外科學(xué)課件-肺部疾病

1、肺部疾病Pulmonary Diseases 肺部疾?。↙UNG DISEASES）肺大皰（pulmonary bulla）支氣管擴(kuò)張（bronchiectasis）肺結(jié)核（pulmonary tuberculosis）肺包蟲(chóng)病（hydatid disease）氣管、支氣管肺腫瘤 肺癌（lung cancer） 支氣管腺瘤（adenoma of bronchus） 肺或支氣管良性腫瘤 肺轉(zhuǎn)移性腫瘤肺大皰（Pulmonary bulla）肺大皰是因肺皰內(nèi)壓力升高，肺泡壁破裂互相融合，最后形成巨大的囊泡狀改變。并發(fā)癥：自發(fā)性氣胸或血?dú)庑卦\斷：胸部CT或X線檢查；巨大肺大皰注意與氣胸鑒別治療：胸腔穿

2、刺或閉式引流，胸腔鏡下肺大皰切除支氣管擴(kuò)張（Bronchiectasis）原因：慢性支氣管壁及其周?chē)谓M織的炎癥性破壞所造成分型：分園柱狀、囊狀和混合型擴(kuò)張好發(fā)部位：肺下葉多見(jiàn)主要表現(xiàn)：咳痰、咯血，反復(fù)發(fā)作呼吸道和肺部感染主要診斷方法：支氣管造影、CT手術(shù)治療：急診或擇期行肺葉切除肺結(jié)核的外科治療適應(yīng)癥：結(jié)核空洞、結(jié)核瘤、毀損肺、藥物無(wú)法控制的咯血；注意：術(shù)后繼續(xù)抗結(jié)核治療612個(gè)月；并發(fā)癥：支氣管胸膜瘺，膿胸等；肺 腫 瘤Tumors of the Lung原發(fā)性: (1)良性腫瘤: 錯(cuò)構(gòu)瘤, 血管瘤. (2)惡性腫瘤: 肺癌.肺 癌: (1)原發(fā)性肺癌: 指發(fā)源于支 氣管上皮的惡性腫瘤.

3、(2)繼發(fā)性肺癌: 晚期惡性腫瘤, 89.5 %可發(fā)生肺轉(zhuǎn)移.原發(fā)性肺癌 發(fā)病率和死亡率增長(zhǎng)最快，對(duì)人類健康和生命威脅最大的惡性腫瘤。目前，全球每年約有250-300萬(wàn)人死于肺癌，中國(guó)每年死于肺癌的病人約40萬(wàn)人。預(yù)測(cè)，如果不進(jìn)行干預(yù)，2025年我國(guó)每年將有100萬(wàn)人死于肺癌！流行病學(xué)慨況 1. 發(fā)病率, 死亡率呈增長(zhǎng)趨勢(shì) (1) 19世紀(jì)初 (Laennec)首次對(duì)肺癌進(jìn)行描述； (2) 20世紀(jì)初, 肺癌仍然是少見(jiàn)??； (3) 近半個(gè)世紀(jì)來(lái)肺癌發(fā)病率和死亡率急劇增高, 約每5年增長(zhǎng)10%. LUNG CANCER Worldwide incidence*Incidence per 100,

4、000 population.Male54.8Female8.1Male75.9Female10.3Male39.3Female11.2Male47.6Female16.1Male41.7Female17.4Male12.9Female2.6Male29.1Female 7.7Male69.6Female32.9Male19.3Female7.9Male55.1Female7.6Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.Eastern EuropeJapanAustraliaNew ZealandChinaNorthern Africa

5、Southern AfricaCentral AmericaWestern Europe NorthAmericaTemperate South America LUNG CANCER Worldwide incidence*Incidence per 100,000 population.Male54.8Female8.1Male75.9Female10.3Male39.3Female11.2Male47.6Female16.1Male41.7Female17.4Male12.9Female2.6Male29.1Female 7.7Male69.6Female32.9Male19.3Fema

6、le7.9Male55.1Female7.6Parkin DM, et al. CA Cancer J Clin. 1999;49:33-64.Eastern EuropeJapanAustraliaNew ZealandChinaNorthern AfricaSouthern AfricaCentral AmericaWestern Europe NorthAmericaTemperate South America LUNG CANCER5-year survival ratesParkin DM, et al. CA Cancer J Clin. 1999;49:33-64. 7%12%

7、21%13%10%8%10% 20%14%Eastern EuropeJapanAustraliaNew ZealandChinaMiddle East/Northern AfricaSub-Saharan AfricaLatin America/CaribbeanNorthwestern Europe NorthAmericaRate per 100,000 Male PopulationYear ONCOLOGYEpidemiologyAdapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:27.Evolution of can

8、cer death rates, malesPancreasLiverProstateStomachLung & bronchusColon & rectumLeukemia102030405060701930194019501960197019801990Rate per 100,000 Female PopulationYear ONCOLOGY EpidemiologyAdapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:26. Evolution of cancer death rates, females01020304

9、0UterusBreastPancreasOvaryStomachLung & bronchusColon & rectum1930194019501960197019801990ONCOLOGYEpidemiologyMale cancer statisticsAdapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:16.Estimated incidenceEstimated deathsMelanoma of skinOral cavity & pharynxLung & bronchusPancreasKidney & re

10、nal pelvisColon & rectumProstateUrinary bladderLeukemiaNon-Hodgkins lymphomaAll others4%3%14%2%3%10%29%6%3%5%19%EsophagusLung & bronchusPancreasLiver & intrahepatic bile ductStomachColon & rectumProstateUrinary bladderLeukemiaNon-Hodgkins lymphomaAll others3%31%5%3%3%10%11%3%4%5%22%ONCOLOGYEpidemiol

11、ogyFemale cancer statisticsAdapted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:16.2%15%25%5%2%11%5%2%5%4%2%21%Melanoma of skinThyroidBreastLung & bronchusPancreasColon & rectumOvaryUterine corpusUrinary bladderNon-Hodgkins lymphomaAll others3%2%30%12%2%11%4%6%2%4%22%Brain & other nervous syst

12、emBreastLung & bronchusPancreasStomachColon & rectumOvaryUterine corpusNon-Hodgkins lymphomaLeukemiaMultiple myelomaAll othersEstimated incidenceEstimated deaths 40-49歲：開(kāi)始升高 50-59歲：急劇升高 70歲以上：稍有下降2、年齡分布特點(diǎn)ONCOLOGYEpidemiology*Non-Hodgkins lymphoma.Other nervous system.Mortality for leading cancersAda

13、pted from Greenlee RT, et al. CA Cancer J Clin. 2000;50:23.Males by Age (years), USAll AgesLung & bronchus91,278Prostate32,891Colon & rectum28,075Pancreas13,470NHL12,28620-39NHL*723Leukemia662Brain & ONS625Lung & bronchus512Colon & rectum41260-79Lung & bronchus59,558Prostate16,277Colon & rectum15,84

14、2Pancreas7,898NHL6,383 80Lung & bronchus15,823Prostate15,511Colon & rectum7,459Bladder2,900Pancreas2,84340-59Lung & bronchus15,379Colon & rectum4,347NHL2,552Pancreas2,584Esophagus2,069ONCOLOGYEpidemiology*Other nervous system.Non-Hodgkins lymphoma.Mortality for leading cancersAdapted from Greenlee R

15、T, et al. CA Cancer J Clin. 2000;50:23.All AgesLung & bronchus61,922Breast41,943Colon & rectum28,621Pancreas14,205Ovary13,50720-39Breast1,629Uterine cervix629Leukemia462Lung & bronchus462Brain & ONS*38560-79Lung & bronchus38,488Breast18,385Colon & rectum12,799Pancreas7,437Ovary7,207 80Lung & bronchu

16、s12,879Colon & rectum12,046Breast9,835Pancreas5,045NHL3,85940-59Breast12,093Lung & bronchus10,088Colon & rectum3,426Ovary2,801Uterine cervix1,803Females by Age (years), US 4、地理分布特點(diǎn) 工業(yè)發(fā)達(dá)的國(guó)家高； 我國(guó)沿海、東三省、云南高。 城市通常是農(nóng)村的25倍。 3、性別分布特點(diǎn) 男女=48 1肺癌病因?qū)W_相關(guān)因素主動(dòng)吸煙電離輻射職業(yè)危害大氣污染既往肺部疾病室內(nèi)微小環(huán)境的污染激素-月經(jīng)與生育史營(yíng)養(yǎng)狀況微量元素遺傳因素其他（心

17、理、免疫，經(jīng)濟(jì)、文化等社會(huì)因素）（1）吸煙量與發(fā)病率呈正相關(guān);（2）戒煙后發(fā)病的危險(xiǎn)逐漸減少;（3）間接吸煙者發(fā)病增多.吸煙 (4) 開(kāi)始吸煙的年齡越小發(fā)病率越高; 煙草與肺癌（5）動(dòng)物實(shí)驗(yàn);（6）病理學(xué)研究 吸煙支氣管粘膜鱗狀化癌1996WHO年度報(bào)道，肺癌中85%男性和46%的女性因吸煙引起；肺癌發(fā)病率： 吸煙者：非吸煙者=10-20倍； 中國(guó)：煙草大國(guó)；吸煙率 男：66.9%; 女：4.2%; 中學(xué)生：20-40%； 吸煙率仍以每年2%上升；煙草與肺癌肺癌病理學(xué)類型非小細(xì)胞肺癌（NSCLC，non-small cell lung cancer） 鱗狀細(xì)胞癌、腺癌、大細(xì)胞癌小細(xì)胞肺癌（SC

18、LC，small cell lung cancer） 鱗狀細(xì)胞癌約占30%，起源于較大的支氣管，與吸煙煙關(guān)系密切，發(fā)展較慢，放化療中等度敏感。 Squamous Cell Carcinoma腺癌：起源于較小的支氣管，女性多見(jiàn)， 與慢性炎癥關(guān)系密切，血源性轉(zhuǎn)移較早， 放化療不敏感。Adenocarcinoma小細(xì)胞肺癌：起源于大支氣管, 惡性程度高，血源性轉(zhuǎn)移較早, 化療敏感，預(yù)后較差。Small Cell Carcinoma大細(xì)胞癌：起源于大支氣管， 腦轉(zhuǎn)移早，預(yù)后差。 Large Cell Carcinoma NON-SMALL CELL LUNG CANCERIncidence of ma

19、jor histologic types* Numbers do not sum to 100% because of differences in diagnostic criteria.18%40%Squamous cellcarcinomaSmall-cellcarcinoma30%Adenocarcinoma15%Large-cellcarcinoma NON-SMALL CELL LUNG CANCER Histologic typesAdapted from Rosenow and Carr.Smoker (%)Nonsmoker (%)Smoker (%)Nonsmoker (%

20、) Male Female 38211723Squamous CellAdenocarcinomaLarge CellSmall CellBronchoalveolar11056236522351327396810211Smokers vs nonsmokers肺癌的擴(kuò)散直接擴(kuò)散淋巴轉(zhuǎn)移血行轉(zhuǎn)移NSCLC 分期Stage 0Stage IAStage IIBStage IIIBStage IVLymph nodesMain bronchusContralateral lymph nodeMetastasis to distant organsInvasion of chest wallNSCL

21、C淋巴結(jié)轉(zhuǎn)移規(guī)律Node involvement sequence:FirstSubsequentFrom upper lobeFrom middle lobeFrom lower lobeRoute of spread:Ginsberg RJ, et al. Cancer: Principles and Practices of Oncology. 5th ed. 1997;858-911.NSCLC局部和遠(yuǎn)處轉(zhuǎn)移情況BrainDraining lymph nodesPericardiumLungPleuraLiverAdrenalsBoneGinsberg RJ, et al. Cance

22、r: Principles and Practices of Oncology. 5th ed. 1997;858-911.臨床表現(xiàn)1、肺癌的常見(jiàn)癥狀2.晚期肺癌的表現(xiàn)：膈肌麻痹；聲帶麻痹，聲音嘶啞；上腔靜脈綜合征；惡性胸水；吞咽困難；3.Pancoast腫瘤臨床表現(xiàn)周?chē)头伟┢鹪从诙沃夤芤韵抡撸辔挥诰喾伍T(mén)較遠(yuǎn)的部位，腺癌居多，多為體檢照胸片發(fā)現(xiàn)肺部包塊，咳嗽、咯血、發(fā)燒不突出。中央型肺癌起源于段支氣管開(kāi)口以上者，位置靠近肺門(mén)，鱗癌、小細(xì)胞癌居多。刺激性咳嗽、咳血突出，多在阻塞性肺炎、發(fā)燒、肺不張，纖支鏡檢可見(jiàn)腫瘤。主要診斷方法及其意義 （1）胸部X線照片 （2）胸部CT （3）痰細(xì)胞學(xué)檢

23、查 （4）支氣管鏡檢 （5）肺穿刺活檢 （6）剖胸探查 （7）MRI 主要診斷方法及其意義 （8）支氣管造影 （9）血管造影 （10）放射性核素67鎵掃描 （11）轉(zhuǎn)移灶活檢 （12）胸水查癌細(xì)胞 （13）縱隔鏡、胸腔鏡檢查 （14）免疫學(xué)診斷阻塞性肺病變遺傳危險(xiǎn)因素 痰細(xì)胞學(xué)腫瘤分子標(biāo)志物CTPET肺癌的早期診斷 如何早期發(fā)現(xiàn)肺癌 A. 提高醫(yī)務(wù)人員的警惕性和診斷水平 B. 減少誤診 C. 尋找簡(jiǎn)單、易行、特異性高的早期診斷方法 D. 深入高發(fā)區(qū)，主動(dòng)發(fā)現(xiàn)病人肺癌的鑒別診斷肺結(jié)核支氣管肺炎肺膿腫肺部良性腫瘤縱隔腫瘤肺癌的治療原則 根據(jù)患者的身心狀況、腫瘤的具體部位、病理類型、侵犯范圍（病期）

24、和發(fā)展趨向，結(jié)合細(xì)胞分子生物學(xué)的改變，有計(jì)劃地、合理地應(yīng)用現(xiàn)有的多學(xué)科各種有效治療手段，以最適當(dāng)?shù)慕?jīng)濟(jì)費(fèi)用，取得最好的治療效果，同時(shí)最大限度地改善患者的生活質(zhì)量。肺癌常用多學(xué)科綜合治療模式傳統(tǒng)模式（先手術(shù)，后放化療）術(shù)前新輔助化療+手術(shù)+放化療術(shù)前新輔助放化療+手術(shù)+放化療術(shù)前新輔助介入化療+手術(shù)+放化療不能手術(shù)肺癌的序貫療法、同時(shí)療法和交替療法。肺癌的手術(shù)治療盡可能徹底切除肺部原發(fā)腫瘤病灶和局部及縱隔淋巴結(jié)，并盡可能保留健康的肺組織肺癌外科手術(shù)治療基本原則盡可能全部切除腫瘤及其肺內(nèi)的引流淋巴；整快切除腫瘤侵犯的組織以保證切緣陰性；所有病人均應(yīng)行同側(cè)縱隔淋巴結(jié)的清掃、并分組送病理檢查；術(shù)中避免腫瘤破裂溢出或橫斷腫瘤以保證腫瘤的完整性。肺癌的手術(shù)方式肺段或肺楔型切除術(shù)肺葉切除術(shù)+淋巴結(jié)清掃全肺切除術(shù)+淋巴結(jié)清掃支氣管袖狀肺葉切除+淋巴結(jié)清掃支氣管袖狀肺動(dòng)脈袖狀肺葉切除+淋巴結(jié)清掃肺癌擴(kuò)大切除+胸壁重建肺癌擴(kuò)大切除+上腔靜脈切除+人工血管置換支氣管肺癌不同時(shí)期外科手術(shù)療效年 代病例數(shù)5年生