煤肺与煤矽肺病理特点及诊断分期(附22例尸检报告)

煤肺与煤矽肺的基本病理改变为弥漫性间质纤维化。后者较早出现,是非特异性改变。煤尘纤维灶和煤矽结节出现较晚,又是煤肺、煤矽肺的特征性病变。本文提出煤肺和煤矽肺的病理特点、变化、分布、诊断分期,供同道商榷。标本来源和方法本文尸检22例,其中接触煤尘17例,接触煤矽尘5例,分别用10%甲醛液固定,其中部分病例用10%甲醛液气管灌注后,同时用前液固定48～72小时,两肺从零位开始,前后各作平行冠状或矢状切片,每片厚1～1.5厘米,选取煤尘灶及煤矽结节最多的切面,两肺共取20块。作石腊包埋,大切片为15～20×5～12厘米。煤肺与煤矽肺分别各作1例,明胶包埋冷冻,全肺及全叶大切片。用H,E V,G Foot 染色法。偏光显镜及显微灰化切片检查。     

120例煤矿工人肺部病理变化与煤矽肺病理诊断的关系

本文根据120例煤矿工人尸检材料,总结分析了肺部病变与煤矽肺病理诊断指标的关系。提出肺内局限性煤尘沉着(煤斑)、煤尘灶及其伴发的小叶中心性肺气肿是煤尘所致的特征性病变。实质上也是尘性间质纤维化的重要表现。煤工尘肺结节性病变较少,不宜只以结节的多寡作为病理诊断的分期标准。本文还认为不应单凭接触煤尘的职业史和 X 线听见做出煤肺的诊断。     

尘肺14例尸检临床病理分析

目的 探讨煤工尘肺的病理组织学特征、并发症、诊断及鉴别诊断.方法 对14例尸检病例的肺组织切片用HE染色光学显微镜下观察,并结合职业史、临床特点进行回顾性分析.结果 14例患者年龄46～71岁(平均57.7岁),2例诊断粉尘性反应,1例为单纯煤工尘肺(煤矽肺Ⅰ期),11例为复杂煤工尘肺(9例为煤矽肺Ⅱ期、1例为Ⅲ期、1例为矽肺Ⅲ期).12例并发慢性支气管炎及肺气肿,8例并发肺心病,4例并发肺结核,3例并发肝硬化、肝癌并肺部转移,2例并发脑出血.结论 接尘时间越长,煤工尘肺病理改变越复杂,煤尘斑是所有煤工尘肺都具有的病理特征,尘性结节和大块状纤维化是病理诊断的必要指标.     

接尘工人肺癌的病理学调查

本文集中我国各地区1960-1990年接尘工人尸检1000例,以非接尘男性尸检612例做对照,对尘肺肺癌的发病率和病理进行分析研究。结果:(1)接尘工人尸检肺癌发病率为17.2%,比对照组(3.16%)显著超高,占全身各器官癌病之首;(2)石棉肺尸检肺癌率最高(26.92%),矽肺(18.5%)与煤工尘肺(16.79%)相近;(3)职业上,煤矿、金属矿和石棉矿是我国尘肺肺癌的三大主要工种,接尘工龄以11～20年段发病最多(55.1%);(4)病理类型依次为腺癌(含肺泡细胞癌)、鳞癌、未分化癌,其中石棉肺一半以上为腺癌。     

不同含矽量、不同剂量煤尘致犬肺纤维化作用的实验研究

本文采用不同含量游离SiO_2(4.9%与8.4%)的煤尘,以不同剂量(500 mg与1000mg/kg体重)对家犬进行气管注入染尘。经28～36个月观察,肺内形成尘灶、尘纤维灶、不同程度间质纤维化及灶周气肿,没见到典型矽结节与进行性大块纤维化过程。煤尘为混合粉尘。混合粉尘泛指低含量游离SiO_2与高含量致纤维化作用较弱的不溶或难溶的无机成份。煤尘肺为混合尘尘肺之一,混合尘尘肺有特定的病因学与病理学含义,应与矽肺、石棉肺并列。     

两例煤肺的尘性病理变化

目前,国内外尘肺病理学家多数倾向于将肺内有煤矽结节病变的列入煤矽肺,而将仅有非结节性的尘性病变一类归为煤肺。煤肺患有肺内的基本病变是尘纤维灶和纤维尘灶以及尘性肺气肿(多为小叶中心性和全小叶性肺气肿)。作者近获两例煤肺病理资料,兹将其简要报告于后。     

不同类型厂矿接尘工人肺癌病因学研究──矽尘或矽肺与肺癌的关系

为评价游离二氧化硅（简称矽尘或ＳｉＯ２）是否致肺癌？矽肺是否是肺癌前变基础？选择四类接尘厂矿进行队列和队列内病例对照研究。队列对象６８２８５人。有矽肺６４８７例，肺癌３３０例（男３１９，女１１），配对照１３５８例。根据厂矿历年工业卫生记录和近期对已知致癌物监测结果，定量评估了每个对象的接尘水平及每个病例对照的累积接触量。研究对象追访到１９８９年底，死亡６１９２人。与全国居民死亡平均数计算的期望值近似。全死因中癌症是第一死因，但全癌低于国家居民死亡率。分析结果说明：（１）矽尘单独存在时不是肺致癌剂。肺癌不超高，与接尘关系不明显；（２）在６４８７名矽肺队列中，肺癌相对危险度仅比非矽肺高０．２２倍，主要反应在铜铁矿工人中（Ｒ＝２．２），而矽肺患病率最严重的钨矿工人，其肺癌危险度反而随接尘水平上升而下降，再则肺癌死亡率与矽肺期别不呈正比；形态学上观察也不支持肺癌病变与矽肺纤维化病变相关。本研究结果难以支持矽尘或矽肺与肺癌病因学相关的假说。     

煤尘及煤矽混合性粉尘所致大白鼠肺脏的形态学变化

本文从病理形态学角度来观察了煤尘及煤矽混合性粉尘对大白鼠肺脏的影响。结果含矽低的煤尘不引起明显纤维化,有轻度致炎作甩,能引起一系列机体变化;而煤矽混合性粉尘是煤尘和矽尘所致病变的联合,兼有矽尘和煤尘的形态学变化。     

脱离粉尘作业已五年为啥还会得矽肺

这是因为矽尘作业工人吸入矽尘后,矽尘刺激肺组织引起肺内巨噬细胞的增生,巨噬细胞大量地吞噬矽尘,矽尘的溶解产物导致巨噬细胞的死亡、崩溃,释放出有毒的细胞液和残余的矽尘,引起肺组织的纤维化。如此反复地致纤维化作用,时间久了就会产生典型的矽肺病变。矽尘作业工人脱离矽尘作业时进行胸部X线照片,虽然未发现矽肺,但因肺内存在大量矽尘,上述病理反应过程仍不断地进行,故可于脱离矽尘作业若干年后还发生矽肺,这就叫做晚发性矽肺。     

益阳市矽尘及煤尘作业工人职业健康监护现状分析

目的了解益阳市粉尘作业工人职业健康状况,为预防尘肺病提供科学建议。方法收集2015—2019年益阳地区矽尘及煤尘作业工人在岗期间职业健康监护资料,并对其胸片检查结果进行统计分析。结果 5 802例矽尘及245例煤尘作业工人胸片尘肺样改变分别检出219及27例,检出率分别为3.77%和11.02%。5年间共报告矽肺165例,煤工尘肺193例。不同地区、性别、企业规模及行业不同年龄组及工龄组矽尘作业工人胸片尘肺样改变检出率比较,差异均有统计学意义(均P0.05);不同年龄组、企业经济类型、企业规模及行业煤尘作业工人胸片尘肺样改变检出率比较,差异均有统计学意义(均P0.05)。结论益阳市煤尘作业工人职业健康检查率偏低,赫山区矽尘作业危害较大,煤尘及矽尘作业工人胸片尘肺样改变的高发特征有男性、40～59岁、采矿及小型企业,应对其职业健康状况进行重点监管。     

Silicosis,mixed dust pneumoconiosis,and lung cancer

A total of 764 autopsy cases with a pathological diagnosis of nonasbestos pneumoconiosis were investigated in a search for lung cancer: 146 patients bore 148 lung cancers (19.1%). The incidence of a lung cancer was associated positively with aging, longer occupational exposures, and smoking habits. A reverse correlation was found between carcinogenesis and the severity of pneumoconiosis. A statistically significant increase in the incidence of certain types of lung cancer (squamous cell carcinoma + small cell carcinoma) was found in silicotic lungs with massive fibrosis as compared to lungs with mixed dust pneumoconiosis of comparable severity. Although there appears to be no dose-response relationship in general between silicosis and lung cancer, it is advisable to consider the possibility that a presumptive silica-induced carcinogenesis might be masked by the severe fibrosis of a silicotic type, which obliterates the lung tissue in a different way from asbestosis, which is associated with epithelial proliferation. Am. J. Ind. Med. 32:595–599, 1997. © 1997 Wiley-Liss, Inc.     

Dust and Fibrosis in the Lungs of Coal-Workers from the Wigan Area of Lancashire

During the years 1953 to 1957 more than 1,000 lungs of coal-workers in the Wigan area were examined and compared with lungs from workers in South Wales. The Wigan lungs in general appeared to be less dusty and progressive massive fibrosis less frequent than in the South Wales lungs. Also, the more advanced cases of progressive massive fibrosis appeared to be of a silicotic type.

Of these lungs, 100 were selected for study of the relation of the type and severity of pneumoconiosis to right ventricular hypertrophy, using Gough-Wentworth sections. The remaining tissues from 47 of these lungs were used for an analysis of the content and composition of the dust and its relation to the grade of fibrosis. The average coal and quartz percentages of the dust from the lungs in the Wigan area were similar to previous findings in lungs from the Cumberland coalfield but differed from those in South Wales where the lung dust has a higher coal and a lower quartz percentage. Two possible explanations for this finding are discussed.

     

搪瓷喷花粉尘致肺纤维化的实验研究

目的：研究搪瓷喷花粉尘的致肺纤维化作用。方法：３组ＳＤ大鼠气管内分别注入搪瓷喷花（白下底料）粉尘、石英石粉尘和生理盐水,染尘后６０ｄ和１８０ｄ宰杀,称取肺鲜重,测定肺胶原含量,肺组织病理学改变。结果：熟料粉尘组大鼠的肺鲜重和肺胶原含量高于生理盐水组,但明显低于石英尘组。病理观察结果显示,熟料粉尘能在肺内形成异物结节及周围轻度纤维增生。结论：一定量的搪瓷喷花粉尘进入肺内不至引起进行性肺纤维化,而是引     

铁矿工人肺癌回顾性队列研究

对１５个铁矿采矿工人的肺癌进行了回顾性队列研究。队列由１６９５１名１９７１年前入放的男职工组成,观察期从１９８０年至１９８９年,失访７６０人（４．５％）,队列内非接尘人群是接尘人群各群的对照人群。接尘人群及其井下、露天、赤铁矿、磁铁矿各舸矿各组中癌均无明显超量。但接尘人群分为非矽肺和矽肺两群时组,矽肺患者人群的肺癌显示超量。赤铁矿、磁铁矿、井下矿、吴矿各群组都再分为非矽肺和矽肺两群组时,除露天采矿     

胸部CT在矽肺诊断中的意义

目的　评价胸部ＣＴ 检查在矽肺临床诊治过程中的应用价值。方法　对５８ 名长期接触矽尘的工人进行临床、Ｘ 射线平片、胸部ＣＴ 等检查, 该组病人平均年龄（５９ ±２） 岁, 平均接尘工龄２９ 年。结果　两种方法在大多数情况下其结果是类似的, 但对早期矽肺的诊断ＣＴ 片并不优于普通Ｘ 射线平片, 在８ 例经ＣＴ 检查诊断为０ ＋ 的病例中有２名Ｘ 射线平片检查诊断为矽肺Ⅰ期; 而对融合团块的发现, ＣＴ 检查要较Ｘ 射线平片检查敏感, 在经ＣＴ 检查发现的２７例有融合团块的复杂矽肺病例中, Ｘ 射线平片检查只发现２２ 例。另外对于矽肺合并症的诊断ＣＴ 检查对临床也很有帮助, 在合并肺癌的７ 例病人中, 均属经ＣＴ 检查证实, 在合并肺结核的１３ 例病人中也有９ 例经ＣＴ 检查证实。结论　胸部ＣＴ 与Ｘ 射线平片比较虽然不能发现更多的早期病例, 但能较早地发现团块融合改变, 此外对肺结核及肺癌等合并症的发现也很有价值。     

Comparison of radiographic appearances with associated pathology and lung dust content in a group of coalworkers

The pathology and dust content of lungs from 261 coalminers in relation to the appearances of their chest radiographs taken within four years of death were examined. Radiological opacities of coalworkers' pneumoconiosis were more profuse the more dust was retained in lungs. Among the men who had mined low rank coal--that is, with a relatively high proportion of ash--the increase in profusion was most closely related to the ash component of the dust, whereas in men who had mined high rank coal both coal and ash increased in the lungs in relation to radiological profusion. The fine p type of opacity was found to be associated with more dust and a higher proportion of coal and less ash than the nodular r opacity, and was also more likely to be associated with emphysema. The pathological basis of the different types of opacity found on the radiographs of coalminers related to the number, size, and nodularity of the dust lesions. Larger fibrotic lesions were likely to appear as r opacities, whereas fine reticular dust deposition was most likely to present as p opacities, q opacities showing a mixture of appearances. The study has shown that the composition of dust retained in the lung, as well as its amount, makes an important contribution to the radiographic appearances of pneumoconiosis. In particular, the r type of lesion on the radiograph of a low rank coalminer indicates the possibility of a silicotic like lesion.     

Comparison of radiographic appearances with associated pathology and lung dust content in a group of coalworkers.

The pathology and dust content of lungs from 261 coalminers in relation to the appearances of their chest radiographs taken within four years of death were examined. Radiological opacities of coalworkers' pneumoconiosis were more profuse the more dust was retained in lungs. Among the men who had mined low rank coal--that is, with a relatively high proportion of ash--the increase in profusion was most closely related to the ash component of the dust, whereas in men who had mined high rank coal both coal and ash increased in the lungs in relation to radiological profusion. The fine p type of opacity was found to be associated with more dust and a higher proportion of coal and less ash than the nodular r opacity, and was also more likely to be associated with emphysema. The pathological basis of the different types of opacity found on the radiographs of coalminers related to the number, size, and nodularity of the dust lesions. Larger fibrotic lesions were likely to appear as r opacities, whereas fine reticular dust deposition was most likely to present as p opacities, q opacities showing a mixture of appearances. The study has shown that the composition of dust retained in the lung, as well as its amount, makes an important contribution to the radiographic appearances of pneumoconiosis. In particular, the r type of lesion on the radiograph of a low rank coalminer indicates the possibility of a silicotic like lesion.     

云锡矿粉诱发F344大鼠肺癌的病理改变

目的建立云锡矿粉（无氡）诱发F344大鼠肺癌的动物模型，探讨其肺癌发生过程及不同阶段的病理变化。方法190只大鼠随机分为矿粉组（100只）、呋喃甲醛组、生理盐水组及正常对照组（各30只）。除正常对照组外，其他3组分别以质量分数为6％的矿粉悬液、体积分数为2％的呋喃甲醛及生理盐水每次0．2ml经气管灌注，每周1次，从灌注1周后定期分批处死大鼠，最后处死的1只大鼠染尘100周。光学显微镜及电子显微镜观察矿粉作用下肺组织的形态改变，免疫组化检测高分子和低分子角蛋白确定诱发肺癌的组织类型，Pollak染色观察肺纤维化的进展。结果矿粉组大鼠最早期出现肺部炎症，随着炎症消退见肺间质纤维增生，肺泡及支气管上皮单纯性增生、乳头状增生及鳞状化生，继而出现肺泡非典型腺瘤样增生、鳞状上皮非典型增生，最终出现肺癌。共发生肺癌14例，其中腺癌9例、鳞癌2例、复合癌3例，其他3组均未发生肺癌，矿粉组癌变率与其他3组比较，差异有统计学意义（P〈0．01）。鳞状化生及鳞癌也可发生于肺泡并表达高分子角蛋白。矿粉组肺纤维化31例，纤维化程度随矿粉沉着增多而呈进行性加重。结论无氡云锡矿粉具有诱癌性，F344大鼠矿粉诱发性肺腺癌及鳞癌都可发生于肺泡，Ⅱ型肺泡上皮是否是肺腺癌及外周型肺鳞癌的起源细胞值得深入研究。     

矽结节银染色的形态学特点及其在矽肺组织病理学检查中的意义

目的观察矽结节在沃森-斯塔理银染色（Warthin—Starry，WS）下的形态学特点，对其在矽肺组织病理学检查中的意义进行初步探讨。方法收集矽肺尸检病例6例，结节病病例21例（其中尸检病例3例、活检病例18例）。对石蜡包埋组织标本的连续切片进行HE染色、WS银染色、鼠抗人CD68单克隆抗体免疫组织化学链酶卵白素过氧化物酶法染色、透射电镜（TEM）标本制作及观察、X线质谱分析（X—RSA）[对矽结节／肉芽肿细胞（指类上皮细胞、尘细胞、多核巨细胞）胞质内的尘粒进行观察和分析]。结果HE染色下，肉芽肿内尘粒的沉积程度如下：在细胞性矽结节为（＋＋或＋＋＋），在纤维性矽结节为（＋），在结节病结节为（-）；WS染色下，在2种形态的矽结节均为（＋＋＋），呈特征性的黑色结节状，在结节病结节为（＋／＋＋），经秩和检验，矽结节内尘粒的沉积程度明显高于结节病结节，差异有统计学意义（P〈0．01）。免疫组织化学显示，2种疾病的肉芽肿细胞CD68抗体标记均阳性，其阳性程度与细胞内尘粒的含量呈反比。TEM下结节病的尘粒较小，矽结节内的尘粒较大，电子密度较高；X—RSA显示，2种疾病尘粒的主要元素成分相同，均为硅。结论WS银染色法可以显示出矽结节内有大量尘粒，其染色效果明显优于HE染色方法，WS银染色法与TEM观察及X—RSA并用，可以观察到病理样本中的微小矽肺病变，对矽肺病变的可能性具有提示作用。     

二氧化硅,矽肺与肺癌的关系

通过耐火材料等四个行业的接尘人员中肺癌死亡回顾性队列调查,发现接尘人员中肺癌危险性明显高于非尘毒暴露组,而且肺癌标化死亡率随含硅量及接触浓度变化呈现出平行的趋势。矽肺合并肺癌多为早期矽肺,肺癌病变多分布在肺上叶,病理形态鳞癌较多。肺癌发生晚于矽肺。吸烟和矽肺同时存在时,有必要注意协同作用。