第十五章、肺癌常見併發症與處置

• 晚期肺癌病患常因腫瘤轉移或局部侵犯，導致嚴重的生理併發症。及時且正確的處置不僅能緩解症狀，更是防止病情急劇惡化的關鍵。

15.1 惡性積液 (Malignant Effusions)

• 約 15% 的癌症病患會發生惡性積液，其中肺癌是導致惡性肋膜積液 (Malignant Pleural Effusion, MPE) 最常見的原因 (佔 35%)。 ^{(7) (104)}

15.1.1 惡性肋膜積液

• 診斷： 胸部 X 光通常可見肋膈角變鈍。確診需依賴胸腔穿刺 (Thoracentesis) 進行液體分析。若液體 Cholesterol > 0.45 mg/dL 或 LDH > 血清正常上限的 0.45 倍，則定義為滲出液 (Exudate)，多數惡性積液且常帶血色。

• 治療策略：

  1. 治療原發腫瘤： 全身性治療是控制積液的根本。

  2. 治療性胸腔穿刺 (Therapeutic Thoracentesis)： 用於快速緩解呼吸困難，但復發率高。

  3. 肋膜沾黏術 (Pleurodesis/Sclerotherapy)： 適用於肺部擴張良好但積液反覆復發的病患。目的是引發肋膜發炎沾黏，消除肋膜腔空間。

     • 滑石粉 (Talc)： 成功率最高 (90-100%)，可透過胸腔鏡噴灑 (Poudrage) 或胸管灌注 (Slurry)。副作用包括疼痛與發燒。

     • Doxycycline： 成功率 60-88%，需多次灌注，伴隨疼痛與發燒。

     • Bleomycin： 成功率 63-85%，較無疼痛但價格昂貴。

  4. 長期留置導管 (Indwelling Pleural Catheter, IPC)： TIME2 試驗顯示，對於無法進行沾黏術或預期壽命有限的病患，IPC 在改善呼吸困難與生活品質方面不亞於滑石粉沾黏術，且可居家照護。

15.1.2 惡性心包膜積液 (Malignant Pericardial Effusion)

• 肺癌是造成惡性心包膜積液最常見的原因。

• 處置：

  • 無症狀： 密切觀察，治療原發腫瘤。

  • 心包填塞 (Cardiac Tamponade)： 屬內科急症 (低血壓、頸靜脈怒張、心音遙遠)。需立即進行心包膜穿刺引流 (Pericardiocentesis)。

  • 復發性積液： 考慮心包膜開窗術 (Pericardial Window) 或硬化劑治療。

15.2 上腔靜脈症候群 (SVC Syndrome)

• 成因。上腔靜脈症候群是由於腫瘤 (最常見為肺癌，佔 75-80%) 直接壓迫或侵犯上腔靜脈，導致頭頸部與上肢血液回流受阻。 ⁽¹⁰⁵⁾

15.2.1 上腔靜脈症候群的臨床表現與分級

• 症狀：因上腔靜脈回流受阻導致，臉部或頸部腫脹、手臂水腫、呼吸困難、咳嗽 (特別是彎腰或躺下時加劇)。但側支循環會在數週內擴張，使上身靜脈壓隨時間下降，症狀常會自行緩解 。

• 嚴重度分級 (Grading System)：

  • Grade 0： 無症狀，僅影像學發現。

  • Grade 1 (Mild)： 頭頸部水腫，無功能障礙。

  • Grade 2 (Moderate)：有功能障礙 (如轉頭受限)。

  • Grade 3 (Severe)：腦水腫 (意識混亂) 或喉頭水腫 (呼吸不順)。

  • Grade 4 (Life-threatening)：嚴重腦水腫、喘鳴 (Stridor)、血流動力學不穩。

15.2.2 上腔靜脈症候群的治療建議：

• 治療目標為緩解壓迫、改善症狀並預防血栓

• 支持性療法。建議立即執行：

  • 抬高床頭：利用重力幫助血液回流，減輕顏面與腦部水腫。

  • 氧氣治療：緩解呼吸困難。

  • 類固醇療法：如 Dexamethasone，用於減輕腫瘤周邊的發炎水腫。雖臨床效益未完全證實，但對於淋巴瘤或接受放療者特別有效。

  • 利尿劑：減輕全身性體液負荷，然臨床效益未完全證實。

• 針對性治療：

  • Grade 4 (危急)：需立即進行血管內支架置放 (Stent)，這是緩解症狀最快的方法。若有血栓，需合併抗凝血或血栓溶解治療。

  • Grade 1-3 (化療敏感腫瘤，如 SCLC、淋巴瘤)： 優先給予全身性化療，腫瘤縮小後壓迫自然緩解。

  • Grade 1-3 (NSCLC)： 由於 NSCLC 對化療反應較慢，若症狀明顯，可優先考慮支架置放或放射治療。

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