| Background and objective Lung cancer is one of the common malignant tumors. The mortality rate of lung cancer is the first in the world. The number of deaths per year is up to 1 million 400 thousand, which has become the largest country in the world. Although the diagnosis and treatment techniques of lung cancer in recent years have continuous development and progress, unfortunately there are still about 75% of lung cancer patients due to lack of specific clinical symptoms,and the majority are in the late term, only about 15% patients had the chance of surgery, 5 year survival rate of lung cancer is only about 15.6%, the average survival time is about 1.5-2 year. People are increasingly aware of the horror caused by lung cancer results and importance to lung cancer earlier detection and diagnosis, early treatment.With more and more increasing of the health consciousness of people, the popularization and application of advanced imaging equipment, the detection rate of lung cancer in significantly improved, and more and more earlier lung cancer is showed nodular morphology, therefore lung nodule detection rate was increased obviously, the detection of lung cancer to improve the proportion of 4 to 10 times higher than the X-ray, and detection of early lung cancer accounted for about 85%. According to the study of international early lung cancer action program: early screening and intervention due to lung cancer, at present the 10 year overall survival rate may increase to 80%(regardless of the clinical staging and given intervention); if surgery for early lung cancer at time, expected 10 year survival rate can be as high as 92%. Therefore, early diagnosis and treatment of PN can significantly improve theoverall prognosis of lung cancer. Iung nodules which nodule diameter less than 1cm will be defined as sub centimeter nodules(s PN).The literature shows that if a nodule diameter is less than 1.0cm, the ratio of the potential malignant and malignant nodules is about 6%-28%. Therefore, s PN has received more and more attention and research. And the relationship between benign and malignant s PN image has been the focus and difficulty of the research. Currently non-invasive examination methods which more used for the diagnosis of small nodules in the lung include chest X-ray, chest CT(including LDCT), chest PET/CT, etc. Invasive methods of pathological diagnosis include bronchoscopy biopsy, percutaneous fine needle aspiration biopsy, open lung biopsy or thoracic surgery. Each kind of examination and diagnosis methods have advantages and disadvantages, the chest X-ray is a little value non-invasive examination method, the density resolution is far less, the requirements of sensitivity and specificity are low, CT scan is the preferred examination method, the report shows the overall sensitivity up to 98%-100%, the specificity of 54%-93%. Through the analysis of lesion location, size, edge, density, internal structure and enhanced features to speculate on the nature of the lesions, some features of CT imaging examinations such as CT perfusion imaging and CT spectroscopy or energy imaging play a certain role in the diagnosis of pulmonary nodules, especially energy spectrum CT has important application value in the detection of pulmonary nodules and diagnosis. The study found that the use of gem spectrum CT to screen for high-risk populations and to follow up the patients with pulmonary nodules is feasible in clinical practice. Some scholars have found that by the using of iodine based dual energy CT value to differential diagnosis of benign and malignant pulmonary nodules, the sensitivity, specificity and accuracy were 92%, 70% and 82.2%, which significantly is higher than the diagnosis of benign and malignant pulmonary nodules in 72%, 70% and 71.1% according to the traditional CT value, however in sub centimeter nodules lesions the early signs of all kinds of characteristic is still not fully demonstrated, diagnosis and differential diagnosis is difficult, which shows a check on the ability of diagnosis is still limited, the application of conventional CT is more in the review by comparison to determine the nodules, guide further treatment, which disadvantages isthat early treatment time of part of the patients may be delayed, the cause of the lesions progress, especially the formation of metastases, and subsequent treatment increased the difficulty and cost, with a poor prognosis, some patients because of psychological burden rather than wait and review. PET/CT can combine the functional image of PET with the anatomical image of CT as a whole, and the diagnostic accuracy and sensitivity of pulmonary nodules can be improved by the combination of the advantages of imaging anatomy and metabolic advantages. A number of studies have shown that the sensitivity and specificity of PET 18F-FDG combined with CT features in the diagnosis of primary lung cancer were 95% ~ 76% and 97% ~ 84%, respectively. Especially for the difficult to characterize the pulmonary nodules, but for the sub centimeter nodules, in the less research data, the individual literature shows that the diagnostic accuracy and sensitivity is still low, only to assess the benign and malignant. Oral or nasal bronchoscopic biopsy is a common clinical means in central lung cancer or the lung lesions invading bronchus, the diagnosis rate is very high, but because of the thickness of lens is limited to bronchial end, only into the mirror to 4-5 grade level for distal bronchial bronchial lesions, incapable of action, and pulmonary sub centimetre nodule bronchoscopy cannot be reached. For using of bronchoscopy, patients feel pain, discomfort, and bronchoscopic biopsy under general anesthesia may involve some side effects of general anesthesia,so patients can not accept, therefore, for subcentimeter pulmonary nodules, bronchoscopy has the limited value; transbronchial needle aspiration(TBNA) and endobronchial ultrasound-guided transbronchial needle aspiration(EBUS-TBNA) is an emerging technology, which can take the trachea and bronchus of lymph node and tumor biopsy, diagnosis, but this check indication is narrow, expensive operation, high requirement for operation, has not yet been widely carried out in clinic. Open lung biopsy or thoracoscopic surgery is the gold standard for diagnosis of pulmonary nodules, s PN feasible thoracoscopic wedge resection of lesions, diagnosis and treatment, but the trauma, the cost is high, some effect on lung function, especially for patients with benign nodules after operation is the need to take part the risk of excessive treatment to select this check. CT guided biopsy diagnosis method isone of the important common, but for s PN, the success rate and the rate of diagnosis is still not satisfactory, reported in PN the accuracy of biopsy in 70-90%, and more for less than 3.0cm in diameter, the biopsy in diameter less than 1.0cm s PN is more difficult, that is rarely reported. This research is mainly carried out from two aspects: 1 ? To optimize the value of CT guided needle biopsy technique in the determination of the properties of sub centimeter nodules in the lung. 2?Clinical study of the complications of CT guided percutaneous biopsy of lung sub centimeter nodules. The main innovations of this study are as follows: 1?Optimizationed CT guided biopsy combined with coaxial biopsy gun can further improve the accuracy of subcentimeter pulmonary nodules, up to about 97%, which provides a method for diagnosis of nodules and which is extremely accurate and safe for clinical treatment, and provides the basis for the perfection and supplement of subcentimeter pulmonary nodules clinical guidelines. 2?In minimally invasive surgery, patients can be diagnosed with pulmonary malignant nodules in advance, and to provide first-hand information on clinical pathology, to guide and improve the prognosis, patients with benign nodules to avoid experimental treatment, and patients get benefit. 3?Active preventive measures can reduce the incidence of complications and lessen the severity of incidence of complications.PART1 The value of optimization of CT guided puncture biopsy technique by using coaxial biopsy gun in the determination of the properties of sub centimeter nodules in the lungObjective Application of 17 G coaxial biopsy gun and optimization of CT guided percutaneous biopsy technique in 68 cases of lung biopsy in patients with sub centimeter nodule, and the rotary cutting biopsy needle aspiration method insubcentimeter pulmonary nodules and the results were compared with the traditional 18 G application, to carries on the discussion from the following aspects: 1, Application skills of coaxial biopsy gun and the optimization of CT guided puncture biopsy technique. 2, Compared with the positive rate, accuracy rate and time of operation of the coaxial tube biopsy gun and cutting biopsy needle in the lung sub centimeter nodule puncture.Materials and methods Experimental group: 68 cases of s PN were collected from Februry 2012 to December 2015 in our hospital for CT examination. Patients age range is 23-84 years old, average 52.6 years old, median age 46 years old, in which the male patients are 31 examples, female patient 37 examples. 68 lesions were used with 17 G coaxial biopsy gun biopsy modified to obtain pathological specimens under CT guide for pathological results. Control group: 52 cases of s PN were collected from Februry 2012 to February 2014 in our hospital, and patients with CT were included in the standard and the test group. Patients age range is 25-80 years old, average 50.3 years old, median age 45 years old. Among them, 23 cases were male patients, 29 cases were female. 52 lesions were applied 18 G biopsy needle, application of rotary cutting aspiration biopsy to obtain pathological specimens under CT guide for pathological results. From the following three aspects of comparative analysis: 1, The two groups of lung biopsy of the lung s PN pathological results analysis. 2, The results of the two groups of pulmonary nodules in the lung and the completion of the results of the comparative analysis. 3. The general data of the two groups of pulmonary nodules and the preoperative CT findings were analyzed.Result 1 ? The experimental group 68 cases, the control group 52 cases. In the experimental group, 66 cases had pathological results, of which 35 cases were benign, the proportion was about 45.59%, 31 cases were malignant, the proportion was about 51.47%. 2 cases were negative results, biopsy results no tissue cells, not qualitative,and in the control group 36 cases with pathological results, of which 15 cases were benign, the proportion is about 28.85%, 21 cases were malignant, the proportion is about 40.38%. No definite pathological results were obtained in 16 cases. 2?Comparison and analysis of the results of the operation of sub centimeter nodules. 2.1 Time of puncture, the test group average completion time was 18.03 + 8.08 min, the longest time is 35 min, the shortest time is 12 min, while the control group, the average completion time is 22.31 + 7.55 min, the longest time is 43 min, the shortest time is 16 min, T test value is 2.090, P value=0.041,which is less than 0.05, according to the number of time spent in the puncture it was statistically significant. 2.2 The pathological findings in the experimental group, in 68 patients 66 cases achieved positive results more clear, the positive rate was 97.06%, 2 cases showed no clear pathology, no exact cellular components, the control group of 52 patients with positive results in a definite number of 36 cases, the positive rate was 69.23%, 16 patients with negative results, 12 cases in the aspirate is visible in the class composition, including 7 cases of pathological examination was negative, no report for the composition of blood components, only 5 cases were pulmonary congestion, complications occurred in 4 patients(2 cases of 1 cases of severe cough, cough blood, 1 cases of lesions obvious hemorrhage, nodules submerged, unclear, suction of blood components, no pathological self termination surgery). The test group and the control group in the positive rate,chi square test=0.000.value of P < 0.05, there was statistical significance, the test group was higher than the control group in the positive rate. 2.3 In bleeding complications, 68 patients in the test group, 32 cases of bleeding in different degrees, the bleeding rate was 47.06%, and 52 patients in the control group, only 14 cases had hemorrhage, bleeding rate was 26.92%, the experimental group and the control group by chi square test in bleeding complications, a value of ?2=5.054.the value of P=0.025 < 0.05, there was statistical significance in the experimental group, bleeding complications was higher than the control group. 3. The general data of pulmonary sub centimeter nodules and the preoperative CT signs in judging benign and malignant. Through the statistics of all subcentimeter pulmonary nodules generalinformation, preoperative CT features including gender, age, lesion location, size, shape, lobulation, pleural indentation, burr sign, air bronchogram, vacuole sign, vascular convergence sign, and postoperative pathological results were analyzed. The results show that in the location and shape of lesions, lesions of the 2 gender values were 5.055, 10.254, 5.945, P = 0.025, 0.036, 0.015, 0.05.respectively, there was statistically significant. Namely gender, a higher proportion of female malignant lesions, position two, less than two of malignant lung lower lobe lung leaves are high, two pulmonary benign nodules, mostly malignant ratio of malignant round or oval nodules than the proportion of triangular or polygonal high. And in the age, size and many malignant CT signs of the 2 test and P test of T value is > 0.05, no statistical difference.Conclusions 1?While the use of coaxial tube biopsy gun and optimization of CT guided puncture biopsy technique to puncture the lung sub centimeter nodules, the accuracy rate was significantly increased. 2?The positive rate and the accuracy of the coaxial tube biopsy gun were significantly higher than the positive rate and the accuracy rate of the needle biopsy of the lung sub centimeter nodules. Biopsy of the lung sub centimeter nodule is recommended using a coaxial tube biopsy gun. 3?A higher proportion of malignant cases of this group is women; two lung lobe malignant proportion is two upper lobe, two pulmonary benign nodules in the majority; proportion of malignant malignant ratio of round or oval nodules than the triangular or polygonal height.Part2 Clinical study of the complications of CT guided percutaneous aspiration biopsy of Subcentimeter pulmonary nodulesObjectives The qualitative diagnosis of subcentimeter pulmonary nodules has been a hotspot and difficulty in clinical research, the hotspot is due to more and more subcentimeter nodules were found, and most in the early stage of the disease, if confirmed as soon as possible, will bring great advantages for clinical treatment, patients with early benefit greatly, save medical cost and the psychological burden of patients, but clinicians and the patients in the choice of examination means don't regard it as the first choice, their fear is that biopsy rate is low, but also have a certain proportion of complications, complications included pneumothorax, puncture, pleural, peripheral needle tract bleeding and hemoptysis, chest pain. In this study, biopsy of subcentimeter pulmonary nodules, application of 17 G coaxial biopsy gun and modified CT guided biopsy technique, preoperative and intraoperative complications in prevention and control are studied, in order to ensure the sensitivity and specificity of biopsy specimens on the premise of reducing biopsy the occurrence of a puncture means provide a more safe and effective methed for clinical and patient.Materials and Methods 68 cases of s PN were collected from Februry 2012 to December 2015 in our hospital, which were found by CT examination in our hospital. Patients age range is 23-84 years old, average 52.6 years old, median age 46 years old, in which the male patient 31 examples, female patient 37 examples. 68 lesions were used with 17 G coaxial biopsy gun biopsy modified to obtain pathological specimens under CT guide for pathological results. The following three aspects were analyzed: 1, Analysis of the related factors of postoperative hemoptysis with blood and sputum insurgery. 2, Analysis of related factors of hemorrhage in intraoperative and postoperative. 3. Multiple factors analysis of pneumothorax.Results 1? This group of 68 cases of nodules, 25 cases of hemoptysis or bloody sputum occur in the intraoperative and postoperative complication rate was 36.76%(25/68), hemoptysis for blood in the sputum or a small amount of hemoptysis, no massive hemoptysis; application of chi square test were analyzed through the puncture needle pleural layers and, with adjustable frequency, the puncture needle and the needlepleural angle, nodular pleural biopsy- distance, when the tip whether relationship in nodules, nodules of peripheral vascular and other aspects of hemoptysis or bloody sputum, results show that the adjustable needle number, nodule in the intraoperative pleural biopsy needle is at distance, in the nodules and nodules of peripheral vascular three factors of the values X2 were 7.721, 4.016, 3.895, 6.071, P value was 0.005, 0.045, 0.048, 0.014, 0.05.respectively, there was statistical significance, adjustable needle number, greater risk of bleeding, the needle tip located in the lower risk of bleeding within the nodules tip in small nodules, with the blood distribution of peripheral vascular factors also affect peripheral bleeding or sputum and hemoptysis. 2?This group of 68 cases of nodules, occurring in the intraoperative and postoperative bleeding around the nodules(perifocal hemorrhage) in 32 cases, the incidence rate is about 47.06%(32/68), bleeding is bleeding around the nodules in the lung, lung or limited period of innerlobe, no inter lobe hemorrhage; application of Chi Square test respectively. Analysis of the number, position and puncture needle through the adjustable needle pleural biopsy needle at times, whether in nodules, nodules of peripheral vascular and other peripheral bleeding, results in intraoperative biopsy needle regulating times, when the tip is in the nodules, nodules of peripheral blood tube three factors the values X2 were 7.387, 5.785, 6.061, P value was 0.007, 0.016, 0.014, 0.05. respectively, there was statistical significance, adjustable needle number, greater risk of bleeding, the needle tip is located in the lower risk of bleeding nodule in nodule tip Small, the distribution of the blood vessel of the week is also the factor that affects the blood of the week. 3?The group of 68 cases, 14 cases of pneumothorax occurred during and after surgery, the incidence rate was 20.59%(14/68), and the amount of local minimal pneumothorax, no obvious lung compression change, none of the patients had dyspnea in 14 cases, using the chi square test were analyzed through the layers, pleural puncture needle the position in operation, adjustable needle number, nodule distance, and pleural puncture needle pleural angle of pneumothorax and relationship, results were 5.015, 5.334 in pleural nodules and pleural puncture needle distance and the angle of the two factors of the value of X2, P value was 0.025, 0.014, 0.05 respectively, there was statistical significance. a greater chance of pneumothoraxpleural nodules the distance<20mm, pleural puncture needle and in the angle of between 45 degrees to 90 degrees has high probability of pneumothorax.Conclusion: 1?The application of preventive measures before and during the operation, the improvement of puncture technique can effectively control the incidence of complications and reduce the severity of puncture complications. 2?Occurring pneumothorax showed a negative correlation with pleural-nodules distance and was positively correlated with the needle-pleural angle; peripheral bleeding and needle tip position,times of needle tunning, nodules peripheral blood vessels were positively correlated; hemoptysis and blood in sputum were positively correlated with peripheral blood vessels, times of needle tunning and were negatively correlated with tumor- pleura distance. 3?CT guided percutaneous puncture biopsy of lung sub-centimeter nodules is a kind of good, cost-effective method, worthy of clinical promotion, and can provide the basis for the improvement of clinical treatment guidelines for lung sub-centimeter nodules. |
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