squamous cell carcinoma,5 cases with large cell undifferentiated carcinoma, lymphoma in 2 cases,5 patients with malignant tumors difficult to classify; Benign lesions in 7 cases, as five cases of sarcoidosis,2 cases with tuberculosis; Non-specific inflammation in 5 cases.
3. Results of Brushing examination Of 87 patients, only 4 cases (4.60%)had positive results. Among which,3 cases showed squamous cell carcinoma,1 case showed tuberculosis.
4. Results of Biopsy examination Only 21cases showed chronic inflammation; the rest 66 cases showed normal bronchial mucosa.
5. Statistical analysis Results:Comparison of the three methods, the positive rate of TBNA group was significantly higher than brushing and biopsy group (p<0.01).
6. Complications:Except eight cases had minor bleeding in the puncture site without special treatment, no infection, mediastinal emphysema and other complications occurred; All patients can well tolerate TBNA.
Conclusion TBNA is a safe, simple and effective way for diagnosing extra bronchial lesions with a high diagnostic rate and minor injuries. It is worthy to be popularized in clinic work.
引文
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49. Tremblay A, Stather DR, MacEachern P, et al. A randomized controlled trial of standard versus endobronchial ultrasonography guided transbronchial needle aspiration in patients with suspected sarcoidosis. [J] Chest,2009,136 (2):340-346.
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