内科胸腔镜多部位活检联合快速现场评价技术对不明原因胸腔积液的诊断价值

徐炜; 李优; 房宇坤; 李玉; 陈清勇; 王剑; 陈彧

doi:10.16766/j.cnki.issn.1674-4152.002851

内科胸腔镜多部位活检联合快速现场评价技术对不明原因胸腔积液的诊断价值

doi: 10.16766/j.cnki.issn.1674-4152.002851

徐炜¹,
李优²,
房宇坤¹,
李玉¹,
陈清勇^1, ,,
王剑¹,
陈彧¹

1.
解放军第903医院呼吸与危重症医学科，浙江杭州 310004
2.
宁波市医疗中心李惠利医院呼吸与危重症医学科，浙江宁波 315040

基金项目:

浙江省公益技术研究项目 LGF19H010002

浙江省公益技术研究项目 LGF20H010007

详细信息

通讯作者:
陈清勇，E-mail：CQYong117@163.com

中图分类号: R561.3 R446.8
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- 被引次数: 0
出版历程
- 收稿日期: 2022-02-07
- 网络出版日期: 2023-04-20

Diagnostic value of rapid on-site evaluation of biopsy specimens during medical thoracoscopy for undiagnosed pleural effusion

1.
Department of Respiratory and Critical Care Medicine, the 903th Hospital of People's Liberation Army, Hangzhou, Zhejiang 310004, China

摘要

摘要: 目的探讨内科胸腔镜检查中镜下表现及多部位活检结合快速现场评价技术(简称ROSE技术)对不明原因胸腔积液的诊断价值。方法回顾性分析解放军第903医院2016年6月—2017年12月因不明原因胸腔积液行内科胸腔镜检查的124例患者的临床资料，通过观察胸腔镜下胸膜变化，术中活检组织的快速现场细胞学表现，并对照最终的病理诊断，对内科胸腔镜检查联合ROSE技术在临床应用中的安全性、有效性及准确性进行系统分析和评价。结果 124例行胸腔镜检查的患者中良性病变77例，恶性病变41例，诊断不明确者6例。胸腔镜镜下诊断恶性病变的阳性预测值为73.81%，阴性预测值为86.84%，灵敏度为75.60%，特异度为85.71%，与病理诊断符合率为82.2%。胸腔镜联合ROSE技术诊断恶性胸腔积液的阳性预测值为82.98%，阴性预测值为97.18%，灵敏度为95.12%，特异度为89.61%，胸腔镜联合ROSE技术与最终病理结果的一致性较好(Kappa值为0.825，P＜0.001)。结论内科胸腔镜在胸腔积液中具有检出率高、准确性高的特点, 而ROSE技术与最终病理结果具有较好的一致性，二者联合进一步提高了不明原因胸腔积液的诊断效率，值得在临床推广应用。
- 胸腔积液 /
- 快速现场评价技术 /
- 内科胸腔镜
Abstract: Objective This study aims to investigate the diagnostic value of manifestations in medical thoracoscopy and multi-site biopsy combined with rapid on-site evaluation (ROSE) in undiagnosed pleural effusion. Methods The clinical data of 124 patients with undiagnosed pleural effusion who underwent medical thoracoscopy from June 2016 to December 2017 in the 903th Hospital of People's Liberation Army were analyzed retrospectively. The safety, effectiveness and accuracy of thoracoscopy combined with ROSE in clinical application were systematically analyzed and evaluated by observing pleural changes under thoracoscope, rapid field cytological manifestations of biopsies during operation and comparing with the final pathological diagnosis. Results Among the 124 patients who underwent thoracoscopy, 77 cases were benign, 41 cases were malignant, and 6 cases were uncertain. The positive predictive value was 73.81%, the negative predictive value was 86.84%, the sensitivity was 75.60%, the specificity was 85.71%, and the coincidence rate with pathological diagnosis was 82.2%. The positive predictive value, negative predictive value, sensitivity and specificity were 82.98%, 97.18%, 95.12% and 89.61% in the diagnosis of malignant pleural effusion by thoracoscopy combined with ROSE (Kappa value was 0.825, P < 0.001), respectively. Conclusion Medical thoracoscopy have the characteristics of high detection rate and high accuracy in pleural effusion, and ROSE technique have a good consistency with the final pathological results. The combination of the two techniques can further improve the diagnostic efficiency of undiagnosed pleural effusion, which is worthy of clinical application.
- Pleural effusion /
- Rapid on-site evaluation /
- Medical thoracoscopy

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图 1 胸腔镜诊断恶性胸腔积液的ROC曲线

Figure 1. ROC curve of thoracoscopic diagnosis of malignant pleural effusion

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图 2 胸腔镜联合ROSE技术诊断恶性胸腔积液的ROC曲线

Figure 2. ROC curve of thoracoscopic combined with ROSE technique in diagnosis of malignant pleural effusion

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图 3 单用胸腔镜与胸腔镜联合ROSE技术诊断恶性胸腔积液的ROC曲线比较

Figure 3. Comparison of ROC curve between thoracoscopic and thoracoscopic combined with ROSE in diagnosis of malignant pleural effusion

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图 4 转移性肺癌的胸腔镜下表现、ROSE镜下表现和病理结果

注：A示胸腔镜下见多个大小不等的结节样隆起；B示ROSE镜下见大量异型细胞(×400)；C示HE染色病理证实为腺癌(×200)。

Figure 4. Thoracoscopic presentation, ROSE microscopic presentation, and pathological findings of metastatic lung cancer

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图 5 脓胸的胸腔镜下表现、ROSE镜下表现和病理结果

注：A示胸腔镜下可见少量淡黄色浑浊液体，粘连明显伴胸膜水肿增厚；B示ROSE镜下见大量中性粒细胞、淋巴细胞浸润(×400)；C示HE染色病理结果提示胸膜炎(×40)。

Figure 5. Thoracoscopic, ROSE-scopic and pathological findings of empyema

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图 6 结核性胸膜炎的胸腔镜下表现、ROSE镜下表现和病理结果

注：A示胸腔镜下表现为胸膜表面弥漫性分布的粟粒样小结节；B示ROSE镜下见典型的肉芽肿及大量淋巴细胞分布(×400)；C示HE染色病理结果提示肉芽肿及大量淋巴细胞(×200)。

Figure 6. Thoracoscopic findings, ROSE microscopic findings, and pathological findings of tuberculous pleurisy

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表 1 胸腔积液的特征胸腔镜下主要特点

Table 1. Features of pleural effusion main features of thoracoscopy

项目	良性疾病(77例)	恶性疾病(41例)	统计量	P值
胸腔积液特征[例(%)]
单侧	69(89.61)	35(85.37)	0.461^a	0.498
双侧	8(10.39)	6(14.63)
黄色	65(84.42)	10(24.39)	41.619^a	< 0.001
血性	12(15.58)	31(75.61)
包裹性	20(25.97)	3(7.32)	5.935^a	0.015
镜下主要表现[例(%)]
胸膜增厚	10(12.99)	23(56.10)	24.683^a	< 0.001
胸膜充血、水肿	31(40.26)	11(26.83)	2.105^a	< 0.001
黏膜粗糙	11(14.29)	1(2.44)	4.110^a	0.042
多发结节	41(53.25)	32(78.05)	6.976^a	0.008
广泛粘连	68(88.31)	4(9.76)	69.410^a	< 0.001
纤维素渗出	37(48.05)	2(4.88)	22.538^a	< 0.001
肺不张	38(49.35)	20(48.78)	0.003^a	0.956
总活检个数(x±s, 个)	6.99±1.78	6.04±2.03	2.524^b	0.326
ROSE标本个数(x±s, 个)	2.04±1.77	2.28±1.45	0.791^b	0.774
相关实验室检查(x±s)
CRP(mg/L)	82.88±4.38	39.04±4.38	51.772^b	0.002
ADA(U/L)	32.15±4.38	25.89±2.88	9.317^b	0.239
LDH(U/L)	485.85±146.15	362.67±40.01	6.925^b	0.224
胸水CEA(ng/mL)	137.27±80.72	142.18±73.17	0.335^b	0.923
胸腔镜下初步诊断[例(%)]
恶性	11(14.29)	37(90.24)	63.969^a	< 0.001
良性	66(85.71)	4(9.76)
注：^a为χ²值，^b为t值。

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表 2 胸腔镜与病理检查对良恶性胸腔积液的诊断结果(例)

Table 2. Diagnosis of benign and malignant pleural effusion by thoracoscopy and pathology (cases)

胸腔镜	病理检查		合计
胸腔镜	恶性	良性	合计
恶性	31	11	42
良性	10	66	76
合计	41	77	118

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表 3 胸腔镜联合ROSE技术诊断与病理检查对良恶性胸腔积液的诊断结果(例)

Table 3. Diagnosis of benign and malignant pleural effusion by thoracoscopy combined with ROSE technique and pathological examination (cases)

胸腔镜联合ROSE技术	病理检查		合计
胸腔镜联合ROSE技术	恶性	良性	合计
恶性	39	8	47
良性	2	69	71
合计	41	77	118

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表 4 单用胸腔镜与胸腔镜联合ROSE技术诊断恶性胸腔积液的诊断价值比较

Table 4. Comparison of the diagnostic value of thoracoscopy and thoracoscopy combined with ROSE in the diagnosis of malignant pleural effusion

诊断方法	灵敏度(%)	特异度(%)	阳性预测值(%)	阴性预测值(%)	AUC	P值	95% CI
胸腔镜	75.60	85.71	73.81	86.84	0.807	＜0.001	0.717~0.896
胸腔镜联合ROSE技术	95.12	89.61	82.98	97.18	0.924	＜0.001	0.868~0.979

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