肺癌氩氦刀冷冻治疗中气胸的防治策略

目的探讨CT引导下肺癌氩氦刀冷冻治疗中气胸的预防及对策。 方法对457例肺癌行CT引导下氩氦刀冷冻消融术,术中密切观察,分析气胸发生的原因,并总结有效的预防措施及气胸处理对策。 结果患者均顺利完成手术,无术中死亡,并发气胸71例,发生率15.54%（71/457）;37例气胸范围>20%,给予反向体位法抽气引流后35例一次治愈,有效率94.59%（35/37）;术后采用反向体位法可预防气胸发生。 结论CT引导下氩氦刀冷冻治疗肺癌采用合理的术式时气胸发生率较低且轻微,反向体位法防治气胸效果理想。     

新生儿肺气漏的床旁 X 线诊断价值分析

目的：分析新生儿肺气漏的X线表现及其诊断价值。方法回顾26例新生儿肺气漏的床旁正位胸部X线表现。结果26例患儿中气胸18例,肺间质气肿4例,纵隔气肿3例,心包积气1例,其中气胸合并肺间质气肿2例,气胸合并纵隔气肿1例,气胸合并气腹1例;新生儿透明膜病6例,新生儿肺炎4例,新生儿湿肺4例,吸入性肺炎3例。4例为呼吸机气道压力过高致肺气漏。2例死亡。结论床旁胸部X线为新生儿肺气漏的首选检查方式,通过它可以正确诊断和分析肺气漏的类型、程度及范围。新生儿患基础疾病进行正压通气时易导致肺气漏产生。     

CT引导下经皮穿刺适形冷冻消融治疗肺癌的临床分析

目的 探讨CT引导监测,经皮穿刺适形冷冻治疗肺癌的安全性、疗效和可行性.方法 研究对象为肺癌患者,纳入标准:(1)肺功能差、年龄大不能耐受开胸者;(2)周围型肺癌累及胸膜及胸壁肿瘤而无法彻底切除者;(3)肺癌通过临床综合治疗病灶缩小稳定,但不能消失者;(4)局限性肺癌,有手术切除适应证,但患者拒绝手术治疗者.排除标准:(1)双侧或单侧多发病灶患者;(2)肿块靠近纵隔大血管,预计穿刺途径不可避免地会伤及大血管者;(3)严重肺功能低下,肺最大通气容积<39%;(4)重度咳嗽,反复出现呼吸困难,不能配合治疗者;(5)肿瘤晚期、明显恶病质及出血倾向者.根据以上标准入选66例共76个病灶进行了冷冻消融,病灶最大径为1.5～16.0 cm,全部病灶按照肿瘤体积行17 G冷冻探针穿刺适形冷冻.肿瘤最大径<3.0 cm者采取双针"夹击"冷冻;肿瘤直径3.0～5.0 cm者采取多针穿刺适形冷冻;肿瘤最大径>5.0 cm者采取瘤内穿刺适形布针,针距<1.5 cm.患者术后随访6个月至2年.疗效评价采用CT增强扫描,观察病灶大小及强化情况.结果 本组18例肿瘤最大径<3.0 cm,术中CT复查显示冷冻范围超过病灶边缘1.0 cm以上,病灶局部密度减低,紧邻病灶周围可见窄带状透亮环绕,其外围肺组织密度增高,呈磨玻璃样环绕病灶形成靶征;术后1、3个月复查显示,病灶及邻近肺组织无强化;6个月后复查,扫描局部可见纤维条索影;7例随访时间达2年,其中5例肿瘤无复发和转移,1例术后1年发现纵隔淋巴结肿大,1例出现肿瘤骨转移.22例肿瘤最大径在3.0～5.0 cm之间,术后即刻CT复查显示,冷冻冰球覆盖全部病灶,病灶边缘的分叶和毛刺等恶性肿瘤征象消失,病灶体积轻度增大;术后1、3个月复查实性病灶逐渐缩小;9例患者随访达2年,其中4例肿瘤无复发,3例肿瘤稳定,2例出现其他部位转移.26例肿瘤最大径>5.0 cm,术中复查,冰球覆盖病灶体积70%～90%,周围肺组织无冷冻损伤改变.26例患者术后进行了放、化疗等综合治疗,随访6个月,9例病灶体积缩小,11例病灶稳定,6例病灶进展伴身体其他部位转移.本组患者术中3例出现咳血;术后26例痰中带血丝,19例出现气胸,其中5例行胸腔闭式引流,气体完全吸收,拔管时间平均为5 d.结论 CT引导监测,经皮穿刺适形冷冻治疗肺癌疗效肯定,是一种可行的微创方法.     

肺穿刺活检肺组织出血和发生气胸相互关系的探讨

目的 探讨肺活检中肺组织出血和发生气胸两者间的关系.资料与方法 选用18G半自动槽式切割活检针,CT定位下经皮经肺穿刺取材进行细胞学、组织学检查.结果 168例中发生气胸63例,占37.5%;肺组织出血76例,占45.2%.肺出血与气胸组发生例数呈明显负相关(P< 0.01);针道周围肺组织出血患者的气胸发生率减少(P<0.05).结论 肺穿刺活检发生针道周围肺组织出血能降低气胸的发生.     

Buscando la burbuja: aire torácico extrapulmonar atípico e inusual

ObjectiveTo describe the radiologic findings of extrapulmonary air in the chest and to review atypical and unusual causes of extrapulmonary air, emphasizing the importance of the diagnosis in managing these patients.ConclusionIn this article, we review a series of cases collected at our center that manifest with extrapulmonary air in the thorax, paying special attention to atypical and uncommon causes. We discuss the causes of extrapulmonary according to its location: mediastinum (spontaneous pneumomediastinum with pneumorrhachis, tracheal rupture, dehiscence of the bronchial anastomosis after lung transplantation, intramucosal esophageal dissection, Boerhaave syndrome, tracheoesophageal fistula in patients with esophageal tumors, bronchial perforation and esophagorespiratory fistula due to lymph-node rupture, and acute mediastinitis), pericardium (pneumopericardium in patients with lung tumors), cardiovascular (venous air embolism), pleura (bronchopleural fistulas, spontaneous pneumothorax in patients with malignant pleural mesotheliomas and primary lung tumors, and bilateral pneumothorax after unilateral lung biopsy), and thoracic wall (infections, transdiaphragmatic intercostal hernia, and subcutaneous emphysema after lung biopsy).     

晚期肺癌125I粒子植入治疗近期疗效观察

目的 观察CT引导下经皮肺穿刺植入125I粒子治疗晚期肺癌的近期疗效.方法 20例晚期肺癌患者在CT引导下经皮肺穿刺肺癌组织间植入125I粒子,通过影像学手段观察近期疗效,并观察临床不良反应.结果 复查20例植入粒子后3个月以上患者的CT影像,其中,完全缓解15％（3/20）、部分缓解55％（11/20）、无变化30％ （6/20）,总有效率为70％,并发气胸15％（3/20）、咳少量血痰20％（4/20）.随访时间3～18个月,1例术后5个月死于呼吸衰竭.结论 125I粒子植入治疗晚期肺癌并发症少,近期疗效满意,远期疗效待观察.     

CT导向下周围型肺癌射频消融治疗的临床分析

目的 探讨CT导向下射频消融（RFA）治疗周围型肺癌的价值。方法 43例周围型肺癌进行了CT导向下射频消融治疗。术前常规CT导向下经皮穿刺活检获取病理学诊断，鳞癌15例，腺癌19例，腺鳞癌4例，大细胞癌3例，未分化癌2例。全部瘤体直径均〈8cm，其中32个病灶直径〈5cm。结果 全部病例手术顺利，术中并发少量气胸者3例，液气胸1例，大量气胸行闭式引流者1例。术后分别在3和6个月CT复查，显示43个病灶中40个体积均有不同程度的进行性缩小，肿瘤内部均出现大片不规则低密度区；3例患者病灶体积无变化，边缘有环状强化，提示肿瘤复发。结论 CT导向下经皮穿刺RFA治疗周围型肺癌是安全有效的微创技术，值得推广应用。     

Unusual new signs of pneumothorax at lung ultrasound

Background

The diagnosis of pneumothorax with a bedside lung ultrasound is a powerful methodology. The conventional lung ultrasound examination consists of a step-by-step procedure targeted towards the detection of four classic ultrasound signs, the lung sliding, the B lines, the lung point and the lung pulse. In most cases, a combination of these signs allows a safe diagnosis of pneumothorax. However, the widespread application of sonographic methodology in clinical practice has brought out unusual cases which raise new sonographic signs. The purpose of this article was to introduce some of these new signs that are described after the analysis of unusual and complex cases encountered during the clinical daily practice in an emergency department.

Findings

The double lung point consists of the alternating patterns of sliding and non-sliding lung intermittently appearing at the two opposite sides of the scan. The septate pneumothorax allows B lines and lung pulse to be still visible in a condition of pneumothorax with absent sliding. In hydropneumothorax, the air/fluid border is imaged by lung ultrasound as the interposition between an anechoic space and a non-sliding A-pattern, a sign that may be named hydro-point.

Conclusions

In bedside lung ultrasound, the operator should be aware and interpret double lung point, septate pneumothorax and hydro-point. The conventional diagnostic protocol of bedside lung ultrasound for pneumothorax should be occasionally adapted to such complex cases.     

CT导向下125I粒子植入治疗难治生肺癌的疗效观察

目的 评价CT导向下125I粒子植入肿瘤组织间治疗难治性肺癌的临床价值.方法 共35例晚期难治性肺癌患者接受125I粒子植入治疗.术前采用治疗计划系统计算布源,术中将活度为2.855～3.087 MBq的125I粒子在CT导向下植入肿瘤组织间,粒子按照0.5～1.0 cm间距平面插植.肿瘤周边匹配剂量为150～180 ...     

不典型肺转移瘤的CT表现及其鉴别

目的：分析不典型肺转移瘤的CT表现形式,以提高对本病的诊断准确性。方法：回顾性分析297例有原发灶并经临床和病理证实肺转移瘤的CT表现,对不典型的进行总结,探讨其与原发肿瘤的关系。结果：45例肺转移瘤表现不典型,主要表现有6种：空洞型转移、自发性气胸、孤立型转移、分叶毛刺、钙化型转移、肺炎样转移及晕征。结论：充分认识肺转移瘤的不典型征象,对不典型肺转移瘤的诊断及治疗有重要意义。     

CT-guided needle localization of lung nodules for thoracoscopic resection

We used CT to guide positioning of hookwires within 19 lung nodules in order to localize them prior to thoracocschic surgery. Both Hawkins III and Kopans-type needles with internal hookwires were employed. Nodule diameter ranged between 0.7 and 4 cm (mean 1.7 cm), and depth from the site of entry of the needle into the pleural surface ranged from 0.5 to 8 cm. Needles were advanced using a technique identical to that for CT-guided biopsy, and localization proved successful in 18 of 19 cases. During surgery, dislodgement of the guidewire occurred in 5 cases, probably due to traction manoeuvers on it. In all these cases the hook of the wire had been opened within the nodule. No dislodgement occurred in patients in whom the needle had been advanced beyond the nodule and the hook allowed to open in the pulmonary parenchyma deep to it. Severe complications did not occur: there was moderate pleuritic pain in 16 cases and asymptomatic pneumothorax in 13 patients. Computer-tomography-guided needle localization of lung nodules is a safe and relatively easy procedure that allows thoracoscopic surgery of lesions which otherwise might be impossible to locate and resect. Correspondence to: L. E. Derchi     

Measurement of Pleural Temperature During Radiofrequency Ablation of Lung Tumors to Investigate Its Relationship to Occurrence of Pneumothorax or Pleural Effusion

The purpose of this study was to investigate the relationship between pleural temperature and pneumothorax or pleural effusion after radiofrequency (RF) ablation of lung tumors. The pleural temperature was measured immediately outside the lung surface nearest to the tumor with a fiber-type thermocouple during 25 ablation procedures for 34 tumors in 22 patients. The procedures were divided into two groups depending on the highest pleural temperature: P-group I and P-group II, with highest pleural temperatures of <40°C and ≥40°C, respectively. The incidence of pneumothorax or pleural effusion was compared between the groups. Multiple variables were compared between the groups to determine the factors that affect the pleural temperature. The overall incidence of pneumothorax and pleural effusion was 56% (14/25) and 20% (5/25), respectively. Temperature data in five ablation procedures were excluded from the analyses because these were affected by the pneumothorax. P-group I and P-group II comprised 10 procedures and 10 procedures, respectively. The incidence of pleural effusion was significantly higher in P-group II (4/10) than in P-group I (0/10) (p = 0.043). However, the incidence of pneumothorax did not differ significantly (p = 0.50) between P-group I (4/10) and P-group II (5/10). Factors significantly affecting the pleural temperature were distance between the electrode and the pleura (p < 0.001) and length of the lung parenchyma between the electrode and the pleura (p < 0.001). We conclude that higher pleural temperature appeared to be associated with the occurrence of pleural effusion and not with that of pneumothorax.     

肺肿瘤射频消融治疗的并发症分析

目的：探讨肺肿瘤行射频消融治疗中的并发症及其防治措施。 方法：选取2010年4月至2017年12月广东省人民医院肿瘤介入科收治的150例接受射频消融治疗的肺恶性肿瘤患者,其中原发性肺癌99例,转移性肺癌51例。99例原发性肺癌包括非小细胞肺癌87例、小细胞肺癌8例及癌肉瘤4例;51例转移性肺癌中来自肝癌的22例,来自软组织肉瘤12例、大肠癌9例、鼻咽癌6例、纵膈卵黄囊瘤及血管平滑肌脂肪肉瘤各1例。所有患者均为单个病灶,肿瘤直径8~47 mm（26±3.6）mm。射频消融均在CT引导下穿刺,其中行1次消融者133例,2次者17例;2次射频消融之间的间隔时间1~4（2±0.5）周。消融功率40~60（51.1±3.9）W,消融时间3~12（6.3±2.7）min。 结果：常见并发症包括气胸29例（19.3%）,肺实质出血35例（23.3%）,咯血12例（8%）,胸腔积液3例（2%）;少见并发症包括肺脓肿并支气管瘘1例（0.7%）,以往未见文献报道,胸部皮下气肿1例（0.7%）。无严重并发症或围手术期死亡病例发生。 结论：肺肿瘤射频消融的并发症多为轻中度,但均应给予足够重视,只有及时诊断并及时处理,才能减少和避免严重并发症及死亡的发生。     

Congenital absence of the pericardium confirmed by spontaneous pneumothorax

This article describes a case of complete absence of the left pericardium which was diagnosed on the chest radiograph and subsequently confirmed on computed tomography and thoracoscopy. Diagnostic confidence was bolstered by the presence of pneumopericardium which communicated via the defect with a spontaneous left pneumothorax. The clinical and imaging findings of pericardial absence are reviewed.     

Postmortem ventilation in cases of penetrating gunshot and stab wounds to the chest

We sought to determine the effect of postmortem ventilation in combination with a suction pump in cases showing penetrating trauma to the chest with haemo- and/or pneumothorax, for better evaluation of the lungs in postmortem computed tomography (PMCT).The study included 6 subjects (1 female, 5 male; age 32–67 years) with a penetrating gunshot or stab wound to the chest and consecutive pneumo- and/or haemothorax. The pneumo- and haemothorax were evacuated by a suction pump, and postmortem ventilation was applied using a home care ventilator. PMCT images with and without postmortem ventilation were compared, as well as the autopsy results.In three cases haemo- and pneumothorax was clearly reduced. Postmortem ventilation led to distinct re-expansion of the lungs in two cases, and to re-expansion of single lung lobes in two cases with shotgun injuries. No visible effect was seen in the remaining two cases, because of extensive destruction of lung tissue and blood aspiration. In two cases the injuries sustained in the individual lung lobes were successfully located during postmortem ventilation. The bullet channel was apparent in one case; in another case, injury of the pericardium became visible by generating pneumopericardium.The present method is capable of improving evaluation of the postmortem lung in the presence of single stab or gunshot wounds and if there is no severe destruction of the respiratory system and aspiration. Forensic autopsy should still be considered as the gold standard, although in some cases the present method might be helpful, especially where no autopsy is required.     

Usefulness and Limitation of Manual Aspiration Immediately After Pneumothorax Complicating Interventional Radiological Procedures with the Transthoracic Approach

The goal of this study was to evaluate the efficacy of simple aspiration of air from the pleural space to prevent increased pneumothorax and avoid chest tube placement in cases of pneumothorax following interventional radiological procedures performed under computed tomography fluoroscopic guidance with the transthoracic percutaneous approach. While still on the scanner table, 102 cases underwent percutaneous manual aspiration of a moderate or large pneumothorax that had developed during mediastinal, lung, and transthoracic liver biopsies and ablations of lung and hepatic tumors (independent of symptoms). Air was aspirated from the pleural space by an 18- or 20-gauge intravenous catheter attached to a three-way stopcock and 20- or 50-mL syringe. We evaluated the management of each such case during and after manual aspiration. In 87 of the 102 patients (85.3%), the pneumothorax had resolved completely on follow-up chest radiographs without chest tube placement, but chest tube placement was required in 15 patients. Requirement of chest tube insertion significantly increased in parallel with the increased volume of aspirated air. When receiver-operating characteristic curves were applied retrospectively, the optimal cutoff level of aspirated air on which to base a decision to abandon manual aspiration alone and resort to chest tube placement was 670 mL. Percutaneous manual aspiration of the pneumothorax performed immediately after the procedure might prevent progressive pneumothorax and eliminate the need for chest tube placement. However, when the amount of aspirated air is large (such as more than 670 mL), chest tube placement should be considered.     

Variables affecting the risk of pneumothorax and intrapulmonal hemorrhage in CT-guided transthoracic biopsy

The influence of various variables on the rate of pneumothorax and intrapulmonal hemorrhage associated with computed tomography (CT)-guided transthoracic needle biopsy of the lung were evaluated retrospectively. One hundred and thirty-three patients underwent CT guided biopsy of a pulmonary lesion. Two patients were biopsied twice. Variables analyzed were lesion size, lesion location, number of pleural needle passes, lesion margin, length of intrapulmonal biopsy path and puncture time. Eighteen-gauge (18G) cutting needles (Trucut, Somatex, Teltow, Germany) were used for biopsy. Pneumothorax occurred in 23 of 135 biopsies (17%). Chest tube placement was required in three out of 23 cases of pneumothorax (2% of all biopsies). Pneumothorax rate was significantly higher when the lesions were located in the lung parenchyma compared with locations at the pleura or chest wall (P < 0.05), but all pneumothorax cases which required chest tube treatment occurred in lesions located less than 2 cm from the pleura. Longer puncture time led to an increase in pneumothorax rate (P < 0.05). Thirty-seven (27%) out of 135 biopsies showed perifocal hemorrhage. Intrapulmonal biopsy paths longer than 4 cm showed significantly higher numbers of perifocal hemorrhage and pneumothorax (P < 0.05). Significantly more hemorrhage occurred when the pleura was penetrated twice during the puncture (P < 0.05). Lesion size <4 cm is strongly correlated with higher occurrence of perifocal hemorrhage (P < 0.05). Lesion margination showed no significant effect on complication rate. CT-guided biopsy of smaller lesions correlates with a higher bleeding rate. Puncture time should be minimized to reduce pneumothorax rate. Passing the pleura twice significantly increases the risk of hemorrhage. Intrapulmonal biopsy paths longer than 4 cm showed significantly higher numbers of perifocal hemorrhage as well as pneumothorax.     

病灶因素对CT导向下经皮肺穿刺活检并发症发生率的影响

目的:探讨CT导向下经皮肺穿刺活检并发症发生率与病灶大小、深度和部位之间的关系。方法:复习CT导向下肺部病变穿刺活检184例,所有病灶按大小分为≥3cm(122个)和<3cm(62个)两组,按病灶深度分为≥2cm(98个)和<2cm(86个)两组,按病灶部位分为上肺野(28个)、中肺野(61个)和下肺野(95个)3组,分别统计各组的并发症发生率。结果:直径<3cm病灶的并发症发生率(气胸19.23%,出血44.19%)明显高于≥3cm病灶(气胸5.17%,出血15.09%,P<0.05);深度≥2cm病灶的并发症发生率(气胸13.27%,出血25.51%)显著高于<2cm者(气胸3.49%,出血11.63%,P<0.05);不同肺野病灶的并发症发生率之间差异无显著性意义(P>0.05)。结论:病灶大小和深度是影响CT导向下经皮肺穿刺活检并发症发生率的主要因素。     

CT-guided cutting needle lung biopsy using modified coaxial technique: factors effecting risk of complications

Purpose

We present our 7-year experience with coaxial computed tomography (CT)-guided cutting needle lung biopsy and evaluate the factors affecting risk of complications.

Material and method

Between June 2000 and March 2007, we performed 225 CT-guided coaxial lung biopsies in 213 consecutive patients (161 men, 52 women). Lesion size, lesion depth, lesion location, needle-pleural angle, presence of pleural effusion, patient's position, and complications secondary to biopsy procedure (pneumothorax and bleeding) were noted. Pneumothorax was graded as mild, moderate, and severe. Bleeding complications were graded as mild, moderate, and severe.

Results

Two hundred twenty-five biopsy procedures were performed in 213 patients. The mean diameter of the lung lesion was 41.3 ± 20.1 mm. The mean distance from the peripheral margin of the lesion to the pleura was 17.3 ± 19.2 mm. After 225 procedures, there were 42 mild (18.6%), 13 moderate (5.7%), and 4 severe (1.7%) pneumothoraxes. Small hemoptysis occurred in 27 patients (12%), and mild parenchymal hemorrhage occurred in 2 patients (0.8%). The overall complication rate was 39.1%. Although, a statistically significant correlation was found between female sex, presence of emphysema, lesion depth, and pneumothorax, none of these factors had a predictive value for pneumothorax. Although, statistically significant correlations were found between female sex, lesion size, and bleeding, only lesion size had a predictive value for bleeding.

Conclusion

The most frequent and important complications of this procedure are pneumothorax and bleeding. But any factor is the predictor of pneumothorax and lesion depth is a poor predictor of bleeding complication.     

CT-guided lung biopsy: incidence of pneumothorax after instillation of NaCl into the biopsy track

This study was conducted to evaluate whether instillation of NaCl 0.9% solution into the biopsy track reduces the incidence of pneumothoraces after CT-guided lung biopsy. A total of 140 consecutive patients with pulmonary lesions were included in this prospective study. All patients were alternatingly assigned to one of two groups: group A in whom the puncture access was sealed by instillation of NaCl 0.9% solution during extraction of the guide needle (n = 70) or group B for whom no sealing was performed (n = 70). CT-guided biopsy was performed with a 18-G coaxial system. Localization of lesion (pleural, peripheral, central), lesion size, needle-pleural angle, rate of pneumothorax and alveolar hemorrhage were evaluated. In group A, the incidence of pneumothorax was lower compared to group B (8%, 6/70 patients vs. 34%, 24/70 patients; P < 0.001). All pneumothoraces occurred directly post punctionem after extraction of the guide needle. One patient in group A and eight patients in group B developed large pneumothoraces requiring chest tube placement (P = 0.01). The frequency of pneumothorax was independent of other variables. After CT-guided biopsy, instillation of NaCl 0.9% solution into the puncture access during extraction of the needle significantly reduces the incidence of pneumothorax.