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胸腺肿瘤的微创治疗前组织学诊断

已有 107 次阅读2021-2-2 16:49 |个人分类:TET学习|系统分类:医学科学| 胸腺

一般来说,只有约20%的胸腺肿瘤是通过治疗前活检方法诊断的,其余的直接手术进行诊断和治疗。
In general, only about 20% of the thymic tumors are diagnosed by pretreatment biopsy methods while the rest go directly to surgery for diagnosis and treatment.

然而,在过去的二十年中,微创治疗前活检方法的使用显着增加(从11.8%增至18.6%),尤其是在局部晚期或转移性胸腺肿瘤中,以获得最佳的治疗和结果。
However, in the last two decades there has been a significant increase (from 11.8% to 18.6%) in the use of minimally invasive pretreatment biopsy methods particularly in locally advanced or metastatic thymic tumors for optimal management and outcome.

胸腺肿瘤的治疗前组织学诊断,获取组织以进行组织病理学诊断
通过手术或非手术方法对胸腺瘤(与重症肌无力相关的非侵袭性纵隔肿瘤)进行治疗前组织学诊断不是标准选择,但如果存在以下至少一种情况则是必需的
(1)可疑或非典型的临床表现和影像学,
(2)根据世界卫生组织(WHO)分类中胸腺肿瘤的新组织学标准,需要非手术方法或术前化疗或化放疗的浸润性肿瘤[鉴别富含淋巴细胞的胸腺瘤(AB,B1,B2)和上皮为主的胸腺瘤(A,B3)和胸腺癌],
(3)影像学高度可疑淋巴瘤,或影像学难以鉴别淋巴瘤与其他实体瘤(非肌无力性胸腺瘤、胸腺癌、生殖细胞瘤等),
(4)怀疑有转移性病变。

Obtaining tissue for histopathologic diagnosis
Pretreatment tissue diagnosis of thymoma (a noninvasive mediastinal tumor associated with myastenia gravis) by surgical or nonsurgical procedures is not a standard option but it is required when at least one of the situations below is present (7-10):
(I)Suspect or atypical clinical presentation and imaging,
(II) Invasive tumor requiring a non-operative approach or preoperative chemotherapy or chemo-radiotherapy according to the new histological criteria for thymic tumors in the World Health Organization (WHO) classification [differentiation of lymphocyte-rich thymomas(AB, B1, B2) from epithelial-predominant thymomas (A, B3) and thymic carcinomas],
(III) Strong possibility of lymphoma or unclear differential diagnosis between lymphoma or other solid tumor (non-myasthenic thymoma, thymic carcinoma, germ cell tumor, etc.) with imaging studies,
(IV) Suspicion of a metastatic lesion.

然而,由于胸腺肿瘤发生胸膜播散的风险很大,因此这些手术或非手术活检方法均不应累及胸膜腔。胸腺肿瘤的非手术组织诊断可通过经胸细针穿刺术(TTFNA)或经胸空芯针穿刺活检(TTCNB)进行 ,常规支气管镜活检程序,支气管内超声引导下经支气管针抽吸术(EBUS-TBNA),内镜超声引导下细针抽吸术(EUS-FNA)或胸腔镜。
However, these surgical or nonsurgical biopsy procedures should not violate the pleural space owing to high possibility of pleural dissemination in thymic tumors.Nonsurgical tissue diagnosis of thymic tumors can be made by transthoracic fine needle aspiration (TTFNA) or transthoracic core needle biopsy (TTCNB), conventional bronchoscopic biopsy procedures, endobronchial ultrasonography-guided transbronchial needle aspiration (EBUS-TBNA), endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) or medical thoracoscopy

对于不适合TTFNA,TTNCB的小实体瘤,应行全胸腺切除术以进行诊断和治疗(图1A,B,C)
需要对切除标本进行大体、组织学和遗传学分析,以确定胸腺肿瘤的以下特征
(I)可能影响放射治疗适应症的分期和切除状态
(II)与预后和治疗有关的组织学亚型
(III)用酪氨酸激酶抑制剂治疗的不可切除或难治性胸腺癌中第9、11和14号外显子上的酪氨酸蛋白激酶KIT(CD117)基因的突变状态。随着新兴的下一代测序技术的出现,新的分子靶标有望很快出现。
For small solid tumors not amenable to TTFNA, TTCNB,total thymectomy is performed for both diagnosis and treatment(Figure 1A,B,C)
Macroscopic, histologic and genetic analysis of the resected specimen is required to determine the following features of thymic tumors (9):
(I)The stage and resection status that can impact radiotherapy indication,
(II) The histological subtype that is relevant to prognosis and treatment,
(III) The mutational status of the thyrosine-protein kinase KIT (CD117) gene on exons 9, 11 and 14 in unresectable or refractory thymic carcinoma for treatment with tyrosine kinase inhibitors.
New molecular targets are expected soon with the emerging next-generation sequencing.

图1 伴重症肌无力的胸腺瘤病例,通过手术诊断和治疗。(A)胸部CT显示前上纵隔较小的非侵袭性肿块; (B)肿瘤的组织学(HE,×100):非侵袭性胸腺瘤(B1型); (C)免疫染色(细胞角蛋白CAM5.2,×100):非侵袭性胸腺瘤(B1型)。
Figure 1 A case of thymoma with myastenia gravis diagnosed and treated by surgery. (A) Thoracic CT section showing noninvasive small mass in the anterior superior mediastinum; (B) histology of the tumor (hematoxylin & eosin, ×100): noninvasive thymoma (type B1); (C) immunostain (Cytokeratin CAM5.2, ×100): noninvasive thymoma (type B1).

a paucity of, 少量;少许;缺乏
由于其发病率低,因此缺乏大样本病例系列研究,来专门阐明胸腺瘤或其他胸腺肿瘤的各种诊断方法的充分性和效能。
Owing to their low incidence, there is a paucity of large case series and studies specifically elucidating the adequacy and performance of various diagnostic modalities for thymomas or other thymic tumors.

There is a paucity of scientific research work in this field. 
在这个领域中很少进行科研工作。

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回复 hyc3140 2021-2-2 17:03
Bilaceroglu S. How to obtain adequate biopsy specimen in suspected thymic tumors[J]. J Thorac Dis, 2020,12:7598-7606.

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