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孟广平 吉林大学第二医院 发布于2024-05-17 浏览 912
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单位：吉林大学第二医院呼吸与危重症医学科
01
CIP潜在的危险因素[5]主要有：①年龄：患者年龄多在70岁以上[6]；②性别：女性发病率高于男性[7]；③吸烟史：吸烟者比不吸烟者更容易发生[8]；④既往肺部疾病史：有间质性肺疾病、慢性阻塞性肺疾病、哮喘、气胸、胸腔积液和肺纤维化病史患者CIP发生率高；⑤肿瘤组织学类型：相较于腺癌，鳞癌患者发生CIP的概率更高；⑥PD-1抑制剂：使用PD-1/PD-L1抑制剂会增加CIP的发生风险[9]；⑦联合治疗：接受联合治疗的患者CIP发生率增加了2～3倍，抗生素和免疫抑制药物是ICIs治疗后肺部感染的主要危险因素；⑧既往放射治疗病史：放射治疗与免疫疗法存在协同作用[10]。
02
目前CIP的发病机制尚未得到明确阐述，仍需深入探究[10]。可能与下述情况有关：①T细胞对肿瘤和正常组织中表达的交叉抗原的活性增加；②自身抗体和炎性细胞因子水平升高：CIP患者血浆抗CD74水平升高；CIP的非小细胞癌患者IL-6、IL-17A、IL-35、CRP、PCT、SP-D和KL-6升高；③增强补体介导的炎症[11]。
03
（2）隐源性机化性肺炎（COP）：是NSCLC中最常见的CIP类型，双侧多灶性实变，周围和下肺分布，伴有GGO和网状阴影[17]。
还可以表现为机化性肺炎（OP），反向环礁或晕征，被认为是CIP中OP的相对特殊特征[18]。
（3）非特异性间质性肺炎（NSIP）：是CIP第二常见的报道类型，通常表现为肺下叶GGO和网状结构[17]。
（7）未分类型。
4. 病理表现[20，21]
CIP的病理表现主要为：①嗜酸性粒细胞浸润；②肉芽肿性炎症；③肺泡实质伴成纤维细胞灶；④肺泡间隔轻度胶原扩张；⑤非特异性慢性炎症；⑥不典型细胞。
04
RIP是一种放射性肺损伤的早期表现，也是CIP的鉴别诊断难点[25-27]。两种疾病的相似之处在于：①发病时间接近（1～3个月）；②相似的影像特征（GGO和弥漫性模糊影）；③共同的病理特征（淋巴细胞性肺泡炎）；④相同的一线治疗方案：糖皮质激素。不同之处在于二者的病变部位存在差异，RIP主要存在于放射性区域，CIP多发生在放射治疗下降剂量以外或低剂量区。
05
托珠单抗是一种IL-6抑制剂，已被用于治疗风湿性免疫相关不良反应[31]。一份病例报告显示，一名NSCLC和CIP患者在接受托珠单抗额外治疗后症状显著缓解[32]。然而，是否应该将托珠单抗作为治疗激素难治性免疫相关不良反应患者的二线药物的选择仍未确定，因为该方法缺乏与其他二线药物的比较。
06
大多数CIP患者在接受糖皮质激素治疗后恢复良好。然而，由于继发感染、肿瘤进展或免疫抑制剂治疗无效，一些患者的预后仍然很差，约1/4的CIP患者会复发。CIP治愈后，临床医生将面临是否重新开启ICIs治疗的决定。大多数患者在重启免疫治疗后没有复发。诊断为3级或4级CIP的患者通常永久停止ICIs治疗，因此，重复使用ICIs治疗的报道主要发生在最初的1级或2级CIP患者中，其复发率从17%至30%不等[33]。复发性肺炎的类型、受累部位和严重程度可能与最初的表现不同。尽管在美国临床肿瘤学实践指南中没有具体说明，但复发性肺炎的治疗方法通常与首次发生时的治疗方法相似。
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