甲状腺结节三维超声及超声引导下甲状腺穿刺的临床研究

【作者】 李文波；

【导师】 姜玉新； 戴晴； 李建初；

【作者基本信息】 中国协和医科大学 ， 影像医学与核医学， 2009， 博士

【摘要】 第一部分甲状腺结节三维灰阶超声及三维能量多普勒超声血管成像与常规超声的对比研究目的观察甲状腺结节的三维灰阶超声(3D)和三维能量多普勒超声血管成像(3D-PDA)特征,与常规超声进行比较,探讨三维灰阶超声及三维能量多普勒超声血管成像对甲状腺良恶性结节的鉴别诊断价值。资料和方法2008年3月～2009年4月94例行甲状腺手术患者共103个甲状腺结节进行三维灰阶超声及三维能量多普勒超声血管成像研究。采用三维灰阶多平面成像方式对甲状腺结节进行三维重建。观察甲状腺结节与被膜关系、形态、边界、晕、内部回声、实性部分回声水平、均一性、钙化形态。采用三维能量多普勒超声成像对甲状腺结节及周边血流进行三维重建。分析血流分布、血管流数量、血管走行是否规则、空间分布是否对称、结节内是否存在局部血流丰富、结节周边实质是否存在局部血流丰富。分析不同病理类型甲状腺结节的三维灰阶超声及三维能量多普勒超声血管成像特征,比较良恶性结节之间的差异,比较三维灰阶超声成像及三维能量多普勒超声血管成像与常规超声诊断敏感性、特异性、阳性预测值、阴性预测值和准确率。结果1.进行三维超声检查的103个甲状腺结节,良性50个(48.5%),恶性53个(51.5%)。甲状腺恶性结节病理构成:乳头状癌48个(90.5%),滤泡癌1个(1.9%),髓样癌3个(5.7%),淋巴瘤1个(1.9%)。恶性结节平均大小为2.13±1.07cm(0.66cm-5.14cm),73.6%的肿瘤为Ⅰ期。良性结节病理构成:结节性甲状腺肿40个(80.0%),腺瘤8个(16.0%),桥本甲状腺炎1个(2.0%),纤维性甲状腺炎(2.0)。良性结节平均大小2.39±0.96 cm(0.78cm-5.32cm)。2.三维灰阶超声成像声像图特征:甲状腺良性病灶形态规则(88.0%)、边界清晰(84.0%)、有完整规则晕(54.0%)、囊实性(52.0%)、等回声(66.0%)、回声不均(72.0%)、无钙化(64.0%)。甲状腺恶性病灶形态不规则(90.6%)、边界模糊(47.2%)、无晕(62.3%)、实性(94.3%)、低回声(90.6%)、回声不均(90.6%)、有微小钙化(79.2%)。3.三维能量多普勒超声血管成像声像图特征:良性病灶血管走行规则(96.0%)、空间分布对称(88.0%)、结节内(96.0%)及结节周边实质(94.0%)不存在局部血流丰富;恶性病灶血管走行不规则(66.2%),空间分布不对称(56.6%),结节内(54.7%)及结节周边实质(60.4%)存在局部血流丰富。4.三维灰阶超声诊断效率(敏感性88.7%,特异性90.0%,阳性预测值90.4%,阴性预测值88.2%,准确率89.3%)高于二维灰阶超声(敏感性86.8%,特异性86.0%,阳性预测值86.8%,阴性预测值86.0%,准确率86.4%。);三维能量多普勒超声诊断效率(敏感性83.0%,特异性94.0%,阳性预测值93.6%,阴性预测值83.9%,准确率90.3%)高于彩色多普勒血流显像(敏感性75.5%,特异性92.0%,阳性预测值90.9%,阴性预测值78.0%,准确率83.5%)。结论甲状腺良恶性结节的三维灰阶超声成像声像图特征及三维能量多普勒超声血管成像声像图特征具有显著差异。三维灰阶超声的诊断敏感性、特异性高于二维灰阶超声。三维能量多普勒超声的诊断敏感性、特异性高于彩色多普勒超声。三维超声成像在灰阶成像和血管成像两方面为甲状腺结节的诊断和鉴别诊断提供了更多的信息,具有重要的临床应用价值。第二部分超声引导下细针吸取细胞学检查及组织活检对甲状腺结节的诊断价值目的1.评估超声引导下细针吸取细胞学检查(US-FNA)及超声引导下粗针活检(US-CNB)对甲状腺结节的诊断价值。2.初步探讨薄层液基细胞学涂片在甲状腺穿刺中的应用价值。资料和方法2004年11月至2008年10月168例患者的175个甲状腺结节进行超声引导下细针吸取细胞学检查。其中男28例,女140例。男女之比为1:5.0。年龄4-75岁,平均43.6岁。其中63例获得手术病理,其余病例全部进行临床随访,随访时间7个月-4年4个月。53例患者的53个甲状腺结节进行超声引导下粗针活检,其中男6例,女47例。男女之比1:7.8。年龄13-74岁,平均44.0岁。其中24例获得手术病理,其余病例全部进行临床随访,随访时间7个月-4年4个月。57个结节同时进行了薄层液基细胞学涂片,随访时间9月-1年2个月。将穿刺细胞学及组织学的诊断资料与手术病理及临床随访结果进行对照分析。细胞学及组织学诊断结果分为四类:良性、恶性、可疑恶性及涂片不满意。分析薄层液基细胞学涂片的细胞学特征。结果1.US-FNA的175个甲状腺结节经病理及临床随访证实恶性结节39个,良性结节136个。细胞学诊断良性71%(124/175),恶性14%(24/175),可疑恶性8%(14/175),涂片不满意7%(13/175)。US-FNA诊断敏感性81.1%,特异性93.6%,准确性90.7%,阳性预测值78.9%,阴性预测值94.4%。恶性结节细胞学涂片诊断率66.7%,凝血组织块诊断率88.9%。假阴性7例,假阳性8例。3例发生穿刺后出血。2.US-FNA对实性甲状腺癌的诊断敏感性82.9%,特异性91.7%准确性88.8%,阳性预测值82.9%,阴性预测值91.7%。对囊实性甲状腺癌的诊断敏感性50.0%,特异性96.3%准确性94.6%,阳性预测值33.3%,阴性预测值98.1%。3.US-FNA对≤1cm实性甲状腺结节的诊断敏感性75.0%,特异性96.7%准确性94.1%,阳性预测值75.0%,阴性预测值96.7%。对＞1cm实性结节的诊断敏感性83.9%,特异性88.1%准确性86.3%,阳性预测值83.9%,阴性预测值88.1%。4.US-CNB的53个甲状腺结节经病理及临床随访证实恶性结节22个,良性结节31个。组织活检诊断良性66%(35/53),恶性28%(15/53),可疑恶性4%(2/53),涂片不满意2%(1/53)。US-CNB对甲状腺结节诊断敏感性81.0%,特异性100%准确性92.5%,阳性预测值100%,阴性预测值88.6%。假阴性4例,无假阳性。2例发生穿刺后出血。5.薄层液基细胞学涂片的不满意率8.8%,相对于常规涂片,其主要特征为背景血细胞明显减少、细胞量较多、集中,利于阅片。胶质量少或浓集、核较深染、细胞皱缩更常见、常见细胞质碎片及裸核。其诊断效率和FNA相仿。结论1.甲状腺US-FNA细胞学检查及US-CNB并发症少,诊断准确性好,是诊断甲状腺结节的可靠方法。2.甲状腺US-FNA与US-CNB相比,CNB诊断的特异性、阳性预测值略高,FNA诊断的阴性预测值略高,其他相仿。FNA操作更为简便,安全性更高,完全能够满足临床需要。3.FNA对实性结节诊断的敏感性高,对囊实性结节诊断敏感性低。在临床应用中应根据实际情况判断穿刺结果。4.细胞学涂片及凝血组织块联合应用可以提高恶性结节的检出率。5.薄层液基细胞学涂片在甲状腺结节FNA中有较好的应用价值,其涂片细胞学特征与常规涂片有一定差异。更多还原

【Abstract】 Part I The Study of Thyroid Nodules with 3-Dimensional Ultrasound and 3-Dimensional Power Doppler UltrasoundPurposeTo observe the sonographic features of thyroid nodules with 3-Dimensional Ultrasound and 3-Dimensional Power Doppler Ultrasound and compare with conventional ultrasound. To assess the value of 3-Dimensional Ultrasound and 3-Dimensional Power Doppler Ultrasound in differentiating benign and malignant thyroid nodules.Material and methodsFrom Mar 2008 to Apr 2009, ninety-four patients scheduled for surgical removal of the nodules were evaluated with 3D ultrasound and 3D-Power Doppler ultrasound. Of the 103 lesions, 50 lesions were benign, 53 were malignant.In 3D ultrasound, with the mltiplanar reformation, the sonographic features of the thyroid nodules were observed for the location with the capsule, shape, margin, halo, internal texture, echogenicity, homogenicity and calcification.In 3D power Doppler ultrasound, with the color mode, the location, quantity, formation, spatial distribution of the thyroid nodules vascular, as well as whether there was the presence of local abundant vascular in the nodules or in the perinodular area of the nodules were observed.To analyse the features of thyroid nodules in the 3D ultrasound and 3D power Doppler ultrasound with respect to the histological results. In additional, the sensitive, specificity, PPV (positive predictive value), NPV(negative predictive value), accuracy of the 3D ultrasound and 3D power Doppler ultrasound were calculated and compared with conventional ultrasound.Results1. Of all the 103 lesions underwent 3D ultrasound examination, 50 (48.5%) were benign and 53 (51.5%) were malignant. The malignant lesions included 48 (90.5%) papillary thyroid carcinoma (PTC), 1 (1.9%) follicular carcinoma, 3 (5.7%) medullary thyroid carcinoma (MTC), 1 (1.9%) lymphoma. The mean size of the malignant lesions was 2.13±1.07cm (0.66cm-5.14cm) , in 73.6% of patients they were stage I. The benign lesions included 40 (80.0%) goiter, 8 (16.0%) adenoma, 1 (2.0%) Hashimoto’s disease, 1 (2.0%) fibrous thyroiditis. The mean size of the benign lesions was 2.39±0.96 cm (0.78cm-5.32cm) .2. The sonographic features of 3D ultrasound of benign lesions included regular contours (88.0%), well-defined margin (84.0%), complete and regular halo (54.0%), solid with cystic components (52.0%), iso-echogenicity (66.0%), ununiform echogenicity(72.0%) ,without calcification (64.0%) . The sonographic features of 3D ultrasound of malignant lesions included irregular contours (90.6%), ill-defined margin (47.2%), no halo (62.3%), solid (94.3%), ununiform echogenicity (90.6%), hypo-echogenicity(90.6%), microcalcification (79.2%) .3. The sonographic features of 3D power Doppler ultrasound of benign lesions included regular (96.0%), symmetric (88.0%) vascular, the absence of the local abundant vascular in the nodules (96.0%) and in the perinodular area of the nodules(94.0%) . The sonographic features of 3D power Doppler ultrasound of malignant lesions included irregular (66.2%), asymmetric vascular (56.6%), the presence of the local abundant vascular in the nodules (54.7%) and in the perinodular area of the nodules (60.4%) .4. The sensitivity, specificity, PPV, NPV, ACC of 3D ultrasound were 88.7%, 90.0%, 90.4%, 88.2%, 89.3%, which were superior to 2D ultrasound with the sensitivity/ specificity/PPV/NPV/ACC of 86.8%/86.0%/86.8%/86.0%/86.4%. The sensitivity, specificity, PPV, NPV, ACC of 3D power Doppler ultrasound was 83.0%, 94.0%, 93.6%, 83.9%, 90.3%, which were superior to CDFI with the sensitivity/specificity/ PPV/NPV/ACC of 75.5%/92.0%/90.9%/78.0%/83.5%.ConclusionsThere is significant difference in sonographic features between the benign and malignant thyroid lesions of 3D ultrasound and 3D power Doppler ultrasound. The sensitivity and specificity of 3D is superior to 2D ultrasound. The sensitivity and specificity of 3D power Doppler ultrasound is superior to CDFI. 3D ultrasound and 3D power Doppler ultrasound provide more information of the thyroid nodules and are of great value in diagnosing and differentiating thyroid nodules. Part II Ultrasound-guided fine-needle aspiration and core-needle biopsy in the diagnosis of thyroidObjective1. Evaluate the efficacy of ultrasound-guided fine-needle aspiration (US-FNA) and core needle biopsy (US-CNB) of thyroid nodules.2. To assess the value of Thin-Layer preparation (TP) in diagnosing thyroid disease and compared with conventional preparation (CP) .Material and methods175 thyroid FNA were prospectively performed on 168 patients ranging from 4 to 75 years of age.53 thyroid CB were prospectively performed on 53 patients ranging from 13 to 74 years of age.57 thyroid FNA were performed with TP preparation simultaneously.The cytology and histological diagnoses were categorized into four groups: benign, malignant, suspicious, and unsatisfactory. Analysis the character of cytology of TP.Results1. There were 39 malignant nodules and 136 benign nodules proved by histological diagnoses and clinical follow-up. One hundred and twenty four (71%) of the aspirates were diagnosed as "benign", twenty four (14%) were diagnosed as "malignant", fourteen (8%) were diagnosed as "suspicious for malignant", thirteen (7%) were read as unsatisfactory for interpretation. Sensitivity of thyroid FNA in diagnosing thyroid malignancy relative to final histological diagnoses and clinical follow-up was 81.1%, specificity was 93.6%, accuracy was 90.7%, PPV was 78.9%, NPV was 94.4%. 7 cases was false negative. 8 cases was false positive. Bleeding was observed in 3 nodules(1.7%).2. Sensitivity/specificity/accuracy/PPV/NPV of US-FNA in diagnosing solid thyroid nodule was 82.9%, 91.7%, 88.8%, 82.9%, 91.7%. Sensitivity/ specificity/ accuracy/PPV/NPV of US-FNA in diagnosing cyst-solid thyroid nodule was 50.0%, 96.3%, 94.6%, 33.3%, 98.1%.3. Sensitivity/specificity/accuracy/PPV/NPV of US-FNA in diagnosing solid thyroid nodule with a diameter of 1cm or smaller was 75.0%, 96.7%, 94.1%, 75.0%, 96.7%. Sensitivity/specificity/accuracy/PPV/NPV of US-FNA in diagnosing solid thyroid nodule with a diameter larger than 1cm was 83.9%, 88.1%, 86.3%, 83.9%, 88.1%.4. There were 22 malignant nodules and 31 benign nodules proved by histological diagnoses and clinical follow-up. Thirty five (66%) of the biopsies aspirates were diagnosed as "benign", fifteen (28%) were diagnosed as "malignant", two (4%) were diagnosed as "suspicious for malignant", one (2%) was read as unsatisfactory for interpretation. Sensitivity of thyroid FNA in diagnosing thyroid malignancy relative to final histological diagnoses and clinical follow-up was 81.0%, specificity was 100%, accuracy was 92.5%, PPV was 100%, NPV was 88.6%. Bleeding was observed in 2 nodules (3.8%).5. The inadequate rate of TP is 8.8%, compared with conventional smears, the cytology character of TP included markedly decreased background blood cells, decreased or dense colloid, more cell shrinkage, densely stained nuclear, disruption of the cytoplasm and numerous naked nuclei.Conclusions1. US-FNA and US-CNB were accurate and reliable methods to diagnose thyroid nodules.2. The specificity and PPV of CNB is a little higher than FNA. The sensitivity of FNA is a little higher than CNB. FNA is more convenient and safe, with satisfactory efficacy.3. The sensitivity of FNA is high in diagnosing solid thyroid nodules but relatively low in diagnosing cyst-solid thyroid nodules. We should interpret the results in consideration with different clinical conditions.4. The combination of cytological smears and histological cell block helps to detect malignant thyroid nodules.5. Thin-layer preparation is of great value in diagnosing thyroid disease, the character of the cytology is different from conventional preparation.更多还原