Harris R J, Kavuru M S, Mehta A C, Medendorp S V, Wiedemann H P, Kirby T J, Rice T W
Department of Pulmonary and Critical Care Medicine, Cleveland Clinic Foundation, OH 44195.
Chest. 1995 Mar;107(3):845-52. doi: 10.1378/chest.107.3.845.
To describe the diagnostic efficacy, morbidity, and patient outcome of thoracoscopy; to quantify the direct impact of thoracoscopy on clinical management; and to determine preoperative variables associated with finding malignancy at thoracoscopy to aid patient selection.
Retrospective chart review of consecutive cases of thoracoscopy for pleural disease.
Single tertiary medical center.
One hundred eighty-two consecutive patients who underwent thoracoscopy for pleural disease over a 5-year period (from 1987 through 1992).
Final diagnoses were 98 (54%) malignant, 58 (32%) benign, and 26 (14%) idiopathic. Thoracoscopy had a diagnostic sensitivity of 95% for malignancy and 100% for benign disease. Malignancy was shown by thoracoscopy in 27 of 41 (66%) patients who had a preoperative nondiagnostic closed pleural biopsy, and in 24 of 35 (69%) patients who had at least 2 preoperative negative pleural cytologic specimens. Chart review by preestablished criteria showed information obtained from thoracoscopy directly influenced treatment in 155 (85%) patients. Thirty-seven (20%) patients, however, had at least one perioperative complication (15% major, 8% minor). Ten (6%) patients died during the same hospitalization in which a thoracoscopy was performed, although none died within 48 h. There was one thoracoscopy-related death. Sixty-two (34%) patients died within 6 months of thoracoscopy (death by all causes). Forty-seven (48%) patients who had intrathoracic malignancy present at thoracoscopy died within 6 months. Patients found to have malignant pleural disease by thoracoscopy were more likely to have a preoperative history of a malignancy (p = 0.001). Age more than 50 years was associated with finding malignancy at thoracoscopy (p = 0.04). A combined lymphocytic and hemorrhagic effusion was associated with malignancy (p = 0.004). Preoperative pleural data showed that idiopathic effusions had a significantly lower median lactate dehydrogenase (LDH) value (192, which was normal) compared with malignant or benign effusions.
(1) Thoracoscopy increases yield for malignant and benign disease when thoracentesis and closed pleural biopsy are nondiagnostic. (2) Thoracoscopy directly affects clinical management in 85% of patients. (3) Significant complications can occur in patients receiving tertiary care. (4) For the evaluation of suspected malignant pleural disease, thoracoscopy has its greatest diagnostic yield in older patients who have a history of malignancy and who present with a lymphocytic, hemorrhagic, high LDH effusion.
描述胸腔镜检查的诊断效能、发病率及患者预后；量化胸腔镜检查对临床管理的直接影响；确定与胸腔镜检查时发现恶性肿瘤相关的术前变量，以辅助患者选择。
对连续性胸腔镜检查治疗胸膜疾病病例进行回顾性病历审查。
单一的三级医疗中心。
1987年至1992年这5年间连续182例因胸膜疾病接受胸腔镜检查的患者。
最终诊断为恶性98例（54%）、良性58例（32%）、特发性26例（14%）。胸腔镜检查对恶性肿瘤的诊断敏感性为95%，对良性疾病的诊断敏感性为100%。41例术前闭式胸膜活检未明确诊断的患者中，27例（66%）经胸腔镜检查显示为恶性；35例术前至少有2次胸膜细胞学检查阴性的患者中，24例（69%）经胸腔镜检查显示为恶性。根据既定标准进行病历审查表明，胸腔镜检查所获信息直接影响了155例（85%）患者的治疗。然而，37例（20%）患者至少发生1例围手术期并发症（15%为严重并发症，8%为轻微并发症）。10例（6%）患者在接受胸腔镜检查的同一住院期间死亡，不过无患者在48小时内死亡。有1例与胸腔镜检查相关的死亡。62例（34%）患者在胸腔镜检查后6个月内死亡（各种原因导致的死亡）。胸腔镜检查时存在胸内恶性肿瘤的47例（48%）患者在6个月内死亡。经胸腔镜检查发现有恶性胸膜疾病的患者更可能有恶性肿瘤术前史（p = 0.001）。年龄超过50岁与胸腔镜检查时发现恶性肿瘤相关（p = 0.04）。淋巴细胞性和血性混合性胸腔积液与恶性肿瘤相关（p = 0.004）。术前胸膜数据显示，与恶性或良性胸腔积液相比，特发性胸腔积液的乳酸脱氢酶（LDH）中位数显著更低（192，属正常范围）。
（1）当胸腔穿刺术和闭式胸膜活检无法明确诊断时，胸腔镜检查可提高对恶性和良性疾病的诊断率。（2）胸腔镜检查直接影响85%患者的临床管理。（3）接受三级医疗护理的患者可能发生严重并发症。（4）对于疑似恶性胸膜疾病的评估，胸腔镜检查在有恶性肿瘤病史、出现淋巴细胞性、血性、高LDH胸腔积液的老年患者中诊断率最高。
