【作者】 王立侠；

【导师】 周纯武； 欧阳汉；

【作者基本信息】 中国协和医科大学 ， 影像医学与核医学， 2007， 博士

【摘要】 第一部分：低场强MRI在子宫内膜癌诊断和分期的应用目的评估低场强MRI（0.5T）对子宫内膜癌诊断和对肌层浸润深度、子宫颈受侵、淋巴结转移及其它部位受侵的价值，同时观察T2WI和增强扫描T1WI／3D序列对肌层浸润深度及子宫颈受侵方面的价值。材料与方法前瞻性分析239例经临床怀疑或经诊断性刮宫证实的子宫内膜癌患者，术前行MRI平扫及增强扫描，分析MRI对子宫内膜癌浸润深度、子宫颈受侵和淋巴结转移的敏感性、特异性、准确性。并比较T2WI和增强扫描T1WI／3D序列在子宫内膜癌肌层浸润深度及子宫颈受侵方面的差异及一致性。结果MRI对子宫内膜癌的检出率为97.80％（222／227），诊断准确率93.31％（223／239）。联合应用T2WI和增强扫描T1WI／3D序列定位肌层浸润深度的诊断符合率为73.2％；肿瘤局限于内膜，其敏感性、特异性、准确性分别为66.7％／95.6％／91.9％，浸润浅肌层67.2％／84％／73.2％／，浸润深肌层93.8％／77.6％／81.3％。单独应用T2WI对肿瘤局限于内膜、浸润浅肌层和深肌层的准确性分别为86.1％／70.0％／80.9％，单独应用增强扫描T1WI／3D序列分别为91.1％／72.6％／81.6％。联合应用两种序列与单独应用T2WI或增强扫描T1WI／3D之间对肌层浸润深度的准确性无统计学意义（P=0.448、0.902），两种序列之间无统计学意义（P=0.268），一致性检验结果为Kappa值为0.751，P=0.000。联合应用T2WI和增强扫描T1WI／3D序列评估子宫颈受侵，其敏感性、特异性、准确性分别为60.6％／91.2％／83.3％，T2WI序列为58.1％／91.2％／81.3％，T1WI／3D序列为71.2％／89.8％／84.5％。两种序列对有无子宫颈受侵评估的准确性无统计学意义（P=0.501），一致性检验结果为：Kappa值0.922，P=0.000。MRI埘淋巴结转移的敏感性、特异性和准确性分别为80.0％／94.7％／93.3％。宫旁受侵分别为50％／97.4％／93.8％。对浆膜受侵的敏感性为54.5％，卵巢转移的敏感性为36.4％。结论低场强MRI对子宫内膜癌的诊断和对肌层浸润深度、子宫颈受侵、淋巴结转移能够作出比较准确的评估，能够更好的指导临床医师选择合适的手术和治疗方案。T2WI和增强T1WI／3D序列对子宫内膜癌肌层浸润深度及子宫颈受侵方面的评估有很好的一致性。第二部分高场强MRI弥散和灌注加权成像在子宫内膜癌的应用探讨目的应用高场强磁共振对子宫内膜癌进行灌注和弥散加权成像，探讨两种成像方法对子宫内膜癌的诊断价值。材料和方法对25例临床怀疑或经诊断性刮宫证实为子宫内膜癌的患者，应用3.0T磁共振扫描仪，行MR常规扫描及弥散加权和灌注加权成像。弥散加权像选择五组不同的b值（200、400、600、800、1000s／mm²），观察病变和肌层的ADC值随b值的变化情况，并观察子宫内膜不同病变之间ADC值的差异。灌注加权像采用LAVA（容积扫描序列）序列，观察肿瘤的灌注形式、灌注曲线的形态、观察病变与正常子宫肌层、不同病变之间和肌层与子宫颈之间灌注值的差异。结果1、子宫内膜病变在弥散加权图像上与肌层相比均呈明显高信号，且两者的ADC值随b值的增大均逐渐减小。肿瘤ADC值／肌层ADC值(R_T／M)也随b值的增大逐渐减小，且在b=1000和600 s／mm²、1000和400 s／mm²、1000和200 s／mm²时R_T／M有统计学意义（P=0.039、0.034、0.036）。内膜病变的ADC值在不同b值下均存在统计学意义（P＜0.05）。对内膜病变和肌层的ADC值比较，两者在任何b值均有统计学意义。在b值为200、400、600、800、1000s／mm²时，子宫内膜癌的ADC值分别为2.22×10^-3、1.58×10^-3、1.32×10^-3、1.21×10^-3、105×10^-3mm²／s．2、16例患者子宫的增强形式为：Ⅰ型内膜下增强带（SEE）5例；Ⅱ型内侧肌层或连接带早期明显强化10例；Ⅲ型为肌层主要是外侧肌层增强，共1例。子宫内膜病变的时间-信号强度曲线形态；逐渐上升型，见于1例子宫内膜增生；上升-平坦型见于1例子宫内膜增生，11例子宫内膜癌和1例宫颈癌侵犯子宫体；上升-下降-平坦型，见于2例子宫内膜痛。子宫内膜癌与肌层的各项灌注值之间在正性增强积分（PEI）、峰值强化时间（TP）、及曲线上升最大斜率（MSI）有统计学意义（P＜0.05）。结论弥散加权像对检出子宫内膜病变非常敏感，但是对于癌和不典型增生的鉴别仍有一定的困难，为了能够准确的显示病变，建议应用b值为800或1000进行弥散加权像。子宫内膜癌和子宫内膜增生的灌注曲线形态有明显不同，并且在峰值强化时间差别较大。我们认为灌注加权成像能够对两种病变进行鉴别，但此结果还有待于大样本量进一步观察。更多还原

【Abstract】 Part 1 Value of low-field MR imaging in diagnosing and staging in endometrial carcinomapurposeTo evaluate the value of low-field MR imaging in diagnosing and staging in endometrial carcinoma, and to discuss the value of non-breath-hold T2-weighted（T2WI） fast spin echo sequence and contrast-enhanced T1-weighted with a 3D gradient echo sequence（T1WI/3D） in detecting depth of myometrial invasion and cervical invasion in patients with endometrial carcinoma.Materials and MethodsTwo hundred and thirty-nine cases which were suspected by clinics or proved by dilatation and curettage with endometrial carcinoma were prospectively studied.The patients were undergone conventional and contrast-enhanced MR scan before operation. The sequences of MR imaging included spin echo T1-weighted imaging（T1WI）, transverse, cornonal and saggital fast spin echo T2-weighted imaging（T2WI） or spectra-presaturation inverted recovery T2-weighted imaging（T2WI/SPIR）. T1WI 3-dimentional gradient echo sequence（T1WI/3D） was applied after administration of Gd-DTPA. Compared with the results of pathology, sensitivity,specificity and accuracy of different myometrial depth of invasion, cervical invasion and lymph nodal metastases in MRI were analysed with SPSS software. And the value in superficial-and deep myometrial invasion and cervical invasion on T2WI and enhanced T1WI/3D were analysed.ResultsMR imaging had a rate of 97.80%（222/227） in detected lesion and accuracy of 93.31 %（223/239） for diagnosing in endometrial carcinoma.MR imaging had coincidence rate of 73.2% for iocaiizing the depth of myometrial depth in endometrial carcinoma on T2WI with contrast-enhanced Tl WI/3D sequences. Compared with the results of pathology, sensitivity, specificity, accuracy of MRI was 66.7%/95.6%/91.9% for tumor confined in endometrium, 67.2%/84%/73.2% for super-myometrial invasion respectively, and 93.8%/77.6%/81.3% for deep-myometrial invasion on T2WI with T1WI/3D. Accuracy was 86.1 %/70.0%/80.9% for tumor confined in endometrium, super-myometrial invasion and deep-myometrial invasion on T2WI and 91.1%/72.6%/81.6% on T1WI/3D. No statistical significance was found for the accuracy of myometrial-depth invasion on T2WI with T1WI/3D and T2WI or T1WI/3D（P=0.448, 0.902）. No statistical significance was found for the accuracy of myometrial invasion on two sequences（P=0.268）. The value of Kappa was.751, P=0.000.MR imaging had sensitivity, specificity and accuracy of 60.6%/91.2%/83.3% for evaluating cervical invasion on T2WI with T1WI/3D, and 58.1%/91.2%/81.3% on T2WI, 71.2%/89.8%/84.5% respectively on T1WI/3D. No statistical significance was found for the accuracy of cervical invasion on two sequences（P=0.501）. The value of Kappa was.922, P=0.000.MR imaging had sensitivity, specificity and accuracy of 80.0%/94.7%/93.3% for lymph nodal metastases, 50%/97.4%/93.8% for paraendometrial invasion, sensitivity of 54.5% for serous coat and 36.4% for ovary metastases.ConclusionLow-field MR imaging had the relatively accurate evaluation in diagnosing and localizing the depth of myometrial invasion, cervical invasion and lymph nodal metastases in endometrial carcinoma.It plays an important role for clinician establishing the right scheme of therapy. T2WI and T1WI/3D had good correlation for the evaluation of the superficial/deep myometrial and cervical invasion in endometrial carcinoma. Part 2 Evaluation of high-field MR diffusion-weighted and perfusion-weighted imaging in endometrial carcinomapurposeTo investigate the usefulness of high-field MR diffusion-weighted imaging（DWI） and perfusion-weighted imaging（PWI） in evaluating endometrial carcinoma.Materials and methods25 female patients with suspected or proved by dilatation and curettage with endometrial carcinoma were prospectively studied and all were underwent surgery after MRI examination. MR images were obtained at a 3.0 T MR scanner（GE, SIGNA EXCITE HD 3.0T） and an 8-element phased-array torsopa coil was used to receive MR signal. The conventional pulse sequences included axial SE T1WI, FSE T2WI and fat saturated FSE T2WI, sagital FSE T2WI, and coronal fat saturated FSE T2WI. Axial DWI was performed in all patients using a SE-EPI sequence with a b value of 200、400、600、800、1000s/mm². Apparent diffusion coefficients（ADC） were measured for every patients and different b value. PWI was performed with LAVA sequence, the type of uterus dynamic enhancement and perfusional curves of the endometrial lesion were investigated and the perfusional value of lesion, myometrium and uterine cervix were measured.resultsAll endometrial lesions were markedly high signal intensity on DWI compared with myometrium. The ADC of endometrial lesions and myometrium was decrease with the increasing of the b value. The ratio of ADC values of the endometrial carcinoma/myometrim(R_T/M)also decreased with the increasing of the b value. Statistical significant difference in R_T/M was found for b value of 1000 and 600 s/mm²（P=0.039）, b value of 1000 and 400 s/mm²（P=0.034）, b value of 1000 and 200 s/mm²（P=0.036）. Significant difference was found for the ADC of different b value compared endometrial lesion and myometrium. The ADC of endometrial carcinoma was 2.22×10^-3,1.58×10^-3,1.32×10^-3,1.21×10^-3, 1.05×10^-3mm²/s respectively on b value of 200、400、600、800、1000s/mm².The types of uterus dynamic e、nhancement of 16 patients who were performed perfusion-weighted imaging successfully were categorized as followed: typeⅠsubendometrial enhancement was found in 5 cases; typeⅡthin layer enhancement corresponding to the superficial myometrium or junctional zone was found in 10 cases; typeⅢouter（deep） myometrium enhancement was found in 1 cases. The perfusional curves in endometrial lesions appeared as: gradual late peak enhancement found in 1 patients with endometrial hyperplasia; early peak enhancement and no gradual washout was found in 11 patients with endometrial carcinoma and 1 patiens with endometrial hyperplasia and 1 patient with cervical carcinoma invased endometrum; early peak enhancement followed with gradual washout and late weak enhancement found in 2 cases with endometrial carcinoma.Statistical significant difference was found in positive enhancement integral（PEI）, time to peak（TP） and maximal slope of increase（MSI） compared endometrial carcinoma with myometrium（P<0.05）.ConclusionDWI had high sensitivity in detecting endometrial lesion, but had some difficulty in differentiating endometrial carcinoma with hyperplasia. For the characteration of lesion and the ADC value measured accurately, the b value of 800 or 1000 s/mm² on DWI was proposed. The different appearance of perfusional curves and earlier TP in endometrial carcinoma with hyperplasia can provide a useful clue in the differentiation of carcinoma and hyperplasia. However, due to our small study population, further evaluation is needed to comfirm the difference in the ADC and perfusion value of endometrial carcinoma and endometrial hyperplasia.更多还原