基于系统评价的肺部病变活检方法的临床更新。
Clinical updates of approaches for biopsy of pulmonary lesions based on systematic review.
机构信息
Department of Thoracic Surgery, Institute of Surgery Research, Daping Hospital, Army Medical University, Chongqing, 400042, People's Republic of China.
出版信息
BMC Pulm Med. 2018 Sep 3;18(1):146. doi: 10.1186/s12890-018-0713-6.
BACKGROUND
Convenient approaches for accurate biopsy are extremely important to the diagnosis of lung cancer. We aimed to systematically review the clinical updates and development trends of approaches for biopsy, i.e., CT-guided PTNB (Percutaneous Transthoracic Needle Biopsy), ENB (Electromagnetic Navigation Bronchoscopy), EBUS-TBNA (Endobroncheal Ultrasonography-Transbronchial Needle Aspiration), mediastinoscopy and CTC (Circulating Tumor Cell).
METHODS
Medline and manual searches were performed. We identified the relevant studies, assessed study eligibility, evaluated methodological quality, and summarized diagnostic yields and complications regarding CT-guided PTNB (22 citations), ENB(31 citations), EBUS-TBNA(66 citations), Mediastinoscopy(15 citations) and CTC (19 citations), respectively.
RESULTS
The overall sensitivity and specificity of CT-guided PTNB were reported to be 92.52% ± 3.14% and 97.98% ± 3.28%, respectively. The top two complications of CT-guided PTNB was pneumothorax (946/4170:22.69%) and hemorrhage (138/1949:7.08%). The detection rate of lung cancer by ENB increased gradually to 79.79% ± 15.34% with pneumothorax as the top one complication (86/1648:5.2%). Detection rate of EBUS-TBNA was 86.06% ± 9.70% with the top three complications, i.e., hemorrhage (53/8662:0.61%), pneumothorax (46/12432:0.37%) and infection (34/11250:0.30%). The detection rate of mediastinoscopy gradually increased to 92.77% ± 3.99% with .hoarseness as the refractory complication (4/2137:0.19%). Sensitivity and specificity of CTCs detection by using PCR (Polymerase Chain Reaction) were reported to be 78.81% ± 14.72% and 90.88% ± 0.53%, respectively.
CONCLUSION
The biopsy approaches should be chosen considering a variety of location and situation of lesions. CT-guided PTNB is effective to reach lung parenchyma, however, diagnostic accuracy and incidence of complications may be impacted by lesion size or needle path length. ENB has an advantage for biopsy of smaller and deeper lesions in lung parenchyma. ENB plus EBUS imaging can further improve the detection rate of lesion in lung parenchyma. EBUS-TBNA is relatively safer and mediastinoscopy provides more tissue acquisition and better diagnostic yield of 4R and 7th lymph node. CTC detection can be considered for adjuvant diagnosis.
背景
准确活检的便捷方法对肺癌的诊断至关重要。本研究旨在系统综述活检方法的临床新进展和发展趋势，包括 CT 引导下经皮穿刺活检（PTNB）、电磁导航支气管镜（ENB）、超声支气管镜引导下经支气管针吸活检（EBUS-TBNA）、纵隔镜和循环肿瘤细胞（CTC）。
方法
通过 Medline 和手工检索，我们确定了相关研究，评估了研究的纳入标准，评价了方法学质量，并分别对 CT 引导下 PTNB（22 篇引文）、ENB（31 篇引文）、EBUS-TBNA（66 篇引文）、纵隔镜（15 篇引文）和 CTC（19 篇引文）的诊断效能和并发症进行了总结。
结果
CT 引导下 PTNB 的总体敏感性和特异性分别为 92.52%±3.14%和 97.98%±3.28%。CT 引导下 PTNB 最常见的两种并发症是气胸（4170 例中有 946 例，22.69%）和出血（1949 例中有 138 例，7.08%）。ENB 的肺癌检出率逐渐提高至 79.79%±15.34%，气胸是最常见的并发症（1648 例中有 86 例，5.2%）。EBUS-TBNA 的检测率为 86.06%±9.70%，最常见的三种并发症是出血（8662 例中有 53 例，0.61%）、气胸（12432 例中有 46 例，0.37%）和感染（11250 例中有 34 例，0.30%）。纵隔镜的肺癌检出率逐渐提高至 92.77%±3.99%，声嘶是难治性并发症（2137 例中有 4 例，0.19%）。采用聚合酶链反应（PCR）检测 CTC 的敏感性和特异性分别为 78.81%±14.72%和 90.88%±0.53%。
结论
应根据病变的位置和情况选择活检方法。CT 引导下 PTNB 可有效到达肺实质，但病变大小或针道长度可能会影响诊断准确性和并发症发生率。ENB 对于肺实质中小而深的病变具有优势。ENB 加 EBUS 成像可进一步提高肺实质病变的检出率。EBUS-TBNA 相对更安全，纵隔镜可提供更多的组织获取和更好的 4R 和 7 区淋巴结的诊断率。CTC 检测可作为辅助诊断方法。
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