【作者】 董晓秋；

【导师】 沈毅；

【作者基本信息】 哈尔滨工业大学 ， 生物医学仪器与工程， 2010， 博士

【摘要】 在我国泌尿外科肿瘤中，肾肿瘤发病率占第二位，良性肾肿瘤以肾血管平滑肌脂肪瘤(RAML)占多数(90%以上)，恶性肾肿瘤以肾透明细胞癌(RCCC)为主(80%以上)。超声、CT和MRI是目前诊断肾肿瘤的主要方法。超声检查因其实时、动态、直观等优点已成为筛查肾肿瘤的首选方法，但对肾脏良、恶性肿瘤的检出及鉴别诊断尚存在一定困难。本论文将超声造影技术应用于肾脏肿瘤的检查，利用造影剂微气泡后散射回声增强的原理，使造影剂与机体组织间产生较大的声特性阻抗差异而清晰显示脏器及病变内、外微小血流信号及微小血管的灌注情况，从而进一步提高肾脏肿瘤的检出和鉴别诊断效果。论文参照欧洲超声医学与生物学联合会制定的肝脏超声造影使用规范和临床应用指南，依据肾脏常规超声的特点，结合肾脏血流动力学特点，对正常肾脏、RAML、RCCC的超声造影图像进行分析，通过图像对比和数据分析以及实际病例的验证，确定了正常肾脏、RAML、RCCC超声造影诊断的定性特征指标为：造影时相、增强程度、灌注方式、增强模式，定量指标为：ST、PT、PI、ASR、DSR、AUC。为探索超声造影在肾脏肿瘤中的应用标准问题，论文将超声造影应用于正常肾脏皮质及髓质的50个病例，先对造影时相进行了划分；然后又进一步对肾脏皮、髓质造影图像进行定量处理。通过二者之间产生差异的机理分析，得出超声造影比彩色及能量多普勒超声对血流显示更敏感的结论，并且明确了肾脏皮质和髓质的灌注相、消退相时间范围，时间-强度曲线定量分析得出肾皮质的ST早于肾髓质、灌注速度快于髓质、PT相近、近于同步消退、肾皮质PI明显高于肾髓质、肾皮质的AUC明显大于肾髓质的结论。接着，论文以肾良性肿瘤的病理组织形态为基础，对86例RAML的超声造影图像进行了数据处理和分析，归纳并总结了代表肾脏良性肿瘤的RAML的超声造影时相特征、灌注方式、增强模式和时间-强度曲线定量参数。分析得出了RAML超声造影灌注方式以“从周边逐渐向中央增强”为主的结论。具体分型特点增强模式分3型：Ⅰ型“快进慢出”、Ⅱ型“慢进慢出”、Ⅲ型“同进慢出”，以Ⅱ型“慢进慢出”为主占68.6%(59/86)。同时通过时间-强度曲线定量参数分析得出：RAML的ST、PT、ASR、AUC大于同侧正常肾皮质的结论。而后，论文以肾脏恶性肿瘤的组织病理及血管密度特征为实验基础，通过对42个RCCC进行超声造影图像分析研究，得出如下肾脏恶性肿瘤诊断的定性及定量结论：RCCC超声灌注方式以“弥漫性不均匀增强”为主；造影增强模式分四型：Ⅰ型“快进快出”、Ⅱ型“快进慢出”、Ⅲ型“同进同出”、Ⅳ型“慢进慢出”，以Ⅱ型“快进慢出”为主。同时，时间-强度曲线定量参数分析得出：RCCC的ST、PT、PI、ASR和DSR不同于同侧正常肾皮质，差异明显。论文最后，通过对比正常肾脏、肾脏良性、恶性肿瘤超声造影图像在造影时相划分、灌注方式判定、增强模式等指标方面的差异，并结合数据分析，分别得出如下结论：超声造影图像以增强均匀程度、灌注方式、增强模式3个定性指标诊断肾脏良、恶肿瘤的灵敏度分别为80.23%、80.23%、93.02%，特异度分别为78.57%、83.33%、71.42%，准确率为79.69%、81.25%、85.93%，ROC曲线下面分别为0.794、0.818、0.822。肾脏良、恶性肿瘤的时间-强度曲线定量参数ST、PT、ASR和AUC之间差异明显。更多还原

【Abstract】 Renal tumour is the second common urological tumor in our country. Renalangioleiomyolipoma (RAML) accounts for more than90%of renal benign tumors,and renal clear cell carcinoma (RCCC) accounts for more than80%of renalmalignant tumors. So far, diagnosis of renal tumor depends on imaging methodssuch as ultrasound, CT and MRI. Ultrasonography has become the most commonlyused method for the screening of kidney tumour because of its real-time, dynamic,visual and other advantages. But it is still difficult to detect and differentiallydiagnose benign and malignant renal tumors. Contrast enhanced ultrasonography(CEUS) using non-destructive low-acoustic-power ultrasounc scanning withinjection of contrast agent microbubbles, allows to display the blood flow andperfusion of capillary in organs or malignant lesions clearly. In this paper, CEUSwas applied to examine renal tumor and it proved to be a high sensitivity indetection and differential diagnosis of renal tumor.Methods for CEUS performed on kidney according to the Clinical Applicationof norm and guidelines on liver contrast enhanced ultrasound established by theEuropean Federation of Ultrasound Medicine and Biology (EFUMB). Rationalexperimental method was developed based on routine ultrasound andhemodynamics characteristics of renal. Contrast enhanced ultrasound wasperformed on the normal kidney, RAML and RCCC and then contrastographicpictures were analyzed. Based on imaging comparison, data analysis and caseconfirmation, specific qualitative index such as contrast enhanced phase, contrastenhanced degree, perfusion mode, enhancement pattern; quantitative index such asstart time (ST), peak time (PT), peak intensity (PI), ascending slope rate (ASR),descending slope rate (DSR) and area under curve (AUC) were used in this study.Firstly, in order to explore the application standards of CEUS on renal tumors,we applied CEUS in50cases with normal renal cortex and medulla. Phase ofCEUS in normal renal were divided first, then contrastographic pictures of renalcortex and medulla were quantitatively analysed. CEUS proved to be more sensitivethan color and power Doppler ultrasound in displaying renal blood flow, cleared therange of renal cortical and medullary perfusion phase and regression phase. Time-intensity curve showed that perfusion in renal cortex started earlier than that inrenal medulla, perfusion rate in renal cortex was faster than that in renal medulla;however, their PT were close, regression were almost simultaneously; and PI andAUC in renal cortex was higher than those in renal medulla. Secondly, in order to determin the characteristics of benign renal tumordetected by CEUS,86patients of RAML, a benign renal tumor, were performed toCEUS. Phase feature, perfusion mode, enhanced mode and time-intensity curverepresent benign renal tumor was summarized by CEUS images analysis. It showedthat the most common perfusion mode was “gradually enhanced intensity from rimto center”. According to perfusion enhancement modes, it was separated by threetypes: type I was “fast in and slow out”, type II was “slow in and slow out”, type IIIwas “simultaneous in and slow out” which accounts for68.6%(59/86). Time-intensity curve showed that ST, PT, ASR and AUC of RAML was greater than thosein ipsilateral normal renal cortex.Thirdly, we perfomred CEUS on42RCCC and based the experiment onpathology and optical density of blood vessels. The most common perfusion modefor RCCC was“enhanced uneven and diffuse”. Perfusion enhancement mode wasclassified into four types: type I, quick in and quick out; type II, quick in and slowout, type III, simultaneous in and simultaneous out; type IV, slow in and slow out.The most common type was type II. Conclusion from quantitation analysis of time-intensity curve was that ST, PT, PI, ASR and DSR of RCCC were significantlydifferent from those in normal renal cortex.Eventually, according to the differences of phase of CEUS, perfusion modeand enhanced pattern in normal kidney, benign and malignant renal tumor,conclusion as followed was obtained. There qualitative indexes, enhancementhomogenecity, perfusion mode and enhancement pattern were used for renal tumordiagnosis with a sensitivity of80.23%,80.23%and93.02%, respecificity; aspecificity of78.57%,83.33%and71.42%, respectively; an accurate diagnosis rateof79.69%,81.25%and85.93%, respectively; area of ROC curve of0.794,0.818and0.822, respectively. Conclusion from quantitation analysis of time intensitycurve was that ST, PT, ASR, AUC and DSR of RAML were significantly differentfrom RCCC.更多还原