肺部疾病PPT课件.ppt

肺部疾病pulmonarydisease,赣南医学院第一附属医院外科教研室胸心外科赣南医学院第一临床医学院,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,.,1,肺部疾病pulmonarydisease,1.肺大疱（pulmonarybulla）（了解）2.支气管扩张症（bronchiectasis）（熟悉）3.肺结核（pulmonarytuberculosis）（了解）4.肺棘球蚴病/肺包虫病（了解）（pulmonaryechinococcosis/pulmonaryhydatid）5.支气管、肺肿瘤（pulmonarytumors）（其中肺癌重点讲解）,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,.,2,讲授内容,原发性支气管肺癌(重点讲解)PrimaryBronchogenicCarcinoma支气管扩张症(简要讲解)Bronchiectasis,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,.,3,原发性支气管肺癌(PrimaryBronchogenicCarcinoma),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,4,概述病因病理(重点掌握内容)转移途径临床分型(重点掌握内容)临床表现(重点掌握内容)诊断和鉴别诊断(难点/重点)治疗(疑点),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,5,PrimaryBronchogenicCarcinoma概述(GENERALDISCUSSION),肺癌的发病率死亡率正在迅速上升，这是一个世界性趋势，很多发达国家中肺癌占男性常见恶性肿瘤的第一位，占女性常见恶性肿瘤的第二三位。吸烟、被动吸烟、环境污染尤其是大气污染是促成这一严峻现实的罪魁祸首，却又都是一个长期得不到解决的老大难问题。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,6,另一流行病学趋势就是肺癌组织学类型在男女性别中的显著变化。鳞癌的发病度在男性中占的比例大幅度下降（导致肺腺癌的比例相应增加），腺癌的发病率在女性中继续增长。肺癌严重危害人民健康，威胁人民的生命，但是迄今为止肺癌的治疗效果十分令人不满。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma概述(GENERALDISCUSSION),.,7,原发性支气管肺癌简称肺癌（LungCancer）指起源于气管粘膜或腺体的癌症。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma概述(GENERALDISCUSSION),.,8,1、吸烟(Cigarettesmoking)是公认的肺癌危险因素。烟雾中含20多种致癌物(苯并芘).国内资料：男性肺癌85-90%，女性19.3-40%与吸烟有关.吸烟量越大、年限越长、吸烟年龄开始越早，肺癌死亡率越高.吸烟者肺癌发生率比非吸烟者高10-20倍，死亡率高10-30倍（被动吸烟者危险性增加50%）.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病因(ETIOLOGY),.,9,1、吸烟(Cigarettesmoking),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病因(ETIOLOGY),.,10,2、职业已知石棉、煤焦油、沥青、石油、无机砷、烟草加热产物、铬、镍、芥子气、氡、二氯甲醚、氯乙烯等与肺癌有关.石棉工人肺癌发生率高8倍(吸烟者)、92倍(非吸烟者).云南锡矿（含氡）的井下工比地面职工高23-98倍.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病因(ETIOLOGY),.,11,3、大气污染(Airpollution)煤、石油燃烧废气、公路沥青、厨房油烟气.4、电离辐射自然界、医疗、工矿产生的辐射线.5、饮食与营养维生素A及其洐生物胡罗卜素缺乏，肺癌发生率增高.6、其它(Others)气道慢性刺激（炎症、疤痕）.遗传因素（致癌及抑癌基因变化）.原癌基因-myc、ras、c-jun、src、lck.抑癌基因-P53、Rb、nm23、P16.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病因(ETIOLOGY),.,12,按细胞形态特征及分化程度分：鳞状细胞癌Squamouscarcinoma小细胞癌Smallcellcarcinoma大细胞癌Largecellcarcinoma腺癌Adenocarcinoma混合型肺癌Mixedlungcancer,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),.,13,肺癌的发病率,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),.,14,1、鳞状上皮细胞癌(Squamouscarcinoma)最多见，约50%+。多见于老年人（50）。男性居大多数,与吸烟有关系密切。常见于中央型。生长速度较缓慢，病程较长。对放疗化疗较敏感。手术切除率高。一般先淋巴结转移、血行转移晚，5年生存率高。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),肿瘤质地坚韧，切面呈浅白色到到黝黑色,.,15,2、小细胞癌(燕麦细胞癌)(Smallcellcarcinoma)发病率仅次于鳞癌。年龄较轻，40左右。男性多，与吸烟有关。大多为中央型。恶性程度高，生长快。较早出现淋巴（为主）、血行广泛转移。对放疗、化疗较敏感。但预后最差。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),外观为白色到黑色的肿瘤在肺的中央并向周围广泛传播。肿瘤致叶支气管阻塞，远端肺组织塌陷,.,16,3、大细胞癌(Largecellcarcinoma)甚少见，可见于中央型或周围型。半数起源于大支气管，细胞大胞浆丰富胞核形态多样，细胞排列不规则，分化程度低。转移较小细胞癌晚，但常发生脑转移后才被发现。预后很差。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),.,17,4、腺癌(Adenocarcinoma)发病率居第三位,占25%。年龄较小,女性多见,与吸烟无关。多周围型（包括腺泡状腺癌、乳头状腺癌、支气管肺泡癌、实体癌粘膜形成）。早期一般没有症状,多为X线发现（球型病变）。生长较缓慢,但局部浸润及血行转移早(血管丰富),易出现胸水,易转移至肝、脑、骨骼.淋巴转移晚。对放疗、化疗敏感性低。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),.,18,5、支气管肺泡癌(肺泡癌)(Alveolarcellcarcinoma)较少见,占2-5%，属腺癌的亚型.肿瘤起源于肺泡粘膜上皮或支气管粘膜上皮,沿肺泡壁生长.常位于肺周边,分化程度较高,生长缓慢,淋巴、血行转移晚,但可直接播散.可呈弥漫小结节分布或局部肿块.结节型:呈单个或多个结节灶;弥漫型:形态类似支气管肺炎.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),肺实变,多病灶.右上肺叶呈现黑-白色到灰色外观,.,19,6、混合型(Mixedlungcancer)鳞腺癌、未定型(分化差或未分化)癌、类癌、支气管腺体癌.由于小细胞癌生物学行为，以及对放、化疗敏感性与其他类型肺癌明显差异，故临床上将肺癌分为：小细胞癌（SmallCellLungCancer,SCLC）.非小细胞癌（Non-SmallCellLungCancer,NSCLC）包括鳞癌、腺癌、肺泡癌.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分型(PATHOLOGICALTYPE),.,20,按生长部位分为中央型肺癌:生长在段以上的支气管，以鳞癌、未分化癌多见.周围型肺癌:生长在段支气管以下，以腺癌多见.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床分型(CLINICALTYPE),.,21,中央型肺癌,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,22,周围型肺癌,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,23,分期TNM分期TNM隐性肺癌TXN0M0a期T3N1M00期(原位癌)TisN0M0T1-3N2M0A期T1N0M0b期任何T,N3,M0B期T2N0M0T4,任何N,M0A期T1N1M0期任何T任何NM1B期T3N0M0T2N1M0T示原发癌肿病灶N示局部区域淋巴结侵犯M代表远处转移,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma病理分期(TNM分期法),.,24,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),肺癌症状取决于发生部位、大小、是否压迫临近器官及有无转移.早期可无症状,而在X线体检时发现.中央型出现症状早.周围型较晚.1.原发肿瘤引起症状和体征咳嗽(Cough)最常见，早期症状，抗炎无效.早期刺激性顽固性、阵发性.肿瘤增大堵塞管腔阻塞性持续高音调，带金属音,肺部感染可有脓痰、痰量多.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,25,咯血(Hemoptysis)占50-60%.癌组织血管丰富持续性或间断性痰中带血,大咯血少见.胸闷或胸痛(Chestpain)占30%，持续性钝痛、隐痛、胸部沉重感.癌肿侵犯胸膜尖锐胸痛.侵及肋骨固定压痛.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,26,发热(Fever)一般不发热，可有低热.癌肿坏死癌性发热,不受抗菌素治疗的影响.癌肿阻塞支气管阻塞性肺炎发热等中毒症状。喘鸣(Wheeze)肿瘤支气管狭窄喘鸣.时间短暂、部位固定、局限、吸气明显，咳嗽不消失.消瘦恶病质(Thinness)体重下降.感染、疼痛、肿瘤毒素引起消耗体质晚期,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,27,2.肿瘤局部扩展引起的症状和体征胸痛侵犯胸膜、肋骨剧烈胸痛.声嘶肿大淋巴结压迫喉返神经导致声带麻痹.呼吸困难、气促管腔内肿瘤大气道狭窄、阻塞或隆突被广泛侵犯.呼肿瘤或肿大淋巴结压迫气管、大支气管.吸病变广泛肺泡癌.困肿瘤侵犯胸膜、胸腔积液、心包积液.难心包膜肿瘤侵犯膈神经膈肌麻痹.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,28,3.晚期肺癌压迫周围器官引起症状压迫侵犯膈神经同侧膈肌麻痹(矛盾运动).压迫或侵犯喉返神经声带麻痹声音嘶哑.上腔静脉受压综合征:面、颈、上肢和上胸部V怒张,皮下组织水肿,上肢静脉压升高.侵犯胸膜胸腔积液(血性胸水).侵犯纵隔、压迫食管吞咽困难.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,29,3.晚期肺癌压迫周围器官引起症状肺上沟癌(Pancoast癌,或肺尖癌)a:压迫交感神经同侧瞳孔缩小,上睑下垂,眼球内陷,额部少汗何纳氏征(honerssyndrome).b:压迫臂丛神经同侧肩关节,上肢内侧剧痛和感觉异常.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,30,4.肿瘤远处转移症状和体征转移至：脑颅高压头痛、呕吐、脑疝骨疼痛及压痛肝肝肿大、肝区痛、黄疸、腹水、厌食淋巴结淋巴结肿大,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,31,5.肺外表现又称副癌综合征(ParaneoplasticSyndrome)1)杵状指、肥大性骨关节病多见于鳞癌前者:发生快、疼痛剧烈、甲床周围出现红晕为特点.后者:以长骨疼痛、骨膜增生、新骨形成或关节疼痛常同时伴发.手术切除肺癌后症状立即减轻或消失.肿瘤复发又可出现.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,32,5.肺外表现(ParaneoplasticSyndrome)2)内分泌失调多见于小细胞癌(燕麦细胞癌)分泌异位激素促肾上腺皮质样激素满月脸、水牛肩cushingssyndrome柯兴氏征,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,33,5.肺外表现(ParaneoplasticSyndrome)2)内分泌失调促性腺样激素：男性乳房发育肿大.常伴肥大性骨关节病.甲状旁腺样激素:高钙、低磷血症,多尿、烦渴、便秘、心律失常、精神错乱.抗利尿激素:水、钠潴留,水中毒表现.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,34,5.肺外表现(ParaneoplasticSyndrome)3)神经肌肉综合征多见于燕麦细胞癌肌力下降(重症肌无力)、小脑运动失调、眼球震颤、精神错乱.可能与肿瘤产生箭毒样物质有关，亦可能与自身免疫反应有关.4)类癌综合征5-羟色胺增多，哮喘、阵发性心动过速、水泻、皮肤潮红.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma临床表现(clinicrepresentation),.,35,PrimaryBronchogenicCarcinoma诊断（diagnose),早期诊断-关键在于提高警惕-加强宣教、普及防癌知识.40岁男性、吸烟者出现下列情况应疑及肺癌:刺激性咳嗽、持续2-3周以上，治疗无效者.持续或间断痰中带血，无其他原因可解释者.反复同一部位肺炎.单侧局限性哮鸣音，不因咳嗽改变.X线胸片示局限性肺气肿、肺不张、孤立性圆形病灶或单侧肺门增大.血性胸水，增长迅速，无毒性症状.原因不明的四肢关节疼痛、杵状指.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,36,主要检查手段(METHOD)1.X线：包括胸片、CT、磁共振.2.痰脱落细胞检查阳性率达70-80%.3.纤维支气管镜检阳性率中央型达90%-93%.4.转移病灶组织活检.5.放射性核素扫描（SPECT）及PET.6.脱水脱落细胞及肿瘤标记物检查.7.纵隔镜检查或胸腔镜检查.8.经胸壁穿刺活组织检查.9.剖胸探查无法确诊高度可疑.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma诊断（diagnose),.,37,PrimaryBronchogenicCarcinomaX线直接征象,中央型肺癌:肺门块影、分叶状(肿瘤+肺门或纵隔肿大淋巴结).周围型肺癌:肺周围圆形或椭圆型块影、密度高、边缘模糊、常呈分叶状、可有脐样切迹或细毛刺,可出现癌性空洞(厚壁偏心、内壁凹凸不平).肺泡癌:结节型、弥漫型.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,38,PrimaryBronchogenicCarcinomaX线直接征象,中央型肺癌:肺泡癌:周围型肺癌:,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,肿瘤向外生长时肺门不规则肿块(肿块由癌肿及肺门淋巴结融合成),右肺下叶见一球形肿块影,呈分叶状,弥漫型形态类似肺炎表现,.,39,PrimaryBronchogenicCarcinomaX线直接征象,CT可发现X线检查隐藏区,如心包后,纵隔处,脊柱旁等.对肺门、纵隔淋巴结有无转移诊断价值高.肿块的实性、囊性可明确诊断.毛刺征分叶状,GannanMedicalUniversityCAI,.,40,PrimaryBronchogenicCarcinomaX线直接征象,癌性空洞,GannanMedicalUniversityCAI,.,41,PrimaryBronchogenicCarcinomaX线直接征象,肺泡癌（弥漫型）,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,42,PrimaryBronchogenicCarcinomaX线间接征象,阻塞征肺不张（叶、段）肺门肿块+上叶肺不张反“S”征局限性肺气肿（叶、段）阻塞性肺炎转移性胸腔积液、心包积液、肺门、纵膈增宽(肺门、纵膈淋巴结肿大),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,43,PrimaryBronchogenicCarcinomaX线间接征象,肺癌阻塞征肺不张反“S”征,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,44,PrimaryBronchogenicCarcinomaX线间接征象,局限性肺气肿,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,45,PrimaryBronchogenicCarcinomaX线间接征象,阻塞性肺炎肺癌胸膜转移(胸腔积液),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,46,PrimaryBronchogenicCarcinoma纤维支气管镜检及肺活检,中央型直接窥视、活检、刷检.明确肿瘤部位.阳性率可达到80-90%.表现为管腔阻塞、隆突增宽等.周围型无法窥视，可行经纤支镜肺活检.纤肺支活镜检检,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,47,PrimaryBronchogenicCarcinoma痰脱落细胞学检查,阳性率70%-90%.深部咳出的新鲜痰液，立即送检.反复多次送检.病理细胞学检查浅表淋巴结、纵膈镜检纵膈淋巴结、胸膜活检.肺活检经胸壁或纤支镜(X线电视引导或B超定位).,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,腺癌,鳞癌,小细胞癌,.,48,PrimaryBronchogenicCarcinoma其它辅助检查,放射性核素扫描135钴69枸橼酸稼.18氧2脱氧D葡萄糖（FDG）.（在肿瘤细胞内积聚）剖胸探查无法确诊而肺癌高度可疑者.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,49,PrimaryBronchogenicCarcinoma鉴别诊断(differentialdiagnosis),中央型淋巴瘤、支气管淋巴结核.周围型结核瘤、炎性假瘤、肺脓肿.肺泡癌粟粒性肺结核.肺癌并阻塞性肺炎肺炎.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,50,PrimaryBronchogenicCarcinoma诊断与鉴别诊断1,中央型肺癌与肺结核和慢性炎症的鉴别中央型肺癌肺结核或慢性炎症支气管改变狭窄或阻塞狭窄等肺段或肺叶均匀多不均匀,有结节影,空阴影洞、蜂窝、空洞(炎症)肺门肿块多无,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,51,PrimaryBronchogenicCarcinoma诊断与鉴别诊断2,周围型肺癌和结核球的鉴别周围型肺癌结核球发生部位任何部位上尖,下背病灶大小3-4cm,分叶多2-3cm,少有分叶密度均匀或有空洞空洞,钙化多见卫星灶无有,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,52,纵隔型肺癌特殊类型的肺癌,易误认为纵隔肿瘤晚期的上叶中央型肺癌纵隔旁的周围型肺癌,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,53,结核球tuberculoma,多见于青年,病程长,常位于上叶后段或下叶背段.X线密度不均匀,有时有钙化点,肺内常有散在结核灶.,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,.,54,肺门淋巴结核,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,常见儿童、青年多有结核中毒症状结核实验阳性抗痨有效,.,55,粟粒性结核miliarytuberculosis,常见青年全身毒性症状明显抗痨有效X线以上中叶明显,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,.,56,肺炎Pneumonia,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,约1/4的肺癌早期以肺炎形式出现,肺癌、肺炎起病缓,无毒性症状,抗炎治疗吸收缓慢.,.,57,肺脓肿Lungabscess,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,有明显感染症状,痰多,脓性.抗痨无效.X线空洞壁较薄,内壁光滑.常有出血.,.,58,结核性胸膜炎Tuberculouspleuritis,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,癌肿侵犯胸膜(血性胸水、生长快、抗痨无效,抽后迅速长出,胸水检出癌细胞可确诊).结核性胸膜炎则抗痨有效.,.,59,良性肿瘤Benigntumor,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,错构瘤、纤维瘤、软骨瘤.病程长,生长缓慢,临床大多无症状.X线密度均匀,多无分叶.,.,60,肺错构瘤,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,肺错构瘤主要由良性软骨构成.如图所示,它与纤维血管基质混在一起,在左边是散布的支气管腺体.错构瘤是发生于一个器官的肿瘤,由所在部位的正常组织成分构成,但却形成了一个不特别的肿块.,.,61,支气管腺瘤Bronchialadenoma,GannanMedicalUniversityCAI,TheFirstClinicalCollegeofGannanMedicalUniversity,发病年龄轻.女性多见.临床表现、X线表现与肺癌相似，鉴别困难.常开胸探查.,纵隔淋巴肉瘤Mediastinallymphosarcoma,肉瘤生长迅速常有发热浅表淋巴结肿大放疗高敏照射后迅速缩小,.,62,PrimaryBronchogenicCarcinoma治疗(therapy),以手术为主的多学科综合性治疗(原则)手术治疗(Operation)(首选)放射线治疗（放疗）(Radiotherapy)化学药物治疗（化疗）(Chemotherapy)免疫治疗(Immunotherapy)基因治疗(Genetherapy)中医中药治疗(Traditionalmedicine),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,63,PrimaryBronchogenicCarcinoma外科治疗策略1(therapy-1),众多临床试验从循证医学的角度证实，外科治疗在肺癌多学科综合治疗中占有极其重要的地位。具备外科治疗条件的肺癌原则上应以手术治疗为首选。现代观点认为：外科治疗肺癌的重要地位不容置疑，根治性切除是肺癌的标准化外科治疗，是手术选择和手术效果评判的金标准。术前全面准确的评估和及时纠治病人的体质状况、营养状态、脏器功能、内科疾病是确保手术成功与安全必不可少的重要环节。如果无视病人的耐受性，盲目片面的追求手术的成功与创新，是极度危险的，应引起外科医生的高度重视。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,64,PrimaryBronchogenicCarcinoma外科治疗策略2(therapy-2),化放疗联合治疗与手术治疗一样，同属根治性治疗，是不能耐受手术局限期病变的最佳选择。多学科综合治疗是肺癌的标准化治疗，但并不意味着可盲目随意组合。理想的治疗方案和措施的选择，是基于病人的临床因素和分子生物学机制而制定的个性化治疗。在肺癌的治疗中为病人提供客观准确的临床诊疗依据，协同相关的专业医生，制定最佳的多学科综合治疗方案，最大限度的延长患者的生存期是我们的职责。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,65,PrimaryBronchogenicCarcinoma治疗策略外科手术(Operation),80%的肺癌患者在明确诊断时已失去手术的机会.但手术治疗仍然是肺癌最重要和最有效的治疗手段.目前我国手术切除率8597%,术后30天死亡率在2%以下,5年生存率为3040%左右.手术目的:彻底切除肺部原发癌肿和局部转移淋巴结,尽可能保留健康肺组织.手术类型:1.肺叶切除(袖状切除)Lobectomy;2.全肺切除Pneumonectomy;3.楔型切除Limitedresection.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,66,PrimaryBronchogenicCarcinoma治疗策略外科手术(Operation),手术适应证1.临床分期为、A期的非小细胞肺癌。2.、期的小细胞肺癌。3.T达四级，N达三级，甚至M为1,(如孤立性脑转移)为了减状可以实行手术。手术禁忌证1.各种T4肿瘤，已经侵入纵膈及心脏、大血管、气管、食管、椎体、隆突、同一肺叶另有结节或恶性胸水。2.N级达到三级，对侧肺门、纵膈、锁骨上、腋下等处淋巴结。3.已有远处转移。4.心、肝、肾等脏器功能障碍，全身情况差(相对禁忌症)。,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,67,手术原则:手术切除病灶肺叶，清除转移淋巴结.手术对鳞癌效果最佳,腺癌次之,未分化癌最差.非小细胞癌:首选手术,早期无转移者手术,切除可治愈.小细胞肺癌:转移较早,手术仅限于期.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma治疗策略外科手术(Operation),.,68,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma肺叶切除（袖状切除）Lobectomy,.,69,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma隆突成型术,.,70,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma全肺切除pneumonectomy,.,71,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,PrimaryBronchogenicCarcinoma楔型切除Limitedresection,.,72,PrimaryBronchogenicCarcinoma治疗策略放疗(Radiotherapy),放疗对小细胞未分化癌最敏感，鳞癌次之，腺癌最差.适应症：禁忌症1.拒绝手术或有手术禁忌症.1.恶病质者2.小细胞未分化癌.2.高度肺气肿3.配合手术（术前后照射）3.全身或胸膜、肺广泛转移4.已有远处转移的晚期病人4.病变范围广泛减轻症状姑息治疗.5.癌性空洞或巨大肿瘤副作用：放射性肺炎肺纤维化.重度肺气肿肺功能不全者慎用.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,73,PrimaryBronchogenicCarcinoma治疗策略化疗(Chemotherapy),化疗对小细胞未分化癌最敏感，鳞癌次之，腺癌最差.常用药物：1.铂类.2.阿霉素(ADR)或表阿霉素(EPI).3.足叶乙叉甙（VP16）或鬼臼噻吩甙（VM26威猛）、环磷酰胺（CTX）或异环磷酰胺(IFO).4.丝裂霉素（MMC）5.紫杉醇（TXL泰素或泰素帝）6.长春花碱酰胺（VDS）或长春瑞宾（NVB）7.吉西他宾（Gemcitabine）,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,74,PrimaryBronchogenicCarcinoma治疗策略化疗(Chemotherapy),常用化疗方案:小细胞癌(SCLC)以化疗为主，辅以手术和（或）放疗、化疗.EP(VP16+DDP).CAV(CTX+ADM+VCR).VP-CP(VP16+CBP)ACE(CTX+ADM+VP16).NP(NVB+DDP).VIP（VP16+IFO+DDP.单药治疗：托泊替康（Tepotecan）、VP16（口服）.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,75,PrimaryBronchogenicCarcinoma治疗策略化疗(Chemotherapy),常用化疗方案:非小细胞癌(NSCLC)1.早期(、期）:以手术为主.2.可切除a:新辅助化疗+手术治疗放疗.3.不可切除b:化疗与放疗联合治疗.4.晚期远处转移:姑息治疗为主.常用方案:1.CAP(CTX+ADM+DDP).2.MVP(MMC+VDS+DDP).3.TP(TXL+DDP).4.ICE(IFO+VDS+DDP).5.GP(Gemciabine+DDP).6.NP.7.EP.8.MIC(MMC+IFO+DDP).副作用：血像降低，骨髓抑制，脱发，肝肾损害，心肌损害.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,76,PrimaryBronchogenicCarcinoma治疗策略其它(Others),免疫治疗(Immunotherapy)辅助作用白介-2,干扰素,转移因子,LAK细胞,肿瘤浸润淋巴细胞.中医中药治疗(Traditionalmedicine)抗癌验方或辨证措施.改善症状,提高机体免疫力,杀灭肿瘤细胞,延长生命.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,77,PrimaryBronchogenicCarcinoma治疗策略基因治疗(Genetherapy),目前,以知与肺癌的发生和发展有关的基因已达20多种,其中显性癌基因的变异以ras、myc和c-erB-2基因为主,几乎三分之一的肺癌病例出现ras基因突变.隐性抑癌基因p53是人类癌症中最常发生突变的一种,它在小细胞肺癌、鳞癌、大细胞癌和腺癌的突变率分别为70%、65%、60%和33%.由于分子生物学及相关学科的发展,应用基因治疗疾病的设想成为现实.基因治疗是通过基因转导赋予靶细胞一种新功能或改变靶细胞的某些基因表达,从而达到治病的目的.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,78,PrimaryBronchogenicCarcinoma预防(Prevention),戒烟.避免吸入含致癌物的污染空气、粉尘、放射线.整治大气污染.宣教和普及防癌知识.高发人群定期普查.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,79,定有诊断肺肿瘤外科诊断流程定性诊断良性肿瘤恶性肿瘤性质不明预后分析定量诊断（TNM诊断）外科诊断空间效应时间效应局限期广泛期恶性良性（占位）（进展）根治性治疗（治愈为目的）姑息性治疗（延长生存改善生活质量）（手术/化疗/放疗/生物/物理/中药/支持）定位诊断可能手术可手术不能手术术前辅助治疗（解剖/生物学评估）化/放疗联合治疗内科诊断耐受手术不耐受手术不耐受手术术后分期诊断术后辅助治疗术后随访观察,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,80,PrimaryBronchogenicCarcinoma思考题,简述原发性支气管肺癌病理分类及临床分型.中、晚期肺癌的临床表现及鉴别诊断.简述肺癌的治疗原则以及针对肺癌不同病理分期所选择的治疗手段.,GannanMedicalUniversityCAI,.,81,支气管扩张症(Bronchiectasis),TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,82,Bronchiectasis定义(definition),支气管扩张是指直径大于2mm中等大小的近端支气管由于管壁的肌肉和弹性组织破坏引起的异常扩张。,慢性咳嗽,大量脓痰,反复咯血,临床特点,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMedicalUniversityCAI,.,83,Bronchiectasis病因和发病机制,支气管-肺组织感染和支气管阻塞,感染的病原菌：百日咳、麻疹病毒、肺炎球菌、流感嗜血杆菌、绿脓杆菌等革兰氏阴性杆菌;支气管阻塞：支气管外淋巴结肿大、支气管异物、右中叶综合征及肿瘤.,TheFirstClinicalCollegeofGannanMedicalUniversity,GannanMe