伴胸部受累的淋巴瘤25例临床分析

目的 分析伴胸部受累的淋巴瘤的临床特点与诊断方法,以提高其诊断率.方法 回顾性分析2000-2007年北京大学第三医院确诊的有胸肺病变的淋巴瘤患者25例,收集患者确诊前的症状、体征、实验室检查结果、影像学资料、确诊方法和病理诊断.结果 25例患者中位年龄46岁,发热(13例)、6个月内体重减轻10%以上(11例)、咳嗽(10例)、气短(9例)、浅表淋巴结无痛性肿大(16例)是最常见的临床表现.72.7%的患者ESR增快;81%的患者血清乳酸脱氢酶(LDH)升高.25例患者中纵隔肺门淋巴结肿大者16例;影像学显示肺受累15例,包括斑片或实变表现、团块、多发结节、弥漫磨玻璃影、粟粒样病变;另外胸腔积液10例,心包积液4例,胸壁肿物2例;上述表现中有2种以上同时存在的患者18例.胸膜受累患者的胸腔积液外观呈黄色浑浊、血性或乳糜性,黏蛋白试验均阳性,比重1.031,白细胞6.72×10~9/L,淋巴细胞86%,中性粒细胞14%,蛋白31.4g/L,LDH 296 U/L,腺苷脱氨酶(ADA)67.4 U/L.外科手术活检确诊16例,其中浅表淋巴结活检确诊12例;超声或CT引导穿刺活检确诊5例;骨髓穿刺确诊1例;胸腔镜胸膜活检和纵隔镜纵隔肿物活检确诊各1例;经支气管镜黏膜活检确诊1例,而接受支气管镜气道黏膜活检和(或)经支气管肺活检(TBLB)确诊共8例.病理诊断除1例霍奇金淋巴瘤外,其余24例均为非霍奇金淋巴瘤.结论 伴胸部受累的淋巴瘤患者临床表现缺乏特异性,同时存在浅表或纵隔淋巴结肿大较为多见,血清学检查、胸腔积液性质和影像学检查亦有一定特点.浅表淋巴结手术活检是确诊淋巴瘤简便易行的方法;微创活检方法如超声或CT引导下浅表肿物、胸膜、肺、肝、脾、深部淋巴结活检及胸腔镜和纵隔镜胸膜、肺、纵隔病变活检亦具有较好的诊断价值,而经支气管镜获取气道黏膜和肺组织确诊率低.

Clinical analysis of lymphoma with chest involvement: report of 25 cases

Objective To study clinical characteristics and diagnostic methods of lymphoma with chest invovement. Methods Twenty-five lymphoma patients with chest involvement were retrospectively analysed, they were all diagnosed in Peking University Third Hospital during 2000 to 2007. The data were collected including clinical manifestations, blood examinations, chest X-ray and CT scan, diagnostic methods and pathologic diagnosis. Results The median age of the 25 patients was 46 years old. Pyrexia(13 cases), weight loss over 10 percent in 6 months(11 cases), cough(10 cases), shortness of breath(9 cases) and painless enlargement of the peripheral lymph nodes(16 cases) were common manifestations. Erythrocyte sedimentation rate and serum lactate dehydrogenase(LDH) level were increased in 72.7% and 81% patients, respectively. The enlargement of mediastinum lymph nodes(16 cases, 64%) was the most common presentation of chest radiography, followed by pulmonary involvement(15 cases, 60%) including infiltration or pulmonary consolidation, mass, multiple nodules, diffuse ground-glass shadow, miliary lesion. There were also presentations of pleural effusion(10 cases, 40%), pericardial effusion(4 cases, 16%), chest wall mass(2 cases, 8%). Eighteen patients(72%) had at least two kinds of these presentations. The appearance of pleural effusion were yellow turbid, bloody or chyliform. Rivaha tests were all positive. The median value of plearal effusion examinations were listed as follows: specific gravity 1.031, total cells 9800×10~6/L, WBC 6.72×10~9/L, lymphocyte 86%, neutrophil 14%, protein 31.4 g/L, LDH 296 U/L,adenosine deaminase (ADA) 67.4 U/L Most patients(16 cases) were diagnosed by surgical biopsy,especialy peripheral lymph nodes biopsy (12 cases). Other patients were diagnosed by ultrasound or CT-guided biopsy (5 cases), video-assisted thoracoscopic pleural biopsy (1 case), video-mediastinoscopic mediastinum lesion biopsy(1 case), bronchial mucosa biopsy through bronchoscope(1 case), bone marrow examination(1 case). All the cases were non-Hodgkin lymphoma except one. Conclusions There was no specific clinical manifestation for lymphoma with chest involvement, but in almost half of patients there were enlargement of not only peripheral but also mediastinum lymph nodes. And there were some characteristics in serum, pleural effusion, chest X-ray and CT scan. Surgical biopsy of peripheral lymph nodes was a simple and convenient method for diagnosis. Micro-invasive biopsy had good diagnostic value for lymphoma with chest involvement, including ultrasound-or CT-guided biopsy for superficial mass, pleura, lung, liver, spleen and deep lymph nodes, video-assisted thoracoseopic and video-mediastinoscopic biopsy for pleura, lung and mediastinum lesions. But bronchial mueosa and lung biopsy during bronchoscopy had a low diagnostic rate for lymphoma.