纵隔疾病的诊断进展

纵隔疾病是临床常见的一组疾病,包括胸腺瘤、纵隔囊肿、结节病等良性疾病,以及恶性疾病如纵隔恶性肿瘤、淋巴瘤、各种癌症纵隔淋巴结转移等。纵隔疾病临近大血管诊断困难,CT及正电子发射计算机断层（PET）扫描仅可提供形态学诊断,不能获得组织病理学诊断。超声支气管镜引导下经支气管针吸活检术、纵隔镜、食管超声引导的细针穿刺活检等微创检查技术,近年来发展迅速,可获得组织病理学诊断,显著提高纵隔疾病的诊断率。     

支气管内超声引导针吸活检术在纵隔病变诊断及鉴别诊断中的应用价值

目的:探析支气管内超声引导针吸活检术在纵隔病变诊断及鉴别诊断中的应用价值。方法:我院2016年1月-2017年1月期间共收治61例疑似存在纵膈病变患者,对其实施CT检查以及支气管内超声引导针吸活检术进行检查,并经手术病理验证。结果:在61例疑似病例中,支气管内超声引导针吸活检术确诊为阳性者57例,占93.44%;确诊为阴性者17例,占6.56%。CT检查确诊为阳性者44例,占72.13%;确诊为阴性者17例,占27.87%。由此可知,在确诊率上,支气管内超声引导针吸活检术高于CT检查,其差异具有统计学意义(P0.05)。结论:支气管内超声引导针吸活检术在纵隔病变诊断及鉴别诊断中具有极高的应用价值,可在临床诊断予以推广。     

纵隔镜手术在纵隔肿物诊断中的应用价值

目的 探讨纵隔镜手术在纵隔肿物诊断中的应用价值.方法 1999年11月～2005年1月该科共为81例纵隔肿物患者进行了纵隔镜手术,对胸部CT等检查发现的纵隔病变进行活检,获取气管周围、胸骨后、隆突下以及双侧肺门等部位的肿物组织送病理检查.结果 该组病人除1例外全部获得明确病理诊断,确诊率98.8﹪（80/81）.其中恶性病变37例（46.3﹪）,良性病变43例（53.7﹪）.术前术后诊断符合率50.0﹪（40/80）,术前误诊率50.0﹪（40/80）.在术前误诊的病例中以良性病变多见,该组43例良性病变中,有60.5﹪（26/43）的患者术前误诊为恶性肿瘤.该组纵隔镜手术后发生声音嘶哑1例,并发症发生率为1.2﹪（1/81）.无围手术期死亡.结论 纵隔镜手术安全、可靠,对于临床上难以确诊的纵隔肿物是一种有效的诊断方法.     

临床应警惕以单侧声带麻痹为首发表现的纵隔转移癌

目的探讨老年声带麻痹的病因及诊断经验,以提高确诊率。方法对以单侧声带麻痹为首发表现的纵隔转移癌老年患者1例的临床资料进行回顾性分析。结果本例因突发声音嘶哑伴进流食呛咳3个月就诊,于当地医院诊断为左侧声带麻痹,予营养神经药物治疗无效转我院。下咽食管造影、胃镜及颈部、腹部超声均未见异常,经喉镜及胸部X线检查诊断为特发性单侧声带麻痹,行支撑喉镜下声带自体脂肪注射填充术,术后症状基本消失。4个月后因咳嗽、进食哽咽感复诊,经胸部CT、颈部超声及左锁骨上淋巴结穿刺活检病理检查确诊为纵隔转移癌。予纵隔及锁骨上淋巴结伽马刀治疗,1年后死亡。结论老年声带麻痹的首发病因是头颈及胸部肿瘤压迫迷走神经或喉返神经,应仔细询问病史、详细查体,完善头颈及胸部影像学检查,并密切随访,以免漏诊。     

疑似结核性腹膜炎腹腔内镜及腹膜活检14例分析

目的：探讨腹腔内镜检查及直视下腹膜活检对结核性腹膜炎的诊断价值。方法：对临床诊断为结核性腹膜炎（TBP）的14例患者进行腹腔内镜检查及腹膜活检。结果：本组均成功行腹腔内镜检查及腹膜活检,病理证实结核性腹膜炎8例,腹膜癌4例,脾淋巴瘤1例,慢性肝炎1例。结论：腹腔内镜检查安全、经济,确诊率高,对结核性腹膜炎的诊断有重要价值。超细胃镜在腹膜疾病的诊断中有其独特的优势。     

56例女性生殖器结核临床分析

目的总结女性生殖器结核的临床特点及诊断方法,减少误诊以期提高诊治水平。方法对2006年1月~2007年2月年本院收治的56例女性生殖器结核患者的临床表现辅助检查及确诊方法进行回顾性分析。结果（1）生殖器结核以农民（36例,64.3%）多见,初步诊断正确率23.2%。56例中以不孕症、盆腔包块、月经不调主诉而就诊者最多,共占91%。（2）18例剖腹探查病理确诊,13例腹腔镜检查确诊,9例诊断性刮宫及宫腔镜检查活检确诊,2例胸片临床特征确诊,14例诊断性抗结核冶疗确诊。确诊后治疗效果满意。结论女性生殖器结核临床表现多样无特异性,需综合分析病史症状及相关辅助检查。对于诊断不明者可行腹腔镜检查或剖腹探查术,尽快明确诊断,提高诊断率。     

B超配合胸部CT引导下经皮纵隔穿刺活检术的护理

纵隔占位病变仅靠影像、化验等检查,诊断正确率较低,给临床进一步治疗带来困难,B超引导下配合CT结果经皮纵隔穿刺活检术,为不明原因纵隔占位病变的诊断提供了可靠的组织细胞学依据[1,2]。我科2001年1月-2004年8月,对16例纵隔占位患者行B超引导下经皮纵隔穿刺活检术,诊断效果满意。如何完成这一操作,避免或减少并发症的发生,是一个值得重视的临床护理问题,现报道如下。临床资料1.一般资料。16例均为纵隔占位患者,男9例,女7例,年龄24~76岁,平均年龄57.5岁。全部患者经过胸部CT扫描为纵隔占位,且临床检查未能确诊,均行B超引导经皮纵隔穿刺活…     

超声引导下经皮穿刺活检诊断纵隔肿瘤

目的探讨超声引导下应用自动活检装置经皮纵隔肿瘤穿刺的安全性和组织诊断学的准确性。方法在超声引导下使用16G或18G活检针内槽式穿刺自动活检装置,对36例纵隔肿瘤行102次穿刺获取病理组织。结果穿刺获取病变组织成功率为100％,病理结合免疫组化确诊34例,确诊率为94．4％（34／36）,无一例并发症。结论超声引导下应用自动活检装置经皮纵隔穿刺获取病理组织安全、经济、病人易接受且结果可靠,是临床确诊纵隔肿瘤的好方法。     

电视纵隔镜手术的护理配合

90年代初,电视纵隔镜手术问世,它有创伤小、操作简便、安全可靠、取材满意等优点,在肺癌术前病理分期中,其敏感性和特异性可分别达到90%以上和100%,在纵隔疑难疾病的诊断中,其敏感性和特异性更高。迄今为止,它仍是纵隔疾病诊断和治疗以及肺癌术前病理分期的最重要检查方法之一[1]。我院2003年8月~2006年8月共施行电视纵隔镜手术23例,均取得满意的临床诊断及治疗效果。现将手术护理配合要点介绍如下。1临床资料本组病例共23例,其中行纵隔镜纵隔淋巴结活检术18例,纵隔镜纵隔囊肿摘除2例,胸骨旁纵隔镜活检术2例,纵隔镜斜角肌淋巴结活检术1例,男…     

经支气管针吸活检术对肺部疾病的诊断价值

目的探讨经支气管针吸活检术(TBNA)对纵隔及肺门病灶、支气管黏膜下病灶的诊断价值。方法采用TBNA技术对59例伴有纵隔及肺门病灶、支气管黏膜下病灶的患者进行检查,观察其诊断的阳性率及安全性。结果 59例接受TB-NA的患者,共计穿刺89次,穿刺成功68次,穿刺成功率76.4%,确诊肺癌纵隔淋巴结转移26例,黏膜下腺癌1例,淋巴结结核5例,纵隔囊肿1例,纵隔淋巴结增生性炎症1例。结论 TBNA弥补了常规纤支镜检查的不足,对纵隔、肺门及支气管黏膜下病灶的诊断具有重要的应用价值,且TBNA安全性高,操作方便,费用低,值得临床推广应用。     

CT引导下经胸骨老年人纵隔内肿块细针穿刺活检

目的探讨老年人纵隔内肿块CT引导下细针穿刺活检术。方法CT引导下细针穿刺活检，所有穿刺中均应用同轴活检技术。先用18G、100mm长千叶针（导向针）用于穿透皮肤及胸骨，再用20—22G、150mm半自动切割针或20—22G、150mm千叶针通过导向针管进到病灶内，进行切割或抽吸，取得标本涂片、固定，并快速行细胞学检查。结果45例纵隔内肿块老年患者，21例病变位于中纵隔，24例位于前纵隔隐于胸骨后，病灶周围均包裹含气肺组织。所有穿刺均经胸骨径路，避开含气肺组织、纵隔内大血管，无一例出现气胸及大出血。活检诊断正确率为86．7％（39／45）。结论CT引导下应用同轴技术经胸骨纵隔内肿块穿刺，对老年人纵隔内肿块病理诊断提供了较安全的方法。     

Value of sonography for follow-up of mediastinal lymphadenopathy in children with tuberculosis

PURPOSE: To assess the clinical value of sonography for the follow-up of mediastinal lymphadenopathy in children diagnosed with pulmonary tuberculosis (TB). METHODS: We conducted a retrospective review of the medical records of 21 children (9 boys, 12 girls) with a mean age of 6 years (range, 7.4 months to 18 years) who had a positive intradermal tuberculin skin test. All patients underwent thorough history-taking, physical examination, frontal and lateral chest radiographs, and sonographic study of the mediastinum. The mediastinum was accessed through the suprasternal and left parasternal approaches. The presence of 1 or more masses with an ovoid or round shape and hypoechoic appearance in the anterior or middle mediastinum was recorded. A comparison was made between the results of the sonographic examination of the mediastinum before administration of anti-TB agents and after 3 months of treatment. RESULTS: Pulmonary radiographic findings were suggestive of TB in 17 patients and were uncertain in 4 patients. Sonographic examination, however, detected mediastinal lymphadenopathy in all patients. A comparison of pretreatment mediastinal sonograms with those obtained after 3 months of anti-TB treatment showed a marked reduction of lymph node involvement in 17 patients (80.9%). In the remaining 4 patients, mediastinal lymphadenopathy was still present. CONCLUSION: Mediastinal sonography appears to be a valuable tool for the diagnosis of TB and in the monitoring of response to treatment in children.     

Successful endoscopic management of iatrogenic mediastinal infection and subsequent esophagomediastinal fistula, following endosonographically guided fine-needle aspiration biopsy

Complications following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy are rare. A 75-year-old man underwent EUS-FNA biopsy of an enlarged mediastinal lymph, which histologic investigation revealed to be a metastasis of a hepatocellular carcinoma. The patient developed the postinterventional complication of suppurative infection within the mediastinum. Under EUS guidance, a pigtail catheter and a soft tube were inserted to respectively drain and rinse the mediastinal lesion for 8 days. The remaining esophagomediastinal fistula was closed by gathering the fistula margins, using band ligations and an Endoloop. The fistula healed with no further complaints or dysphagia. Infection is a possible complication of endoluminal FNA biopsy. An endoscopically guided therapeutic approach can be favored as the initial treatment of choice and as a reasonable alternative that avoids surgical intervention.     

Mature mediastinal bronchogenic cyst with left pericardial defect: A case report

BACKGROUNDMediastinal bronchogenic cysts and pericardial defects are both rare. It is extremely rare that both occur simultaneously. To the best of our knowledge, this is the first case of a coexistent bronchogenic cyst and pericardial defect reported in China. We performed a literature review and found a relationship between bronchogenic cysts and pericardial defects, which further revealed the correlation between the bronchus and pericardium during embryonic development.CASE SUMMARYA 14-year-old boy attended a local hospital for ankylosing spondylitis. Chest radiography showed an enhanced circular-density shadow near the left mediastinum. The patient had no chest symptoms and the physical examination was normal. Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment. During surgery, a left pericardial defect was observed. The bronchogenic cyst was removed by thoracoscopic surgery, but the pericardial defect remained untreated, and a satisfactory outcome was achieved after the operation. The patient was diagnosed with a mediastinal tumor. The pathological diagnosis of the tumor was a bronchogenic cyst.CONCLUSIONThis case further reveals the correlation between the bronchus and pericardium during embryonic development.     

Ganglioneuroma masquerading as spinal pain

OBJECTIVE: To discuss the clinical features of ganglioneuroma and to propose it as a differential diagnosis for a young patient suffering from chronic back pain. CLINICAL FEATURES: A 25-year-old patient suffered from chronic mid-thoracic pain and a history of scoliosis. The physical examination result was unremarkable; thus radiographs were obtained. A posteroanterior and lateral chest radiograph demonstrated a well-defined opacity extending from the region of the left hilum to below the diaphragm. A differential diagnosis of a posterior mediastinal mass was advanced. Computed tomography revealed a homogenous, nonenhancing left posterior mediastinal mass with adjacent posterior rib deformity. Computed tomography (CT)-guided biopsy subsequently defined the mass as a ganglioneuroma. INTERVENTION AND OUTCOME: The mass was surgically resected. Although the patient experienced some postsurgical discomfort, she has fared well. CONCLUSION: Twenty percent of mediastinal tumors are neurogenic, and 10% of neurogenic tumors are ganglioneuromas. In spite of the rarity of this tumor, ganglioneuroma should be considered in the differential diagnosis of young patients suffering from back pain. The diagnosis is important to ascertain because surgical resection is curative and can relieve the symptoms.     

Single-port thoracoscopic resection of a posterior mediastinal Mullerian cyst in a woman

Mullerian cysts are benign tumors that are very rare in the posterior mediastinum. It is necessary to distinguish Mullerian cysts from benign tumors or other types of cyst in the posterior mediastinum. A 42-year-old woman visited our hospital for a routine check-up, and a mediastinal mass was identified on chest computed tomography (CT). Contrast-enhanced chest magnetic resonance imaging (MRI) revealed a 4.0 × 2.6 × 2.8-cm mass, and a neurogenic tumor or esophageal cyst was suspected. Single-port thoracoscopic surgery was performed for cyst removal. Histopathological examination of the resected tissue revealed that the cyst wall was covered with a single layer of ciliated columnar epithelium. Immunohistochemical staining revealed positivity for paired box gene 8 (PAX8), Wilms tumor protein 1 (WT-1), estrogen receptor (ER), and progesterone receptor (PR). Therefore, a diagnosis of mediastinal Mullerian cyst was made. Mediastinal Mullerian cysts should be included in the differential diagnosis of posterior mediastinal cysts. Cystic lesions in the posterior mediastinum should be removed surgically and undergo immunohistochemical examination.     

奥希替尼治疗获得性表皮生长因子受体-酪氨酸激酶抑制剂耐药T790M突变肺腺癌晚期1例

报告1例使用奥西替尼治疗表皮生长因子受体(epithelial growth factor receptor,EGFR)基因19外显子缺失突变耐药后T790M突变肺腺癌晚期患者。患者,女,72岁,无明显诱因出现左侧胸闷、气喘5 d于当地医院治疗,查胸部CT示双侧胸腔积液,右肺中叶占位,并纵隔淋巴结肿大。为求进一步治疗遂来郑州大学第一附属医院,入院完善相关检查,PET-CT示右肺中叶软组织肿块代谢较活跃,考虑肺癌,建议结合病理诊断;双侧锁骨上区、纵隔及右肺门多发淋巴结肿大,代谢活跃,考虑转移。不符合手术指征,未进行手术治疗,第1次CT引导下经皮肺穿刺活检确诊肺腺癌,基因检测示EGFR基因第19外显子缺失突变,于2017年11月29日开始服用吉非替尼,至2018年12月4日停止服用。期间复查CT发现右上肺结节较前增大,第2次CT引导下经皮肺穿刺活检结果示肺腺癌,基因检测示EGFR基因18外显子缺失突变,合并EGFR基因第20外显子T790M突变,于2018年12月4日开始服用奥希替尼至今,复查未见异常。     

同轴活检技术在CT引导下纵隔内肿块穿刺活检中的临床应用

目的评价应用同轴活检技术及快速细胞学检查,进行CT引导下纵隔内肿块穿刺活检的临床价值.方法CT引导下应用同轴活检技术和快速细胞学检查经皮纵隔内肿块穿刺活检48例.先用18G,10cm长chiba针(导向针)穿透皮肤、胸壁软组织,甚至胸骨、椎体到达病灶边缘外5mm处,再用20～22G半自动切割针或chiba针通过导向针管到达病灶内,并对病灶进行切割或抽吸,取得标本进行涂片固定,然后行快速细胞学检查.结果48例活检病变穿刺25例经胸骨旁径路,19例经胸骨径路,4例俯卧经椎旁径路.穿刺时均避开了含气的肺组织和纵隔内大血管.所有病例均无重复穿刺.活检诊断正确率91.7%(44/48).结论应用同轴活检技术和快速细胞学检查为各类纵隔内肿块的穿刺活检提供了一种更安全、更可靠的方法.     

Mediastinoscopy

When lung cancer is suspected from chest x-ray films but other appropriate tests are negative, direct inspection of the mediastinum, with biopsy of suspicious nodes, can give the evidence needed for a positive diagnosis in many cases. Often this spares the patient exploratory thoracotomy. Since mediastinal spread of pulmonary carcinoma is such an unfavorable sign, mediastinoscopy is of particular value in judging the resectability of the lesion.