{"id":1502,"date":"2013-03-25T11:35:01","date_gmt":"2013-03-25T11:35:01","guid":{"rendered":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1502"},"modified":"2013-06-11T07:46:50","modified_gmt":"2013-06-11T07:46:50","slug":"5-onemocneni-plic-2","status":"publish","type":"page","link":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/?page_id=1502","title":{"rendered":"5 Onemocn\u011bn\u00ed plic"},"content":{"rendered":"<h3>5.1 Anatomie<\/h3>\n<h4>5.1.1 Plicn\u00ed laloky a segmenty<\/h4>\n<p style=\"text-align: justify;\">Prav\u00e1 pl\u00edce je \u010dlen\u011bna dv\u011bma interlob\u00e1rn\u00edmi z\u00e1\u0159ezy (fissurami) na 3 laloky: horn\u00ed lalok, st\u0159edn\u00ed lalok a doln\u00ed lalok. Hlavn\u00ed (\u0161ikm\u00fd) interlob\u00e1rn\u00ed z\u00e1\u0159ez odd\u011bluje doln\u00ed plicn\u00ed lalok od obou zb\u00fdvaj\u00edc\u00edch a ve sv\u00e9m pr\u016fb\u011bhu kop\u00edruje p\u0159ibli\u017en\u011b pr\u016fb\u011bh 6. \u017eebra. V polovin\u011b t\u00e9to r\u00fdhy, tedy asi ve st\u0159edn\u00ed axil\u00e1rn\u00ed \u010d\u00e1\u0159e, odstupuje z hlavn\u00edho interlobia fissura vedlej\u0161\u00ed (horizont\u00e1ln\u00ed), kter\u00e1 prob\u00edh\u00e1 ventr\u00e1ln\u011b sm\u011brem ke 4. sternokost\u00e1ln\u00edmu sklouben\u00ed. Tento z\u00e1\u0159ez odd\u011bluje horn\u00ed lalok od st\u0159edn\u00edho. Lev\u00e1 pl\u00edce m\u00e1 pouze 2 laloky odd\u011blen\u00e9 hlavn\u00ed (\u0161ikmou) fissurou. Plicn\u00ed laloky se d\u00e1le d\u011bl\u00ed po anatomick\u00e9 i fyziologick\u00e9 str\u00e1nce na plicn\u00ed segmenty, co\u017e jsou okrsky plicn\u00ed tk\u00e1n\u011b, kter\u00e9 maj\u00ed vlastn\u00ed terci\u00e1ln\u00ed hilus, vlastn\u00ed segment\u00e1rn\u00ed arterii a pr\u016fdu\u0161ku, drobnou intrasegment\u00e1rn\u00ed \u017e\u00edlu a jsou obklopeny dren\u00e1\u017en\u00ed oblast\u00ed intersegment\u00e1ln\u00edch plicn\u00edch \u017eil. Prav\u00e1 pl\u00edce m\u00e1 10 segment\u016f, lev\u00e1 pouze 8. Je to d\u00e1no t\u00edm, \u017ee vlevo je obvykle spole\u010dn\u00e1 pr\u016fdu\u0161ka i arterie pro apikoposteriorn\u00ed segment (S1,2), kter\u00fd tvo\u0159\u00ed spole\u010dnou anatomickou jednotku. Druh\u00fdm rozd\u00edlem je chyb\u011bn\u00ed mediobaz\u00e1ln\u00edho segmentu lev\u00e9 pl\u00edce, jeho\u017e m\u00edsto zauj\u00edm\u00e1 srdce (S7,8) (obr. 1).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1191.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 1 \u2013 Segment\u00e1ln\u00ed uspo\u0159\u00e1d\u00e1n\u00ed plic\" alt=\"Obr. 1 \u2013 Segment\u00e1ln\u00ed uspo\u0159\u00e1d\u00e1n\u00ed plic\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1191.png\" width=\"200\" height=\"284\" \/><\/a><p class=\"wp-caption-text\">Obr. 1<br \/>Segment\u00e1ln\u00ed uspo\u0159\u00e1d\u00e1n\u00ed plic<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1211.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 2 \u2013 Prav\u00fd plicn\u00ed hilus zep\u0159edu. (AP \u2013 a. pulmonalis, B \u2013 bronchus, P \u2013 perikard, VA \u2013 v. azygos, VPS \u2013 v. pulmonalis sup., VPI v. pulmonalis inf.)\" alt=\"Obr. 2 \u2013 Prav\u00fd plicn\u00ed hilus zep\u0159edu. (AP \u2013 a. pulmonalis, B \u2013 bronchus, P \u2013 perikard, VA \u2013 v. azygos, VPS \u2013 v. pulmonalis sup., VPI v. pulmonalis inf.)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1211.png\" width=\"200\" height=\"126\" \/><\/a><p class=\"wp-caption-text\">Obr. 2<br \/>Prav\u00fd plicn\u00ed hilus zep\u0159edu.<br \/>(AP \u2013 a. pulmonalis, B \u2013 bronchus, P \u2013 perikard, VA \u2013 v. azygos, VPS \u2013 v. pulmonalis sup., VPI v. pulmonalis inf.)<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4>5.1.2 Plicn\u00ed hilus<\/h4>\n<p style=\"text-align: justify;\">Plicn\u00ed hilus pout\u00e1 pl\u00edci k mezihrud\u00ed, obsahuje z\u00e1kladn\u00ed anatomick\u00e9 struktury, kter\u00e9 se d\u00e1le d\u011bl\u00ed v pl\u00edci do struktur ni\u017e\u0161\u00edch \u0159\u00e1d\u016f. Pravostrann\u00fd plicn\u00ed hilus le\u017e\u00ed za horn\u00ed dutou \u017e\u00edlou, z horn\u00ed strany je ohrani\u010den oblou\u010dkem v. azygos. Ve ventr\u00e1ln\u00edm a krani\u00e1ln\u00edm p\u00f3lu plicn\u00edho hilu prob\u00edh\u00e1 pulmon\u00e1ln\u00ed tepna, dist\u00e1ln\u011b od n\u00ed v kraniokaud\u00e1ln\u00edm sm\u011bru vystupuje z perikardu horn\u00ed a doln\u00ed plicn\u00ed \u017e\u00edla, n\u011bkdy vystupuje na spojnici \u017eil z perikardu anom\u00e1ln\u011b drobn\u00e1 samostatn\u00e1 \u017e\u00edla st\u0159edn\u00ed. Dorz\u00e1ln\u011b nejv\u00fd\u0161e v horn\u00edm p\u00f3lu hilu se nal\u00e9z\u00e1 hlavn\u00ed pr\u016fdu\u0161ka, kter\u00e1 sm\u011b\u0159uje \u0161ikmo kraniokaud\u00e1ln\u011b. Po p\u0159edn\u00ed stran\u011b plicn\u00edho hilu prob\u00edh\u00e1 pod mediastin\u00e1ln\u00ed pleurou n. phrenicus, vasa pericardiophrenica a drobn\u00e9 bronchi\u00e1ln\u00ed tepny. Z dorz\u00e1ln\u00ed strany vstupuj\u00ed do pl\u00edce po zadn\u00ed st\u011bn\u011b pr\u016fdu\u0161ky rami pulmonales nn. vagi a jedna nebo n\u011bkolik v\u011bt\u0161\u00edch bronchi\u00e1ln\u00edch tepen.<\/p>\n<p style=\"text-align: justify;\">Vlevo le\u017e\u00ed plicn\u00ed hilus v konkavit\u011b aort\u00e1ln\u00edho oblouku a p\u0159ed descendentn\u00ed aortou. V kraniokaud\u00e1ln\u00edm sm\u011bru je po\u0159ad\u00ed jednotliv\u00fdch stuktur takov\u00e9: pulmon\u00e1ln\u00ed tepna, horn\u00ed plicn\u00ed \u017e\u00edla, hlavn\u00ed pr\u016fdu\u0161ka. Doln\u00ed plicn\u00ed \u017e\u00edla je nejkaud\u00e1ln\u011bj\u0161\u00ed strukturou plicn\u00edho\u00a0hilu, le\u017e\u00ed v krani\u00e1ln\u00ed \u010d\u00e1sti pulmon\u00e1ln\u00edho ligamenta. Zep\u0159edu nal\u00e9h\u00e1 na plicn\u00ed stopku n. phrenicus a vasa pericardiophrenica, zezadu n. vagus a j\u00edcen (obr. 2).<\/p>\n<h4>5.1.3 Anatomie trachey\u00a0a bronchi\u00e1ln\u00edho stromu<\/h4>\n<p style=\"text-align: justify;\">Trachea je elastick\u00e1 trubice p\u0159ibli\u017en\u00e9 d\u00e9lky 10\u201313 cm, vyztu\u017een\u00e1 18\u201322 podkovovit\u00fdmi chrupav\u010dit\u00fdmi prstenci, kter\u00e9 j\u00ed d\u00e1vaj\u00ed \u0161\u00ed\u0159ku mezi 18\u201328 mm. Ve v\u00fd\u0161i 2. sternokost\u00e1ln\u00edho sklouben\u00ed, tedy ve v\u00fd\u0161i t\u011bla Th4-Th5, se trachea d\u011bl\u00ed na prav\u00fd a lev\u00fd hlavn\u00ed bronchus. Bifurkace le\u017e\u00ed vpravo od\u00a0v\u011btven\u00ed plicnice, v\u00edce za pravou plicn\u00ed tepnou. Prav\u00fd hlavn\u00ed bronchus (bronchus principalis dexter) odstupuje v ostr\u00e9m \u00fahlu cca 30\u00b0 doprava a vstupuje do prav\u00e9ho hemitoraxu dorz\u00e1ln\u011b od prav\u00e9 plicnice pod oblou\u010dkem vena azygos, neb\u00fdv\u00e1 del\u0161\u00ed ne\u017e 2 cm. Kolmo z jeho horn\u00edho obvodu vystupuje asi 1cm dlouh\u00fd horn\u00ed lob\u00e1rn\u00ed bronchus (bronchus lobaris superior). \u00dasek pr\u016fdu\u0161ky mezi odstupy horn\u00edho a st\u0159edn\u00edho bronchu dlouh\u00fd 1\u20133 cm se naz\u00fdv\u00e1 spojn\u00fd bronchus (bronchus intermedius). Sm\u011brem ventrokaud\u00e1ln\u00edm ze spojn\u00e9ho bronchu odstupuje pr\u016fdu\u0161ka pro st\u0159edn\u00ed lalok (bronchus lobaris medius). Segment\u00e1ln\u00ed v\u011btven\u00ed pr\u016fdu\u0161ek pro doln\u00ed lalok za\u010d\u00edn\u00e1 ji\u017e ve v\u00fd\u0161i st\u0159edn\u00edho bronchu.<\/p>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1221.png\"><img loading=\"lazy\" decoding=\"async\" style=\"text-align: justify;\" title=\"Obr. 3 \u2013 V\u011btven\u00ed plicn\u00ed tepny a pr\u016fdu\u0161ek\" alt=\"Obr. 3 \u2013 V\u011btven\u00ed plicn\u00ed tepny a pr\u016fdu\u0161ek\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1221.png\" width=\"200\" height=\"146\" \/><\/a><p class=\"wp-caption-text\">Obr. 3<br \/>V\u011btven\u00ed plicn\u00ed tepny a pr\u016fdu\u0161ek<\/p><\/div>\n<p style=\"text-align: justify;\">Naprosto typicky toti\u017e pr\u016fdu\u0161ka pro apik\u00e1ln\u00ed segment doln\u00edho laloku (bronchus apicalis inferior event. bronchus superior lobiinf. \u2013 b6) odstupuje naproti odstupu st\u0159edn\u00edho lob\u00e1rn\u00edho bronchu. Asi 1\u20131,5 cm pod odstupem b6 je dal\u0161\u00ed d\u011blen\u00ed pr\u016fdu\u0161ky pro baz\u00e1ln\u00ed pyramidu. Lev\u00fd hlavn\u00ed bronchus (bronchus principalis sinister) odstupuje z bifurkace v \u00fahlu 50\u201360\u00b0, zezadu nal\u00e9h\u00e1 na v\u011btven\u00ed kmene plicnice. Vstupuje dist\u00e1ln\u011b od lev\u00e9 plicnice do lev\u00e9ho hemitoraxu a nal\u00e9h\u00e1 na ventr\u00e1ln\u00ed plochu st\u0159edn\u00edho hrudn\u00edho j\u00edcnu a p\u0159edn\u00ed st\u011bnu sestupn\u00e9 aorty. Je dlouh\u00fd asi 4\u20134,5cm. Jeho prvn\u00ed v\u011btv\u00ed je pr\u016fdu\u0161ka lev\u00e9ho horn\u00edho laloku, bronchus lobaris superior. Tak\u0159ka ihned po odstupu, nejd\u00e1le 1 cm od horn\u00edho lob\u00e1rn\u00edho bronchu, za\u010d\u00edn\u00e1 segment\u00e1ln\u00ed v\u011btven\u00ed doln\u00edho laloku odstupem pr\u016fdu\u0161ky pro apik\u00e1ln\u00ed segment doln\u00edho laloku vlevo (bronchus apicalis inferior seu bronchus superior lobi inf. \u2013 b6), pod n\u00edm se d\u00e1le v\u011btv\u00ed pr\u016fdu\u0161ky pro baz\u00e1ln\u00ed segmenty.<\/p>\n<h4 style=\"text-align: justify;\">5.1.4 Pl\u00edcn\u00ed tepna<\/h4>\n<p style=\"text-align: justify;\">Plicnice vystupuje z prav\u00e9 srde\u010dn\u00ed komory vlevo vp\u0159edu od ascendentn\u00ed aorty, sm\u011b\u0159uje nahoru, st\u00e1\u010d\u00ed se dorz\u00e1ln\u011b pod oblouk aorty a je\u0161t\u011b v perikardu se d\u011bl\u00ed na sv\u00e9 dv\u011b hlavn\u00ed v\u011btve. V \u00fahlu 90<sup>o<\/sup> odstupuje doprava za ascendentn\u00ed aortu prav\u00e1 plicn\u00ed tepna, kter\u00e1 d\u00e1le prob\u00edh\u00e1 retroperikardi\u00e1ln\u011b za zadn\u00ed st\u011bnou ascendentn\u00ed aorty a horn\u00ed dut\u00e9 \u017e\u00edly. Prav\u00e1 plicn\u00ed tepna je u dosp\u011bl\u00e9ho pom\u011brn\u011b dlouh\u00e1 (a\u017e 4 cm) a \u0161irok\u00e1 (a\u017e 2,5 cm). Zpoza horn\u00ed dut\u00e9 \u017e\u00edly, resp. okraje perikardu, vystupuje tepna later\u00e1ln\u011b, klade se na p\u0159edn\u00ed plochu hlavn\u00edho bronchu, st\u00e1\u010d\u00ed se pod\u00e9l n\u011bj sm\u011brem dist\u00e1ln\u00edm, ventr\u00e1ln\u011b od prav\u00e9 horn\u00ed pr\u016fdu\u0161ky. Prob\u00edh\u00e1 za horn\u00ed plicn\u00ed \u017eilou do interlobia, zde se klade za st\u0159edn\u00ed pr\u016fdu\u0161ku a posl\u00e9ze se termin\u00e1ln\u011b v\u011btv\u00ed na anterolater\u00e1ln\u00ed plo\u0161e d\u011blen\u00ed bronchu pro doln\u00ed lalok dorz\u00e1ln\u011b od p\u0159\u00edtok\u016f doln\u00ed plicn\u00ed \u017e\u00edly. Lev\u00e1 plicn\u00ed tepna (arteria pulmonalis sinistra) z kmene plicnice odstupuje v tup\u00e9m \u00fahlu later\u00e1ln\u011b doleva, v perikardu prob\u00edh\u00e1 p\u0159ibli\u017en\u011b l cm. Bezprost\u0159edn\u011b extraperikardi\u00e1ln\u011b je fixov\u00e1na k oblouku aorty Botallov\u00fdm ligamentem. Po v\u00fdstupu z perikardu k\u0159\u00ed\u017e\u00ed lev\u00e1 plicnice v horizont\u00e1ln\u00ed rovin\u011b z ventr\u00e1ln\u00ed strany lev\u00fd hlavn\u00ed bronchus, klade se za lev\u00fd horn\u00ed bronchus a pot\u00e9 se st\u00e1\u010d\u00ed laterokaud\u00e1ln\u011b k termin\u00e1ln\u00edmu v\u011btven\u00ed zevn\u011b od bronchu (obr. 3).<\/p>\n<h4>5.1.5 Plicn\u00ed \u017e\u00edly<\/h4>\n<p style=\"text-align: justify;\">Vpravo jsou stejn\u011b jako vlevo 2 plicn\u00ed \u017e\u00edly, kter\u00e9 vstupuj\u00ed do lev\u00e9 p\u0159eds\u00edn\u011b odd\u011blen\u011b. Horn\u00ed plicn\u00ed \u017e\u00edla vpravo (vena pulmonalis superior dextra) m\u00e1 kr\u00e1tk\u00fd intraperikardi\u00e1ln\u00ed pr\u016fb\u011bh, ale je zep\u0159edu ze 3\/4 kryta epikardem, tak\u017ee k vlastn\u00edmu perikardu je fixov\u00e1na jen \u00fazk\u00fdm mezokardiem, kter\u00e9 lze snadno protnout p\u0159i intraperikardi\u00e1ln\u00ed preparaci. Doln\u00ed plicn\u00ed \u017e\u00edla (vena pulmonalis inferior dextra) je v perikardu v\u00edce ukryta, epikardem je kryta jen z p\u0159edn\u00ed strany. Perikardi\u00e1ln\u00ed duplikatura pokra\u010duje z doln\u00ed plicn\u00ed \u017e\u00edly na \u00fast\u00ed doln\u00ed dut\u00e9 \u017e\u00edly. Do perikardu vstupuj\u00ed plicn\u00ed \u017e\u00edly na p\u0159edn\u00ed stran\u011b plicn\u00edho hilu jako prost\u0159edn\u00ed a dist\u00e1ln\u00ed struktura. Lev\u00e1 pl\u00edce m\u00e1 2 \u017eiln\u00ed kmeny, horn\u00ed a doln\u00ed plicn\u00ed \u017e\u00edlu (vena pulmonalis superior sinistra a vena pulmonalis inferior sinistra). Ob\u011b \u017e\u00edly maj\u00ed del\u0161\u00ed, asi centimetrov\u00fd intraperikardi\u00e1ln\u00ed pr\u016fb\u011bh a ob\u011b maj\u00ed u\u017e\u0161\u00ed (voln\u011bj\u0161\u00ed) mezokardi\u00e1ln\u00ed z\u00e1v\u011bs, ne\u017e je tomu vpravo, proto je jejich intraperikardi\u00e1ln\u00ed preparace jednodu\u0161\u0161\u00ed.<\/p>\n<h4>5.1.6 Nutritivn\u00ed c\u00e9vy pl\u00edce<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1241.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 4 \u2013 Roz\u0161\u00ed\u0159en\u00e1 bronchi\u00e1ln\u00ed tepna u pl\u00edce destruovan\u00e9 bronchiekt\u00e1ziemi\" alt=\"Obr. 4 \u2013 Roz\u0161\u00ed\u0159en\u00e1 bronchi\u00e1ln\u00ed tepna u pl\u00edce destruovan\u00e9 bronchiekt\u00e1ziemi\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1241.png\" width=\"200\" height=\"190\" \/><\/a><p class=\"wp-caption-text\">Obr. 4<br \/>Roz\u0161\u00ed\u0159en\u00e1 bronchi\u00e1ln\u00ed tepna u pl\u00edce destruovan\u00e9 bronchiekt\u00e1ziemi<\/p><\/div>\n<p style=\"text-align: justify;\">Nutritivn\u00ed bronchi\u00e1ln\u00ed tepny (arteriae bronchiales) jsou syst\u00e9mov\u00e9 c\u00e9vy zaji\u0161\u0165uj\u00edc\u00ed v\u00fd\u017eivu pr\u016fdu\u0161kov\u00e9ho stromu okysli\u010denou krv\u00ed z aorty. Jejich po\u010det i odstupy jsou variabiln\u00ed. Nej\u010dast\u011bji existuje 1 bronchi\u00e1ln\u00ed tepna pro pravou pl\u00edci a 2 pro pl\u00edci levou (obr. 4). \u017diln\u00ed krev z nutritivn\u00edho ob\u011bhu kon\u010d\u00ed v \u017eil\u00e1ch mal\u00e9ho ob\u011bhu.<\/p>\n<h4>5.1.7 Lymfatick\u00fd syst\u00e9m plic a mediastina<\/h4>\n<p style=\"text-align: justify;\">Lymfatick\u00e9 c\u00e9vy plic za\u010d\u00ednaj\u00ed jako perialveol\u00e1rn\u00ed pleten\u011b bez vlastn\u00ed endoteli\u00e1ln\u00ed v\u00fdstelky, centr\u00e1ln\u011bj\u0161\u00ed lymfatick\u00e9 kapil\u00e1ry jsou ji\u017e vystlan\u00e9 endotelem. Lymfatick\u00e9 c\u00e9vy hlubok\u00e9 (bronchoalveol\u00e1rn\u00ed) s\u00edt\u011b prov\u00e1zej\u00ed plicn\u00ed arterie a \u017e\u00edly. Ka\u017edou plicn\u00ed tepnu prov\u00e1zej\u00ed2 paraleln\u00ed lymfatick\u00e9 c\u00e9vy, dal\u0161\u00ed 2\u20133 kmeny prob\u00edhaj\u00ed v intersticiu pod\u00e9l v\u011btv\u00ed plicn\u00edch \u017eil. V pr\u016fdu\u0161k\u00e1ch vedou lymfatick\u00e9 c\u00e9vy z\u010d\u00e1sti submuk\u00f3zn\u011b, p\u0159ev\u00e1\u017en\u011b v\u0161ak obaluj\u00ed bronchy ve form\u011b peribronchi\u00e1ln\u00ed lymfatick\u00e9 pleten\u011b, do n\u00ed\u017e jsou v\u0159azeny jednotliv\u00e9 lymfatick\u00e9 folikuly a uzliny. V\u0161echny tyto lymfatick\u00e9 c\u00e9vy spolu bohat\u011b anastom\u00f3zuj\u00ed. Lymfatick\u00e9 kmeny dr\u00e9nuj\u00edc\u00ed hlubok\u00fd syst\u00e9m tvo\u0159\u00ed spolu s uzlinami hilu plete\u0148, do kter\u00e9 \u00fast\u00ed tak\u00e9 subpleur\u00e1ln\u00ed lymfatick\u00e1 s\u00ed\u0165. Tato plete\u0148 pokra\u010duje pod\u00e9l tracheobronchi\u00e1ln\u00edho \u00fahlu na later\u00e1ln\u00ed partie pr\u016fdu\u0161nice. Zde le\u017e\u00edc\u00ed lymfatick\u00e9 uzliny a lymfatick\u00e9 c\u00e9vy formuj\u00ed dva hlavn\u00ed kmeny \u2013 trunci mediastinales posteriores seu bronchomediastinales. Truncus bronchomediastinalis dx. \u00fast\u00ed do prav\u00e9ho ven\u00f3zn\u00edho \u00fahlu, vz\u00e1cn\u011bji do samostatn\u00e9ho truncus thoracicus dx. Truncus bronchomediastinalis sinister \u00fast\u00ed do ductus thoracicus \u010di do n\u011bkter\u00e9 ze \u017eiln\u00edch v\u011btv\u00ed p\u0159i lev\u00e9m ven\u00f3zn\u00edm \u00fahlu.<\/p>\n<h5>5.1.7.1 Klasifikace lymfatick\u00fdch uzlin<\/h5>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1251.png\"><img decoding=\"async\" title=\"Obr. 5 - Klasifikace lymfatick\u00fdch uzlin plic a mediastina\" alt=\"Obr. 5 - Klasifikace lymfatick\u00fdch uzlin plic a mediastina\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1251.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 5<br \/>Klasifikace lymfatick\u00fdch uzlin plic a mediastina<\/p><\/div>\n<p style=\"text-align: justify;\">Anatomickou klasifikaci intra a extrapulmon\u00e1ln\u00edch uzlin rozpracovali Naruke (1967) a pozd\u011bji Mountain (1997), a to z klinick\u00e9ho hlediska. Jejich klasifika\u010dn\u00ed sch\u00e9mata se stala z\u00e1kladem pro systematicky prov\u00e1d\u011bnou lymfadenektomii p\u0159i resekc\u00edch pro plicn\u00ed karcinom (obr. 5, tab. 1).<\/p>\n<h4>5.1.8 Inervace plic<\/h4>\n<p style=\"text-align: justify;\">Na vegetativn\u00ed inervaci plic se pod\u00edl\u00ed parasympatikus a sympatikus v typicky antagonistick\u00e9m pojet\u00ed. Somatick\u00e1 inervace plic je chud\u00e1, plicn\u00ed parenchym je necitliv\u00fd, opa\u010dn\u011b je tomu u sliznice v\u011bt\u0161\u00edch pr\u016fdu\u0161ek, kter\u00e1 je naopak vysoce senzitivn\u00ed. Parasympatickou inervaci plic zprost\u0159edkov\u00e1v\u00e1 n. vagus. Dr\u00e1\u017ed\u011bn\u00ed jeho vl\u00e1ken vyvol\u00e1v\u00e1 bronchokonstrikci a vazodilataci. Pravostrann\u00fd bloudiv\u00fd nerv (n. vagus dx.) vstupuje do hrudn\u00edku horn\u00ed hrudn\u00ed aperturou pod\u00e9l trachey. Vysoko v kupule z n\u011bj odstupuje pravostrann\u00fd vratn\u00fd nerv (n. recurrens dx.), kter\u00fd zespodu obt\u00e1\u010d\u00ed podkl\u00ed\u010dkovou tepnu a stoup\u00e1 k hrtanu. N. vagus podb\u00edh\u00e1 oblouk v. azygos, p\u0159ikl\u00e1d\u00e1 se k bo\u010dn\u00ed st\u011bn\u011b j\u00edcnu a zat\u00e1\u010d\u00ed se na jeho dorzolater\u00e1ln\u00ed stranu. Levostrann\u00fd n. vagus se od pr\u016fdu\u0161nice na \u00farovni horn\u00ed hrudn\u00ed apertury vzdaluje later\u00e1ln\u011b, k\u0159\u00ed\u017e\u00ed zevn\u00ed stranu aort\u00e1ln\u00edho oblouku, zde vyd\u00e1v\u00e1 \u0159adu v\u011btv\u00ed k srdci a perikardu a posl\u00e9ze n. recurrens sin., kter\u00fd podb\u00edh\u00e1 aort\u00e1ln\u00ed oblouk medi\u00e1ln\u011b od Bottallova ligamenta a stoup\u00e1 ezofagotrache\u00e1ln\u00edm z\u00e1\u0159ezem k laryngu. Pod\u00e9l aorty pokra\u010duje n. vagus na zadn\u00ed stranu lev\u00e9ho plicn\u00edho hilu, p\u0159ikl\u00e1d\u00e1 se k lev\u00e9mu a p\u0159edn\u00edmu obvodu j\u00edcnu, kde se pod\u00edl\u00ed na formov\u00e1n\u00ed plexus oesophageus, a pokra\u010duje k hiatus oesophageus. Sympatick\u00e1 inervace plic jde\u00a0cestou 3.\u20135. ganglia hrudn\u00edho sympatiku z m\u00ed\u0161n\u00edch segment\u016f Th1\u20135. Sympatikus p\u016fsob\u00ed na pl\u00edce ve smyslu bronchodilatace a vazokonstrikce.<\/p>\n<table class=\"CSSTableGenerator\" style=\"width: 100%;\" border=\"0\" cellspacing=\"2\" cellpadding=\"2\">\n<tbody>\n<tr>\n<td style=\"text-align: center;\" scope=\"col\"><span style=\"color: #ffffff;\">Tab. 1<\/span><br \/>\n<span style=\"color: #ffffff;\">Pozice region\u00e1ln\u00edch lymfatick\u00fdch uzlin\u00a0<\/span><br \/>\n<span style=\"color: #ffffff;\"><i>(Goldstraw et al.)<\/i>:<\/span><\/td>\n<\/tr>\n<tr>\n<td>1. horn\u00ed mediastin\u00e1ln\u00ed<\/td>\n<\/tr>\n<tr>\n<td>2. horn\u00ed paratrache\u00e1ln\u00ed<\/td>\n<\/tr>\n<tr>\n<td>3. prevaskul\u00e1rn\u00ed a\u00a0retrotrache\u00e1ln\u00ed<\/td>\n<\/tr>\n<tr>\n<td>4. doln\u00ed paratrache\u00e1ln\u00ed, v\u010detn\u011b uzlin p\u0159i v. azygos<\/td>\n<\/tr>\n<tr>\n<td>5. subaort\u00e1ln\u00ed (aortopulmon\u00e1ln\u00edho ok\u00e9nka)<\/td>\n<\/tr>\n<tr>\n<td>6. paraaort\u00e1ln\u00ed \u2013 p\u0159i ascendentn\u00ed aort\u011b a\u00a0n. phrenicus<\/td>\n<\/tr>\n<tr>\n<td>7. subkarin\u00e1ln\u00ed<\/td>\n<\/tr>\n<tr>\n<td>8. paraezofage\u00e1ln\u00ed \u2013 dist\u00e1ln\u011b od\u00a0uzlin subkarin\u00e1ln\u00edch<\/td>\n<\/tr>\n<tr>\n<td>9. uzliny plicn\u00edho ligamenta<\/td>\n<\/tr>\n<tr>\n<td><span style=\"color: #ffffff;\">.<\/span><\/td>\n<\/tr>\n<tr>\n<td>10. hilov\u00e9<\/td>\n<\/tr>\n<tr>\n<td>11. interlob\u00e1rn\u00ed<\/td>\n<\/tr>\n<tr>\n<td>12. lob\u00e1rn\u00ed<\/td>\n<\/tr>\n<tr>\n<td>13. segment\u00e1ln\u00ed<\/td>\n<\/tr>\n<tr>\n<td>14. subsegment\u00e1ln<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>5.2 Vrozen\u00e1 onemocn\u011bn\u00ed plic<\/h3>\n<p style=\"text-align: justify;\">Nejz\u00e1va\u017en\u011bj\u0161\u00ed v\u00fdvojov\u00e9 vady plic vedou k porodu mrtv\u00e9ho plodu nebo t\u011b\u017ek\u00e9 asfyxii a \u010dasn\u00e9 smrti novorozence. M\u00e9n\u011b v\u00e1\u017en\u00e9 plicn\u00ed vady mohou z\u016fstat dlouho asymptomatick\u00e9 a b\u00fdvaj\u00ed diagnostikov\u00e1ny p\u0159i p\u00e1tr\u00e1n\u00ed po p\u0159\u00ed\u010din\u011b recidivuj\u00edc\u00edch plicn\u00edch z\u00e1n\u011bt\u016f a opakovan\u00fdch hemopt\u00fdz v d\u011btsk\u00e9m v\u011bku \u010di adolescenci. P\u0159i p\u00e1tr\u00e1n\u00ed po nespecifick\u00fdch pot\u00ed\u017e\u00edch lokalizovan\u00fdch do hrudn\u00edku b\u00fdvaj\u00ed n\u011bkdy jejich kone\u010dn\u00fdm vysv\u011btlen\u00edm i v dosp\u011blosti. N\u011bkdy n\u00e1s k diagn\u00f3ze bezp\u0159\u00edznakov\u00fdch vrozen\u00fdch onemocn\u011bn\u00ed p\u0159ivede vedlej\u0161\u00ed n\u00e1lez n\u011bkter\u00e9 ze zobrazovac\u00edch metod.<\/p>\n<h4>5.2.1 Ageneze, aplazie, hypoplazie<\/h4>\n<p style=\"text-align: justify;\">Ageneze plic je nevytvo\u0159en\u00ed pl\u00edce, chyb\u00ed tepna i pr\u016fdu\u0161ka. Oboustrann\u00e1 nen\u00ed slu\u010diteln\u00e1 se \u017eivotem. Aplazie m\u016f\u017ee postihovat lalok nebo cel\u00e9 plicn\u00ed k\u0159\u00eddlo, je zalo\u017een z\u00e1rodek bronchu, chyb\u00ed plicn\u00ed tk\u00e1\u0148. U hypoplazie jsou pr\u016fdu\u0161ky a plicn\u00ed c\u00e9vy nedokonale vyvinut\u00e9, stejn\u011b jako perifern\u00ed plicn\u00ed tk\u00e1\u0148. Pokud je aplastick\u00fd, resp. hypoplastick\u00fd pouze lalok, m\u016f\u017ee b\u00fdt pr\u016fb\u011bh asymptomatick\u00fd. Nevyvinut\u00ed cel\u00e9ho plicn\u00edho k\u0159\u00eddla se m\u016f\u017ee obej\u00edt tak\u00e9 bez p\u0159\u00edznak\u016f. Hemopt\u00fdza m\u016f\u017ee b\u00fdt d\u016fsledkem plicn\u00ed hypertenze, ka\u0161el spolu s plicn\u00edmi z\u00e1n\u011bty projevem dysplastick\u00fdch pr\u016fdu\u0161ek.<\/p>\n<h4>5.2.2 Kongenit\u00e1ln\u00ed lob\u00e1rn\u00ed emfyz\u00e9m<\/h4>\n<p style=\"text-align: justify;\">Kongenit\u00e1ln\u00ed lob\u00e1rn\u00ed emfyz\u00e9m je definov\u00e1n nadm\u011brn\u00fdm rozepnut\u00edm jednoho nebo v\u00edce lalok\u016f histologicky norm\u00e1ln\u00edch plic. Stav je zp\u016fsoben poprask\u00e1n\u00edm interalveol\u00e1rn\u00edch sept v \u010dasn\u00e9m novorozeneck\u00e9m obdob\u00ed zap\u0159\u00ed\u010din\u011bn\u00e9m ventilovou obstrukc\u00ed segment\u00e1ln\u00edch nebo lob\u00e1rn\u00edch pr\u016fdu\u0161ek. Z\u010d\u00e1sti se na n\u00ed m\u016f\u017ee pod\u00edlet nedokonale vyvinut\u00fd chrupav\u010dit\u00fd skelet bronchu. V\u011bt\u0161ina p\u0159\u00edpad\u016f se klinicky projev\u00ed do 6. t\u00fddne \u017eivota r\u016fzn\u00fdm stupn\u011bm dechov\u00e9 t\u00edsn\u011b. Posti\u017een\u00fd hemitorax je vyklenut\u00fd, ale se slab\u0161\u00edmi d\u00fdchac\u00edmi fenom\u00e9ny, na sn\u00edmku je hyperinflace parenchymu posti\u017een\u00e9 strany a p\u0159etla\u010den\u00ed mediastina na stranu druhou. CT, p\u0159\u00edpadn\u011b bronchoskopie jsou indikov\u00e1ny sp\u00ed\u0161e z d\u016fvodu diferenci\u00e1ln\u00ed diagn\u00f3zy, resp. k vylou\u010den\u00ed jin\u00fdch anom\u00e1li\u00ed \u010di endobronchi\u00e1ln\u00ed obstrukce. L\u00e9\u010dbou volby je resekce posti\u017een\u00e9ho laloku, nal\u00e9havost operace z\u00e1vis\u00ed na t\u00ed\u017ei dechov\u00fdch pot\u00ed\u017e\u00ed, nez\u0159\u00eddka b\u00fdv\u00e1 nutn\u00e1 do 6 hodin po porodu. Sporadick\u00e9 reference hovo\u0159\u00ed o bronchi\u00e1ln\u00ed stent\u00e1\u017ei, implantaci endobronchi\u00e1ln\u00edch ventil\u016f \u010di staplerov\u00e9 volumredukci, ale pouze v p\u0159\u00edpadech s pozvoln\u00fdm v\u00fdvojem.<\/p>\n<h4>5.2.3 Plicn\u00ed sekvestrace<\/h4>\n<p style=\"text-align: justify;\">Jako plicn\u00ed sekvestraci ozna\u010dujeme nefunk\u010dn\u00ed \u010d\u00e1st plicn\u00ed tk\u00e1n\u011b, kter\u00e1 nekomunikuje s tracheobronchi\u00e1ln\u00edm stromem (obr. 6). Typick\u00fdm atributem sekvestrace je arteri\u00e1ln\u00ed krevn\u00ed z\u00e1soben\u00ed ze syst\u00e9mov\u00e9ho ob\u011bhu (z hrudn\u00ed \u010di b\u0159i\u0161n\u00ed aorty).<\/p>\n<p style=\"text-align: justify;\">Rozezn\u00e1v\u00e1me intralob\u00e1rn\u00ed sekvestraci, kdy je patologick\u00e1 tk\u00e1\u0148 ulo\u017eena uvnit\u0159 pl\u00edce a \u017eiln\u00ed krev je drenov\u00e1na do plicn\u00edch \u017eil, a extralob\u00e1rn\u00ed sekvestraci, kdy je posti\u017een\u00fd okrsek od pl\u00edce zcela odd\u011blen, m\u00e1 vlastn\u00ed \u017eiln\u00ed dren\u00e1\u017e do syst\u00e9mov\u00e9ho ob\u011bhu a je obalen vlastn\u00ed pleurou. M\u016f\u017ee tak imitovat akcesorn\u00ed plicn\u00ed lalok, kter\u00fd m\u00e1 na rozd\u00edl od sekvestrace typickou bronchovaskul\u00e1rn\u00ed strukturu. Diagn\u00f3za se op\u00edr\u00e1 o klinick\u00e9 pot\u00ed\u017ee (ka\u0161el, dyspnoe, febriln\u00ed stavy), na sn\u00edmku lze nal\u00e9zt zast\u00edn\u011bn\u00ed odpov\u00eddaj\u00edc\u00ed nevzdu\u0161n\u00e9 tk\u00e1ni, n\u011bkter\u00e9 intralob\u00e1rn\u00ed sekvestrace mohou m\u00edt obraz komplikovan\u00e9 cysty \u010di abscesu (obr. 7). Angiografie (CTAG, MRAG, aortografie) potvrd\u00ed podez\u0159en\u00ed a mohou poskytnout cenn\u00e9 informace pro chirurgick\u00fd v\u00fdkon. L\u00e9\u010dba je chirurgick\u00e1, resekce extralob\u00e1rn\u00ed sekvestrace i operace pro intralob\u00e1rn\u00ed sekvestraci by m\u011bly za\u010d\u00ednat podvazem p\u0159\u00edvodn\u00e9 tepny, pokud odstupuje infradiafragmaticky, m\u016f\u017ee b\u00fdt nutn\u00fd torakoabdomin\u00e1ln\u00ed p\u0159\u00edstup nebo kombinovan\u00fd postup \u2013 radioinvazivn\u00ed okluze tepny a n\u00e1sledn\u00e1 resekce.<\/p>\n<p>N\u011bkte\u0159\u00ed auto\u0159i preferuj\u00ed u intralob\u00e1rn\u00edch sekvestrac\u00ed oblig\u00e1tn\u011b lobektomii, jin\u00ed doporu\u010duj\u00ed zachovat norm\u00e1ln\u011b utv\u00e1\u0159en\u00fd parenchym posti\u017een\u00e9ho laloku cestou sublob\u00e1rn\u00ed resekce.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1281.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 6 \u2013 Tepna vystupuj\u00edc\u00ed do sekvestrace z descendentn\u00ed aorty je ozna\u010dena \u0161ipkou\" alt=\"Obr. 6 \u2013 Tepna vystupuj\u00edc\u00ed do sekvestrace z descendentn\u00ed aorty je ozna\u010dena \u0161ipkou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1281.png\" width=\"200\" height=\"163\" \/><\/a><p class=\"wp-caption-text\">Obr. 6<br \/>Tepna vystupuj\u00edc\u00ed do sekvestrace z descendentn\u00ed aorty je ozna\u010dena \u0161ipkou<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1291.png\"><img decoding=\"async\" title=\"Obr. 7 \u2013 Intralob\u00e1rn\u00ed sekvestrace\" alt=\"Obr. 7 \u2013 Intralob\u00e1rn\u00ed sekvestrace\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1291.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 7<br \/>Intralob\u00e1rn\u00ed sekvestrace<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>5.3 Z\u00e1n\u011btliv\u00e1 onemocn\u011bn\u00ed plic<\/h3>\n<h4>5.3.1 Pneumonie<\/h4>\n<p style=\"text-align: justify;\">Pneumonie je akutn\u00ed z\u00e1n\u011btliv\u00e9 onemocn\u011bn\u00ed plicn\u00edho parenchymu (alveol\u016f, bronchiol\u016f, intersticia), charakterizovan\u00e9 p\u0159\u00edtomnost\u00ed nov\u011b vznikl\u00e9ho rentgenologick\u00e9ho n\u00e1lezu (jeli sn\u00edmek proveden) prov\u00e1zen\u00e9ho alespo\u0148 dv\u011bma typick\u00fdmi p\u0159\u00edznaky \u010di n\u00e1lezy (febrilie, ka\u0161el, bolesti na hrudi, typick\u00fd poslechov\u00fd n\u00e1lez, leukocyt\u00f3za). D\u0159\u00edve pou\u017e\u00edvan\u00e9 d\u011blen\u00ed na pneumonie typick\u00e9 a atypick\u00e9, reflektuj\u00edc\u00ed sp\u00ed\u0161e p\u0159edpokl\u00e1dan\u00e9 vyvol\u00e1vaj\u00edc\u00ed agens, pomalu ztr\u00e1c\u00ed na v\u00fdznamu. Z klinick\u00e9ho hlediska m\u00e1 v\u00fdznam d\u011blen\u00ed podle z\u00e1va\u017enosti na<\/p>\n<ul>\n<li style=\"text-align: justify;\">pneumonie lehk\u00e9, dovoluj\u00edc\u00ed empirickou ambulantn\u00ed l\u00e9\u010dbu,<\/li>\n<li style=\"text-align: justify;\">pneumonie st\u0159edn\u00ed z\u00e1va\u017enosti, kdy se o nutnosti hospitalizace rozhoduje podle efektu empiricky nasazen\u00e9 l\u00e9\u010dby a komorbidit nemocn\u00e9ho,<\/li>\n<li style=\"text-align: justify;\">pneumonie t\u011b\u017ek\u00e9, kdy jsou ohro\u017eeny z\u00e1kladn\u00ed vit\u00e1ln\u00ed funkce, l\u00e9\u010dba tedy mus\u00ed b\u00fdt razantn\u00ed a za hospitalizace (\u010dasto na intenzivn\u00edm l\u016f\u017eku).<\/li>\n<li style=\"text-align: justify;\">pneumonie komunitn\u00ed, kter\u00e9 vznikaj\u00ed mimo nemocni\u010dn\u00ed prost\u0159ed\u00ed, v\u011bt\u0161inou jsou zp\u016fsobeny obvykl\u00fdmi patogeny citliv\u00fdmi na obvykl\u00e1 antibiotika(<i>Streptococcus pneumoniae<\/i>, <i>Mycoplasma pneumo<\/i>niae, Chlamydia pneumoniae, Haemophilus influensae, Staphylococcus aureus),<\/li>\n<li style=\"text-align: justify;\">pneumonie nozokomi\u00e1ln\u00ed, kter\u00e9 vznikaj\u00ed v souvislosti s pobytem v nemocni\u010dn\u00edm za\u0159\u00edzen\u00ed.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Pokud vznikne nozokomi\u00e1ln\u00ed n\u00e1kaza do 4 dn\u016f od p\u0159ijet\u00ed,ozna\u010duje se pneumonie za \u010dasnou nozokomi\u00e1ln\u00ed n\u00e1kazu, po 4 dnech pak za pozdn\u00ed, kter\u00e1 je charakterizov\u00e1na v\u00fdrazn\u011b nebezpe\u010dn\u011bj\u0161\u00edm spektrem polyrezistentn\u00edch patogen\u016f (Klebsiella species, Klebsiella\u00a0pneumoniae, Pseudomonas aeruginosa, Escherichia\u00a0coli, Staph. aureus, Strept. pyogenes, Bacteroide<em>s<\/em>).<\/p>\n<p style=\"text-align: justify;\">Obzvl\u00e1\u0161\u0165\u00a0z\u00e1va\u017en\u00e9 jsou pneumonie u dlouhodob\u011b ventilovan\u00fdch pacient\u016f (ventil\u00e1torov\u00e9 pneumonie).Diagnostika se op\u00edr\u00e1 o anamn\u00e9zu (infek\u010dn\u00ed onemocn\u011bn\u00ed v okol\u00ed, cestov\u00e1n\u00ed, epidemiologick\u00e1 situace), klinick\u00e9 vy\u0161et\u0159en\u00ed (zkr\u00e1cen\u00fd poklep, utlumen\u00e9, trubicov\u00e9 \u010di vymizel\u00e9 d\u00fdch\u00e1n\u00ed s vlhk\u00fdmi fenom\u00e9ny, krepitus), laboratorn\u00ed n\u00e1lez (zv\u00fd\u0161en\u00e1 sedimentace, leukocyt\u00f3za, elevace CRP) a rentgenologick\u00fd n\u00e1lez (\u010derstv\u00fd infiltr\u00e1t v segment\u00e1ln\u00edm, lob\u00e1rn\u00edm \u010di al\u00e1rn\u00edm rozsahu, v\u00fdpotek). V p\u0159\u00edpad\u011b pochybnost\u00ed a z d\u016fvodu diferenci\u00e1ln\u00ed rozvahy je n\u011bkdy nutn\u00e9 CT, bronchoskopie m\u00e1 v\u00fdznam podobn\u00fd, nav\u00edc dovoluje tracheobronchi\u00e1ln\u00ed toaletu a c\u00edlen\u00e9 odb\u011bry materi\u00e1lu pro mikrobiologa. L\u00e9\u010dba je pov\u011bt\u0161inou nechirurgick\u00e1 (antibiotika dle citlivosti, mukolytika, expektorancia, oxygenoterapie, ECMO, toaleta bronchi\u00e1ln\u00edho stromu, fyzioterapie). Invazivn\u00ed, event. chirurgick\u00e1 l\u00e9\u010dba je indikov\u00e1na zcela v\u00fdjime\u010dn\u011b, a to pro komplikace (empy\u00e9m, absces, sek. pneumotorax).<\/p>\n<h4>5.3.2 Plicn\u00ed absces<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1311.png\"><img decoding=\"async\" title=\"Obr. 8 \u2013 Dren\u00e1\u017e abscesu pod CT navigac\u00ed\" alt=\"Obr. 8 \u2013 Dren\u00e1\u017e abscesu pod CT navigac\u00ed\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1311.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 8<br \/>Dren\u00e1\u017e abscesu pod CT navigac\u00ed<\/p><\/div>\n<p style=\"text-align: justify;\">Plicn\u00ed absces je lokalizovan\u00fd hnisav\u00fd proces v dutin\u011b vytvo\u0159en\u00e9 destrukc\u00ed parenchymu. Nej\u010dast\u011bji vznik\u00e1 v d\u016fsledku aspirace nebo zate\u010den\u00ed infikovan\u00e9ho sekretu \u010di \u017ealude\u010dn\u00ed \u0161\u0165\u00e1vy do d\u00fdchac\u00edch cest, nap\u0159. u nemocn\u00fdch s poruchami v\u011bdom\u00ed nebo na artefici\u00e1ln\u00ed plicn\u00ed ventilaci. U imunokompromitovan\u00fdch nemocn\u00fdch b\u00fdv\u00e1 typickou a v\u00e1\u017enou komplikac\u00ed nekrotizuj\u00edc\u00ed pneumonie. Akumulace bronchi\u00e1ln\u00edho sekretu za sten\u00f3zou (n\u00e1dorovou i benign\u00ed) b\u00fdv\u00e1 dal\u0161\u00ed typickou p\u0159\u00ed\u010dinou vzniku abscesu. Abscedovat mohou preexistuj\u00edc\u00ed plicn\u00ed l\u00e9ze \u2013 n\u00e1dory, kaverny, infarkty, septick\u00e9 emboly, mnoho\u010detn\u00e9 abscesy mohou prov\u00e1zet t\u011b\u017ek\u00e9 septick\u00e9 stavy, kanylovou sepsi apod. Plicn\u00ed absces, ale sp\u00ed\u0161e empyem, m\u016f\u017ee vzniknout \u0161\u00ed\u0159en\u00edm hnisav\u00e9ho procesu z podbr\u00e1ni\u010dn\u00edch nebo hlubok\u00fdch kr\u010dn\u00edch prostor\u016f. Kultiva\u010dn\u011b lze nal\u00e9zt nej\u010dast\u011bji <i>Staph. aureus, Strept. pyogenes, Strept. pneumoniae, Klebsiella sp., Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus species, Escherichia coli,\u00a0<\/i><i>Enterobacter<\/i>, u aspirac\u00ed a u imunokompromitovan\u00fdch nemocn\u00fdch jsou \u010dast\u011bj\u0161\u00ed anaerobn\u00ed gramnegativn\u00ed bakterie \u2013 <i>Bacteroides, Peptococcus, Peptostreptococcus, Fusobacterium<\/i>, v\u011bt\u0161inou v kombinaci. Diagnostika se op\u00edr\u00e1 o typick\u00e9 symptomy: febrilie, ka\u0161el s expektorac\u00ed hnisav\u00e9ho nebo a\u017e putridn\u00edho sputa, mal\u00e1tnost, \u00fanavnost, v\u00e1hov\u00fd \u00fabytek, dyspnoe, pleur\u00e1ln\u00ed bolest, v\u00fdjime\u010dn\u011b hemopt\u00fdza. Fyzik\u00e1ln\u00ed n\u00e1lez v\u0161ak v\u011bt\u0161inou b\u00fdv\u00e1 chud\u00fd. P\u0159i podez\u0159en\u00ed na plicn\u00ed absces je proto nutn\u00e9 zhotovit zadop\u0159edn\u00ed a bo\u010dn\u00fd sn\u00edmek, typick\u00fdm n\u00e1lezem je infiltr\u00e1t a pozd\u011bji dutina s hladinkou. Hladinka neb\u00fdv\u00e1 vid\u011bt u ventilovan\u00fdch nemocn\u00fdch sn\u00edmkovan\u00fdch na l\u016f\u017eku vertik\u00e1ln\u00edm paprskem. P\u0159esn\u011bj\u0161\u00ed diagnostika sporn\u00fdch infiltr\u00e1t\u016f je mo\u017en\u00e1 pomoc\u00ed CT, lze odli\u0161it jin\u00e9 kavitovan\u00e9 l\u00e9ze (n\u00e1dorov\u00e9 \u010di specifick\u00e9 kaverny) \u010di empy\u00e9m. Z laboratorn\u00edch v\u00fdsledk\u016f lze vysledovat leukocyt\u00f3zu, elevaci CRP, anemizaci, p\u0159i teplotn\u00edch \u0161pi\u010dk\u00e1ch je vhodn\u00e9 odebrat hemokulturu. Materi\u00e1l k aerobn\u00ed i anaerobn\u00ed kultivaci lze krom\u011b sputa z\u00edskat p\u0159i bronchoskopii, kter\u00e1 je indikov\u00e1na k vylou\u010den\u00ed aspirace \u010di obstrukce, nebo transpariet\u00e1ln\u00ed punkc\u00ed, pokud jsou p\u0159edchoz\u00ed kroky nep\u0159\u00ednosn\u00e9.<\/p>\n<p style=\"text-align: justify;\">L\u00e9\u010dba je antibiotick\u00e1, zprvu empirick\u00e1 a intraven\u00f3zn\u00ed (1\u20132 t\u00fddny), co nejd\u0159\u00edve \u0159\u00edzen\u00e1 dle citlivosti, po pominut\u00ed toxick\u00fdch zn\u00e1mek infekce i peror\u00e1ln\u00ed v d\u00e9lce 4\u20136 t\u00fddn\u016f. K empirick\u00e9mu nastaven\u00ed terapie slou\u017e\u00ed znalost epidemiologick\u00e9 situace ve sp\u00e1du a v nemocnici, zejm\u00e9na u nozokomi\u00e1ln\u00edch n\u00e1kaz a aspirac\u00ed je t\u0159eba po\u010d\u00edtat s gramnegativn\u00ed a anaerobn\u00ed fl\u00f3rou. Velk\u00e9 abscesy nereaguj\u00edc\u00ed na konzervativn\u00ed terapii je n\u011bkdy nutn\u00e9 punktovat, resp. l\u00e9pe dr\u00e9novat transpariet\u00e1ln\u011b, pod skiaskopickou, sonografickou \u010di CT navigac\u00ed (obr. 8). Jen v naprosto v\u00fdjime\u010dn\u00fdch p\u0159\u00edpadech je nutn\u00e1 terapie chirurgick\u00e1 \u2013 dren\u00e1\u017e na zp\u016fsob kavernostomie nebo resekce pl\u00edce s abscesovou dutinou. Separace neoperovan\u00e9 pl\u00edce b\u011bhem operace je velmi \u017e\u00e1douc\u00ed.<\/p>\n<h6>Indikac\u00ed k chirurgick\u00e9 l\u00e9\u010db\u011b jsou:<\/h6>\n<ul>\n<li>p\u0159etrv\u00e1vaj\u00edc\u00ed abscesov\u00e1 dutina,<\/li>\n<li>mykotick\u00e1 superinfekce,<\/li>\n<li>masivn\u00ed hemopt\u00fdza,<\/li>\n<li>bronchopleur\u00e1ln\u00ed p\u00ed\u0161t\u011bl,<\/li>\n<li>aspirovan\u00e9 ciz\u00ed t\u011bleso,<\/li>\n<li>podez\u0159en\u00ed na neoplazii.<\/li>\n<\/ul>\n<h4>5.3.3 Bronchiekt\u00e1zie<\/h4>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1331.png\"><img decoding=\"async\" title=\"Obr. 9 \u2013 Kompletn\u00ed destrukce prav\u00e9 pl\u00edce bronchiekt\u00e1ziemi\" alt=\"Obr. 9 \u2013 Kompletn\u00ed destrukce prav\u00e9 pl\u00edce bronchiekt\u00e1ziemi\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1331.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 9<br \/>Kompletn\u00ed destrukce prav\u00e9 pl\u00edce bronchiekt\u00e1ziemi<\/p><\/div>\n<p style=\"text-align: justify;\">Bronchiekt\u00e1zie jsou definov\u00e1ny jako ireverzibiln\u00ed dilatace pr\u016fdu\u0161ek. Mohou b\u00fdt vrozen\u00e9 nebo \u010dast\u011bji z\u00edskan\u00e9, lokalizovan\u00e9 i difuzn\u00ed. Typicky jsou prov\u00e1zeny m\u011bstn\u00e1n\u00edm bronchi\u00e1ln\u00edho sekretu a infekc\u00ed, co\u017e vede k chronick\u00e9 infiltraci bronchi\u00e1ln\u00edch a peribronchi\u00e1ln\u00edch struktur a k postupn\u00e9 progresi v \u010dase.<\/p>\n<p style=\"text-align: justify;\">V patogenezi se uplat\u0148uje vrozen\u00e1 slabost bronchi\u00e1ln\u00ed st\u011bny, cili\u00e1rn\u00ed dysfunkce, patologick\u00e9 slo\u017een\u00ed hlenu (nap\u0159. u mukoviscid\u00f3zy). Inflamace indukuje destrukci sval\u016f a chrupavek st\u011bny pr\u016fdu\u0161ek a jejich substituci vazivem, retinovan\u00fd sekret tvo\u0159\u00ed z\u00e1tky, kter\u00e9 p\u0159i ka\u0161li zvy\u0161uj\u00ed intrabronchi\u00e1ln\u00ed tlak a prohlubuj\u00ed dal\u0161\u00ed destrukci. Klinicky se projevuj\u00ed zpo\u010d\u00e1tku jako recidivuj\u00edc\u00ed plicn\u00ed infekty, p\u0159id\u00e1v\u00e1 se hojn\u00e1 expektorace, kter\u00e1 se \u010dasem v\u00e1\u017ee na zm\u011bnu polohy. M\u016f\u017ee se objevit hemopt\u00fdza z podr\u00e1\u017ed\u011bn\u00e9 bronchi\u00e1ln\u00ed sliznice, p\u0159i kter\u00e9 spolup\u016fsob\u00ed \u010dast\u00e1 hypertrofie bronchi\u00e1ln\u00edch tepen. V diagnostice byla bronchografie uspokojiv\u011b nahrazena HRCT, proto ztratily na v\u00fdznamu obs\u00e1hl\u00e9 popisn\u00e9 klasifikace jednotliv\u00fdch tvar\u016f bronchiekt\u00e1zi\u00ed. Z dal\u0161\u00edch vy\u0161et\u0159en\u00ed m\u00e1 v\u00fdznam kultivace sputa a monitorace marker\u016f z\u00e1n\u011btu.L\u00e9\u010dba je antibiotick\u00e1, c\u00edlen\u00e1 dle vykultivovan\u00e9 fl\u00f3ry, v trv\u00e1n\u00ed 2\u20133 t\u00fddn\u016f. Expektorace je podporov\u00e1na mukolytiky, mukomodula\u010dn\u00edmi l\u00e9ky, expektoranciemi, vibra\u010dn\u00edmi a poklepov\u00fdmi mas\u00e1\u017eemi a v d\u0159\u00edv\u011bj\u0161\u00ed dob\u011b klasickou polohovou dren\u00e1\u017e\u00ed. Dechov\u00e1 rehabilitace, fyzioterapie a klimatick\u00e1 l\u00e9\u010dba maj\u00ed tak\u00e9 sv\u016fj v\u00fdznam.<\/p>\n<p style=\"text-align: justify;\">Resek\u010dn\u00ed l\u00e9\u010dba je indikov\u00e1na pouze u lokalizovan\u00fdch l\u00e9z\u00ed refraktern\u00edch na konzervativn\u00ed terapii, c\u00edlem je odstran\u011bn\u00ed infek\u010dn\u00edho fokusu p\u0159i maxim\u00e1ln\u00edm \u0161et\u0159en\u00ed neposti\u017een\u00e9ho parenchymu (obr. 9). D\u016fvodem k operaci mohou b\u00fdt tak\u00e9 recidivuj\u00edc\u00ed hemopt\u00fdzy, u nemocn\u00fdch s limitem ventila\u010dn\u00ed rezervy lze nam\u00edsto resekce katetriza\u010dn\u00ed technikou selektivn\u011b embolizovat dilatovan\u00e9 bronchi\u00e1ln\u00ed tepny.<\/p>\n<h4 style=\"text-align: justify;\">5.3.4 Plicn\u00ed tuberkul\u00f3za<\/h4>\n<p style=\"text-align: justify;\">Tuberkul\u00f3za je infek\u010dn\u00ed onemocn\u011bn\u00ed zp\u016fsoben\u00e9 <i>Mycobacterium tuberculosis<\/i>. Postihuje nej\u010dast\u011bji pl\u00edce (plicn\u00ed tuberkul\u00f3za), ostatn\u00edm org\u00e1n\u016fm a tk\u00e1n\u00edm se nevyh\u00fdb\u00e1 (mimoplicn\u00ed tuberkul\u00f3za). Pro diagnostiku m\u00e1 v\u00fdznam anamn\u00e9za (kontakt s TBC), fyzik\u00e1ln\u00ed n\u00e1lez je v\u011bt\u0161inou chud\u00fd i p\u0159i v\u00fdznamn\u00e9m posti\u017een\u00ed a je nespecifick\u00fd. Pro tuberkul\u00f3zu na skiagramu hrudn\u00edku sv\u011bd\u010d\u00ed infiltr\u00e1t \u010di oboustrann\u00fd mili\u00e1rn\u00ed rozsev v horn\u00edch plicn\u00edch pol\u00edch, rozpadov\u00e1 kaverna, kalcifikovan\u00e9 uzliny mediastina, pleur\u00e1ln\u00ed v\u00fdpotek, fibr\u00f3zn\u00ed pruhy. Diagn\u00f3za by m\u011bla b\u00fdt postavena na z\u00e1klad\u011b kultiva\u010dn\u00edho vy\u0161et\u0159en\u00ed (sputum, bronchi\u00e1ln\u00ed aspir\u00e1t, punkt\u00e1t z hrudn\u00edku). Histologick\u00fd rozbor prokazuj\u00edc\u00ed epiteloidn\u00ed granulom s kaseifika\u010dn\u00ed nekr\u00f3zou by m\u011bl b\u00fdt tak\u00e9 dopln\u011bn kultiva\u010dn\u00edm pr\u016fkazem. L\u00e9\u010dba plicn\u00ed tuberkul\u00f3zy je medikament\u00f3zn\u00ed. Pod\u00e1v\u00e1 se kombinace standardn\u00edch antituberkulotik (Rifampicin, Etambutol, Pyrazinamid, Izoniazid, Streptomycin) v r\u016fzn\u00fdch sch\u00e9matech po dobu nejm\u00e9n\u011b 6 m\u011bs\u00edc\u016f. Chirurgick\u00e1 l\u00e9\u010dba je indikov\u00e1na v sou\u010dasnosti u\u017e jen zcela v\u00fdjime\u010dn\u011b, po inici\u00e1ln\u00ed medikament\u00f3zn\u00ed terapii. Kolapsov\u00e1 terapie (terapeutick\u00fd pneumotorax, apikol\u00fdza) u\u017e byla zcela opu\u0161t\u011bna. Torakoplastiky jsou indikov\u00e1ny naprosto raritn\u011b jako dopl\u0148uj\u00edc\u00ed v\u00fdkony po komplikovan\u00fdch resek\u010dn\u00edch v\u00fdkonech. Chirurgick\u00e1 l\u00e9\u010dba b\u00fdv\u00e1 posledn\u00ed instanc\u00ed v t\u011bchto p\u0159\u00edpadech:<\/p>\n<ul>\n<li>\u017eivotohro\u017euj\u00edc\u00ed hemopt\u00fdza,<\/li>\n<li>tuberkulom,<\/li>\n<li>destrukce pl\u00edce (plicn\u00edho laloku),<\/li>\n<li>endoskopicky ne\u0159e\u0161iteln\u00e1 striktura bronchu,<\/li>\n<li>objemn\u00e1 kaverna \u010di zbytkov\u00fd prostor.<\/li>\n<\/ul>\n<p style=\"text-align: justify;\">Principem chirurgie tuberkul\u00f3zy je parenchym \u0161et\u0159\u00edc\u00ed resek\u010dn\u00ed v\u00fdkon (staplerov\u00e1 resekce, segmentektomie, lobektomie) a mobilizace zbyl\u00e9 pl\u00edce, v p\u0159\u00edpad\u011b t\u011b\u017ek\u00fdch jizevnat\u00fdch striktur pr\u016fdu\u0161ek p\u0159ipad\u00e1 v \u00favahu i pneumonektomie. Bronchoplastick\u00e9 v\u00fdkony jsou z povahy nemoci zna\u010dn\u011b komplikovan\u00e9. V p\u0159\u00edpad\u011b masivn\u00ed hemopt\u00fdzy je nezbytn\u00e9 p\u0159ed samotnou resekc\u00ed lokalizovat bronchoskopicky alespo\u0148 stranu krv\u00e1cen\u00ed, jeli to v mo\u017enostech pracovi\u0161t\u011b, vytamponovat bronchus nebo zav\u00e9st ventila\u010dn\u00ed rourku do zdrav\u00e9 pl\u00edce. Krv\u00e1cen\u00ed m\u00e1 zdroj pov\u011bt\u0161inou v arodovan\u00e9 bronchi\u00e1ln\u00ed tepn\u011b, v\u00fdhodn\u00e9 je proto zasvorkovat odpov\u00eddaj\u00edc\u00ed pr\u016fdu\u0161ku na po\u010d\u00e1tku resekce z d\u016fvodu hemost\u00e1zy a prevence zalit\u00ed kontralater\u00e1ln\u00ed pl\u00edce.<\/p>\n<h3>5.4 Interstici\u00e1ln\u00ed plicn\u00ed procesy<\/h3>\n<p style=\"text-align: justify;\">Interstici\u00e1ln\u00ed plicn\u00ed procesy (IPP) zahrnuji velmi \u0161irokou skupinu nemoc\u00ed, pro kter\u00e9 je charakteristick\u00e9 difuzn\u00ed posti\u017een\u00ed plicn\u00edho intersticia a plicn\u00edch skl\u00edpk\u016f aseptick\u00fdm z\u00e1n\u011btem a fibr\u00f3zou. Pokud p\u0159eva\u017euj\u00ed z\u00e1n\u011btliv\u00e9 zm\u011bny, lze p\u0159edpokl\u00e1dat lep\u0161\u00ed progn\u00f3zu a reverzibilitu procesu, nap\u0159. u sarkoid\u00f3zy \u010di exogenn\u00edch alveolitid. Pr\u016fb\u011bh fibrotizuj\u00edc\u00edch proces\u016f je v\u011bt\u0161inou ireverzibiln\u00ed s r\u016fznou rychlost\u00ed progrese. IPP lze d\u011blit na prim\u00e1rn\u00ed (sarkoid\u00f3za, amyloid\u00f3za, histiocyt\u00f3za, lymfangioleiomymat\u00f3za) a sekund\u00e1rn\u00ed, v\u00e1zan\u00e9 na jin\u00e9 nemoci, syndromy, l\u00e9\u010dbu nebo na expozici r\u016fzn\u00fdm nox\u00e1m. Z hlediska vyvol\u00e1vaj\u00edc\u00edch p\u0159\u00ed\u010din rozezn\u00e1v\u00e1me IPP idiopatick\u00e9 (nap\u0159. akutn\u00ed interstici\u00e1ln\u00ed pneumonie HammanRich, idiopatick\u00e1 plicn\u00ed fibr\u00f3za) a IPP autoimunn\u00ed (nap\u0159. idiopatick\u00e1 trombocytopenick\u00e1 purpura, bili\u00e1rn\u00ed cirh\u00f3za, autoimunn\u00ed hemolytick\u00e1 an\u00e9mie).<\/p>\n<p style=\"text-align: justify;\">Diagnostika se op\u00edr\u00e1 o klinick\u00e9 symptomy (du\u0161nost, unavitelnost, n\u011bkdy ka\u0161el, hemopt\u00fdza, v pokro\u010dil\u00fdch stadi\u00edch hypoxemick\u00e1 cyan\u00f3za). Laboratorn\u00ed vy\u0161et\u0159en\u00ed m\u00e1 v\u00fdznam u syst\u00e9mov\u00fdch onemocn\u011bn\u00ed pojiva a vaskulitid (revmatoidn\u00ed markery, autoprotil\u00e1tky). O stavu posti\u017een\u00ed plic n\u00e1s nejl\u00e9pe informuje funk\u010dn\u00ed vy\u0161et\u0159en\u00ed (sn\u00ed\u017een\u00ed vit\u00e1ln\u00ed kapacity, funk\u010dn\u00ed rezidu\u00e1ln\u00ed kapacity, transfer faktoru). Kles\u00e1 tolerace z\u00e1t\u011b\u017ee a lze prok\u00e1zat r\u016fzn\u011b vyj\u00e1d\u0159enou poruchu v\u00fdm\u011bny plyn\u016f. Ze zobrazovac\u00edch metod m\u00e1 v\u00fdznam skiagram (nodulace, retikulace, prchav\u00e9 infiltr\u00e1ty, opacity ml\u00e9\u010dn\u00e9ho skla). Daleko v\u011b\u0161\u00ed v\u00fdznam m\u00e1 high resolution CT (HRCT). Bronchoalveol\u00e1rn\u00ed lav\u00e1\u017e\u00ed lze z\u00edskat vzorky tekutiny, bun\u011bk, inhalovan\u00fdch \u010d\u00e1stic \u010di mikrob\u016f z doln\u00edch d\u00fdchac\u00edch cest. Nejspolehliv\u011bj\u0161\u00ed cesta k ur\u010den\u00ed diagn\u00f3zy je validn\u00ed biopsie korelovan\u00e1 s klinick\u00fdm stavem. Lze ji prov\u00e9st transpariet\u00e1ln\u011b, ale v\u011bt\u0161inou je vy\u017eadov\u00e1n dostaten\u011b velk\u00fd vzorek z m\u00edst s maximem patologick\u00fdch zm\u011bn. Ten lze z\u00edskat videotorakoskopicky, videoasistovan\u011b \u010di z mal\u00e9 torakotomie. Z\u00e1kladem l\u00e9\u010dby IPP jsou kortikoidy a imunosupresiva, v posledn\u00ed dob\u011b se u n\u011bkter\u00fdch syndrom\u016f pou\u017e\u00edv\u00e1 biologick\u00e1 l\u00e9\u010dba. V kone\u010dn\u00fdch stadi\u00edch je indikov\u00e1na dom\u00e1c\u00ed oxygenoterapie, definitivn\u00edm \u0159e\u0161en\u00edm m\u016f\u017ee b\u00fdt transplantace plic.<\/p>\n<h3>5.5 Plicn\u00ed emfyz\u00e9m<\/h3>\n<p style=\"text-align: justify;\">Plicn\u00ed emfyz\u00e9m je definov\u00e1n jako dilatace plicn\u00edch struktur dist\u00e1ln\u011b od termin\u00e1ln\u00edch bronchiol\u016f spojen\u00e1 s destrukc\u00ed st\u011bn alveol\u016f a v\u00fdjime\u010dn\u011b s limitovanou fibr\u00f3zou. Tento stav je d\u00e1n zv\u00fd\u0161enou distenzibilitou pl\u00edce a jej\u00ed sn\u00ed\u017eenou retraktibilitou. Emfyzemat\u00f3zn\u00ed pl\u00edce pot\u0159ebuje men\u0161\u00ed infla\u010dn\u00ed tlak, zato desuflace parenchymu je obt\u00ed\u017en\u011bj\u0161\u00ed. Ve v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f nen\u00ed distribuce emfyzematozn\u00edch zm\u011bn homogenn\u00ed, proto v\u00edce posti\u017een\u00e9 okrsky parenchymu maj\u00ed tendenci neventilovat a rozp\u00ednat se na \u00fakor zbyl\u00e9 pl\u00edce se zachovalou strukturou. Negativn\u00ed roli sehr\u00e1v\u00e1 i neefektivn\u00ed pohyb vzduchu mezi zdrav\u00fdmi a nemocn\u00fdmi okrsky plicn\u00ed tk\u00e1n\u011b p\u0159i d\u00fdch\u00e1n\u00ed dan\u00fd rozd\u00edln\u00fdmi infla\u010dn\u00edmi tlaky, vzduch ze zdrav\u011bj\u0161\u00edch okrsk\u016f nam\u00edsto vydechnut\u00ed sm\u011b\u0159uje z\u010d\u00e1sti do emfyzemat\u00f3zn\u00ed pl\u00edce. Takto je limitov\u00e1na v\u00fdm\u011bna vzduchu se zevn\u00edm prost\u0159ed\u00edm i na alveolokapil\u00e1rn\u00ed membr\u00e1n\u011b. Hyperinflace pl\u00edce m\u016f\u017ee v\u00e9st a\u017e k pozitivn\u00edmu alveol\u00e1rn\u00edmu tlaku na konci expirace (autoPEEP), kter\u00fd d\u00e1le zhor\u0161uje mo\u017enost v\u00fdm\u011bny vzduchu v alveolech, proto\u017ee k vytvo\u0159en\u00ed negativn\u00edho inspira\u010dn\u00edho tlaku v alveolech je zapot\u0159eb\u00ed vy\u0161\u0161\u00edho \u00fasil\u00ed. Zv\u011bt\u0161ov\u00e1n\u00ed objemu pl\u00edce vede k oplo\u0161t\u011bn\u00ed br\u00e1nice, roz\u0161\u00ed\u0159en\u00ed a nap\u0159\u00edmen\u00ed mezi\u017eeb\u0159\u00ed, to v\u0161e je nev\u00fdhodn\u00e9 pro mechaniku d\u00fdch\u00e1n\u00ed a vy\u017eaduje zv\u00fd\u0161enou pr\u00e1ci vlastn\u00edch i auxili\u00e1rn\u00edch d\u00fdchac\u00edch sval\u016f. D\u016fsledkem t\u011bchto zm\u011bn je r\u016fzn\u00fd stupe\u0148 dyspnoe. Smyslem volumreduktivn\u00ed chirurgie plic je odstranit nefunk\u010dn\u00ed okrsky pl\u00edce, a tak redukovat hyperinflaci a mrtv\u00fd prostor, zlep\u0161it proud\u011bn\u00ed vzduchu v d\u00fdchac\u00edch cest\u00e1ch a v\u00fdm\u011bnu plyn\u016f na alveolokapil\u00e1rn\u00ed membr\u00e1n\u011b ve zbyl\u00e9 pl\u00edci.<\/p>\n<h4>5.5.1 Evaluace a selekce<\/h4>\n<p style=\"text-align: justify;\">Volumreduktivn\u00ed chirurgie plic je paliativn\u00ed l\u00e9\u010dba s jistou morbiditou a nezanedbatelnou mortalitou. Z\u00e1kladn\u00edm c\u00edlem je vyhledat nemocn\u00e9, kter\u00fdm emfyz\u00e9m navzdory medikament\u00f3zn\u00ed terapii v\u00fdrazn\u011b komplikuje b\u011b\u017en\u00fd \u017eivot, a z nich vybrat takov\u00e9, kte\u0159\u00ed maj\u00ed dobrou \u0161anci profitovat z volumredukce p\u0159i mal\u00e9m opera\u010dn\u00edm riziku. Dobrou \u0161anci maj\u00ed nemocn\u00ed s nerovnom\u011brnou distribuc\u00ed emfyz\u00e9mu s bul\u00f3zn\u00edmi okrsky p\u0159\u00edstupn\u00fdmi resekci a zn\u00e1mkami hyperinflace hrudn\u00edku. Z paraklinick\u00fdch vy\u0161et\u0159en\u00ed je d\u016fle\u017eit\u00e1 spirometrie (zv\u00fd\u0161en\u00fd celkov\u00fd i rezidu\u00e1ln\u00ed plicn\u00ed volum, sn\u00ed\u017een\u00e1 v\u00fddechov\u00e1 rychlost) a sn\u00ed\u017een\u00e1 difuzn\u00ed kapacita. Rentgenogram a zejm\u00e9na CT zobraz\u00ed objem hrudn\u00edku a distribuci bul. Ventila\u010dn\u011b perfuzn\u00ed scan m\u016f\u017ee posoudit stupe\u0148 emfyzemat\u00f3zn\u00ed destrukce a jej\u00ed heterogenitu a pomoci ur\u010dit rozsah resekce, p\u0159\u00edpadn\u011b limitovat operaci na jednu stranu. Uspokojiv\u00e9 v\u00fdsledky operace lze o\u010dek\u00e1vat u neku\u0159\u00e1k\u016f pod 70 let, s ide\u00e1ln\u00edm BMI, s FEV1 a DLCO v intervalu 20\u201340%, s PaCO<sub>2<\/sub>&lt; 45 a PaO<sub>2<\/sub>&gt;50. Nemocn\u00ed s difuzn\u00ed kapacitou pro CO pod 20% nebo s homogenn\u00ed distribuc\u00ed emfyz\u00e9mu nejsou k volumredukci indikov\u00e1ni.<\/p>\n<h4>5.5.2 P\u0159\u00edprava<\/h4>\n<p style=\"text-align: justify;\">P\u0159ed samotnou operac\u00ed je nutn\u00e1 dokonal\u00e1 rehabilitace v z\u00e1jmu dosa\u017een\u00ed optim\u00e1ln\u00edch plicn\u00edch funkc\u00ed. Tento program zahrnuje vylou\u010den\u00ed kou\u0159en\u00ed, bronchodilata\u010dn\u00ed l\u00e9\u010dbu, optimalizaci kortikoterapie a p\u0159\u00edpadnou vakcinaci proti ch\u0159ipce a pneumokokov\u00e9 infekci, nutri\u010dn\u00ed podporu a event. psychologickou p\u0159\u00edpravu.<\/p>\n<h4>5.5.3 Operace<\/h4>\n<h5>5.5.3.1 Bulektomie<\/h5>\n<p style=\"text-align: justify;\">P\u0159i n\u00e1lezu jednotliv\u00e9 \u010di n\u011bkolika bul je mo\u017en\u00e9 odstranit je parenchym \u0161et\u0159\u00edc\u00ed resekc\u00ed miniinvazivn\u00edm p\u0159\u00edstupem nebo z mal\u00e9 torakotomie (obr. 10). V\u011bt\u0161ina men\u0161\u00edch solit\u00e1rn\u00edch bul je asymptomatick\u00e1. Operuj\u00ed se, pokud se objev\u00ed symptomy, komplikace nebo objem buly p\u0159es\u00e1hne t\u0159etinu a\u017e polovinu hemitoraxu.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_136.png\"><img decoding=\"async\" title=\"Obr. 10 \u2013 Resekovan\u00e1 expanzivn\u011b se chovaj\u00edc\u00ed bula\" alt=\"Obr. 10 \u2013 Resekovan\u00e1 expanzivn\u011b se chovaj\u00edc\u00ed bula\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_136.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 10<br \/>Resekovan\u00e1 expanzivn\u011b se chovaj\u00edc\u00ed bula<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1371.png\"><img decoding=\"async\" title=\"Obr. 11 \u2013 Staplerov\u00e1 tangenci\u00e1ln\u00ed resekce z bul\u00f3zn\u011b zm\u011bn\u011bn\u00e9ho horn\u00edho laloku\" alt=\"Obr. 11 \u2013 Staplerov\u00e1 tangenci\u00e1ln\u00ed resekce z bul\u00f3zn\u011b zm\u011bn\u011bn\u00e9ho horn\u00edho laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1371.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 11<br \/>Staplerov\u00e1 tangenci\u00e1ln\u00ed resekce z bul\u00f3zn\u011b zm\u011bn\u011bn\u00e9ho horn\u00edho laloku<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h5>5.5.3.2 Volumreduktivn\u00ed chirurgie<\/h5>\n<p style=\"text-align: justify;\">Typicky se prov\u00e1d\u00ed z oboustrann\u00e9ho p\u0159\u00edstupu (sternotomie, bilater\u00e1ln\u00ed mal\u00e9 torakotomie, bilater\u00e1ln\u00ed miniinvazivn\u00ed p\u0159\u00edstup (VTS, VATS) v jedn\u00e9 dob\u011b), v\u00fdjime\u010dn\u011b sekven\u010dn\u011b nebo pouze jednostrann\u011b. Principem operace je zresekovat tangenci\u00e1ln\u011b do 30 % nejv\u00edce zm\u011bn\u011bn\u00e9ho parenchymu s prezervac\u00ed funkce zbyl\u00e9 pl\u00edce (tak, aby ze segmentu \u010di laloku nez\u016fstaly pouze hilov\u00e9 struktury). Nejv\u00edce b\u00fdvaj\u00ed posti\u017eeny apexy plic, princip operace ukazuje n\u00e1kres (obr. 11).<\/p>\n<p style=\"text-align: justify;\">V\u011bt\u0161inou se pou\u017e\u00edvaj\u00ed postupn\u011b nakl\u00e1dan\u00e9 line\u00e1rn\u00ed (endo)staplery. Z d\u016fvodu prevence \u00faniku vzduchu z resek\u010dn\u00edch lini\u00ed lze svorky podkl\u00e1dat pleurou, perikardem, goretexov\u00fdmi \u010di kolagenov\u00fdmi n\u00e1vleky nebo o\u0161et\u0159it resek\u010dn\u00ed linie tk\u00e1\u0148ov\u00fdmi lepidly.<\/p>\n<h4>5.5.4 Poopera\u010dn\u00ed p\u00e9\u010de<\/h4>\n<p style=\"text-align: justify;\">V\u011bt\u0161inou je podstatn\u011b n\u00e1ro\u010dn\u011bj\u0161\u00ed ne\u017e po klasick\u00fdch plicn\u00edch resekc\u00edch. Je to d\u00e1no obecn\u011b \u0161patnou kondic\u00ed nemocn\u00fdch, malnutric\u00ed, d\u016fsledky dlouhodob\u00e9 kortikoterapie a \u010dast\u00fdmi komorbiditami. Aktivn\u00ed s\u00e1n\u00ed n\u011bkte\u0159\u00ed auto\u0159i nedoporu\u010duj\u00ed, jin\u00ed ho aplikuj\u00ed jen na prvn\u00ed hodiny po operaci. Nezbytn\u00e1 je dechov\u00e1 rehabilitace a fyzioterapie.<\/p>\n<h3>5.6 Benign\u00ed plicn\u00ed n\u00e1dory<\/h3>\n<p style=\"text-align: justify;\">Benign\u00ed plicn\u00ed n\u00e1dory jsou pom\u011brn\u011b vz\u00e1cn\u00e9, tvo\u0159\u00ed asi 3\u20134 % v\u0161ech plicn\u00edch n\u00e1dor\u016f. Nezhoubn\u00e1 povaha je determinov\u00e1na t\u011bmito atributy: nemetast\u00e1zuj\u00ed, nep\u0159er\u016fstaj\u00ed p\u0159irozen\u00e9 tk\u00e1\u0148ov\u00e9 bari\u00e9ry a po kompletn\u00ed resekci nerecidivuj\u00ed. Klasifikace je nejednotn\u00e1, proto\u017ee tyto neoplazie vych\u00e1zej\u00ed z r\u016fzn\u00fdch struktur.<\/p>\n<h4>5.6.1 Klasifikace (zjednodu\u0161en\u011b):<\/h4>\n<p>Epiteli\u00e1ln\u00ed n\u00e1dory:<\/p>\n<ul>\n<li>papilom<\/li>\n<li>adenom\n<ul>\n<li>\u00a0bronchi\u00e1ln\u00ed cystadenom<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>Mezenchym\u00e1ln\u00ed n\u00e1dory:<\/p>\n<ul>\n<li>fibrom<\/li>\n<li>lipom<\/li>\n<li>leiomyom<\/li>\n<li>chondrom<\/li>\n<li>granulocelul\u00e1rn\u00ed n\u00e1dor<\/li>\n<li>sklerozuj\u00edc\u00ed hemangiom<\/li>\n<li>fibr\u00f3zn\u00ed histiocytom<\/li>\n<\/ul>\n<p>Jin\u00e9 a nejasn\u00e9ho p\u016fvodu:<\/p>\n<ul>\n<li>hamartom<\/li>\n<li>n\u00e1dor z jasn\u00fdch bun\u011bk (sugar tumor)<\/li>\n<li>xantom<\/li>\n<li>teratom<\/li>\n<li>mucosaassociated lymphoid tumor (MALT)<\/li>\n<\/ul>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_139.png\"><img decoding=\"async\" title=\"Obr. 12 \u2013 Enukleovan\u00fd hamartom\" alt=\"Obr. 12 \u2013 Enukleovan\u00fd hamartom\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_139.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 12<br \/>Enukleovan\u00fd hamartom<\/p><\/div>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00edm benign\u00edm novotvarem plic je hamartom, p\u0159edstavuje asi 70% nezhoubn\u00fdch plicn\u00edch lo\u017eisek, druh\u00e9 v po\u0159ad\u00ed jsou adenomy. Hamartomy jsou v naprost\u00e9 v\u011bt\u0161in\u011b p\u0159\u00edpad\u016f asymptomatick\u00e9, histologicky se skl\u00e1daj\u00ed z nepravideln\u011b uspo\u0159\u00e1d\u00e1n\u00fdch okrsk\u016f zral\u00e9 tk\u00e1n\u011b hyalinn\u00ed chrupavky, myxoidn\u00ed pojivov\u00e9 tk\u00e1n\u011b a tukov\u00fdch a respira\u010dn\u00edch bun\u011bk (obr. 12).<\/p>\n<h4>5.6.2 Diagnostika<\/h4>\n<p style=\"text-align: justify;\">M\u00e9n\u011b ne\u017e desetina n\u00e1dor\u016f se manifestuje ka\u0161lem, recidivuj\u00edc\u00edmi infekty \u010di hemopt\u00fdzou, v t\u011bchto p\u0159\u00edpadech je d\u016fvodem endobronchi\u00e1ln\u00ed propagace \u010di zevn\u00ed \u00fatlak pr\u016fdu\u0161ky p\u0159i t\u011bsn\u00e9m peribronchi\u00e1ln\u00edm r\u016fstu. Diagnostika se op\u00edr\u00e1 o rentgenologick\u00fd (CT) pr\u016fkaz dob\u0159e ohrani\u010den\u00e9ho uzlu \u010dasto s hrudkovit\u00fdmi kalcifikacemi. Transpariet\u00e1ln\u00ed biopsie m\u016f\u017ee potvrdit benign\u00ed povahu l\u00e9ze, nediagnostick\u00fd n\u00e1lez m\u016f\u017ee b\u00fdt vy\u0159e\u0161en chirurgicky. Endobronchi\u00e1ln\u00ed hamartomy b\u00fdvaj\u00ed diagnostikov\u00e1ny \u010dasto a\u017e v d\u016fsledku sekund\u00e1rn\u00edch z\u00e1n\u011btliv\u00fdch zm\u011bn plicn\u00edho parenchymu za z\u00fa\u017een\u00edm. Analogickou symptomatologii maj\u00ed i ostatn\u00ed benign\u00ed n\u00e1dory. Pokud jsou ulo\u017eeny perifern\u011b a extrabronchi\u00e1ln\u011b, je jejich symptomatologie velmi chud\u00e1 a \u010dasto jsou pouze n\u00e1hodn\u00fdm n\u00e1lezem na rentgenogramu (lipomy, teratomy, fibromy, granulomy). N\u00e1dory s intrabronchi\u00e1ln\u00edm r\u016fstem nebo takov\u00e9, kter\u00e9 p\u0159i t\u011bsn\u00e9m peribronchi\u00e1ln\u00edm ulo\u017een\u00ed zp\u016fsobuj\u00ed \u00fatlak pr\u016fdu\u0161ky, vyvol\u00e1vaj\u00ed pot\u00ed\u017ee (ka\u0161el, recidivuj\u00edc\u00ed infekty nebo hemopt\u00fdzy), n\u011bkdy b\u00fdvaj\u00ed diagnostikov\u00e1ny a\u017e b\u011bhem p\u00e1tr\u00e1n\u00ed po zdroji sekund\u00e1rn\u00edch zm\u011bn plicn\u00edho parenchymu (adenomy, papilomy, endobronchi\u00e1ln\u00ed fibr\u00f3zn\u00ed histiocytomy).V diagnostice je typick\u00fd sled vy\u0161et\u0159en\u00ed RTG, CT, bronchoskopie, u dosa\u017eiteln\u00fdch l\u00e9z\u00ed transpariet\u00e1ln\u00ed biopsie pod sono nebo CT navigac\u00ed. Hranice diagnostick\u00e9 bronchoskopie posunuj\u00ed mo\u017enosti elektromagnetick\u00e9 \u010di endosonografick\u00e9 navigace.<\/p>\n<h4>5.6.3 Indikace<\/h4>\n<p style=\"text-align: justify;\">Z\u00e1kladn\u00ed d\u016fvod k revizi je vylou\u010den\u00ed potenci\u00e1ln\u00ed malignity l\u00e9ze, druh\u00fdm je prevence nebo odstran\u011bn\u00ed p\u0159\u00edznak\u016f u symptomatick\u00fdch n\u00e1dor\u016f. V dne\u0161n\u00ed dob\u011b u\u017e v\u011bt\u0161inou nen\u00ed nutn\u00e9 revidovat n\u00e1dor p\u0159edpokl\u00e1dan\u00e9 benign\u00ed povahy ze \u0161irok\u00e9 torakotomie.<\/p>\n<h4>5.6.4 L\u00e9\u010dba<\/h4>\n<p style=\"text-align: justify;\">Perifern\u00ed uzly mohou b\u00fdt enukleov\u00e1ny \u010di resekov\u00e1ny cestou parenchym \u0161et\u0159\u00edc\u00edch neanatomick\u00fdch operac\u00ed videotorakoskopicky \u010di videoasistovan\u011b. Centr\u00e1ln\u011bj\u0161\u00ed l\u00e9ze je n\u011bkdy nutn\u00e9 \u0159e\u0161it resekcemi anatomick\u00fdmi do rozsahu laloku. Endobronchi\u00e1ln\u011b \u010di centr\u00e1ln\u011b ulo\u017een\u00e9 l\u00e9ze lze \u0159e\u0161it exciz\u00ed z bronchotomie, resekc\u00ed bronchu \u010di bronchoplastickou resekc\u00ed. Pneumonektomie u benign\u00ed plicn\u00ed l\u00e9ze nen\u00ed relevantn\u00edm \u0159e\u0161en\u00edm.Polypoidn\u00ed n\u00e1dory velk\u00fdch pr\u016fdu\u0161ek lze odstranit endobronchi\u00e1ln\u011b (obr. 13). C\u00edlem je dosa\u017een\u00ed zdrav\u00e9 stopky l\u00e9ze, co\u017e je nap\u0159. u laseroterapie obt\u00ed\u017en\u011b p\u0159edstaviteln\u00e9, nicm\u00e9n\u011b dlouhodob\u00e9 v\u00fdsledky i takto odstran\u011bn\u00fdch endobronchi\u00e1ln\u00edch tumor\u016f (karcinoidy) jsou uspokojiv\u00e9.<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_141.png\"><img decoding=\"async\" title=\"Obr. 13 \u2013 Endobronchi\u00e1ln\u00ed polyp\" alt=\"Obr. 13 \u2013 Endobronchi\u00e1ln\u00ed polyp\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_141.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 13<br \/>Endobronchi\u00e1ln\u00ed polyp<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1421.png\"><img decoding=\"async\" title=\"Obr. 14 \u2013 Kavitovan\u00fd karcinom horn\u00edho laloku\" alt=\"Obr. 14 \u2013 Kavitovan\u00fd karcinom horn\u00edho laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1421.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 14<br \/>Kavitovan\u00fd karcinom horn\u00edho laloku<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3>5.7 Malign\u00ed plicn\u00ed n\u00e1dory, karcinom plic<\/h3>\n<p>Viz obr. 14.<\/p>\n<h4>5.7.1 Epidemiologie<\/h4>\n<p style=\"text-align: justify;\">1.7.1.1 Plicn\u00ed rakovina je nej\u010dast\u011bj\u0161\u00edm typem zhoubn\u00e9ho n\u00e1doru v lidsk\u00e9 populaci a pat\u0159\u00ed obecn\u011b k n\u00e1dorov\u00fdm onemocn\u011bn\u00edm s nejvy\u0161\u0161\u00ed letalitou. V roce 2007 bylo na sv\u011bt\u011b diagnostikov\u00e1no 1,5 milionu nov\u00fdch p\u0159\u00edpad\u016f, tomu odpov\u00eddalo 1,35 milionu \u00famrt\u00ed na tento novotvar. V \u010cR byla ve stejn\u00e9m roce relativn\u00ed incidence 91\/100 000 mu\u017e\u016f a 33\/100 000 \u017een, \u010demu\u017e odpov\u00edd\u00e1 celkov\u00e1 relativn\u00ed incidence rakoviny plic 61,6\/100 000 obyvatel.<\/p>\n<h4>5.7.2 Etiologie<\/h4>\n<p style=\"text-align: justify;\">P\u0159esto\u017ee vznik rakoviny plic je jist\u011b multifaktori\u00e1ln\u00ed (jde o onemocn\u011bn\u00ed genomu), pravdou je, \u017ee p\u0159ibli\u017en\u011b 90 % nemocn\u00fdch bylo vystaveno aktivn\u011b \u010di pasivn\u011b tab\u00e1kov\u00e9mu kou\u0159i. Existuje \u0159ada dal\u0161\u00edch \u0161kodlivin,kter\u00e9 mohou p\u0159i d\u00e9letrvaj\u00edc\u00ed expozici vyvolat plicn\u00ed n\u00e1dorov\u00e9 bujen\u00ed. Nej\u010dast\u011bji zmi\u0148ovan\u00fdmi noxami jsou azbest, arsen, chrom, nikl a vinylchlorid, exhal\u00e1ty dieselov\u00fdch motor\u016f, v na\u0161\u00ed zemi je specifick\u00e1 problematika uranu a radonu. Naopak \u0159ada dal\u0161\u00edch l\u00e1tek m\u016f\u017ee p\u016fsobit preventivn\u011b, a tedy riziko karcinomu sni\u017eovat (nap\u0159\u00edklad zv\u00fd\u0161en\u00e1 konzumace ovoce a zeleniny, n\u00edzkotukov\u00e1 dieta).<\/p>\n<h4>5.7.3 Histologick\u00e1 klasifikace<\/h4>\n<p style=\"text-align: justify;\">Plicn\u00ed karcinom d\u011bl\u00edme z histologick\u00e9ho hlediska na 2 z\u00e1kladn\u00ed subtypy: malobun\u011b\u010dn\u00fd plicn\u00ed karcinom (small cell lung cancer \u2013 SCLC) a nemalobun\u011b\u010dn\u00fd plicn\u00ed karcinom (nonsmall cell lung cancer \u2013 NSCLC). Zat\u00edmco malobun\u011b\u010dn\u00fd plicn\u00ed karcinom (asi 15\u201320 % v\u0161ech karcinom\u016f) je v\u011bt\u0161inou ji\u017e v dob\u011b diagn\u00f3zy syst\u00e9mov\u00fdm onemocn\u011bn\u00edm, proto\u017ee \u010dasn\u011b metast\u00e1zuje krevn\u00ed i lymfatickou cestou, nemalobun\u011b\u010dn\u00fd karcinom roste pomaleji, preferuje lymfogenn\u00ed cestu metastatick\u00e9ho rozsevu a v po\u010d\u00e1tku sv\u00e9ho r\u016fstu si zachov\u00e1v\u00e1 lok\u00e1ln\u00ed charakter proliferace. Z toho se odv\u00edj\u00ed terapie a p\u0159edpokl\u00e1dan\u00e1 progn\u00f3za. SCLC reaguje zpo\u010d\u00e1tku velmi dob\u0159e na r\u016fzn\u00e9 re\u017eimy radioa chemoterapie. Po inici\u00e1ln\u00ed remisi v\u0161ak v intervalu m\u011bs\u00edc\u016f doch\u00e1z\u00ed k relapsu s limitovanou reakc\u00ed na l\u00e9\u010dbu. Onemocn\u011bn\u00ed kon\u010d\u00ed let\u00e1ln\u011b v\u011bt\u0161inou b\u011bhem n\u011bkolika m\u011bs\u00edc\u016f od zji\u0161t\u011bn\u00ed diagn\u00f3zy. Chirurgick\u00e1 terapie m\u00e1 v p\u0159\u00edpad\u011b SCLC v\u00fdznam pouze podru\u017en\u00fd, a to u velmi \u010dasn\u00fdch stadi\u00ed nebo u negeneralizovan\u00fdch rezidu\u00e1ln\u00edch n\u00e1dor\u016f po ukon\u010den\u00ed syst\u00e9mov\u00e9 l\u00e9\u010dby. NSCLC m\u00e1 diferencovanou citlivost na radioterapii a chemoterapii, generalizuje pozd\u011bji, chirurgick\u00e1 l\u00e9\u010dba m\u00e1 u nemetastatick\u00e9 nemoci kurativn\u00ed potenci\u00e1l a d\u00e1v\u00e1 u radik\u00e1ln\u011b odoperovan\u00fdch nemocn\u00fdch \u0161anci na dlouhodob\u00e9 p\u0159e\u017eit\u00ed. Proto je v\u010dasn\u00e1 a spr\u00e1vn\u00e1 histologick\u00e1 klasifikace ka\u017ed\u00e9ho n\u00e1doru vit\u00e1ln\u011b d\u016fle\u017eit\u00e1. Nej\u010dast\u011bj\u0161\u00edm typem nemalobun\u011b\u010dn\u00e9 plicn\u00ed rakoviny je dla\u017edicobun\u011b\u010dn\u00fd karcinom (asi 35 % v\u0161ech plicn\u00edch karcinom\u016f). Je charakterizov\u00e1n sp\u00ed\u0161e centr\u00e1ln\u011bj\u0161\u00edm r\u016fstem a relativn\u011b p\u0159\u00edzniv\u011bj\u0161\u00ed progn\u00f3zou. Adenokarcinomy jsou druh\u00fdm nej\u010dast\u011bj\u0161\u00edm histologick\u00fdm typem (asi 30 %), ve Spojen\u00fdch st\u00e1tech dokonce nej\u010dast\u011bj\u0161\u00edm. Vznikaj\u00ed v bronchi\u00e1ln\u00edch \u017el\u00e1zk\u00e1ch, proto b\u00fdvaj\u00ed ulo\u017eeny perifern\u011b. Bronchioloalveol\u00e1rn\u00ed karcinomy vych\u00e1zej\u00ed z pneumocyt\u016f II. \u0159\u00e1du, rostou pod\u00e9l alveol\u00e1rn\u00edch sept jako perifern\u00ed uzly, v\u00edce\u010detn\u00e9 l\u00e9ze nebo se mohou manifestovat jako rychle progreduj\u00edc\u00ed pneumonick\u00e9 formy. Velkobun\u011b\u010dn\u00fd karcinom p\u0159edstavuje asi10\u201315 % z pod\u00edlu prim\u00e1rn\u00edch plicn\u00edch novotvar\u016f, je tvo\u0159en velk\u00fdmi atypick\u00fdmi bu\u0148kami nevykazuj\u00edc\u00edmi ani keratinizaci, ani glandul\u00e1rn\u00ed formace. Plicn\u00ed karcinom se m\u016f\u017ee diferencovat v jak\u00fdkoli typ, resp. subtyp n\u00e1doru, a to do kter\u00e9hokoli stupn\u011b, nav\u00edc v jednom a tomt\u00e9\u017e n\u00e1doru mohou b\u00fdt okrsky r\u016fzn\u011b diferencovan\u00e9 n\u00e1dorov\u00e9 tk\u00e1n\u011b. Stejn\u011b tak se v jednom n\u00e1doru mohou kombinovat r\u016fzn\u00e9 histologick\u00e9 typy n\u00e1doru. Terapeutick\u00e1 a prognostick\u00e1 rozvaha pak odpov\u00edd\u00e1 hor\u0161\u00ed variant\u011b tumoru.<\/p>\n<h5>5.7.3.1 Zkr\u00e1cen\u00e1 klasifikace prim\u00e1rn\u00edch plicn\u00edch n\u00e1dor\u016f<\/h5>\n<p>karcinom:<\/p>\n<ul>\n<li>dla\u017edicobun\u011b\u010dn\u00fd karcinom<\/li>\n<li>adenokarcinom<\/li>\n<li>velkobun\u011b\u010dn\u00fd karcinom<\/li>\n<li>malobun\u011b\u010dn\u00fd karcinom<\/li>\n<li>karcinosarkom<\/li>\n<li>karcinom typu slinn\u00fdch \u017el\u00e1z<\/li>\n<\/ul>\n<p>karcinoid:<\/p>\n<ul>\n<li>typick\u00fd karcinoid<\/li>\n<li>atypick\u00fd karcinoid sarkommezoteliomplazmocytomlymfommelanomneklasifikovan\u00e9 n\u00e1dory<\/li>\n<\/ul>\n<h4>5.7.4 Klinick\u00e1 prezentace<\/h4>\n<p>Plicn\u00ed karcinom je onemocn\u011bn\u00ed typick\u00e9 dlouh\u00fdm asymptomatick\u00fdm pr\u016fb\u011bhem. Proto\u017ee l\u00e9\u010dba karcinomu v \u010dasn\u00e9m stadiu (early cancer) je jednodu\u0161\u0161\u00ed a m\u00e1 podstatn\u011b lep\u0161\u00ed v\u00fdsledky ne\u017e terapie pokro\u010dil\u00fdch stadi\u00ed, m\u00e1 pro nemocn\u00e9ho zcela z\u00e1sadn\u00ed v\u00fdznam v\u010dasn\u00e1 diagn\u00f3za. Krom\u011b screeningov\u00fdch metod (skiagram hrudn\u00edku, cytologie sputa), kter\u00e9 v\u0161ak nejsou pro depist\u00e1\u017e rutinn\u011b vyu\u017e\u00edv\u00e1ny, m\u00e1 pro rozpozn\u00e1n\u00ed plicn\u00ed rakoviny vit\u00e1ln\u00ed d\u016fle\u017eitost detailn\u00ed znalost klinick\u00e9 symptomatologie. Bohu\u017eel stanoven\u00ed diagn\u00f3zy na podklad\u011b klinick\u00fdch pot\u00ed\u017e\u00ed je mo\u017en\u00e9 pouze u pozdn\u00edch, lok\u00e1ln\u011b pokro\u010dil\u00fdch \u010di generalizovan\u00fdch n\u00e1dor\u016f. Samotn\u00fd n\u00e1dor se m\u016f\u017ee projevovat p\u0159\u00edznaky z lok\u00e1ln\u00edho r\u016fstu, symptomy z region\u00e1ln\u00ed extenze, symptomatologi\u00ed metast\u00e1z a paraneoplastick\u00fdmi jevy.<\/p>\n<ul>\n<li style=\"text-align: justify;\"><strong>Projevy lok\u00e1ln\u00edho r\u016fstu<\/strong><br \/>\nZ\u00e1kladn\u00edm a nej\u010dast\u011bj\u0161\u00edm projevem (a\u017e 70 % p\u0159\u00edpad\u016f) lok\u00e1ln\u00edho r\u016fstu plicn\u00edho karcinomu je ka\u0161el, jeho\u017e vyvol\u00e1vaj\u00edc\u00ed p\u0159\u00ed\u010dinou m\u016f\u017ee b\u00fdt posti\u017een\u00ed bronchi\u00e1ln\u00ed sliznice, nadprodukce hlenu, pneumonie za strikturou, rozpad tumoru nebo pleur\u00e1ln\u00ed v\u00fdpotek. Varuj\u00edc\u00edm p\u0159\u00edznakem je ka\u0161el trvaj\u00edc\u00ed d\u00e9le jak 4 t\u00fddny, zm\u011bna jeho charakteru nebo jeho koincidence s dal\u0161\u00edmi p\u0159\u00edznaky, zejm\u00e9na hemopt\u00fdzou.<br \/>\nP\u0159ibli\u017en\u011b u t\u0159etiny nemocn\u00fdch se plicn\u00ed rakovina m\u016f\u017ee projevit hemopt\u00fdzou vyvolanou nekr\u00f3zou tumoru, ulceracemi bronchi\u00e1ln\u00ed sliznice, aroz\u00ed plicn\u00edch c\u00e9v \u010di postobstruk\u010dn\u00ed pneumoni\u00ed. P\u0159ibli\u017en\u011b t\u0159etina a\u017e polovina nemocn\u00fdch trp\u00ed n\u011bkter\u00fdmz kombinace p\u0159\u00edznak\u016f vyvolan\u00fdch z\u00e1n\u011btem za n\u00e1dorovou strikturou \u010di inflamac\u00ed p\u0159\u00edmo v tumoru(teploty, t\u0159esavky, hnisav\u00e1 expektorace, pleur\u00e1ln\u00ed v\u00fdpotek). \u010ctvrtina a\u017e polovina nemocn\u00fdch si st\u011b\u017euje na bolesti hrudn\u00edku dan\u00e9 n\u00e1dorovou infiltrac\u00ed pleury, hrudn\u00ed st\u011bny \u010di mediastina. Zbyl\u00e9 p\u0159\u00edznaky jsou p\u0159\u00edli\u0161 nespecifick\u00e9 pro stanoven\u00ed klinick\u00e9 suspekce na plicn\u00ed rakovinu.<\/li>\n<li style=\"text-align: justify;\"><strong>Projevy region\u00e1ln\u00ed<\/strong><br \/>\nP\u0159\u00edznaky region\u00e1ln\u00ed (torak\u00e1ln\u00ed) jsou v\u00edce specifick\u00e9, bohu\u017eel sv\u011bd\u010d\u00ed ji\u017e o velmi pokro\u010dil\u00e9m (v\u011bt\u0161inou inoperabiln\u00edm) n\u00e1doru. \u010ctvrtina a\u017e polovina nemocn\u00fdch si st\u011b\u017euje na bolesti hrudn\u00edku dan\u00e9 n\u00e1dorovou infiltrac\u00ed pleury, hrudn\u00ed st\u011bny \u010di mediastina. Typick\u00fdmi projevy, dan\u00fdmi p\u0159\u00edmou propagac\u00ed centr\u00e1ln\u00edho n\u00e1doru do mediastin\u00e1ln\u00edch struktur \u010di metastatick\u00fdm posti\u017een\u00edm mediastin\u00e1ln\u00edch uzlin, jsou jednostrann\u00e9 l\u00e9ze br\u00e1ni\u010dn\u00edho, event. levostrann\u00e9ho vratn\u00e9ho nervu, kter\u00fdm odpov\u00eddaj\u00ed par\u00e9zy stejnostrann\u00e9 br\u00e1nice, resp. hlasivky. Dysfagie je typick\u00fdm projevem tlaku mediastin\u00e1ln\u00edch uzlin na j\u00edcen,pokud nejde o direktn\u00ed invazi. Ezofagobronchi\u00e1ln\u00ed p\u00ed\u0161t\u011bl se projevuje vyka\u0161l\u00e1v\u00e1n\u00edm potravy po j\u00eddle,podobn\u00fdm zp\u016fsobem se ale m\u016f\u017ee manifestovat tak\u00e9 aspirace p\u0159i par\u00e9ze hlasivky. Posti\u017een\u00ed perikardu (srdce) je nej\u010dast\u011bji prov\u00e1zeno v\u00fdpotkem,v\u011bt\u0161inou asymptomatick\u00fdm, vz\u00e1cn\u011bji zp\u016fsobuj\u00edc\u00edm tachyarytmie \u010di tampon\u00e1du. Karcinom plic a prsuje nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou malign\u00edho pleur\u00e1ln\u00edho v\u00fdpotku, jeho\u017e p\u0159\u00ed\u010dinou m\u016f\u017ee b\u00fdt karcin\u00f3za pleury, obstrukce lymfatick\u00fdch struktur, pneumonie, chylotorax, plicn\u00ed embolizace, hypoalbuminemie nebokomplikace terapie. Ka\u017ed\u00fd suspektn\u00ed v\u00fdpotek mus\u00ed b\u00fdt vy\u0161et\u0159en opakovan\u011b cytologicky, a nen\u00ed-li v\u00fdsledek jednozna\u010dn\u00fd, je indikov\u00e1na torakoskopie. Malign\u00ed bu\u0148ky ve v\u00fdpotku kontraindikuj\u00ed chirurgickou resekci. Syndrom horn\u00ed dut\u00e9 \u017e\u00edly je soubor p\u0159\u00edznak\u016f prov\u00e1zej\u00edc\u00edch uz\u00e1v\u011br horn\u00ed dut\u00e9 \u017e\u00edly objemn\u00fdmi uzlinami horn\u00edho mediastina vpravo, p\u0159\u00edm\u00fdm r\u016fstem n\u00e1doru prav\u00e9ho tracheobronchi\u00e1ln\u00edho \u00fahlu \u010di kombinac\u00ed obou p\u0159\u00ed\u010din. Projevuje se bolestmi hlavy, otokem, zarudnut\u00edm a\u017e cyan\u00f3zou obli\u010deje a sliznic, chem\u00f3zou spojivek a n\u00e1padn\u00fdmi kolater\u00e1lami na horn\u00ed polovin\u011b hrudn\u00edku. Pancoast\u016fv syndrom, zp\u016fsoben\u00fd pror\u016fst\u00e1n\u00edm n\u00e1doru apexu pl\u00edce do c\u00e9vn\u00edch a nervov\u00fdch struktur horn\u00ed hrudn\u00ed apertury, se projevuje bolestmi v oblasti lopatky a ramene, irita\u010dn\u00edmi nebo z\u00e1nikov\u00fdmi jevy v oblasti dist\u00e1ln\u00edch kr\u010dn\u00edch a l. hrudn\u00edho ko\u0159ene (C7, C8, Th1), Hornerovou tri\u00e1dou (pt\u00f3za, mi\u00f3za, enoftalmus).<\/li>\n<li style=\"text-align: justify;\"><strong>Projevy metastatick\u00e9<br \/>\n<\/strong>Extratorak\u00e1ln\u00ed metastick\u00e9 projevy jsou v\u011bt\u0161inou pozdn\u00edmi, pretermin\u00e1ln\u00edmi p\u0159\u00edznaky pokro\u010dil\u00fdch stadi\u00ed nemoci. Malobun\u011b\u010dn\u00fd karcinom metast\u00e1zuje d\u0159\u00edve a mnoho\u010detn\u011b, je pova\u017eov\u00e1n za syst\u00e9movou nemoc ji\u017e v dob\u011b diagn\u00f3zy. Nemalobun\u011b\u010dn\u00fd plicn\u00edkarcinom b\u00fdv\u00e1 diagnostikov\u00e1n ve stadiu metastatick\u00e9 nemoci asi ve 40\u201350 %. Nej\u010dast\u011bj\u0161\u00edmi c\u00edlov\u00fdmi org\u00e1ny \u010di tk\u00e1n\u011bmi pro metastatick\u00fd rozsev plicn\u00ed rakoviny jsou pl\u00edce, nadledviny, j\u00e1tra, CNS a skelet.Solit\u00e1rn\u00ed metast\u00e1zy nadledvin, jater \u010di CNS nevylu\u010duj\u00ed kurativn\u00ed chirurgick\u00fd z\u00e1krok, samoz\u0159ejm\u011b jako sou\u010d\u00e1st komplexn\u00ed l\u00e9\u010dby.<\/li>\n<li style=\"text-align: justify;\"><strong>Paraneoplastick\u00e9 projevy<\/strong><br \/>\nParaneoplastick\u00e9 (extratorak\u00e1ln\u00ed nemetastatick\u00e9)projevy jsou na plicn\u00ed karcinom a zejm\u00e9na na jeho malobun\u011b\u010dn\u00fd subtyp v\u00e1zany asi ve 20 %. Jde o celou \u0159adu v\u011bt\u0161inou nespecifick\u00fdch projev\u016f p\u016fsoben\u00fdch ektopickou produkc\u00ed biologicky aktivn\u00edch peptid\u016f, cytokin\u016f, protil\u00e1tek a dal\u0161\u00edch substanc\u00ed charakteru hormon\u016f. \u010cast\u00e1 je hyperkalcemie dan\u00e1 sekrec\u00ed ektopick\u00e9ho paratyroidhormonrelatedpeptidu, hyponatremie a retence vody z ektopick\u00e9produkce antidiuretick\u00e9ho hormonu, Cushing\u016fv syndrom z n\u00e1dorov\u00e9 sekrece corticotropin releasing hormonu, karcinoidn\u00ed syndrom u karcinoid\u016fa malobun\u011b\u010dn\u00fdch karcinom\u016f a \u0159ada dal\u0161\u00edch endokrinn\u00edch odchylek. Dal\u0161\u00ed paraneoplastick\u00e9 projevy mohou b\u00fdt ko\u017en\u00ed (dermatomyositis, acantosis nigricans, eryt\u00e9my, hyperpigmentace), muskuloskelet\u00e1ln\u00ed (hypertrofick\u00e1 osteoartropatie, polymyositida, myopatie), neurologick\u00e9 (pseudomyastenie, perifern\u00ed neuropatie, polyradikulopatie), hematologick\u00e9 (an\u00e9mie, polycytemie, hyperkoagula\u010dn\u00ed stavy, leukocyt\u00f3za, eozinofilie) a ren\u00e1ln\u00ed (glomerulonefritida, tubulointerstici\u00e1ln\u00ed nemoci, nefrotick\u00fd syndrom).<\/li>\n<\/ul>\n<h4>5.7.5 Diagnostika<\/h4>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_145.png\"><img decoding=\"async\" title=\"Obr. 15 \u2013 CT n\u00e1dorov\u00e9 (Joresovy) kaverny horn\u00edho laloku vpravo\" alt=\"Obr. 15 \u2013 CT n\u00e1dorov\u00e9 (Joresovy) kaverny horn\u00edho laloku vpravo\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_145.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 15<br \/>CT n\u00e1dorov\u00e9 (Joresovy) kaverny horn\u00edho laloku vpravo<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1471.png\"><img decoding=\"async\" title=\"Obr. 16 \u2013 MR aortografie po n\u00e1hrad\u011b descendentn\u00ed aorty v r\u00e1mci pneumonektomie pro karcinom\" alt=\"Obr. 16 \u2013 MR aortografie po n\u00e1hrad\u011b descendentn\u00ed aorty v r\u00e1mci pneumonektomie pro karcinom\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1471.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 16<br \/>MR aortografie po n\u00e1hrad\u011b descendentn\u00ed aorty v r\u00e1mci pneumonektomie pro karcinom<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1481.png\"><img decoding=\"async\" title=\"Obr. 17 \u2013 Patologick\u00e1 akumulace 6-FDG v recidiv\u011b tumoru prav\u00e9 pl\u00edce a v paratrache\u00e1ln\u00ed uzlin\u011b\" alt=\"Obr. 17 \u2013 Patologick\u00e1 akumulace 6-FDG v recidiv\u011b tumoru prav\u00e9 pl\u00edce a v paratrache\u00e1ln\u00ed uzlin\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1481.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 17<br \/>Patologick\u00e1 akumulace 6FDG v recidiv\u011b tumoru prav\u00e9 pl\u00edce a v paratrache\u00e1ln\u00ed uzlin\u011b<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1501.png\"><img decoding=\"async\" title=\"Obr. 18 \u2013 Bronchoskopick\u00fd n\u00e1lez u karcinomu plic\" alt=\"Obr. 18 \u2013 Bronchoskopick\u00fd n\u00e1lez u karcinomu plic\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1501.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 18<br \/>Bronchoskopick\u00fd n\u00e1lez u karcinomu plic<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_151.png\"><img decoding=\"async\" title=\"Obr. 19 \u2013 Mediastinoskop, ods\u00e1vac\u00ed kanyla a bioptick\u00e9 kle\u0161t\u011b\" alt=\"Obr. 19 \u2013 Mediastinoskop, ods\u00e1vac\u00ed kanyla a bioptick\u00e9 kle\u0161t\u011b\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_151.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 19<br \/>Mediastinoskop, ods\u00e1vac\u00ed kanyla a bioptick\u00e9 kle\u0161t\u011b<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\"><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<ul>\n<li style=\"text-align: justify;\"><strong>Klinick\u00e9 vy\u0161et\u0159en\u00ed<br \/>\n<\/strong>Pe\u010dliv\u00e9 klinick\u00e9 vy\u0161et\u0159en\u00ed hodnot\u00ed z komplexn\u00edho pohledu v\u0161echny d\u016fle\u017eit\u00e9, m\u00e9n\u011b d\u016fle\u017eit\u00e9 i margin\u00e1ln\u00ed aspekty celkov\u00e9ho klinick\u00e9ho stavu se zvl\u00e1\u0161tn\u00edm zam\u011b\u0159en\u00edm na respira\u010dn\u00ed syst\u00e9m. Oslaben\u00e9 \u010di vymizel\u00e9 d\u00fdch\u00e1n\u00ed, zkr\u00e1cen\u00fd poklep \u010di trubicov\u00e9 d\u00fdch\u00e1n\u00ed mohou sv\u011bd\u010dit pro atelekt\u00e1zu nebo v\u00fdpotek, jde v\u0161ak o symptomy zna\u010dn\u011b nespecifick\u00e9. Je nezbytn\u00e9 vy\u0161et\u0159it uzliny nadkl\u00ed\u010dku, na krku a v axil\u00e1ch. D\u016fle\u017eit\u00e9 je posouzen\u00ed celkov\u00e9ho zdravotn\u00edho stavu, kter\u00fd m\u016f\u017ee b\u00fdt alterov\u00e1n jak samotn\u00fdm n\u00e1dorov\u00fdm onemocn\u011bn\u00edm, tak dal\u0161\u00edmi komorbiditami.<\/li>\n<li style=\"text-align: justify;\"><strong>Skiagram hrudn\u00edku<br \/>\n<\/strong>Krom\u011b standardn\u00ed zadop\u0159edn\u00ed projekce je indikov\u00e1na i projekce bo\u010dn\u00ed z d\u016fvodu mo\u017en\u00e9 sumace centr\u00e1ln\u011b ulo\u017een\u00fdch n\u00e1dor\u016f vlevo se srde\u010dn\u00edm st\u00ednema baz\u00e1ln\u00edch l\u00e9z\u00ed s kupulemi br\u00e1ni\u010dn\u00edmi. Bohu\u017eel p\u0159ibli\u017en\u011b 4 % nemocn\u00fdch s plicn\u00edm n\u00e1dorem maj\u00ed sn\u00edmek bez patologie a p\u0159ibli\u017en\u011b u jedn\u00e9 p\u011btiny nemocn\u00fdch s plicn\u00edm novotvarem b\u00fdv\u00e1 l\u00e9ze patrn\u00e1 na sn\u00edmku p\u0159ehl\u00e9dnuta. V \u0159ad\u011b p\u0159\u00edpad\u016f d\u00e1 nativn\u00ed sn\u00edmek informace relevantn\u00ed pro staging (velikost tumoru, lokalizace, p\u0159\u00edtomnost satelitn\u00edch lo\u017eisek,invaze do skeletu, \u017eeber, v\u00fdpotek). N\u00e1dor se m\u016f\u017ee na sn\u00edmku zobrazit jako okrouhl\u00fd perifern\u00ed st\u00edn, jednostrann\u00e9 roz\u0161\u00ed\u0159en\u00ed plicn\u00edho hilu, roz\u0161\u00ed\u0159en\u00ed mediastina, atelekt\u00e1za, apik\u00e1ln\u00ed st\u00edn \u010di pleur\u00e1ln\u00ed v\u00fdpotek. Pro malignitu sv\u011bd\u010d\u00ed velikost l\u00e9ze nad 3 cm,lokalizace v horn\u00edm laloku, spikulace, nep\u0159\u00edtomnost, resp. excentricita kalcifikac\u00ed, progrese v \u010dase.<\/li>\n<li style=\"text-align: justify;\"><strong>V\u00fdpo\u010detn\u00ed tomografie (computed tomography\u2013 CT)<\/strong><br \/>\nKrom\u011b velikosti a lokalizace tumoru umo\u017e\u0148uje CT posoudit zn\u00e1mky invaze (do hrudn\u00ed st\u011bny, apik\u00e1ln\u00edch struktur, br\u00e1nice, mediastina a mediastin\u00e1ln\u00edch struktur), satelitn\u00ed plicn\u00ed uzly a pleur\u00e1ln\u00ed v\u00fdpotek \u010di pleur\u00e1ln\u00ed nodulace (obr. 15). Penetrace do okoln\u00edch struktur nen\u00ed v\u017edy pomoc\u00ed CT v\u011brohodn\u011b diagnostikovateln\u00e1, d\u016fkazem direktn\u00ed infiltrace je nap\u0159. destrukce skeletu, extratorak\u00e1ln\u00ed propagace \u010di exofytick\u00e9 formace v dut\u00fdch struktur\u00e1ch(vena cava sup., p\u0159eds\u00ed\u0148).CT nem\u016f\u017ee spolehliv\u011b rozhodnout o metastatick\u00e9m, resp. morfologick\u00e9m posti\u017een\u00ed uzlin. Pouh\u00e9 zv\u011bt\u0161en\u00ed uzliny nen\u00ed p\u0159esn\u00fdm ukazatelem mo\u017en\u00e9 infiltrace. Obvykle se za ,,pozitivn\u00ed\u201c pova\u017euje uzlina v\u011bt\u0161\u00ed ne\u017e 1 cm. Uzliny men\u0161\u00ed ne\u017e 1 cm b\u00fdvaj\u00ed posti\u017eeny metast\u00e1zami m\u00e9n\u011b ne\u017e v 10 % p\u0159\u00edpad\u016f, \u010dast\u011bji u a denokarcinomu, vz\u00e1cn\u011b u spinocelul\u00e1rn\u00edho karcinomu. Senzitivita, resp. specificita CT diagnostiky lymfadenopatie mediastina se pohybuje kolem 50 a\u017e 70 %, kombinace s pozitronovou emisn\u00ed tomografi\u00ed (PET) podstatn\u011b zvy\u0161uje diagnostickou v\u00fdt\u011b\u017enost (v obou parametrech nad 90 %). Z d\u016fvodu statistick\u00e9 pravd\u011bpodobnosti diseminaceplicn\u00ed rakoviny do predilek\u010dn\u00edch org\u00e1n\u016f \u010di tk\u00e1n\u00ed se doporu\u010duje prov\u00e1d\u011bt CT hrudn\u00edku v rozsahu od nadkl\u00ed\u010dkov\u00e9 krajiny po doln\u00ed p\u00f3ly ledvin \u2013 tak lze zachytit l\u00e9ze v hlubok\u00fdch kr\u010dn\u00edch a skalenick\u00fdch uzlin\u00e1ch, v j\u00e1trech, nadledvin\u00e1ch, ledvin\u00e1ch a abdomin\u00e1ln\u00edch \u010di retroperitone\u00e1ln\u00edch lymfatick\u00fdchuzlin\u00e1ch. Postprocesingov\u00e9 zpracov\u00e1n\u00ed \u00fadaj\u016f z po\u010d\u00edta\u010de dovoluje trojdimenzion\u00e1ln\u00ed rekonstrukci.Takto lze vytvo\u0159it nap\u0159. v\u011brn\u00fd obraz pr\u016fdu\u0161kov\u00e9ho stromu \u2013 virtu\u00e1ln\u00ed bronchoskopii, kter\u00e1 je v\u00fdhodn\u00e1 u nemocn\u00fdch, kte\u0159\u00ed norm\u00e1ln\u00ed bronchoskopii netoleruj\u00ed, u l\u00e9z\u00ed, kter\u00e9 nejsou bronchoskopem dostupn\u00e9(za z\u00fa\u017een\u00edm), v r\u00e1mci poopera\u010dn\u00edch kontrol apod.<\/li>\n<li style=\"text-align: justify;\"><strong>Magnetick\u00e1 rezonance<\/strong><br \/>\nMagnetick\u00e1 rezonance (magnetic resonance imaging, MRI) nep\u0159in\u00e1\u0161\u00ed v r\u00e1mci b\u011b\u017en\u00e9ho klinick\u00e9 ho vyu\u017eit\u00ed z\u00e1sadn\u011bj\u0161\u00ed zm\u011bnu kvality informace, m\u00e1 ale v\u00fdhodu nulov\u00e9 radia\u010dn\u00ed z\u00e1t\u011b\u017ee. Samotn\u00e1 pl\u00edce obsahuje m\u00e1lo vody, proto nevytv\u00e1\u0159\u00ed dostate\u010dn\u011b siln\u00fd rezonan\u010dn\u00ed sign\u00e1l. Jednozna\u010dnou p\u0159ednost p\u0159ed CT m\u00e1 MRI u Pancoastova tumoru, zejm\u00e9na v posouzen\u00ed invaze do \u017eeber, obratl\u016f a brachi\u00e1ln\u00edho plexu a p\u0159\u00edpadn\u00e9 intraspin\u00e1ln\u00ed propagace, p\u0159esn\u011bj\u0161\u00ed je touto cestou tak\u00e9 posouzen\u00ed invaze do hrudn\u00ed st\u011bny, br\u00e1nice, mediastina \u010di perikardu (obr. 16).<\/li>\n<li style=\"text-align: justify;\"><strong>Sonografie<\/strong><br \/>\nSonografie hrudn\u00edku b\u00fdv\u00e1 n\u011bkdy neopr\u00e1vn\u011bn\u011b opom\u00edjena. Dovoluje nap\u0159\u00edklad diagnostiku v\u00fdpotk\u016f nebo ohrani\u010den\u00fdch nitrohrudn\u00edch kolekc\u00ed, p\u0159\u00edpadn\u011b umo\u017e\u0148uje navigaci p\u0159i punkc\u00edch, biopsi\u00edch \u010di dren\u00e1\u017e\u00edch.<\/p>\n<ul style=\"text-align: justify;\">\n<li><strong>Sonografie b\u0159icha<br \/>\n<\/strong>Sonograficky lze vylou\u010dit nebo potvrdit patologick\u00e1 lo\u017eiska v j\u00e1trech, ledvin\u00e1ch \u010di nadledvin\u00e1ch. Pokud nen\u00ed provediteln\u00e1 CT (n\u011bkter\u00e9 p\u0159\u00edstroje jsou nap\u0159.limitov\u00e1ny hmotnost\u00ed pacienta), je akceptovatelnou alternativou CT.<\/li>\n<\/ul>\n<\/li>\n<li style=\"text-align: justify;\"><strong>Scintigrafie skeletu<\/strong><br \/>\nRutinn\u011b je vyu\u017e\u00edv\u00e1na k vylou\u010den\u00ed kostn\u00edch metast\u00e1z malobun\u011b\u010dn\u00e9ho karcinomu, u nemalobun\u011b\u010dn\u00fdch tumor\u016f je indikov\u00e1na pouze u symptomatick\u00fdch pacient\u016f (bolesti, hmatn\u00e1 lo\u017eiska) a p\u0159i elevaci n\u011bkter\u00fdch s\u00e9rov\u00fdch parametr\u016f (ALP, Ca). Vy\u0161et\u0159en\u00ed samo o sob\u011b je vzhledem na svou citlivost zna\u010dn\u011b nespecifick\u00e9 s vysok\u00fdm po\u010dtem fale\u0161n\u011b pozitivn\u00edch v\u00fdsledk\u016f.<\/li>\n<li style=\"text-align: justify;\"><strong>Pozitronov\u00e1 emisn\u00ed tomografie (PET)<\/strong><br \/>\nPET vykazuje pom\u011brn\u011b vysokou spolehlivost v diferenci\u00e1ln\u00ed diagnostice fok\u00e1ln\u00edch plicn\u00edch l\u00e9z\u00ed o pr\u016fm\u011bru v\u011bt\u0161\u00edm ne\u017e 10 mm. V p\u0159\u00edpad\u011b mediastin\u00e1ln\u00ed lymfadenopatie jsou zat\u00edm v\u00fdsledky rozpa\u010dit\u00e9, nicm\u00e9n\u011b v kombinaci PETCT b\u00fdv\u00e1 popisov\u00e1na a\u017e 100% senzitivita a 95% specificita. Z\u00e1sadn\u00edm p\u0159\u00ednosem PET je mo\u017enost vylou\u010dit okultn\u00ed vzd\u00e1len\u00e9 metast\u00e1zy (obr. 17).<\/li>\n<li style=\"text-align: justify;\"><strong>Bronchoskopie<\/strong><br \/>\nB\u00fdv\u00e1 indikov\u00e1na na podklad\u011b suspektn\u00edho rentgenologick\u00e9ho n\u00e1lezu s c\u00edlem opticky a histologicky \u010di cytologicky potvrdit nebo vylou\u010dit n\u00e1dorov\u00fd proces a odhadnout jeho rozsah. Optick\u00fd n\u00e1lez m\u016f\u017ee b\u00fdt neoby\u010dejn\u011b variabiln\u00ed, od nepatrn\u00fdch zm\u011bn a\u017e po exulcerovan\u00e9 krv\u00e1cej\u00edc\u00ed l\u00e9ze obturuj\u00edc\u00ed velk\u00e9 d\u00fdchac\u00ed cesty, nicm\u00e9n\u011b a\u017e 40\u201350 % plicn\u00edch karcinom\u016f je mimo dosah optiky.V p\u0159\u00edpad\u011b perifern\u00edch l\u00e9z\u00ed m\u016f\u017ee pomoci MRI navigace \u010di endobronchi\u00e1ln\u00ed sonografie. Za p\u0159\u00edm\u00e9 optick\u00e9 zn\u00e1mky n\u00e1doru lze pova\u017eovat exofytick\u00e9 a polyp\u00f3zn\u00ed l\u00e9ze, infiltraci \u010di nepravidelnost endobronchi\u00e1ln\u00ed slizni\u010dn\u00ed v\u00fdstelky \u010di ztr\u00e1tu chrupav\u010dit\u00e9 kresby (obr. 18). Nep\u0159\u00edm\u00e9 zn\u00e1mky jsou d\u00e1ny tlakem n\u00e1doru \u010di uzliny na bronchus ze zevn\u011bj\u0161ku,projevuj\u00ed se jako z\u00fa\u017een\u00ed nebo roz\u0161\u00ed\u0159en\u00ed kariny. Pomoc\u00ed bronchoskopie lze z\u00edskat materi\u00e1l k cytologick\u00e9mu vy\u0161et\u0159en\u00ed cestou aspirace bronchi\u00e1ln\u00edhosekretu, sond\u00e1\u017ee \u010di v\u00fdplachu bronchu, bronchoalveol\u00e1rn\u00ed lav\u00e1\u017ee, kart\u00e1\u010dkov\u00e9 abraze, punkce n\u00e1doru a transbronchi\u00e1ln\u00ed, resp. transtrache\u00e1ln\u00ed punkce.<br \/>\nV\u011bt\u0161\u00ed vzorek k histologick\u00e9mu vy\u0161et\u0159en\u00ed lze v\u011bt\u0161inou z\u00edskat pouze p\u0159\u00edmou, nap\u0159. kl\u00ed\u0161\u0165kovou biopsi\u00ed. Topografick\u00e9 \u00fadaje z\u00edskan\u00e9 touto cestou maj\u00ed z\u00e1sadn\u00ed v\u00fdznam p\u0159i volb\u011b rozsahu resekce u centr\u00e1ln\u00edch n\u00e1dor\u016f a v \u00favaze o bronchoplastick\u00fdch a tracheoplastick\u00fdch v\u00fdkonech. \u010casn\u00e1 diagnostika recidiv v pah\u00fdlu bronchu je bez bronchoskopick\u00fdch kontrol v r\u00e1mci followup nemysliteln\u00e1.<br \/>\n<em id=\"__mceDel\">Na okraj je t\u0159eba zm\u00ednit fluorescen\u010dn\u00ed bronchoskopii, kter\u00e1 vyu\u017e\u00edv\u00e1 bu\u010f rozd\u00edln\u00e9 autofluorescence zdrav\u00e9 a n\u00e1dorov\u00e9 tk\u00e1n\u011b, nebo detekuje fluorescenci fotosenzitivuj\u00edc\u00edch l\u00e1tek v r\u00e1mci fotodynamick\u00e9 diagnostiky.<\/em><\/li>\n<li style=\"text-align: justify;\"><strong>Transpariet\u00e1ln\u00ed plicn\u00ed biopsie<\/strong><br \/>\nT\u00edmto zp\u016fsobem lze ov\u011b\u0159it perifern\u00ed plicn\u00ed l\u00e9ze,stejn\u011b jako afekce dosahuj\u00edc\u00ed mediastina nebo penetruj\u00edc\u00ed do hrudn\u00ed st\u011bny. K punkci se pou\u017e\u00edvaj\u00ed tenk\u00e9 jehly, trucut jehlami lze z\u00edskat v\u00e1le\u010dek tk\u00e1n\u011b k histologick\u00e9mu vy\u0161et\u0159en\u00ed. Zaveden\u00ed jehly je mo\u017en\u00e9 u perifern\u00edch l\u00e9z\u00ed navigovat sonograficky,obvykle se v\u0161ak pou\u017e\u00edv\u00e1 skiaskopick\u00e1 nebo CT monitorace.<\/li>\n<li style=\"text-align: justify;\"><strong>Biopsie supraklavikul\u00e1rn\u00edch uzlin<\/strong><br \/>\nPot\u0159eba explorovat supraklavikul\u00e1rn\u00ed uzliny je pov\u011bt\u0161inou d\u00e1na pozitivn\u00edm n\u00e1lezem zobrazovac\u00edch metod (USG, CT, PET). V p\u0159\u00edpad\u011b dob\u0159e hmatn\u00e9 uzliny nad kl\u00ed\u010dkem je v\u011bt\u0161inou dostate\u010dn\u00e1 punk\u010dn\u00ed biopsie, negativn\u00ed histopatologick\u00fd n\u00e1lez indikujechirurgickou biopsii. Pozitivita supraklavikul\u00e1rn uzliny u rakoviny plic ur\u010duje N3 lymfadenopatii.<\/li>\n<li style=\"text-align: justify;\"><strong>Kr\u010dn\u00ed mediastinoskopie<\/strong><br \/>\nDovoluje bioptovat paratrache\u00e1ln\u00ed a p\u0159edn\u00ed bifurka\u010dn\u00ed uzliny, m\u016f\u017ee tedy u karcinomu plic rozli\u0161itN2 a N3 posti\u017een\u00ed, a pokud jsou bioptov\u00e1ny hilov\u00e9 uzliny (pozice 10), lze rozli\u0161it mezi posti\u017een\u00edm N1 a N2 uzlin. V ur\u010dit\u00fdch situac\u00edch m\u016f\u017ee b\u00fdt mediastinoskopie n\u00e1pomocna v posouzen\u00ed resekability centr\u00e1ln\u00edch n\u00e1dor\u016f, zejm\u00e9na v prav\u00e9m tracheobronchi\u00e1ln\u00edm \u00fahlu (diagn\u00f3za invaze do horn\u00ed dut\u00e9 \u017e\u00edly \u010di do st\u011bny pr\u016fdu\u0161nice). Diagnostick\u00e1 v\u00fdt\u011b\u017enost mediastinoskopie je limitov\u00e1na t\u00edm, \u017ee uzliny pod\u00e9l a p\u0159ed obloukem aorty (pozice 5 a 6), stejn\u011b jako uzliny doln\u00edho mediastin\u00e1ln\u00edho kompartmentu (zadn\u00ed bifurka\u010dn\u00ed z pozice 7, pozice 8 a 9) jsou touto cestou nedostupn\u00e9 (obr. 19). Videomediastinoskopie m\u00e1 v\u00fdhodu zv\u011bt\u0161en\u00ed obrazu na monitoru.<\/li>\n<li style=\"text-align: justify;\"><strong>Roz\u0161\u00ed\u0159en\u00e1 mediastinoskopie<\/strong><br \/>\nUmo\u017e\u0148uje odebrat uzliny aortopulmon\u00e1ln\u00edho ok\u00e9nka a p\u0159ed obloukem aorty (pozice 5 a 6), kter\u00e9 b\u00fdvaj\u00ed pravideln\u011b posti\u017eeny p\u0159i n\u00e1dorech horn\u00edch plicn\u00edch lalok\u016f vlevo. Roz\u0161\u00ed\u0159en\u00e1 mediastinoskopiese v\u011bt\u0161inou neprov\u00e1d\u00ed samostatn\u011b, ale po dokon\u010den\u00ed mediastinoskopie klasick\u00e9 se mediastinoskop zavede do tunelu vytvo\u0159en\u00e9ho tupou preparac\u00ed nad obloukem aorty mezi truncus brachiocephalicusa levou karotickou tepnou.<\/li>\n<li style=\"text-align: justify;\"><strong>P\u0159edn\u00ed mediastinotomie<\/strong><br \/>\nChamberlainova operace je v\u00fdkon umo\u017e\u0148uj\u00edc\u00ed posouzen\u00ed lymfadenopatie v aortopulmon\u00e1ln\u00edm ok\u00e9nku \u010di mediastin\u00e1ln\u00ed invaze u tumor\u016f horn\u00edho laloku vlevo.<\/li>\n<li style=\"text-align: justify;\"><strong>Torakoskopie a videotorakoskopie<\/strong><br \/>\nVideotorakoskopie v posledn\u00ed dob\u011b nahradila jednostrann\u00e9 postupy (p\u0159edn\u00ed mediastinoskopii, resp.p\u0159edn\u00ed mediastinotomii) a v n\u011bkter\u00fdch indikac\u00edch z\u010d\u00e1sti i klasickou mediastinoskopii. Zpravidla b\u00fdv\u00e1 indikov\u00e1na k ov\u011b\u0159en\u00ed a definitivn\u00ed diagnostice plicn\u00edch a pleur\u00e1ln\u00edch proces\u016f a uzlin nedostupn\u00fdch mediastinoskopii (uzliny aortopulmon\u00e1ln\u00ed a preaort\u00e1ln\u00ed pozice 5 a 6, uzliny doln\u00edho mediastin\u00e1ln\u00edho kompartmentu z pozice 8 a 9). Krom\u011b stagingu uzlinov\u00e9ho posti\u017een\u00ed m\u016f\u017ee p\u0159in\u00e9st tak\u00e9 z\u00e1sadn\u00ed informace o resekabilit\u011b tumoru, event. jeho generalizaci.<\/li>\n<li style=\"text-align: justify;\"><strong>Otev\u0159en\u00e1 plicn\u00ed biopsie<\/strong><br \/>\nDnes u\u017e t\u00e9m\u011b\u0159 obsoletn\u00ed metoda slou\u017e\u00edc\u00ed k rychl\u00e9 diagnostice plicn\u00edho posti\u017een\u00ed nebo generalizace,prov\u00e1d\u011bn\u00e1 v\u011bt\u0161inou z mal\u00e9ho anterolater\u00e1ln\u00edho p\u0159\u00edstupu.<\/li>\n<li style=\"text-align: justify;\"><strong>Torakotomie<\/strong><br \/>\nV\u0161echny v\u00fd\u0161e uveden\u00e9 medoty vedou ke spr\u00e1vn\u00e9 diagn\u00f3ze a p\u0159\u00edpadn\u011b k ur\u010den\u00ed stadia nemoci a\u017e v 90 % p\u0159\u00edpad\u016f. Jinak nezb\u00fdv\u00e1 ne\u017e se uch\u00fdlit k probatorn\u00ed torakotomii, kter\u00e1 dovoluje korelovat n\u00e1lezy paraklinick\u00fdch vy\u0161et\u0159en\u00ed se skute\u010dn\u00fdm rozsahem prim\u00e1rn\u00edho n\u00e1doru, potvrdit \u010di vylou\u010dit jeho operabilitu, posoudit afekce na pleu\u0159e \u010di v mediastinu nebo vyhodnotit stav stejnostrann\u00fdch mediastin\u00e1ln\u00edch uzlin.<\/li>\n<\/ul>\n<h5>5.7.5.1 TNM klasifikace<\/h5>\n<p>TNM klasifikace popisuje rozsah n\u00e1doru na podklad\u011b vyhodnocen\u00ed 3 parametr\u016f:<\/p>\n<ul>\n<li>T \u2013 rozsah prim\u00e1rn\u00edho n\u00e1doru,<\/li>\n<li>N \u2013 rozsah posti\u017een\u00ed region\u00e1ln\u00edch lymfatick\u00fdch\u00a0uzlin,<\/li>\n<li>M \u2013 p\u0159\u00edtomnost \u010di nep\u0159\u00edtomnost vzd\u00e1len\u00fdch metast\u00e1z.<\/li>\n<\/ul>\n<h6>TNM k lasifi kace bronchogenn\u00ed ho karcinomu z roku 2009<\/h6>\n<p><em><strong>T: prim\u00e1rn\u00ed n\u00e1dor<\/strong><\/em><\/p>\n<ul>\n<li><strong>TX<\/strong>: prim\u00e1rn\u00ed n\u00e1dor nehodnotiteln\u00fd, je pozitivn\u00ed\u00a0cytologie, n\u00e1dor nebyl prok\u00e1z\u00e1n bronchoskopickyani zobrazovac\u00edmi vy\u0161et\u0159en\u00edmi<\/li>\n<li><strong>T0<\/strong>: beze zn\u00e1mek prim\u00e1rn\u00edho n\u00e1doru<\/li>\n<li><strong>Tis<\/strong>: karcinom in situ<\/li>\n<li><strong>T1<\/strong>: n\u00e1dor \u2264 3cm v nejv\u011bt\u0161\u00edm rozm\u011bru, bez pleur\u00e1ln\u00ed (mediastin\u00e1ln\u00ed) invaze, limitovan\u00fd na lob\u00e1rn\u00edbronchus\n<ul>\n<li><strong>T1a<\/strong>: n\u00e1dor \u2264 2cm v nejv\u011bt\u0161\u00edm rozm\u011bru<\/li>\n<li><strong>T1b<\/strong>: n\u00e1dor &gt; 2cm a \u2264 3cm<\/li>\n<\/ul>\n<\/li>\n<li><strong>T2<\/strong>: n\u00e1dor je &gt; 3cm a z\u00e1rove\u0148 \u2264 7cm nebo spl\u0148uje\u00a0nejm\u00e9n\u011b jedno z n\u00e1sleduj\u00edc\u00edch krit\u00e9ri\u00ed<br \/>\n\u2013 infiltruje hlavn\u00ed bronchus do vzd\u00e1lenosti \u2265 2cm dist\u00e1ln\u011b od kariny<br \/>\n\u2013 invaduje do viscer\u00e1ln\u00ed pleury<br \/>\n\u2013 podmi\u0148uje atelekt\u00e1zu nebo obstruk\u010dn\u00ed bronchopneumonii v subal\u00e1rn\u00edm rozsahu<\/p>\n<ul>\n<li><strong>T2a<\/strong>: n\u00e1dor v intervalu &gt; 3cm a \u2264 5cm<\/li>\n<li><strong>T2b<\/strong>: n\u00e1dor v intervalu &gt; 5cm a \u2264 7cm<\/li>\n<\/ul>\n<\/li>\n<li><strong>T3<\/strong>: n\u00e1dor je &gt; 7cm, podmi\u0148uj\u00edc\u00ed atelekt\u00e1zu cel\u00e9ho\u00a0plicn\u00edho k\u0159\u00eddla, vytv\u00e1\u0159ej\u00edc\u00ed satelitn\u00ed uzel ve stejn\u00e9mlaloku nebo infiltruj\u00edc\u00ed n\u011bkterou z n\u00e1sleduj\u00edc\u00edch struktur:<br \/>\n\u2013 hrudn\u00ed st\u011bna<br \/>\n\u2013 br\u00e1nice<br \/>\n\u2013 br\u00e1ni\u010dn\u00ed nerv<br \/>\n\u2013 mediastin\u00e1ln\u00ed pleura<br \/>\n\u2013 perikard<br \/>\n\u2013 hlavn\u00ed bronchus ve vzd\u00e1lenosti &lt; 2 cm od kariny<\/li>\n<li><strong>T4<\/strong>: n\u00e1dor jak\u00e9koli velikosti, kter\u00fd m\u00e1 satelitn\u00ed l\u00e9zi\u00a0v jin\u00e9m stejnostrann\u00e9m laloku nebo se \u0161\u00ed\u0159\u00ed do:<br \/>\n\u2013 mediastina<br \/>\n\u2013 srdce<br \/>\n\u2013velk\u00fdch c\u00e9v<br \/>\n\u2013 pr\u016fdu\u0161nice<br \/>\n\u2013 zvrat\u00e9ho nervu<br \/>\n\u2013 j\u00edcnu<br \/>\n\u2013 obratlov\u00fdch t\u011bl<br \/>\n\u2013 bifurkace pr\u016fdu\u0161nice<\/li>\n<\/ul>\n<p><strong><em>N: region\u00e1ln\u00ed lymfatick\u00e9 uzliny<\/em><\/strong><\/p>\n<ul>\n<li><strong>NX<\/strong>: region\u00e1ln\u00ed lymfatick\u00e9 uzliny nen\u00ed mo\u017en\u00e9 hodnotit<\/li>\n<li><strong>N0<\/strong>: bez p\u0159\u00edtomnosti metast\u00e1z v region\u00e1ln\u00edch lymfatick\u00fdch uzlin\u00e1ch<\/li>\n<li><strong>N1<\/strong>: metast\u00e1zy v ipsilater\u00e1ln\u00edch peribronchi\u00e1ln\u00edch\u00a0a\/nebo ipsilater\u00e1ln\u00edch hilov\u00fdch uzlin\u00e1ch a intrapulmon\u00e1ln\u00edch uzlin\u00e1ch<\/li>\n<li><strong>N2<\/strong>: metast\u00e1zy v ipsilater\u00e1ln\u00edch mediastin\u00e1ln\u00edch\u00a0a\/nebo subkarinn\u00edch lymfatick\u00fdch uzlin\u00e1ch<\/li>\n<li><strong>N3<\/strong>: metast\u00e1zy v:<br \/>\n\u2013 kontralater\u00e1ln\u00edch hilov\u00fdch nebo mediastin\u00e1ln\u00edch uzlin\u00e1ch<br \/>\n\u2013 v ipsilater\u00e1ln\u00edch nebo kontralater\u00e1ln\u00edch skalenov\u00fdch anebo supraklavikul\u00e1rn\u00edch lymfatick\u00fdchuzlin\u00e1ch<\/li>\n<\/ul>\n<p><strong><em>M: vzd\u00e1len\u00e9 metast\u00e1zy<\/em><\/strong><\/p>\n<ul>\n<li><strong>MX<\/strong>: vzd\u00e1len\u00e9 metast\u00e1zy nen\u00ed mo\u017en\u00e9 hodnotit<\/li>\n<li><strong>M0<\/strong>: vzd\u00e1len\u00e9 metast\u00e1zy nejsou p\u0159\u00edtomny\n<ul>\n<li><strong>M1a<\/strong>: \u2013 separ\u00e1tn\u00ed n\u00e1dorov\u00e9 uzly v kontralater\u00e1ln\u00edm laloku<br \/>\n\u2013 malign\u00ed pleur\u00e1ln\u00ed nebo perikardi\u00e1ln\u00ed v\u00fdpotek<\/li>\n<li><strong>M1b<\/strong>: vzd\u00e1len\u00e9 metast\u00e1zy<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><em><strong>Stadia nemoci dle TNM:<\/strong><\/em><\/p>\n<ul>\n<li>O \u2013 TisN0M0<\/li>\n<li>IA \u2013 T1N0M0<\/li>\n<li>IB \u2013 T2aN0M0<\/li>\n<li>IIA \u2013 T1N1M0 \/ T2bN0M0 \/ T2aN1M0<\/li>\n<li>IIB \u2013 T2bN1M0 \/ T3N1M0<\/li>\n<li>IIIA \u2013 T1N2M0 \/ T2N2M0 \/ T3N1M0 \/ T3N2M0\u00a0\/ T4N0M0 \/ T4N1M0<\/li>\n<li>IIIB \u2013 T1N3M0 \/ T2N3M0 \/ T3N3M0 \/ T4N2M0\u00a0\/ T4N3M0<\/li>\n<li>IV \u2013 jak\u00e9koli T, jak\u00e9koli N, M1<\/li>\n<\/ul>\n<h4>5.7.6 L\u00e9\u010dba<\/h4>\n<h6>Chirurgie stadia I TNM klasifikace<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1541.png\"><img decoding=\"async\" title=\"Obr. 20 \u2013 N\u00e1dor T1b N0 (pr\u016fm\u011br 3 cm, stadium IA)\" alt=\"Obr. 20 \u2013 N\u00e1dor T1b N0 (pr\u016fm\u011br 3 cm, stadium IA)\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1541.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 20<br \/>N\u00e1dor T1b N0 (pr\u016fm\u011br 3 cm, stadium IA)<\/p><\/div>\n<p style=\"text-align: justify;\">Z\u00e1kladn\u00edm typem resekce pro karcinom ve stadiu I je asi v 75 % lobektomie s odstran\u011bn\u00edm lymfatick\u00fdch uzlin pl\u00edce, plicn\u00edho hilu a mediastina minim\u00e1ln\u011b v rozsahu, kter\u00fd dovoluje relevantn\u00ed staging. Centr\u00e1ln\u00ed r\u016fst tumoru nebo pror\u016fst\u00e1n\u00ed n\u00e1doru p\u0159es interlob\u00e1rn\u00ed r\u00fdhu je nutno \u0159e\u0161it v\u00fdkonem v\u011bt\u0161\u00edm ne\u017e lobektomie asi v 15\u201320 %. Naopak 5\u201310 % p\u0159\u00edpad\u016f v\u011bt\u0161inou T1 tumor\u016f je dnes \u0159e\u0161eno men\u0161\u00edmi, parenchym z\u00e1chovn\u00fdmi v\u00fdkony (videotorakoskopick\u00fdmi staplerov\u00fdmi resekcemi nebo otev\u0159en\u00fdmi \u010di asistovan\u00fdmi anatomick\u00fdmi segmentektomiemi). Tyto v\u00fdkony jsou dobrou alternativou pro nemocn\u00e9 s limitem respira\u010dn\u00ed nebo kardi\u00e1ln\u00ed rezervy. Podobnou chirurgickou ekvilibristikou se zdaj\u00ed b\u00fdt video-asistovan\u00e9\u00a0\u010di robotick\u00e9 lobektomie. V dne\u0161n\u00ed dob\u011b p\u0159ib\u00fdv\u00e1 prac\u00ed popisuj\u00edc\u00edch spolehlivost i onkologickou bezpe\u010dnost video-asistovan\u00fdchi robotick\u00fdch anatomick\u00fdch plicn\u00edch resekc\u00ed. Rozd\u00edl n\u00e1klad\u016f na robotickou resekci oproti torakoskopick\u00e9 v\u0161ak st\u011b\u017e\u00ed nalezne adekv\u00e1tn\u00ed odraz v p\u0159\u00ednosu pro nemocn\u00e9ho. P\u0159ibli\u017en\u011b 30 % radik\u00e1ln\u011b odoperovan\u00fdch ve stadiu I se do\u010dk\u00e1 recidivy. Men\u0161\u00ed \u010d\u00e1st t\u011bchto recidiv m\u016f\u017ee b\u00fdt diagnostikov\u00e1na je\u0161t\u011b v operabiln\u00edm stadiu a vy\u0159e\u0161ena chirurgicky s uspokojiv\u00fdmi dlouhodob\u00fdmi v\u00fdsledky. V\u011bt\u0161ina recidiv (asi 70 %) je v\u0161ak syst\u00e9mov\u00fdch, kter\u00e9 v\u011bt\u0161inou i p\u0159es onkologickou terapii neodvratn\u011b sp\u011bj\u00ed k fat\u00e1ln\u00edmu konci. Adjuvantn\u00ed syst\u00e9mov\u00e1 terapie nen\u00ed ve stadiu I dle TNM obecn\u011b indikov\u00e1na, radioterapie pak pouze v p\u0159\u00edpad\u011b nekompletn\u00ed resekce bez mo\u017enosti korekce reoperac\u00ed. Velk\u00e9 procento syst\u00e9mov\u00fdch recidiv provokuje pneumoonkology a molekul\u00e1rn\u00ed biology ke st\u00e1le podrobn\u011bj\u0161\u00edm v\u00fdzkum\u016fm ve snaze v p\u0159edstihu identifikovat n\u00e1dory s vysoce malign\u00edm fenotypem, u kter\u00fdch lze p\u0159edpokl\u00e1dat riziko selh\u00e1n\u00ed prost\u00e9 lokoregion\u00e1ln\u00ed terapie. Ty by si pak zaslou\u017eily adjuvantn\u00ed l\u00e9\u010dbu. Existuje \u0159ada parametr\u016f, kter\u00e9 v univariantn\u00edch \u010di multivariantn\u00edch anal\u00fdz\u00e1ch vykazuj\u00ed korelaci s v\u00fdskytem metastatick\u00e9ho rozsevu po operaci, av\u0161ak \u017e\u00e1dn\u00fd z nich ani jejich kombinace zat\u00edm nejsou v klinick\u00e9m m\u011b\u0159\u00edtku pou\u017e\u00edv\u00e1ny jako vod\u00edtka k nasazen\u00ed adjuvantn\u00ed l\u00e9\u010dby po resekci nemalobun\u011b\u010dn\u00e9ho plicn\u00edho karcinomu ve stadiu I (obr. 20).<\/p>\n<h6>Chirurgie stadia II TNM klasifikace<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_156.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 21 \u2013 N\u00e1dor T IIb N1 (stadium IIB), v\u011bt\u0161\u00ed \u0161ipka ukazuje tumor o pr\u016fm\u011bru 6 cm, men\u0161\u00ed \u0161ipka uzlinu N1\" alt=\"Obr. 21 \u2013 N\u00e1dor T IIb N1 (stadium IIB), v\u011bt\u0161\u00ed \u0161ipka ukazuje tumor o pr\u016fm\u011bru 6 cm, men\u0161\u00ed \u0161ipka uzlinu N1\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_156.png\" width=\"200\" height=\"202\" \/><\/a><p class=\"wp-caption-text\">Obr. 21<br \/>N\u00e1dor T IIb N1 (stadium IIB), v\u011bt\u0161\u00ed \u0161ipka ukazuje tumor o pr\u016fm\u011bru 6 cm, men\u0161\u00ed \u0161ipka uzlinu N1<\/p><\/div>\n<p style=\"text-align: justify;\">Klasick\u00fdm v\u00fdkonem pro T12N1 tumory je lobektomie, pokud jsou lokalizov\u00e1ny v horn\u00edch laloc\u00edch.N\u00e1dory doln\u00edch lalok\u016f s posti\u017een\u00edm hilov\u00fdch uzlin\u010di interlobia by zasluhovaly pneumonektomii, lze akceptovat lobektomii s pe\u010dlivou lymfadenektomi\u00ed uzlininterlobia, hilu a mediastina. N\u00edzk\u00fd v\u011bk nemocn\u00e9hoa histologick\u00e1 diagn\u00f3za adenokarcinomu vel\u00ed p\u0159idat na radikalit\u011b (obr. 21). N\u00e1dory charakterizovan\u00e9jako T3N0 maj\u00ed dobrou progn\u00f3zu, jsouli resekov\u00e1nykompletn\u011b. Proto je t\u0159eba vy\u0161et\u0159it resek\u010dn\u00ed linie v\u0161echdot\u010den\u00fdch struktur, stejn\u011b jako prov\u00e9st lymfadenektomii hilov\u00fdch a mediastin\u00e1ln\u00edch uzlin k potvrzen\u00ed stadia N0. Bronchoplastick\u00e9 postupy jsou samoz\u0159ejm\u011b<\/p>\n<p>indikov\u00e1ny pro centr\u00e1ln\u00ed n\u00e1dory postihuj\u00edc\u00ed hlavn\u00ed bronchus \u010di \u00fast\u00ed lob\u00e1rn\u00edch bronch\u016f. Recidivy lze o\u010dek\u00e1vat asi v 50 % p\u0159\u00edpad\u016f po kurativn\u00ed resekci ve stadiu II NSCLC. Asi 70 % z nich jsou vzd\u00e1len\u00e9, \u010dast\u011bj\u0161\u00ed jsou u adenokarcinom\u016f ne\u017e u jin\u00fdch histologick\u00fdch typ\u016f. To d\u00e1v\u00e1 racion\u00e1ln\u00ed d\u016fvod k indikaci adjuvantn\u00ed terapie. Radioterapie u nemocn\u00fdch s N1 lymfadenopati\u00ed sni\u017euje po\u010det lok\u00e1ln\u00edch recidiv, ale na dlouhodob\u00e9 p\u0159e\u017eit\u00ed vliv nem\u00e1. \u00daloha neoadjuvantn\u00ed chemoterapie je nejednozna\u010dn\u00e1, adjuvantn\u00ed terapie je pova\u017eov\u00e1na za standard.<\/p>\n<h6>Chirurgie stadia III TNM klasifikace<\/h6>\n<p style=\"text-align: justify;\">Z\u00e1kladn\u00edm atributem tohoto stadia je lok\u00e1ln\u00ed progresea nep\u0159\u00edtomnost vzd\u00e1len\u00fdch metast\u00e1z.Toto stadium jezna\u010dn\u011b nesourod\u00e9 jak z hlediska p\u0159edpokl\u00e1dan\u00e9 progn\u00f3zy, tak v mo\u017enostech terapeutick\u00e9ho z\u00e1sahu. Protoje v\u00fdhodn\u011bj\u0161\u00ed pojednat zvl\u00e1\u0161\u0165 o tumorech definovan\u00fdch jako T3, T4, N2, event. N3.<\/p>\n<h6>Operace n\u00e1dor\u016f T3<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1571.png\"><img decoding=\"async\" title=\"Obr. 22 \u2013 Karcinom pror\u016fstaj\u00edc\u00ed do hrudn\u00ed st\u011bny pod lopatkou\" alt=\"Obr. 22 \u2013 Karcinom pror\u016fstaj\u00edc\u00ed do hrudn\u00ed st\u011bny pod lopatkou\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1571.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 22<br \/>Karcinom pror\u016fstaj\u00edc\u00ed do hrudn\u00ed st\u011bny pod lopatkou<\/p><\/div>\n<p style=\"text-align: justify;\">Tumory definovan\u00e9 jako T3 infiltruj\u00ed ve sv\u00e9m r\u016fstu:<\/p>\n<ol>\n<li>perifern\u00ed struktury \u2013 hrudn\u00ed st\u011bnu nebo br\u00e1nici,<\/li>\n<li>mediastin\u00e1ln\u00ed pleuru, perikard, n. phrenicus, v. azygos, a. pulmonalis,<\/li>\n<li>hlavn\u00ed bronchus \u2013 m\u00e9n\u011b ne\u017e 2 cm od kariny, bezposti\u017een\u00ed bifurkace,<\/li>\n<li>struktury v horn\u00ed hrudn\u00ed apertu\u0159e \u2013 proxim\u00e1ln\u00ed \u017eebra, obratle, brachi\u00e1ln\u00ed plexus, subklavi\u00e1ln\u00ed c\u00e9vn\u00ed svazek, sympatikus.<\/li>\n<\/ol>\n<p style=\"text-align: justify;\">P\u011btilet\u00e9 p\u0159e\u017eit\u00ed kompletn\u011b resekovan\u00fdch bez posti\u017een\u00ed uzlin (N0), event. p\u0159i lymfadenopatii limitovan\u00e9 na pl\u00edci (N1) je mezi 20\u201330 %. Pokud jsou posti\u017eeny mediastin\u00e1ln\u00ed uzliny (N2, N3), nedosahuje p\u011btilet\u00e9 p\u0159e\u017eit\u00ed 10 %. V p\u0159\u00edpad\u011b nekompletn\u00ed resekce nelze o\u010dek\u00e1vat p\u0159e\u017eit\u00ed p\u0159es 2 roky. Problematika relevantn\u00edho stagingu je kruci\u00e1ln\u00ed, klinick\u00fd staging je toti\u017e zat\u00ed\u017een chybou a\u017e 40 %. P\u0159ibli\u017en\u011b 20 % p\u0159\u00edpad\u016f hodnocen\u00fdch klinicky jako T3 je definitivn\u011b za\u0159azeno jako T2, stejn\u00e9 procento naopak jako T4 nebo N2. Videotorakoskopie dok\u00e1\u017ee odhalit hranici mezi neexistuj\u00edc\u00ed invaz\u00ed a infiltrac\u00ed okoln\u00edch struktur (tedy T2 versus T3\u20134). Posouzen\u00ed o kvalitu v\u00fd\u0161e, tedy mezi resekabiln\u00edm a neresekabiln\u00edm n\u00e1dorem (T3 versus T4), je obvykle mo\u017en\u00e9 pouze b\u011bhem torakotomie. Infiltrace hrudn\u00ed st\u011bny: Morbidita v\u00e1zan\u00e1 na resekci hrudn\u00ed st\u011bny je nev\u00fdrazn\u00e1 ve srovn\u00e1n\u00ed s rizikem lok\u00e1ln\u00ed recidivy, proto v p\u0159\u00edpadech, kdy nejde o evidentn\u00ed poz\u00e1n\u011btlivou adhezi pl\u00edce k hrudn\u00ed st\u011bn\u011b, je blokov\u00e1 resekce pl\u00edce a segmentu hrudn\u00ed st\u011bny metodou volby. Inkompletn\u00ed resekce d\u00e1v\u00e1 neuspokojiv\u00e9 v\u00fdsledky, ani jej\u00ed zaji\u0161t\u011bn\u00ed radioterapi\u00ed nebo radiochemoterapi\u00ed tento stav v\u00fdznamn\u011b nezlep\u0161\u00ed (obr. 22).<\/p>\n<p style=\"text-align: justify;\">V\u00fdskyt n\u00e1dor\u016f infiltruj\u00edc\u00edch br\u00e1nici je vz\u00e1cn\u00fd. V p\u0159\u00edpad\u011b T3N0 je dlouhodob\u00e9 p\u0159e\u017eit\u00ed stejn\u00e9 jako v p\u0159\u00edpad\u011b posti\u017een\u00ed hrudn\u00ed st\u011bny. \u010casto v\u0161ak z\u016fst\u00e1v\u00e1 takov\u00fd n\u00e1dor dlouho nepozn\u00e1n, pro rentgenology skryt za st\u00ednem br\u00e1nice, a b\u00fdv\u00e1 diagnostikov\u00e1n ve stadiu generalizace. Pouh\u00e1 lymfatick\u00e1 diseminace do uzlin pl\u00edce zhor\u0161uje progn\u00f3zu v\u00fdznamn\u011b, nemocn\u00ed s n\u00e1dory infiltruj\u00edc\u00edmi br\u00e1nici a mediastin\u00e1ln\u00ed lymfadenopati\u00ed p\u0159e\u017e\u00edvaj\u00ed 5 let od operace zcela v\u00fdjime\u010dn\u011b.N\u00e1dory pror\u016fstaj\u00edc\u00ed do mediastina postihuj\u00ed nej\u010dast\u011bji mediastin\u00e1ln\u00ed pleuru, mediastin\u00e1ln\u00ed tuk a hlavn\u00ed plicn\u00ed c\u00e9vy. Pr\u016fm\u011brn\u00e9 p\u011btilet\u00e9 p\u0159e\u017eit\u00ed radik\u00e1ln\u011b resekovan\u00fdch se bl\u00ed\u017e\u00ed 30 % nez\u00e1visle na tom, zda jde o nemocn\u00e9 s N0 \u010di N1 lymfadenopati\u00ed. Z\u00e1kladn\u00edm negativn\u00edm prognostick\u00fdm parametrem je nekompletnost resekce.N\u00e1dory infiltruj\u00edc\u00ed hlavn\u00ed bronchus je mo\u017en\u00e9 tak\u00e9 resekovat kompletn\u011b. Pak maj\u00ed \u0161anci na p\u0159e\u017eit\u00ed op\u011bt bl\u00edzkou 40 %, jdeli o N0, a 30 %, jde-li o N1. Posti\u017een\u00ed mediastin\u00e1ln\u00edch uzlin vylu\u010duje nad\u011bji na dlouhodob\u00e9 p\u0159e\u017eit\u00ed.Apik\u00e1ln\u00ed l\u00e9ze Pancoastova typu lze odstranit kompletn\u011b s p\u0159edpokladem p\u011btilet\u00e9ho p\u0159e\u017eit\u00ed okolo 40 % v p\u0159\u00edpad\u011b N0. Pr\u016fm\u011brn\u00e9 p\u0159e\u017eit\u00ed v neselektovan\u00fdch souborech je kolem 30 %. N2 lymfadenopatie, posti\u017een\u00ed brachi\u00e1ln\u00edho plexu nad ko\u0159en C8 a p\u0159edopera\u010dn\u011b prok\u00e1zan\u00e1 intraspin\u00e1ln\u00ed propagace kontraindikuj\u00ed operaci.T3N2 n\u00e1dory maj\u00ed obecn\u011b velmi \u0161patnou progn\u00f3zu, av\u0161ak i v jejich p\u0159\u00edpad\u011b lze prov\u00e9st v kombinovan\u00e9m protokolu kompletn\u00ed resekci. V p\u0159\u00edpad\u011b mnoho\u010detn\u00e9ho posti\u017een\u00ed uzlin mediastina je p\u011btilet\u00e9 p\u0159e\u017eit\u00ed pod 10%. Mediastin\u00e1ln\u00ed lymfadenopatie rozpoznan\u00e1 a\u017e p\u0159i operaci a posti\u017een\u00ed pouze jedn\u00e9 mediastin\u00e1ln\u00ed uzliny (singlenodal involvement) d\u00e1vaj\u00ed asi 20% \u0161anci na p\u011btilet\u00e9 p\u0159e\u017eit\u00ed.<\/p>\n<h6>Operace n\u00e1dor\u016f T4<\/h6>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1591.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 23 \u2013 Karcinom pror\u016fstaj\u00edc\u00ed do descendentn\u00ed aorty\" alt=\"Obr. 23 \u2013 Karcinom pror\u016fstaj\u00edc\u00ed do descendentn\u00ed aorty\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1591.png\" width=\"200\" height=\"173\" \/><\/a><p class=\"wp-caption-text\">Obr. 23<br \/>Karcinom pror\u016fstaj\u00edc\u00ed do descendentn\u00ed aorty<\/p><\/div>\n<p style=\"text-align: justify;\">N\u00e1dory mohou infiltrovat kteroukoli okoln\u00ed tk\u00e1\u0148 \u010di strukturu. Podle Grunewalda (2000) jsou T4 n\u00e1dory potenci\u00e1ln\u011b resekabiln\u00ed (infiltrace horn\u00ed dut\u00e9 \u017e\u00edly, kariny, doln\u00ed \u010d\u00e1sti pr\u016fdu\u0161nice, lev\u00e9 p\u0159eds\u00edn\u011b) \u2013 T41, na rozd\u00edl od definitivn\u011b neresekabiln\u00edch \u2013 (infiltrace j\u00edcnu, obratl\u016f, malign\u00ed pleur\u00e1ln\u00ed \u010di perikardi\u00e1ln\u00ed v\u00fdpotek) \u2013 T42. Pom\u011brn\u011b vysok\u00e9 riziko opera\u010dn\u00ed (a\u017e 20%) je vysokou cenou za \u0161anci na del\u0161\u00ed p\u0159e\u017eit\u00ed. V p\u0159\u00edpad\u011b karin\u00e1ln\u00edch resekc\u00ed lze dos\u00e1hnout p\u011btilet\u00e9ho p\u0159e\u017eit\u00ed p\u0159es 20%. Ostatn\u00ed struktury lze \u0159e\u0161it chirurgicky se \u0161anc\u00ed jen nepatrn\u011b men\u0161\u00ed za p\u0159edpokladu, \u017ee mediastin\u00e1ln\u00ed uzliny nejsou posti\u017eeny a nejsou prok\u00e1z\u00e1ny vzd\u00e1len\u00e9 metast\u00e1zy (obr. 23).<\/p>\n<h6>Operace p\u0159i stejnostrann\u00e9 mediastin\u00e1ln\u00ed lymfadenopatii (N2 dle TNM)<\/h6>\n<p style=\"text-align: justify;\">Malign\u00ed lymfadenopatie mediastina p\u0159edstavuje z\u00e1va\u017en\u00fd negativn\u00ed prognostick\u00fd faktor. Progn\u00f3za nel\u00e9\u010den\u00fdch je \u0161patn\u00e1, medi\u00e1n p\u0159e\u017eit\u00ed je p\u0159ibli\u017en\u011b 7 m\u011bs\u00edc\u016f, 1let\u00e9 p\u0159e\u017eit\u00ed do 10 %, nikdo nep\u0159e\u017eije 2 roky od stanoven\u00ed diagn\u00f3zy. Kompletn\u00ed resekce d\u00e1v\u00e1 \u0161anci a\u017e na 30% p\u0159e\u017e\u00edv\u00e1n\u00ed v p\u0159\u00edpad\u011b posti\u017een\u00ed pouze jedn\u00e9 uzliny mediastina (single node disease), p\u0159i minim\u00e1ln\u00edm posti\u017een\u00ed uzlin mediastina (klinicky neprok\u00e1zan\u00e9m, objeven\u00e9m a\u017e p\u0159i operaci) a p\u0159i T1 prim\u00e1rn\u00edm tumoru. Je\u0161t\u011b lep\u0161\u00ed v\u00fdsledky d\u00e1v\u00e1 kompletn\u00ed resekce n\u00e1dor\u016f lev\u00e9 pl\u00edce s posti\u017een\u00edm uzlin pozice 5 a 6, tedy preaort\u00e1ln\u00edch a subaort\u00e1ln\u00edch. Naproti tomu dlouhodob\u00e9 v\u00fdsledky operovan\u00fdch, kte\u0159\u00ed maj\u00ed radiograficky patrn\u00e9 uzliny (bulky disease) a v definitivn\u00edm prepar\u00e1tu prok\u00e1zan\u00fd extrakapsul\u00e1rn\u00ed r\u016fst metast\u00e1z, jsou neuspokojiv\u00e9. P\u011btilet\u00e9 p\u0159e\u017eit\u00ed nedosahuje 10 %, v\u011bt\u0161ina nemocn\u00fdch zem\u0159e do 3 let od operace na generalizaci, kter\u00e1 tvo\u0159\u00ed p\u0159ibli\u017en\u011b 80 % v\u0161ech recidiv. Tato \u010d\u00edsla jasn\u011b ukazuj\u00ed, \u017ee chirurgie jako samostatn\u00e1 modalita m\u00e1 jen velmi omezenou \u00falohu v terapii stadia IIIA\/N2. Radioterapie jako metoda lokoregion\u00e1ln\u00ed tak\u00e9 nem\u016f\u017ee vy\u0159e\u0161it ot\u00e1zku syst\u00e9mov\u00e9ho selh\u00e1n\u00ed, i kdy\u017e m\u016f\u017ee sn\u00ed\u017eit po\u010det lok\u00e1ln\u00edch recidiv. Pouze syst\u00e9mov\u00e1 l\u00e9\u010dba d\u00e1v\u00e1 racion\u00e1ln\u00ed p\u0159edpoklad pro zlep\u0161en\u00ed progn\u00f3zy t\u011bchto stadi\u00ed plicn\u00ed rakoviny, i kdy\u017e doposud st\u00e1le nen\u00ed jasn\u00e9, jak\u00e1 kombinace a \u010dasov\u00fd sled jednotliv\u00fdch l\u00e9\u010debn\u00fdch modalit je nejvhodn\u011bj\u0161\u00ed, jak\u00e9 maj\u00ed b\u00fdt d\u00e1vky chemoterapeutik nebo z\u00e1\u0159en\u00ed, jak aplikovat biologickou l\u00e9\u010dbu a jak\u00e1 je v\u016fbec \u00faloha chirurga v tomto stadiu.<\/p>\n<h6>Chirurgie p\u0159i kontralater\u00e1ln\u00ed mediastin\u00e1ln\u00ed lymfadenopatii (N3 dle TNM)<\/h6>\n<p style=\"text-align: justify;\">Stadium IIIB\/N3 nad\u00e1le plat\u00ed za nechirurgick\u00e9. Nicm\u00e9n\u011b zejm\u00e9na japon\u0161t\u00ed auto\u0159i dokl\u00e1daj\u00ed, \u017ee i u t\u011bchto nemocn\u00fdch lze dos\u00e1hnout p\u011btilet\u00e9ho p\u0159e\u017eit\u00ed po chirurgick\u00e9 intervenci. Jsou to v\u0161ak ojedin\u011bl\u00e9 studie, kter\u00e9 nemaj\u00ed obdobu v evropsk\u00e9 ani severoamerick\u00e9 literatu\u0159e. Nicm\u00e9n\u011b zaveden\u00ed principu induk\u010dn\u00ed terapie do klinick\u00e9 praxe znamenalo o\u017eiven\u00ed z\u00e1jmu o chirurgii tohoto stadia. N\u011bkter\u00e9 pr\u00e1ce dokl\u00e1daj\u00ed v\u00edce jak 20% p\u011btilet\u00e9 p\u0159e\u017eit\u00ed u nemocn\u00fdch s biopticky ov\u011b\u0159en\u00fdm stadiem IIIB\/N3 l\u00e9\u010den\u00fdch kombinac\u00ed agresivn\u00ed radiochemoterapie a radik\u00e1ln\u00ed (kompletn\u00ed \u2013 R0) chirurgick\u00e9 operace. \u00dadaj\u016f je v\u0161ak zat\u00edm m\u00e1lo na to, aby byla role chirurgie p\u0159i kontralater\u00e1ln\u00ed malign\u00ed lymfadenopatii p\u0159ehodnocena (10).Z v\u00fd\u0161e uveden\u00fdch skute\u010dnost\u00ed plyne, \u017ee III. stadium plicn\u00ed rakoviny, stadium lok\u00e1ln\u011b pokro\u010dil\u00e9 nemoci, je nutno l\u00e9\u010dit kombinovan\u00fdmi protokoly, ve kter\u00fdch m\u00e1 chirurgie ne zcela jasn\u011b definovanou roli. Tak jako je nep\u0159edstaviteln\u00fd \u00fasp\u011bch syst\u00e9mov\u00e9 terapie bez lok\u00e1ln\u00ed kontroly tumoru, 80 % syst\u00e9mov\u00fdch recidiv po operaci zcela jasn\u011b ukazuje, \u017ee bez syst\u00e9mov\u00e9 l\u00e9\u010dby m\u00e1 chirurgie smysl jen u ojedin\u011bl\u00fdch nemocn\u00fdch v tomto stadiu.Samotnou chirurgickou terapii lze u III. stadia akceptovat za t\u011bchto okolnost\u00ed:1. Velmi limitovan\u00e9 stadium III dan\u00e9 pouze jedn\u00edm parametrem (jen T3, N2, nebo jen T4).2. Lze p\u0159edpokl\u00e1dat kompletn\u00ed (R0) resekci.3. Je vylou\u010dena pe\u010dliv\u011b kontralater\u00e1ln\u00ed lymfadenopatiea generalizace.<\/p>\n<h6>Chirurgie stadia IV TNM klasifikace<\/h6>\n<p style=\"text-align: justify;\">Metastazuj\u00edc\u00ed plicn\u00ed karcinom m\u00e1 velmi minim\u00e1ln\u00ed \u0161ance na kurativn\u00ed l\u00e9\u010dbu, a to pro mnoho\u010detnost metastatick\u00e9ho procesu a jeho pravidelnou multilokalitu.<\/p>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00edm c\u00edlov\u00fdm org\u00e1nem, resp. tk\u00e1n\u00ed je skelet (33%), mozek (18%), kontralater\u00e1ln\u00ed pl\u00edce, resp. pleura (16%, resp. 12%), j\u00e1tra (9%) a nadledviny (6%).Jen zcela v\u00fdjime\u010dn\u011b metast\u00e1zuje plicn\u00ed karcinom solit\u00e1rn\u011b (a\u0165 u\u017e synchronn\u011b \u010di metachronn\u011b). V takov\u00e9m p\u0159\u00edpad\u011b m\u016f\u017ee metastazektomie zlep\u0161it dlouhodob\u00e9 p\u0159e\u017eit\u00ed.<\/p>\n<h3>5.8 Sekund\u00e1rn\u00ed plicn\u00ed novotvary<\/h3>\n<h4>5.8.1 Patofyziologie metastatick\u00e9ho procesu<\/h4>\n<p style=\"text-align: justify;\">Krom\u011b lok\u00e1ln\u00ed invazivity tumoru je druh\u00fdm z\u00e1kladn\u00edm atributem malign\u00edho n\u00e1doru potenci\u00e1l k metastatick\u00e9mu rozsevu. V prvn\u00ed \u0159ad\u011b se mus\u00ed vit\u00e1ln\u00ed n\u00e1dorov\u00e1 bu\u0148ka uvolnit z prim\u00e1rn\u00edho n\u00e1doru a skrze stroma, baz\u00e1ln\u00ed membr\u00e1nu a endotel vycestovat do c\u00e9vy (intravazace). Pomoc\u00ed krevn\u00edho nebo lymfatick\u00e9ho syst\u00e9mu se mus\u00ed dostat do tk\u00e1n\u011b, ve kter\u00e9 jsou p\u0159\u00edhodn\u00e9 podm\u00ednky pro dal\u0161\u00ed r\u016fst metast\u00e1zy. V t\u00e9to tk\u00e1ni \u010di org\u00e1nu se mus\u00ed zastavit, resp. p\u0159ichytit k endotelu p\u0159\u00edslu\u0161n\u00e9 c\u00e9vy a pomoc\u00ed analogick\u00fdch mechanism\u016f, kter\u00e9 n\u00e1dorov\u00e9 bu\u0148ce pomohly do ob\u011bhu vcestovat, syst\u00e9m zase opustit (extravazace). Na p\u0159\u00edhodn\u00e9m m\u00edst\u011b pak znovu za\u010d\u00edn\u00e1 koloto\u010d proliferace a lok\u00e1ln\u00ed invaze. Metast\u00e1zy solidn\u00edch novotvar\u016f jsou nej\u010dast\u011bji lokalizov\u00e1ny v j\u00e1trech, druh\u00fdm nej\u010dast\u011bji posti\u017een\u00fdm org\u00e1nem jsou pl\u00edce.<\/p>\n<h4>5.8.2 Histologie<\/h4>\n<p style=\"text-align: justify;\">Nej\u010dast\u011bj\u0161\u00edmi kandid\u00e1ty chirurgie jsou nemocn\u00ed s metast\u00e1zami sarkom\u016f, a\u0165 u\u017e m\u011bkk\u00fdch tk\u00e1n\u00ed \u010di osteosarkomu. Pro n\u00e1dory hlavy a krku je krom\u011b lymfogenn\u00edho rozsevu metast\u00e1zov\u00e1n\u00ed do plic typick\u00e9. Kolorekt\u00e1ln\u00ed karcinom metast\u00e1zuje nej\u010dast\u011bji do jater, ale asi u 10 % nemocn\u00fdch se v pr\u016fb\u011bhu nemoci vyvinou i plicn\u00ed metast\u00e1zy. Resekabiln\u00ed b\u00fdvaj\u00ed z\u0159\u00eddka zejm\u00e9na pro \u010dast\u00e9 synchronn\u00ed posti\u017een\u00ed jater. Tak\u00e9 u karcinomu prsu je metast\u00e1zov\u00e1n\u00ed pouze do plic vz\u00e1cn\u00e9. Solit\u00e1rn\u00ed \u010di ne\u010detn\u00e9 metast\u00e1zy mohou b\u00fdt resekov\u00e1ny s benefitem prodlou\u017een\u00ed p\u0159e\u017eit\u00ed. U n\u00e1dor\u016f ledvin je naopak solit\u00e1rn\u00ed metast\u00e1zov\u00e1n\u00ed pom\u011brn\u011b \u010dast\u00e9, pokud jde o metachronn\u00ed v\u00fdskyt a nejsou posti\u017eeny uzliny, je resekce i v\u00edce lo\u017eisek metodou volby. Testikul\u00e1rn\u00ed n\u00e1dory metast\u00e1zuj\u00ed do plic \u010dasto, ale reaguj\u00ed velmi dob\u0159e na radiochemoterapii, chirurgick\u00e1 intervence se omezuje v\u011bt\u0161inou na resekci rezidu\u00e1ln\u00edch lo\u017eisek, ve kter\u00fdch lze o\u010dek\u00e1vat nekr\u00f3zu, rezidu\u00e1ln\u00ed tumor \u010di vyzr\u00e1l\u00fd teratom. Operace je pak d\u016fle\u017eit\u00e1 pro posouzen\u00ed nutnosti dal\u0161\u00ed l\u00e9\u010dby. Gynekologick\u00e9 n\u00e1dory se nej\u010dast\u011bji projevuj\u00ed malign\u00edm peritone\u00e1ln\u00edm\/pleur\u00e1ln\u00edm v\u00fdpotkem, oligometastatick\u00fd rozsev m\u016f\u017ee b\u00fdt l\u00e9\u010den chirugicky, ale v\u00fdsledky nejsou zcela uspokojiv\u00e9. U \u0159ady dal\u0161\u00edch solidn\u00edch n\u00e1dor\u016f (melanoblastom, karcinom prostaty, n\u00e1dory \u0161t\u00edtn\u00e9 \u017el\u00e1zy) m\u016f\u017ee b\u00fdt metastazektomie benefitem za p\u0159edpokladu kontroly prim\u00e1rn\u00edho lo\u017eiska a kompletn\u00ed resekce.<\/p>\n<h4>5.8.3 Diagnostika<\/h4>\n<p style=\"text-align: justify;\">A\u017e 90% nemocn\u00fdch s plicn\u00edmi metast\u00e1zami je asymptomatick\u00fdch, proto\u017ee l\u00e9ze rostou \u010dasto perifern\u011b, n\u011bkdy je naopak metast\u00e1za diagnostikov\u00e1na d\u0159\u00edve ne\u017e prim\u00e1rn\u00ed n\u00e1dor. Ka\u0161el ani hemopt\u00fdza nejsou typick\u00e9, objevuj\u00ed se jen u centr\u00e1ln\u00edch lo\u017eisek nebo u vz\u00e1cn\u00fdch endobronchi\u00e1ln\u00edch metast\u00e1z. Du\u0161nost je pak projevem masivn\u00ed infiltrace parenchymu \u010di lymfatick\u00fdch cest, indukovan\u00e9ho v\u00fdpotku nebo obstrukce d\u00fdchac\u00edch cest. Pokud se tedy metastatick\u00fd rozsev manifestuje klinicky, jde v\u011bt\u0161inou o termin\u00e1ln\u00ed, inkurabiln\u00ed stav.<\/p>\n<p style=\"text-align: justify;\">Diagnostick\u00fd protokol je podobn\u00fd jako u karcinomu plic, asi t\u0159i \u010dtvrtiny plicn\u00edch metast\u00e1z b\u00fdvaj\u00ed diagnostikov\u00e1ny pomoc\u00ed RTG\/CT pod obrazem v\u00edce\u010detn\u00fdch (mnoho\u010detn\u00fdch) plicn\u00edch uzl\u016f, obvykle kulat\u00fdch a dob\u0159e ohrani\u010den\u00fdch. V\u011bt\u0161inou postr\u00e1daj\u00ed kalcifikace (s v\u00fdjimkou sekund\u00e1rn\u00edch lo\u017eisek osteo\u010di chondrosarkom\u016f, teratom\u016f). V diferenci\u00e1ln\u00ed diagnostice je t\u0159eba uva\u017eovat o nodul\u00e1rn\u00edch specifick\u00fdch infekc\u00edch \u010di plicn\u00edch abscesech. Pro CT je typick\u00e9, \u017ee v\u011bt\u0161inou podhodnocuje skute\u010dn\u00fd stav metastatick\u00e9ho rozsevu, zaveden\u00ed PET\/CT do diagnostick\u00e9ho protokolu p\u0159ineslo z\u0159eteln\u00fd posun, ale diagnostika l\u00e9z\u00ed men\u0161\u00edch ne\u017e1 cm tak\u00e9 nen\u00ed zcela spolehliv\u00e1. V\u00fdhodou PET\/CT je mo\u017enost zhodnocen\u00ed intrai extratorak\u00e1ln\u00edho rozsevu, mo\u017enost n\u00e1lezu prim\u00e1rn\u00edho lo\u017eiska \u010di vylou\u010den\u00ed lok\u00e1ln\u00ed recidivy. Krom\u011b plicn\u00edho parenchymu mohou b\u00fdt posti\u017eeny i lymfatick\u00e9 uzliny mediastina, st\u00e1v\u00e1 se tak u testikul\u00e1rn\u00edch n\u00e1dor\u016f, melanoblastom\u016f, n\u00e1dor\u016f prsu, ledvin.Bronchoskopie b\u00fdv\u00e1 \u010dasto negativn\u00ed, diagnostika se proto op\u00edr\u00e1 o bioptick\u00e9 metody, transpariet\u00e1ln\u00ed biopsii nebo \u010dast\u011bji videotorakoskopickou \u010di videoasistovanou excizi. Chirurgick\u00e9 excize mohou b\u00fdt vedeny p\u0159i validn\u00edm peropera\u010dn\u00edm histologick\u00e9m vy\u0161et\u0159en\u00ed jako terapeutick\u00e9.<\/p>\n<h4>5.8.4 Chirurgick\u00e1 l\u00e9\u010dba<\/h4>\n<p>Metastazektomie je indikov\u00e1na za p\u0159epokladu, \u017ee nen\u00ed jin\u00e1 lep\u0161\u00ed alternativa l\u00e9\u010dby a jsou spln\u011bny tyto podm\u00ednky:<\/p>\n<ul>\n<li>prim\u00e1rn\u00ed tumor je vy\u0159e\u0161en,<\/li>\n<li>nejsou extrapulmon\u00e1ln\u00ed metast\u00e1zy (a\u017e na raritn\u00ed\u00a0v\u00fdjimky),<\/li>\n<li>z lok\u00e1ln\u00edho i celkov\u00e9ho hlediska je provediteln\u00e1\u00a0kompletn\u00ed resekce.<\/li>\n<\/ul>\n<div style=\"width: 210px\" class=\"wp-caption alignright\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1621.png\"><img decoding=\"async\" title=\"Obr. 24 \u2013 Plicn\u00ed metast\u00e1zy kolorekt\u00e1ln\u00edho karcinomu v resek\u00e1tech ozna\u010deny \u0161ipkami\" alt=\"Obr. 24 \u2013 Plicn\u00ed metast\u00e1zy kolorekt\u00e1ln\u00edho karcinomu v resek\u00e1tech ozna\u010deny \u0161ipkami\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1621.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 24<br \/>Plicn\u00ed metast\u00e1zy kolorekt\u00e1ln\u00edho karcinomu v resek\u00e1tech ozna\u010deny \u0161ipkami<\/p><\/div>\n<p style=\"text-align: justify;\">Principem chirurgie sekund\u00e1rn\u00edch plicn\u00edch novotvar\u016f je kompletn\u00ed resekce p\u0159i dosa\u017een\u00ed negativn\u00edch resek\u010dn\u00edch lini\u00ed (po\u017eaduje se 1 cm) a zachov\u00e1n\u00ed maxim\u00e1ln\u00edho mno\u017estv\u00ed zbyl\u00e9ho funk\u010dn\u00edho parenchymu (obr. 24). Kl\u00ednovit\u011b lze resekovat metast\u00e1zy na periferii lalok\u016f, hloub\u011bji ulo\u017een\u00e9 l\u00e9ze lze \u0159e\u0161it kr\u00e1teriformn\u00edmi excizemi, centr\u00e1ln\u011bji ulo\u017een\u00e9 l\u00e9ze vy\u017eaduj\u00ed anatomick\u00e9 v\u00fdkony v rozsahu segment\u016f \u010di lalok\u016f. Pneumonektomie je naprosto v\u00fdjime\u010dnou cenou za kontrolu metastatick\u00e9ho procesu, bronchoplastick\u00fd, resp. angioplastick\u00fd v\u00fdkon by m\u011bl b\u00fdt v ka\u017ed\u00e9m p\u0159\u00edpad\u011b preferov\u00e1n. Metast\u00e1zy lze operovat videotorakoskopicky, videoasistovan\u011b \u010di otev\u0159en\u00fdm p\u0159\u00edstupem. P\u0159i<\/p>\n<p style=\"text-align: justify;\">bilater\u00e1ln\u00edm v\u00fdskytu lze operovat v jedn\u00e9 dob\u011b cestou 2 later\u00e1ln\u00edch p\u0159\u00edstup\u016f \u010di transstern\u00e1ln\u011b, nebo ve dvoudob\u00e1ch, zale\u017e\u00ed na lokalizaci metast\u00e1z a kondici nemocn\u00e9ho. Remetastazektomie jsou mo\u017en\u00e9 za spln\u011bn\u00ed v\u00fd\u0161e uveden\u00fdch kautel a dostate\u010dn\u00e9 funk\u010dn\u00ed rezerv\u011bplic. Lymfadenektomie mediastin\u00e1ln\u00edch uzlin je pova\u017eov\u00e1na za nutnou sou\u010d\u00e1st operace, PET\/CT negativn\u00edscan mediastina p\u0159i akumuluj\u00edc\u00edch metast\u00e1z\u00e1ch tuto podm\u00ednku relativizuje.<\/p>\n<h4>5.8.5 Progn\u00f3za<\/h4>\n<p style=\"text-align: justify;\">U kompletn\u011b resekovan\u00fdch nemocn\u00fdch lze u v\u00fd\u0161e uveden\u00fdch diagn\u00f3z o\u010dek\u00e1vat po metastazektomii p\u011btilet\u00e9 p\u0159e\u017eit\u00ed p\u0159ibli\u017en\u011b v 13\u201360 %. Z prognostick\u00fdch ukazatel\u016f m\u00e1 nejv\u011bt\u0161\u00ed v\u00e1hu kompletnost resekce, solit\u00e1rn\u00ed n\u00e1lez a dlouh\u00fd inteval mezi prim\u00e1rn\u00ed operac\u00ed a metastazektomi\u00ed.<\/p>\n<h3>5.9 Vyu\u017eit\u00ed laseru\u00a0v plicn\u00ed chirurgii<\/h3>\n<p style=\"text-align: justify;\">U\u017eit\u00ed laseru v plicn\u00ed chirurgii m\u00e1 dlouhou historii sahaj\u00edc\u00ed do 60. let minul\u00e9ho stolet\u00ed, kdy byl pulzn\u00ed typ laseru u\u017e\u00edv\u00e1n p\u0159i l\u00e9\u010db\u011b plicn\u00edch metast\u00e1z. S v\u00fdvojem a zdokonalov\u00e1n\u00edm laserov\u00fdch p\u0159\u00edstroj\u016f se u\u017e\u00edv\u00e1n\u00ed laserov\u00e9ho paprsku zvl\u00e1\u0161t\u011b v chirurgii plicn\u00edch metast\u00e1z v posledn\u00edch desetilet\u00edch st\u00e1le v\u00edce roz\u0161i\u0159uje. \u00dapravou vlnov\u00e9 d\u00e9lky laserov\u00e9ho paprsku bylo dosa\u017eeno zlep\u0161en\u00e9 vaporizace a koagulace plicn\u00ed tk\u00e1n\u011b. Jako optim\u00e1ln\u00ed pro u\u017eit\u00ed v plicn\u00ed chirurgii se v sou\u010dasnosti jev\u00ed Nd:YAG Laser System s vlnovou d\u00e9lkou 1,318 nm. Mezi p\u0159ednosti u\u017eit\u00ed laseru se uv\u00e1d\u00ed mo\u017enost precizn\u00ed resekce perifern\u00edch i centr\u00e1ln\u011b ulo\u017een\u00fdch metast\u00e1z, optim\u00e1ln\u00ed kontrola resek\u010dn\u00ed plochy s dokonal\u00fdm uz\u00e1v\u011brem bronch\u016f a c\u00e9v, a t\u00edm minimalizace krv\u00e1cen\u00ed. U\u017eit\u00ed laseru umo\u017e\u0148uje excizi mnoho\u010detn\u00fdch metast\u00e1z p\u0159i maxim\u00e1ln\u00edm \u0161et\u0159en\u00ed plicn\u00edho parenchymu. K nev\u00fdhod\u00e1m pat\u0159\u00ed pon\u011bkud v\u011bt\u0161\u00ed \u010dasov\u00e1 n\u00e1ro\u010dnost v\u00fdkonu a vy\u0161\u0161\u00ed n\u00e1klady na po\u0159\u00edzen\u00ed laserov\u00e9ho p\u0159\u00edstroje. V sou\u010dasnosti pou\u017e\u00edv\u00e1 tuto techniku v \u010cesk\u00e9 republice chirurgick\u00e1 klinika v Plzni a chirurgick\u00e9 odd\u011blen\u00ed nemocnice a Komplexn\u00edho onkologick\u00e9ho centra v Nov\u00e9m Ji\u010d\u00edn\u011b (obr. 25, 26, 27, 28).<\/p>\n<table style=\"width: 100%;\" border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n<tbody>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1651.png\"><img decoding=\"async\" title=\"Obr. 25a \u2013 Nd:YAG Laser pro plicn\u00ed chirurgii\" alt=\"Obr. 25a \u2013 Nd:YAG Laser pro plicn\u00ed chirurgii\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1651.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 25a<br \/>Nd:YAG Laser pro plicn\u00ed chirurgii<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1641.png\"><img loading=\"lazy\" decoding=\"async\" class=\" \" title=\"Obr. 25b \u2013 Pr\u00e1ce na opera\u010dn\u00edm s\u00e1le\" alt=\"Obr. 25b \u2013 Pr\u00e1ce na opera\u010dn\u00edm s\u00e1le\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1641.png\" width=\"200\" height=\"139\" \/><\/a><p class=\"wp-caption-text\">Obr. 25b<br \/>Pr\u00e1ce na opera\u010dn\u00edm s\u00e1le<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1671.png\"><img decoding=\"async\" title=\"Obr. 26a \u2013 Excize metast\u00e1zy laserov\u00fdm paprskem\" alt=\"Obr. 26a \u2013 Excize metast\u00e1zy laserov\u00fdm paprskem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1671.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 26a<br \/>Excize metast\u00e1zy laserov\u00fdm paprskem<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1661.png\"><img decoding=\"async\" title=\"Obr. 26b \u2013 Excize metast\u00e1zy laserov\u00fdm paprskem\" alt=\"Obr. 26b \u2013 Excize metast\u00e1zy laserov\u00fdm paprskem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1661.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 26b<br \/>Excize metast\u00e1zy laserov\u00fdm paprskem<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" colspan=\"2\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1681.png\"><img loading=\"lazy\" decoding=\"async\" title=\"Obr. 27 \u2013 Stav po odstran\u011bn\u00ed pl\u00edcn\u00ed metast\u00e1zy laserem\" alt=\"Obr. 27 \u2013 Stav po odstran\u011bn\u00ed pl\u00edcn\u00ed metast\u00e1zy laserem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1681.png\" width=\"200\" height=\"106\" \/><\/a><p class=\"wp-caption-text\">Obr. 27<br \/>Stav po odstran\u011bn\u00ed pl\u00edcn\u00ed metast\u00e1zy laserem<\/p><\/div><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 50%; border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1701.png\"><img decoding=\"async\" title=\"Obr. 28a \u2013 CT obraz plicn\u00ed metast\u00e1zy v lev\u00e9m doln\u00edm plicn\u00edm laloku\" alt=\"Obr. 28a \u2013 CT obraz plicn\u00ed metast\u00e1zy v lev\u00e9m doln\u00edm plicn\u00edm laloku\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1701.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 28a<br \/>CT obraz plicn\u00ed metast\u00e1zy v lev\u00e9m doln\u00edm plicn\u00edm laloku<\/p><\/div><\/td>\n<td style=\"border: 1px solid #ffffff;\" align=\"center\" valign=\"top\">\n<p><div style=\"width: 210px\" class=\"wp-caption alignnone\"><a href=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1711.png\"><img decoding=\"async\" style=\"color: #333333; font-family: Georgia, 'Times New Roman', 'Bitstream Charter', Times, serif; font-size: 13px; line-height: 19px; text-align: start;\" title=\"Obr. 28b \u2013 Odstran\u011bn\u00e1 metast\u00e1za s okoln\u00edm plicn\u00edm parenchymem\" alt=\"Obr. 28b \u2013 Odstran\u011bn\u00e1 metast\u00e1za s okoln\u00edm plicn\u00edm parenchymem\" src=\"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/wp-content\/uploads\/2013\/03\/Image_1711.png\" width=\"200\" \/><\/a><p class=\"wp-caption-text\">Obr. 28b<br \/>Odstran\u011bn\u00e1 metast\u00e1za s okoln\u00edm plicn\u00edm parenchymem<\/p><\/div><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h3><span style=\"font-size: 1.17em;\">5.10 Literatura<\/span><\/h3>\n<ol>\n<li>Becker HD, Hohenberger W, Junginger T, Schlag PM, editors. Chirurgick\u00e1 onkologie. Praha: Grada Publishing; 2005.<\/li>\n<li>Cahan WG, Watson WL, Pool JL. Radical pneumonectomy. J Thorac Surg. 1951;22:476\u2013483.<\/li>\n<li>Ginsberg RA. Atlas of clinical oncology. Lung cancer. Hamilton: BC Decker Inc; 2002.<\/li>\n<li>Grunenwald DH. Surgery for advanced stage lung cancer. Semin Surg Oncol. 2000;18:137\u2013142.<\/li>\n<li>Klein J. Chirurgie karcinomu plic. Praha: GradaPublishing; 2006.<\/li>\n<li>Kolek V, Va\u0161\u00e1k V. Pneumologie. Praha: Maxdorf;2010.<\/li>\n<li>LoCicero J, Hartz RS, Frederiksen JW, MichaelisLL. New applications of the laser in pulmonarysurgery. Hemostasis and sealing of air leaks. AnnThorac Surg. 1985;40:546\u2013550.<\/li>\n<li>Mathisen DJ, Grillo HC. Carinal resection forbronchogenic carcinoma. J Thorac Cardo VascSurg. 1991;102:16\u201323.<\/li>\n<li>Minton JP, Andrews NC, Jesseph JE. Pulsed laserenergy in the management of multiple metastase. J Thorac Cardiovasc Surg. 1967;54:707\u2013713.<\/li>\n<li>Nakahara H, Ohno K, Matsumura A. Extendedoperation for lung cancer invading the aorticarch and superior vena cava. J Thorac CardiovascSurg. 1989;97:428\u2013433.<\/li>\n<li>Pearson GF, Cooper JD, Deslauriers J, Ginsberg RJ, Hiebert CA, Patterson GA, Urschel HC. Thoracic surgery. New York: Churchil Livingstone;2002.<\/li>\n<li>Pitz CC, Brutel de la Riviere A, van Swieten HA,Westermann CJJ, Lammers JWJ, Bosch JMM. Results of surgical treatment of T4 nonsmall celllung cancer. Europ J Cardio Thorac Surg. 2003;24:1013\u20131018.<\/li>\n<li>Pichlmaier H, Schildberg FW. Thoraxchirurgie.Heidelberg: Springer; 2006.<\/li>\n<li>PriceThomas C. Conser vative resection ofthe bronchial three. J R Coll Sulg Edinb. 1956;1:169\u2013173.<\/li>\n<li>Proch\u00e1zka J. Resekce plic. Praha. SZN; 1954.<\/li>\n<li>Rendina EA, Venuta F, De Giacomo T, Ciccone AM, Ruvolo G, Coloni GF, Ricci C. Inductionchemotherapy for T4 centrally located nonsmalllung cancer. J Thorac Cardiovasc Surg. 1999;117:225\u201329.<\/li>\n<li>Rolle A, Pereszlenyi A, Koch R, Bis B, Baier B. Laser Resection Technique and Results of MultipleLung Metastasectomies Using a New 1,318 nmNd: ZAG Laser Syst\u00e9m. Laser Med Surg. 2006;38:26\u20132.<\/li>\n<li>\u0158eh\u00e1k F, \u0160mat V. Chirurgie plic a mediastina.Praha: Avicenum; 1986.<\/li>\n<li>Tsuchiya R, Asamura H, Kondo H. Extended resection of the left atrium, reat vessels, or both forlung cancer. Ann Thorac Surg. 1994;57:960\u2013965.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"<p>5.1 Anatomie 5.1.1 Plicn\u00ed laloky a segmenty Prav\u00e1 pl\u00edce je \u010dlen\u011bna dv\u011bma interlob\u00e1rn\u00edmi z\u00e1\u0159ezy (fissurami) na 3 laloky: horn\u00ed lalok, st\u0159edn\u00ed lalok a doln\u00ed lalok. Hlavn\u00ed (\u0161ikm\u00fd) interlob\u00e1rn\u00ed z\u00e1\u0159ez odd\u011bluje doln\u00ed plicn\u00ed lalok od obou zb\u00fdvaj\u00edc\u00edch a ve sv\u00e9m pr\u016fb\u011bhu kop\u00edruje p\u0159ibli\u017en\u011b pr\u016fb\u011bh 6. \u017eebra. V polovin\u011b t\u00e9to r\u00fdhy, tedy asi ve st\u0159edn\u00ed axil\u00e1rn\u00ed \u010d\u00e1\u0159e, [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":1347,"menu_order":25,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":"","_links_to":"","_links_to_target":""},"class_list":["post-1502","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1502","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=1502"}],"version-history":[{"count":28,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1502\/revisions"}],"predecessor-version":[{"id":1695,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1502\/revisions\/1695"}],"up":[{"embeddable":true,"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=\/wp\/v2\/pages\/1347"}],"wp:attachment":[{"href":"https:\/\/eportal.chirurgie.upol.cz\/portal_final\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=1502"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}