可弯曲电子内科胸腔镜在胸腔积液诊断中的应用

目的明确可弯曲电子内科胸腔镜(奥林巴斯-240型)在胸腔积液诊断的价值及意义。方法本文选择了在我院住院127例胸腔积液患者,其中男性87例,女性40例,行内科胸腔镜检查,直视下取病变组织行病理检查,所获资料进行分析,结果 127例患者胸腔镜下,局部胸膜充血水肿粒砂样改变72例,可见胸腔大量黄色胸水及胸膜增厚粘连形成多个囊腔的40例,胸膜见白色样病变及硬结节病变4例,胸膜弥漫性充血见散在粟粒样结节4例,胸膜多个硬结节样新生物突起3例,胸壁散在白色斑片病变,膈面见肉芽样病变1例,胸腔内大量白色干酪样坏死物及纤维包裹粘连1例,胸壁及膈面见凹凸不平结节1例,可见像多个葡萄样病变的肺大疱1例,病理诊断:胸膜结核109例,12例恶性,4例炎症,2例未确诊。结论可弯曲电子内科胸腔镜在胸腔积液中项微创、易操作、诊断率高的检查方法。     

多发性骨髓瘤累及中枢神经系统8例的临床观察

正多发性骨髓瘤(multiple myeloma,MM)是单克隆浆细胞在骨髓中异常增生的恶性肿瘤,通常局限于骨髓。约5%的MM患者会累及髓外软组织器官(淋巴结、肝、鼻咽、喉及上呼吸道、胃肠道、皮肤、会阴、内分泌腺等)~([1]),称为髓外浆细胞瘤。高黏滞综合征、M蛋白相关的神经病变、高钙血症或脊髓压迫引起MM患者神经系统症状并不少见,     

胸膜淀粉样病变1例并文献复习

目的 提高胸膜淀粉样病变的诊断率.方法 报道1例原发性淀粉样病变,主要累及胸膜、心脏,并复习相关文献,对其病因、发病机制、临床表现、诊断、治疗及预后进行分析.结果 本例原发性系统性淀粉样病变患者无家族史及慢性疾病史,胸膜病理诊断原发性淀粉样病变AL型,其他组织如皮下脂肪、骨髓未见淀粉样物质沉淀.结论 对于反复出现不明原因的顽固性胸腔积液的鉴别诊断,应考虑本病的可能;为治疗大量顽固性胸腔积液,可行胸膜腔黏连术缓解症状.     

1 例淋巴瘤误诊为结核性胸腔积液并文献复习简

结核性胸腔积液是临床常见的一类胸腔积液,而它的确诊还是相对困难的.结核性胸膜炎的确诊需要胸腔积液或胸膜活检标本中找到结核杆菌,或胸膜活检有典型结核性肉芽肿改变;然而根据病史和临床表现,以及胸腔积液ADA增高,临床上也可诊断结核性胸腔积液[1].超过一半的结核性胸腔积液患者,胸腔积液是唯一的临床表现.由于结核性胸腔积液胸膜结核分枝杆菌负荷低,胸腔积液离心沉淀后的结核菌涂片阳性率在5%以下[2],结核性胸腔积液胸水培养结果阳性率〈20%[3],而且这往往需要等待几个星期.胸膜活检病理检查作为诊断结核性胸腔积液的一种重要手段,但并非只有结核性胸腔积液的胸膜病理呈肉芽肿病变,还有如真菌性疾病、结节病、土拉菌病和类风湿胸膜炎也可有肉芽肿病变[1],有时还得抗酸染色或活检标本的培养.     

胸腔镜冷冻治疗纤维黏连为主型结核性胸腔积液的临床观察

目的探讨经胸腔镜微创冷冻治疗结核性胸腔积液形成纤维黏连及壁层胸膜结核结节的临床疗效。方法对38例结核性胸腔积液形成纤维黏连的患者通过内科胸腔镜微创检查并对纤维黏连带采用冷冻探针清除,并对壁层胸膜结核结节进行冻融治疗。结果患者胸腔内见大量纤维黏连形成,采用冷冻探针进行冻切后可清除胸腔内病变,壁层胸膜结核结节通过冻融治疗后迅速坏死。经治疗后患者症状改善,胸腔积液吸收明显。显效:12例(31.6%);有效24例(63.2%),无效2例(5.3%),总有效率94.7%。结论内科胸腔镜能及时发现胸腔纤维黏连,并可以在直视下对病变进行清除,冷冻治疗是内镜介入治疗胸膜病变的有效方法,且安全。     

胸腔镜检查应用于胸膜、肺部肿瘤

胸腔镜检查作为诊断各种肺、胸膜疾患的一种方法,愈来愈受到重视,具体方法亦已有所介绍,本文着重讨论胸腔镜检查用于胸膜、肺肿瘤的诊断和对恶性胸腔积液的胸腔内滑石粉治疗。胸膜-肺肿瘤的诊断胸膜肿瘤各种原发或继发的恶性胸膜肿瘤、恶性胸腔积液临床诊断较为困难。常规胸腔穿刺和胸液细胞学检查阳性率甚低。胸膜针刺活检的阳性率亦仅50～60%左右。Armengod 通过对180例胸膜肿瘤的观察,发现仅95例病变侵犯壁层胸膜,因而认为作胸膜     

多发性骨髓瘤少见的并发症

本文将我院自1967～1987年资料完整的MM53例中发现的浆细胞白血病6例,合并胸腔积液2例,报告如下: 诊断标准如末梢血象示浆细胞>20％,伴形态异常和/或绝对值>2,000/mm~3,即可诊断浆细胞白血病(PCL);发生一侧或双侧胸水,胸水呈渗出液,细胞以单核细胞为主,病理检查证实有较多浆细胞,诊为MM合并胸腔积液. 临床资料及结果 6例MM合并浆细胞白血病的临床资料见是1。     

结节病胸膜病变分析并文献复习

目的 分析结节病胸膜病变的临床特征，探讨鉴别诊断方法。方法回顾性分析确诊的有病理证据的结节病32例，报告以胸膜病变为主要表现的典型病例，对临床特点和鉴别诊断进行分析。检索国内文献中结节病胸膜病变的病例报告和病例总结，分析其发生率和临床特征。结果1989年至2004年共确诊胸内结节病32例，以胸腔积液为主要表现者2例（2／32，6．3％），其中1例双侧胸腔积液经内科胸腔镜检查确诊；自发性气胸1例（1／32，3．1％），经开胸肺活检确诊。胸腔积液分析为渗出液，细胞分类以淋巴细胞为主，腺苷脱氨酶（ADA）均未超过30U／L，其中1例胸腔积液血管紧张素转换酶（ACE）升高。3例在确诊前均被误诊为肺结核，接受抗结核治疗1-12个月不等。国内发表的病例总结中，结节病胸膜病变发生率为3．4％-16．7％；个案报道显示结节病胸腔积液最常被误诊为结核性胸膜炎。结论结节病胸膜病变并非罕见，临床上常被误诊。这一认识无论对于结节病的及时诊断，还是对于胸膜病变的鉴别诊断都有重要临床意义。     

闭式经皮胸膜刷检在疑难性胸腔积液病因诊断中的价值

胸腔积液的病因较多 ,大部分通过常规检查可确诊 ,但仍有相当数量的疑难性胸腔积液不能做出病因诊断。我科从1999年 2月～ 2 0 0 0年 10月对胸腔积液患者行胸膜刷检 (闭式经皮胸膜刷检 ) ,并与胸膜活检 (闭式经皮胸膜活检 )比较。对象与方法1.对象 :选择胸腔积液性质待查的住院患者 3 1例 ,入院后经胸部Ｘ线、ＣＴ扫描、纤维支气管镜、2～ 3次胸腔积液及痰液检查而不能确诊 ,并予诊断性抗痨治疗半月效果不佳。男性 2 0例 ,女性 11例 ,年龄 2 6～ 75岁 ,平均年龄 5 1.3岁。大量胸腔积液 18例 ,中等量胸腔积液 13例。随机分成刷检组 16例 ,活…     

恶性胸腔积液的实验诊断进展

恶性胸腔积液是由恶性肿瘤胸膜转移或原发于胸膜的恶性肿瘤所致,早期诊断困难,临床迫切需要实验室提供检查手段,以诊断恶性胸腔积液.本文就恶性胸腔积液的实验诊断进行综述.     

A rare case of extramedullary plasmacytoma in the mediastinum.

A rare case of extramedullary plasmacytoma in the mediastinum is reported. An 80-year-old man was admitted for further examination of a mediastinal tumor. Chest computed tomography (CT) revealed a large mediastinal mass and right interlobar pleural effusion. Needle biopsy under CT guidance established a diagnosis of plasmacytoma. Immunohistochemical staining revealed that the tumor cells were producing monoclonal IgA kappa. Serum immunoelectrophoresis revealed an IgA kappa monoclonal component with a serum concentration of 5,040 mg/ml. The bone marrow aspiration was normal. Bone roentgenogram and bone scintigram showed osteoporosis but no neoplastic lesion.     

A case of extramedullary plasmacytoma in the mediastinum]

A 80-year-old man was admitted to our hospital for examination of a mediastinal mass. Chest CT showed a 6 x 9 cm mass in the left anterior mediastinum. The left main bronchus and pulmonary artery were invaded by the mass. Bronchoscopic examination showed compression of the left main bronchus by the mass and enlarged lymph nodes. The left upper lobe and lingular bronchi were almost occluded. The overlying mucosa was invaded by tumor tissue. Microscopic findings of specimen obtained by transtracheal biopsy showed plasma cells of various sizes were at different stages of differentiation. Immunohistochemical staining revealed IgA monoclonality. Whole-body bone scan and bone marrow aspiration excluded multiple myeloma and a diagnosis of extramedullary plasmacytoma was made. Serum protein electrophoresis showed an IgA monoclonal gammopathy. Immunoelectrophoresis of the serum revealed an IgA kappa monoclonal component. These suggested that tumor cells were producing monoclomal IgA kappa light chain. Radiotherapy was effective in reducing the size of the plasmacytoma, and serum IgA reverted to normal. A 67-Ga scan showed strongly increased uptake in the left anterior mediastinum. Chest CT after radiotherapy showed that the decreased mass had an extrapleural sign against the mediastinal pleura. We determined that the origin of the plasmacytoma was probably the mediastinum. We reported a rare case of extramedullary plasmacytoma in the mediastinum.     

Response of the extramedullary lung plasmacytoma with pleural effusion to chemotherapy

 An elderly patient with an extramedullary lung plasmacytoma and subsequent pleural effusion is described. The presence of abnormal plasma cells in the pleural fluid led to diagnosis. Histologically similar conditions such as multiple myeloma and solitary myeloma of bone were ruled out by clinical evaluation. These neoplasms usually occur in the head and neck area and are not characterized by paraprotein accumulation. Few cases in the lung have been reported. We describe a case of extramedullary plasmacytoma of the lung with plasmacytoma-induced pleural effusion and the presence of monoclonal paraprotein in both the serum and urine. Chemotherapy with melphalan was effective in reducing the size of the plasmacytoma, and pleurodesis was used to manage the pleural effusion. Received: 16 December 1996 / Accepted: 16 April 1997     

Unilateral Massive Pleural Effusion: A Presentation of Unsuspected Multiple Myeloma

Pleural effusion in case of multiple myeloma is usually multifactorial but effusion due to myelomatous deposition of pleura is extremely uncommon. We are reporting a unique case of unsuspected multiple myeloma presenting as left sided massive pleural effusion due to myelomatous deposit in pleura and a rare M-band in the alpha-2 region in serum protein electrophoresis. A 61 year lady presented with cough, weakness and progressive shortness of breath. Examination revealed mild pallor and left sided massive pleural effusion that re-accumulated despite treatment. PAP stained smear of pleural fluid showed a large number of plasma cells and pleural biopsy revealed infiltration of plasma cells. Fiber-optic bronchoscopy was inconclusive. Blood examination revealed high value of alpha-2 globulin. Serum electrophoresis showed M band in alpha-2 region and urine electrophoresis showed faint monoclonal light chain pattern. X-ray skull showed multiple punched out osteolytic lesions. Bone marrow examination revealed hypercellular marrow with atypical plasma cells including binucleate forms in large number (above 55% of nucleated cell population).     

Isolated extramedullary relapse in the pleural fluid of a patient with acute myeloid leukemia following allogeneic BMT

We report an unusual case of AML, in which the patient showed extramedullary relapse in the pleural fluid and the skin without bone marrow recurrence even 3 years after allogeneic BMT. On examination of the pleural effusion and the skin, which relapsed 31 months and 40 months, respectively, after BMT, we found that most of cells were as the XY-type recipient by quantitative X/Y FISH (fluorescence in situ hybridization). However, 100% of the bone marrow cells remained XX-type donor cells. In the present case, we believe that the graft-versus-leukemia (GVL) response in the extramedullary site was not so effective as that in the bone marrow, where it remains effective.     

Secondary extramedullary plasmacytoma involving the pancreas

Extramedullary plasmacytoma is a rare variant of plasma cell tumor involving organs outside the bone marrow. The vast majority of extramedullary plasmacytomas present as a secondary tumor of systemic myelomatosis of the bone marrow. We experienced a patient with extramedullary plasmacytomas of the head and tail of the pancreas presenting as secondary masses from extramedullary plasmacytoma of the maxillary sinus that had been treated 5 years previously. A 38‐year‐old Japanese man had undergone radiation therapy for an extramedullary plasmacytoma of the maxillary sinus 5 years before the current presentation. He experienced severe upper abdominal pain in November 1999, when laboratory data showed elevation of the serum amylase level. Computed tomography showed two isodensity masses, in the head and tail of the pancreas. Angiography showed two hypervascular masses, one in the head and the other in the tail of the pancreas, and encasement of the portal vein trunk junction. Laparotomy was performed, with the tentative diagnosis of extramedullary plasmacytoma of the pancreas, in order to obtain a definite diagnosis. Intraoperative biopsy revealed that the two pancreatic masses were extramedullary plasmacytomas. External radiation therapy was performed after the operation. When a pancreatic mass is noticed in patients with a history of plasmacytoma, secondary extramedullary plasmacytoma of the pancreas should be considered as a differential diagnosis.     

A case of malignant lymphoma diagnosed by thoracoscopy with local anesthesia]

A 67-year-old woman was hospitalized with right pleural effusion on chest radiography. Chest CT showed a thickened parietal pleura and pleural effusion in the right thorax. Cytological examination of pleural effusion showed atypical plasma cells. We performed thoracoscopy with local anesthesia for diagnosis and observed an about 5 x 5 cm seized red soft tumor on the parietal pleura. Pathological and immunohistochemical examination of the pleural tumor revealed that it was marginal zone B-cell malignant lymphoma. In this case, we could not reach a diagnosis only by cytological examination of the pleural effusion. Thoracoscopy with local anesthesia was safe and useful for diagnosis of malignant lymphoma with pleural effusion. Most cases of primary pleural malignant lymphoma have a history of chronic pyothorax. This case is thought to be a very rare case of primary pleural malignant lymphoma with no history of pyothorax.     

Multiple myeloma with myelomatous pleural effusion: a case report and review of the literature

Multiple myeloma (MM) is a malignant neoplasm of plasma cell origin. Pleural effusion may develop in the setting of MM due to various reasons, but myelomatous pleural effusion (MPE) is rare. We report a case of MPE in a patient with advanced MM. A 76-year-old woman with MM was admitted to hospital because of dyspnea. Chest X-ray showed right-sided pleural effusion. Protein electrophoresis of the pleural fluid showed monoclonal protein, and cytology demonstrated monoclonal plasma cells. Hospice care was implemented, and the patient died one month later. We present an analysis of the clinical characteristics of 57 MPE cases reported in the English literature. Our review revealed that MPE patients had poor overall survival irrespective of whether MPE develops in the course of their disease or presents as the initial manifestation of MM. Based on this analysis, MPE is a poor prognostic factor, and aggressive treatment should be considered, especially for patients with early-onset MPE.     

Multiple myeloma causing obstructive jaundice by extramedullary plasmacytoma after Bence Jones protein loss--an autopsy case report

A 63-year-old man was admitted to our hospital with a chief complaint of general malaise in March 1986. A diagnosis of Bence Jones protein (kappa) type of multiple myeloma was made from increased atypical plasma cells in the bone marrow, urinary BJP (kappa) and osteolytic lesions. Urinary BJP (kappa) was decreased by MP and VENP therapies. In April 1987, he visited us again with the complaint of pain on the left shoulder. An examination revealed multiple osteolytic lesions and bilateral pleural effusion containing atypical plasma cells. Jaundice was developed at the end of July 1987. An ultrasound examination revealed a hypoechoic mass in the area of pancreatic head. The effusion was gradually increased without response to the treatment. He died of respiratory failure on July 31, 1987. On autopsy, extramedullary plasmacytoma was found in the head of pancreas. It was a rare case of multiple myeloma in which pleural effusion and multiple plasmacytomas, and finally obstructive jaundice were developed although urinary BJP (kappa) was reduced by treatment.     

Pleural malignant mesothelioma complicated by multiple myeloma]

A 79-year-old woman was admitted because of dyspnea. Chest X-ray films and computed tomographic scans disclosed left pleural effusion and diffuse pleural thickening. A diagnosis of multiple myeloma was made on the basis of blood tests and bone marrow aspiration biopsy findings. Multiple myeloma was the suspected cause of the pleural lesions. However, a postmortem diagnosis of malignant mesothelioma of the pleura was made on the basis of histological and immunohistological studies of autopsy specimens.