肺癌的筛查和早期诊断

肺癌的筛查和早期诊断是提高肺癌治愈率、降低死亡率、延长生存期和改善肺癌患者生活质量的主要手段。简便易行、经济适用和准确可靠的检查手段是肺癌筛查和早期诊断的主要方法 ,其中引人注目的是低剂量螺旋CT和肺癌分子标志物的研究。 2 0 0 3年 8月 10～ 14日在加拿大温哥华举行的第十届世界肺癌大会上 ,有 6 0余篇论文涉及到肺癌的筛查和早期诊断方法 ,分别从胸部X线片、CT、痰细胞学、纤维支气管镜和肺癌的分子标记物等方面进行了论述 ,尤其是前几年多中心大样本的前瞻性随机对照研究 (RCT)的结果已开始有报道。现就本次大会及最近…     

肺癌骨转移340例临床分析

我院自1988年～1997年共收治肺癌病人2812例,其中经病理组织学和/或细胞学检查诊断明确者2635例,发现骨转移者340例,现将其临床情况分析报告如下:1 临床资料1.1 发生率 本组病理组织学和/或细胞学诊断明确肺癌患者2635例中,发现骨转移者340例,骨转移发生率为12.9%.1.2 性别 所统计肺癌数男1860例,女775例,男女之比为2.4:1.骨转移者男247例,女93例,骨转移者男女之比为2.7:1;两组男女间比较,无显著差异(P>0.05).1.3 病程 诊断肺癌至骨转移确诊时间为3个月以内者112例,占32.9%;3～6个月以内者83例,占24.4%;6个月～1年者73例,占21.5%;1年以上者56例,占16.5%.骨转移表现先于肺癌临床表现,即以骨转移为肺癌首发临床表现者16例,占骨转移总数的4.7%,骨转移时间先于肺癌诊断平均时间为2.5个月.     

PET/CT在肺癌早期诊断和分期的临床应用价值

肺癌乃长期威胁国人生命的第一大恶性肿瘤,早期肺癌少有症状,一旦发现症状多已至晚期,疗效不佳。PET/CT极大提高了肺癌癌诊断的灵敏度和特异性,其优越的解剖和功能同时成像、早期探查、准确定性和精确定位诊断性能使肺癌的诊断、分期、治疗决策和预后判断以及随访提供了新的手段,对延长肺癌患者的生命时间和提高生存质量具有重要意义。本文介绍了PET/CT显像对肺癌原发灶的诊断及分期的重要临床价值。     

肿瘤标志物诊断肺癌转移的临床价值

目的:检测肿瘤标志物在肺癌与肺癌并转移患者中的水平差异,并分析其鉴别诊断价值。方法:纳入388例肺癌患者及67例肺癌并转移患者,采集血液样本,采用凝集素亲和方法检测肿瘤异常蛋白（TAP）,采用化学发光免疫分析法检测糖类抗原125（CA125）、癌胚抗原（CEA）、细胞角蛋白19片段（CYFRA21-1）、糖类抗原50（CA50）、铁蛋白(FRT)、神经元特异性烯醇化酶（NSE）、鳞状细胞癌抗原（SCC）。比较上述肿瘤标志物在肺癌与肺癌并转移患者中的水平差异,利用受试者工作特征曲线（ROC）,分析肿瘤标志物对两组患者的鉴别诊断价值。利用Logistic回归分析鉴定肺癌转移的风险因素。Spearman相关性分析患者肿瘤标志物之间的相关性。结果:CEA、CYFRA21-1及NSE在肺癌并转移患者中的水平明显高于肺癌患者（P＜0.05）,而其他肿瘤标志物在两组患者之间无明显差异（P＞0.05）。与各自的参考区间相比,TAP在肺癌及肺癌并转移患者中的阳性率最高（>98%）,SCC阳性率最低（<10%）,其他指标的阳性率介于10%~65%。肺癌并转移患者CEA阳性率明显高于肺癌患者（62.69% vs 43.8%,P＜0.05）。ROC分析结果显示,CEA对两组患者的鉴别效能最优（特异性:82%、敏感性:42%）。联合指标分析显示,与其他指标联合并不能明显提升CEA的鉴别诊断价值（P＞0.05）。Logistic回归分析显示,CEA是肺癌转移的风险因素。相关性分析显示,在肺癌与肺癌并转移患者中,各肿瘤标志物之间的相关性不一致。结论:与肺癌患者组相比,肺癌并转移患者中的CEA阳性率及水平均明显升高,对肺癌转移的诊断具有一定的临床意义。     

肺癌的遗传易感性和环境致癌

第十届世界肺癌大会于 2 0 0 3年 8月 10～ 14日在加拿大温哥华举行 ,本文就本次大会有关肺癌遗传易感性和环境致癌方面的内容作一评述。1　肺癌发生的危险因素和病因学研究肺癌是当今世界各国常见的恶性肿瘤 ,已成为绝大多数国家因癌症死亡的首要原因 ,并被认为是目前对人类健康和生命威胁最大的恶性肿瘤。目前 ,肺癌发病率和死亡率在男性均占第一位 ,在女性发病率占第二位 ,而死亡率占第一位。据WHO统计 ,每年全世界估计有超过 10 0万例的新肺癌患者 ,死亡约 10 0万。2 0 0 0年全世界肺癌新发病例 12 4万人 ,据估计 ,2 0 0 3年在美国因…     

经支气管超声引导针吸活检在肺癌纵隔分期和胸腔内病变诊断中的应用

既往研究显示,经支气管超声引导针吸活检(endobronchial ultrasound-guided transbronchial needle aspiration, EBUS-TBNA)是一项微创技术,可用于肺癌患者的纵隔分期、胸腔内病变的诊断、不明原因淋巴结肿大的诊断以及非小细胞肺癌(non-small cell lung cancer, NSCLC)新辅助化疗后的纵隔再分期。本综述旨在关注EBUS在NSCLC纵隔分期中的作用,以及EBUS在进一步评估通过常规检查仍诊断未明的胸腔内病变中的应用。总之,就NSCLC患者纵隔分期而言,由于EBUS的诊断敏感性和特异性均较高,其为纵隔镜检查的有效替代,亦可用于疑似胸腔病变的活检,且不会给患者带来任何并发症风险。     

电视纵隔镜在纵隔肿瘤的诊断和肺癌术前分期中的应用

纵隔镜检查是纵隔疑难疾病和肺癌术前分期的常用方法之一 ,电视纵隔镜检查术 (video mediastinoscopy)进一步提高了这一技术的安全性和准确性。自 2 0 0 2年9月～ 2 0 0 3年 8月我科进行了 30例电视纵隔镜检查术 ,有一些初步体会 ,现将结果报告如下。1　资料和方法1.1　临床资料　本组 30例 ,男 2 2例 ,女 8例 ,平均年龄 4 7岁 (2 9～ 6 4岁 ) ,术前均行查体、胸部X线片、CT、纤支镜、痰细胞学检查 ,其中纵隔肿瘤 (不能排除淋巴瘤、结节病等 ) 14例 ,怀疑纵隔型肺癌 10例 ,已确诊为肺癌但因纵隔淋巴结肿大 (直径大于 1cm)需作术前分期的 6…     

肺癌的外科治疗进展

第 10届世界肺癌大会于 2 0 0 3年 8月 10～ 14日在加拿大温哥华召开 ,有关肺癌的外科治疗 ,会议共安排了“肺的孤立性结节”、“局部晚期肺癌的手术”、“诱导治疗后的手术”、“电视辅助胸外科”、“新辅助化疗”等 5个专题 ,还有 3场墙报展示和讨论。1　关于肺孤立性结节诊断治疗的进展肺孤立性结节 (solitarypulmonarynode ,SPN )的诊断一直是临床难点之一 ,本次大会对此的诊治策略体现如下几个特点。随着多探头螺旋CT的应用 ,越来越多直径小于 2cm的肺孤立性结节被发现 ,由于确诊手段的局限 ,这类结节的诊治策略一直是所谓的“等待与…     

磁共振成像在肺癌诊断和分期中的作用

磁共振成像(MRI)是常用的影像学检查技术,其在肺癌诊断和分期中的作用备受关注.研究表明,MRI可用于肺部良恶性结节的鉴别及肺癌的筛查,并可用于非小细胞肺癌(NSCLC)的TNM分期,其敏感性和特异性与18氟-脱氧葡萄糖(18F-FDG) PET-CT相当,可作为NSCLC诊断和分期的替代影像学检查手段.     

Imaging diagnosis in preoperative TNM staging of lung cancer

Conventional chest radiography (CR), computed tomography (CT) and magnetic resonance imaging (MRI) as staging modalities were compared in assessing the tumor extension and node status before operation in 57 patients with non-small cell bronchogenic carcinoma. The results showed that accuracy of 47 T1 and T2 lesions was 94%, 73% and 77% for CR, CT and MRI, respectively. CR and CT correctly evaluated 1 of the 2 T3 lesions and MRI was correct in both. CT and MRI correctly evaluated 4 of the 7 T4 lesions. MRI was superior to CT for left pulmonary artery invasion, but inferior to CT for pleural metastases. CR underestimated all of the 7 T4 lesions. The mediastinal lymph node metastases were evaluated preoperatively, giving sensitivities in CR, CT and MRI of 17%, 71% and 67%, respectively. The sensitivity of CT and MRI was higher than CR (P less than 0.01). The short axis of nodes greater than or equal to 10 mm was recommended for metastasis on the right side of mediastinum and the long axis greater than or equal to 10 mm for that in the other areas of mediastinum.     

Endoscopic ultrasound evaluation in the diagnosis and staging of lung cancer

The detection of mediastinal lymph node metastases in patients with lung cancer is most important. These nodes may be used for tissue diagnosis of the malignancy, if sampling techniques of the primary have failed. Their presence implies a stage III disease and may exclude a patient from surgery. CT is the standard imaging, but is relatively poor at staging the mediastinum (overall sensitivity: 50-70%), and is especially unreliable for lesions <1 cm. PET is a new physiological imaging technique, which seems to be superior to CT (sensitivity: 67-100%). Transesophageal EUS delivers high resolution imaging, offers the advantage of simultaneous tissue sampling (EUS-FNA sensitivity: 84-94%), but is limited to the posterior mediastinum. This review compares the diagnostic value of CT, PET and EUS as well as the different tissue sampling methods for mediastinal metastases with EUS-FNA. The technique of EUS and FNA is described, and a special interest is taken to stress out the different areas of the mediastinum accessible for each of the tissue sampling methods as well as the pros and cons for its use. Advantages and disadvantages of EUS-FNA are shown and the new efforts described to improve the outcome of EUS-FNA by adding molecular methods for the detection of micrometastases.     

Endoscopic ultrasound-guided fine-needle aspiration in the diagnosis and staging of lung cancer and its impact on surgical staging.

PURPOSE: The diagnosis and staging of lung cancer critically depends on surgical procedures. Endoscopic ultrasound (EUS) -guided fine-needle aspiration (FNA) is an accurate, safe, and minimally invasive technique for the analysis of mediastinal lymph nodes (LNs) and can additionally detect tumor invasion (T4) in patients with centrally located tumors. The goal of this study was to assess to what extent EUS-FNA could prevent surgical interventions. PATIENTS AND METHODS: Two hundred forty two consecutive patients with suspected (n = 142) or proven (n = 100) lung cancer and enlarged (> 1 cm) mediastinal LNs at chest computed tomography were scheduled for mediastinoscopy/tomy (94%) or exploratory thoracotomy (6%). Before surgery, all patients underwent EUS-FNA. If EUS-FNA established LN metastases, tumor invasion, or small-cell lung cancer (SCLC), scheduled surgical interventions were cancelled. Surgical-pathologic verification occurred when EUS-FNA did not demonstrate advanced disease. Cancelled surgical interventions because of EUS findings was the primary end point. RESULTS: EUS-FNA prevented 70% of scheduled surgical procedures because of the demonstration of LN metastases in non-small-cell lung cancer (52%), tumor invasion (T4) (4%), tumor invasion and LN metastases (5%), SCLC (8%), or benign diagnoses (1%). Sensitivity, specificity, and accuracy for EUS in mediastinal analysis were 91%, 100% and 93%, respectively. No complications were recorded. CONCLUSION: EUS-FNA qualifies as the initial staging procedure of choice for patients with (suspected) lung cancer and enlarged mediastinal LNs. Implementation of EUS-FNA in staging algorithms for lung cancer might reduce the number of surgical staging procedures considerably.     

纵隔镜检查在纵隔疾病诊断和肺癌分期中的应用

背景与目的:CT、纤维支气管镜等检查对某些纵隔疾病确诊仍十分困难;而准确地判定肺癌是否有纵隔淋巴结转移并对肺癌进行合理分期,对制定治疗方案和初步预测预后具有重要意义.本研究旨在探讨纵隔镜检查在纵隔疾病诊断和合并纵隔淋巴结肿大的肺癌分期中的应用价值和经验.方法:对16例CT等影像学检查发现有纵隔疾病的患者和14例术前经CT或PET、纤维支气管镜等检查诊断肺癌合并纵隔淋巴结肿大的患者进行纵隔镜检查和活检,行病理诊断.根据病理结果对肺癌进行分期.结果:未能确诊的纵隔疾病16例,经纵隔镜检查活检后获得病理确诊,分别为结节病5例,纵隔淋巴结结核3例,纵隔淋巴结炎性改变2例,淋巴瘤2例,胃肠道外胃肠道型恶性间质瘤1例,胸腺瘤1例,转移性小细胞癌1例,转移性腺癌1例;术前诊断肺癌并有纵隔淋巴结肿大的14例患者,经纵隔镜淋巴结活检,发现6例有纵隔淋巴结转移,8例无转移,后者经开胸手术,病理确诊为肺癌无纵隔淋巴结转移.14例患者经纵隔镜淋巴结活检均获得准确的肺癌分期;手术无严重并发症发生.结论:在纵隔疾病诊断和肺癌分期的应用方面纵隔镜检查是一种安全、准确的有效方法.     

Noninvasive staging of lung cancer

Accurate evaluation of disease extent is mandatory when the diagnosis of resectable lung cancer is established. Staging has a significant impact on subsequent therapeutic options and prognosis. Radiologists can now rely on numerous instruments, each with different advantages and limitations. The procedure of choice is still chest X-ray whose intrinsic limitations require better tumor characterization with chest CT. CT difficulties in the differential diagnosis between the tumor and secondary changes occurring in adjacent structures can be overcome by 18F-FDG-PET or MRI. Functional information is acquired with the former and multiparametric information with the latter. According to the case, further extension to adjacent structures can be evaluated based on CT or MRI. For lymph node and distant metastasis PET is increasingly used, except for brain parenchyma where MRI is definitely more accurate in the detection of brain metastasis.     

18F-FDG双探头符合线路单光子发射计算机体层摄影术-计算机体层摄影术在肺癌诊断与分期中的应用

目的 评价18F-FIX;双探头符合线路单光子发射计算机体层摄影术-计算机体层摄影术(SPECT-CT)在肺癌患者诊断与分期中的临床应用价值.方法 对71例肺内病变怀疑肺癌患者进行SPECT-CT和常规CT检查.共57例患者获得病理或细胞学证实,其中52例为肺部恶性肿瘤,5例为肺部良性病变.37例患者有完整病理分期资料.结果 以病理诊断为金标准,SPECT-CT诊断肺内病变的敏感性、特异性和准确率分别为92.3%、80.0%和91.2%,常规CT分别为84.6%、80.0%和84.2%,两种检查方法诊断准确率差异无统计学意义(P=0.2S4).以病理分期为金标准,SPECT/CT的TNM分期准确率为67.6%,常规CT为59.5%,两种检查方法诊断准确率差异无统计学意义(P=0.469).SPECT-CT对肺门及纵隔淋巴结诊断的敏感性、特异性、准确性、阳性预测值和阴性预测值分别为61.5%、75.0%、70.3%、57.1%和78.3%,而常规CT分别为76.9%、79.2%、78.4%、66.6%和86.4%,两种检查方法诊断准确率差异无统计学意义(P=0.425).结论 SPECT-CT在肺部病变良恶性判断和分期方面略优于常规CT,可以用于一部分患者病变的良恶性鉴别和直径≥1 cm淋巴结性质的判断.     

Initial surgical staging of lung cancer

Many patients with early stage lung cancer (stage I and II) are curable by surgical resection. In patients with locally advanced disease surgery plays an important role in order to provide local tumor control. Therefore, the aim of all staging efforts in NSCLC must be to identify all patients, who might be potential candidates for a surgical approach. Current staging tools include imaging techniques like CT- and PET-scan, transthoracic, transbronchial or transeosophageal needle biopsies and finally surgical staging methods including mediastinoscopy and video-assisted thoracoscopic surgery (VATS). With respect to mediastinal lymph node staging, cervical mediastinoscopy is reported to have a sensitivity between 81 and 89%. This mainly due to the fact, that some lymph node levels (# 8, 9, 5, 6) are not accessible by the standard cervical approach. The morbidity and mortality of cervical mediastinoscopy is in experienced centers only minimal. In series with more than 1000 patients, the mortality was almost 0% and morbidity varied between 0.5 and 1%. Cervical mediastinoscopy can be performed also as an outpatient procedure. In addition to 'simple' lymph node staging, mediastinoscopy clarifies the local resectability of central tumors (T-factor). Currently, cervical mediastinoscopy is recommended by almost all scientific societies in patients with apparently resectable NSCLC who present with enlarged mediastinal lymph nodes of >1 cm in short axis diameter. Video-mediastinoscopy allows that the procedure gets even more standardized and preliminary data suggest that the sensitivity might be improved in comparison to conventional mediastinoscopy. Since VATS is widely accepted by the community of thoracic surgeons, it has become an important staging tool in many situations. VATS can be used to rule out or confirm a suspected contralateral lung metastasis. Furthermore, VATS is extremely useful to exclude malignant pleural effusions in otherwise operable patients. This examination can be done in the operating room immediately prior to formal thoracotomy. Additionally, VATS is effective to explore the local resectability in patients with suspected mediastinal infiltration or a lymphangiosis carcinomatosa within the mediastinum. VATS allows an accurate staging of more than 90% of the patients with suspected stage IIIB NSCLC. With respect to lymph node staging, VATS is complimentary to cervical mediastinoscopy because it helps to stage the lymph nodes in the A-P. window (#5, 6), as well as the lymph nodes paraesophageal (#8) and in the pulmonary ligament (#9). In conclusion, surgical staging methods provide a 100% specificity in combination with a high sensitivity and only a minimal morbidity. Currently, surgical staging is recommended by the majority of scientific societies for the staging of patients with apparently resectable NCSLC.