“美国非小细胞肺癌NCCN指南，该指南旨在给患者提供治疗信息，帮助患者从“0”到“1”认识肺癌，找到适合的治疗方案。本指南有些建议也许不适合你，你的医生可能会根据你的情况和其他因素制定不一样的治疗方案。”

译者：朱志华、梅伟健

Part4.7 活检

大多数肺癌患者会对淋巴结或其他转移灶进行活检。临床分期将决定活检的部位。活检结果可改变临床分期。

Most people with lung cancer will have a biopsy of their lymph nodes or other sites. The clinical stage will be used to decide which sites to biopsy. Biopsy results may change the clinical stage.

肿瘤分期与活检

两肺之间的区域被称为纵隔。这个区域有淋巴结。当肺肿瘤变得更大，更接近这些淋巴结时，它们更容易发生癌变。因此，IA期可能不需要纵隔淋巴结活检。Ib、II和IIIA期则提倡纵隔穿刺活检。

The area between your two lungs is called the mediastinum. This area has lymph nodes. These nodes are more likely to have cancer when the lung tumor is larger and closer to this area. As such, a biopsy of mediastinal nodes may not be needed for stage IA. A mediastinal biopsy is advised for clinical stage IB, II, and IIIA.

在IIIB和IIIC期，活检的类型取决于哪些淋巴结可能有转移。对一些人来说，纵隔活检可能是最好的。对另一些人来说，对锁骨上或斜角淋巴结的活检可能更好的确认N3分期。

For stages IIIB and IIIC, the type of biopsy depends on which nodes may have cancer. For some people, a mediastinal biopsy may be best. For others, a biopsy of supraclavicular or scalene nodes might be better to confirm N3 disease.

不同肿瘤分期的患者的纵膈活检有不同的时机。对于I和II期，在手术前才需要做纵隔活检。手术前应该完成这一个步骤。这样做可以节省金钱和时间，降低风险。对于某些III期(N2或N3)癌症，可以在手术前一天进行纵隔活检。如果在手术过程中不能进行癌症的实验室检测，也可以提前完成。

The timing of a mediastinal biopsy can differ across stages. For stages I and II, a mediastinal biopsy may not be needed until the day of surgery. It should be done right before surgery as one procedure. Doing so saves money and time, and reduces health risks. For some stage III (N2 or N3) cancers, a mediastinal biopsy may be done before the day of surgery. It may also be done beforehand if lab tests for cancer can’t be done during the operation.

如果之前的检查提示为IV期,治疗前活检是必要的。你的医生会根据成像结果来选择活检部位。这个部位通常是肾上腺、肝脏和骨头。在第四期癌症中，很少做纵隔活组织检查。一些肺癌扩散到肺部或心脏周围的胸液。如果这种情况可能发生,胸液可能需要活检。

If tests suggest stage IV, a biopsy is needed before treatment. Your doctor will use imaging results to select the biopsy sites. This site is often the adrenal gland, liver, and bone. A mediastinal biopsy is very rarely done for stage IV cancers. Some lung cancers spread into the fluid around the lungs or heart. If this has likely happened, some fluid may need to be removed.

有很多方法活检淋巴结和其他转移灶。在前一节中描述的导航支气管镜是一种评估纵隔淋巴结转移的方法。接下来将介绍其他常见的活检类型。

There are many ways to biopsy lymph nodes and other sites. Navigational bronchoscopy, described in the prior section, is one way to access mediastinal nodes. Other common types of biopsies are described next.

TTNA

TTNA(经胸廓的针刺活检)可用于某些肺部结节和淋巴结活检。这项测试也被称为经皮穿刺活检。一根非常细的针会被插入你的胸壁，以便得到一个组织样本。在插入针之前,你的皮肤将会与局部麻醉清洗和麻醉。

TTNA (transthoracic needle aspiration) can be used to biopsy certain lung nodules and also some lymph nodes. This test is also called a percutaneous needle biopsy. A very thin needle will be inserted through your chest wall to get a tissue sample.

接下来，会在你的皮肤做一个小切口。针会通过医生的切口插入到结节中。穿刺活检中应该使用辅助成像检查来帮助引导针头到达正确的位置。这个检查可以是CT或超声波。

Before inserting the needle, your skin will be cleaned and numbed with local anesthesia. Next, a small cut will be made into your skin. The needle will be inserted through the cut and into the nodule by your doctor. An imaging test should be used to help guide the needle to the right spot. This test may be a CT or ultrasound.

活组织检查期间,你可能会被要求静止不动，屏住呼吸。活检后，伤口将被包扎，你将接受胸部x光检查评估结果。TTNA之后，你可能会感到疼痛，并在针刺部位有一些发红。

During the biopsy, you may be asked to stay still and hold your breath at times. After the biopsy, the cut will be bandaged and you will be given a chest x-ray to check the results. After TTNA, you may feel sore and have some redness at the needle site.

纵隔镜检查

这种活检方法能通过纵膈镜对胸中间的淋巴结进行活检。纵隔镜非常像支气管镜。会在你的胸骨正上方做一个切口，将纵隔镜插入你的身体。当在胸骨旁进镜时，活检被称为张伯伦纵隔镜。这种方法能够评估你胸部左侧的淋巴结。全身麻醉将用于这些活检。你可能会有一些疼痛和肿胀不适，还有一个小伤疤。

This biopsy accesses lymph nodes in the middle of the chest with a mediastinoscope. A mediastinoscope is very much like a bronchoscope. A cut right above your breastbone will be made to insert the mediastinoscope into your body. When a cut alongside the breastbone is made, the biopsy is called a Chamberlain mediastinoscopy. This method allows access to lymph nodes on the left side of your chest. General anesthesia will be used for these biopsies. You may have some pain and swelling and a small scar afterward.

EBUS-TBNA

EBUS-TBNA(支气管内超声引导针刺活检)可以对纵隔淋巴结进行活检。一个带着超声探头的软支气管镜会被放入气管。对于这个活检，超声设备不需要被移除，以便准确插入取样工具。一旦支气管镜就位，一根针将通过支气管进入淋巴结以获得样本。EBUSTBNA需要局部麻醉。

EBUS-TBNA (endobronchial ultrasound-guided transbronchial needle aspiration) can access mediastinal lymph nodes. A flexible bronchoscope fitted with an ultrasound device will be guided down your trachea. For this biopsy, the device doesn’t need to be removed in order to insert the sampling tool. Once the bronchoscope is in place, a needle will be inserted through the bronchus and into a lymph node to obtain a sample. EBUS-TBNA requires local anesthesia.

EUS-FNA

食物通过食管从喉咙进入到胃。食道比支气管在身体内的位置更低。因此，支气管下方的淋巴结可通过食道接近。对于eus - fna(经食道内镜超声引导的细针穿刺)，支气管镜将引导进入食道。超声波被用来帮助找到合适的位置。然后，一根针会穿过你的食道并进入淋巴结以获取样本。局部麻醉被用于预防疼痛。

Food passes from the throat into the stomach through the esophagus. The esophagus extends lower into the body than the bronchi. Thus, lymph nodes below the bronchi can be accessed through the esophagus. For EUS-FNA (endoscopic ultrasound-guided fine-needle aspiration), a bronchoscope will be guided down your esophagus. Ultrasound is used to help find the right spot.A needle will then be inserted through your esophagus and into a lymph node to obtain a sample. Local anesthesia is used to prevent pain.

胸腔穿刺术

当癌症扩散到肺周围的胸液,它可能导致胸液的累积。这种过量的胸液被称为胸膜腔积液。液体样本可以用胸腔穿刺术获得。首先，麻醉将被注入到你的皮肤。然后，在你的肋骨和胸腔之间插入一根针来取得胸液。用显微镜对胸液进行评估，看是否有癌细胞。如果在胸腔穿刺术中没有发现癌症，可以做胸腔镜检查。参见图11。

When cancer spreads into the fluid around the lungs, it can cause a buildup of fluid.This excess fluid is called pleural effusion. Fluid samples can b removed with thoracentesis. First, anesthesia will be injected into your skin. Then, a needle will be inserted between your ribs and into your chest cavity to remove fluid.The fluid will be assessed with a microscope to see if there are cancer cells. If cancer isn’t found by thoracentesis, a thoracoscopy may be done. See Figure 11.

心包穿刺术

心包穿刺术与胸腔穿刺术类似。就像肺部一样，心脏周围也有一些液体。如果癌症侵入，液体可能会增加。这种过量的液体称为心包积液。心包穿刺就是用针插入你的胸壁，获得心包积液。你会事先接受局部麻醉。

Pericardiocentesis is much like thoracentesis. Like the lungs, there is fluid around the heart. Excess fluid may build up if cancer invades it.This excess fluid is called pericardial effusion. Pericardiocentesi removes the excess fluid with a needle inserted through your chest wall. You will receive local anesthesia beforehand.

胸腔镜检查

这个过程可以获得的N2和N3的淋巴结以及肺和心脏周围的积液。它需要全身麻醉。胸腔镜将通过肋骨之间的切口进入胸腔。胸腔镜很像支气管镜，可以让医生看到任何异常的组织。可以用不同类型的工具收集的样本。这个手术可能会引起一些疼痛和肿胀，并留下一个小疤痕。这个测试也叫VATS(视频辅助胸腔镜手术)。

This procedure can obtain samples of N2 and N3 lymph nodes as well as fluid from around the lungs and heart. It requires general anesthesia. A thoracoscope will be inserted through a cut between your ribs.

Thoracoscopes work much like bronchoscopes allowing doctors to see any abnormal tissue. Samples can be collected with different types of tools. This surgery may cause some pain and swelling and will leave a small scar. This test is also called a VATS (video-assisted thoracoscopic surgery).