【作者】 杨凯；

【导师】 杨漪； 时高峰；

【作者基本信息】 河北医科大学 ， 影像医学与核医学， 2012， 硕士

【摘要】 第一部分CT增强扫描对于甲状腺结节良恶性的鉴别诊断中的应用价值目的：探讨CT增强扫描对于甲状腺结节良恶性鉴别诊断中的应用价值方法：自2011年5月至2012年1月在河北医科大学第四医院行甲状腺CT增强扫描的64例甲状腺结节的病人纳入本研究。本研究中，所有病例均经手术或穿刺活检取得病理证实。其中男性19例，女性45例，年龄范围27-86岁，平均年龄48岁，共84个甲状腺结节，结节大小范围0.5-8.8cm，平均3.3cm。本研究中，恶性结节35例，其中包括25例甲状腺乳头状癌，灶性乳头状癌7例，2例滤泡状癌，1例髓样癌，良性结节49例，其中包括36例结节性甲状腺肿，其中19例伴腺瘤样增生，11例甲状腺腺瘤，以及2例桥本氏甲状腺炎。使用德国第二代双源CT（SOMATOM Definition Flash），首先应用双能量模式（管电压分别为80KV和140KV,层厚5mm）进行平扫，而后利用高压注射器以3ml/S的速度经肘静脉注入造影剂碘海醇(300mg/ml)，注射量1.5-2.0mg/kg，注入对比剂后30s及60s进行双能增强扫描，分别观察甲状腺结节的形态，边界、有无囊性变、内部有无钙化及细颗粒状钙化，强化特点，有无颈部淋巴结肿大等征象。采用SPSS13.0统计软件进行统计学分析。计数资料的比较采用x2检验，如果1个或多个格子的理论频数T<5，改用Fisher’s Exact Test，P<0.05为差异有统计学意义。以病理结果为金标准计算甲状腺结节的形态，边界，细颗粒状钙化，强化特点等征象诊断甲状腺恶性病变的灵敏度、特异度和准确度。结果：甲状腺恶性结节多表现为形态不规则，边界不清，内可见细颗粒状钙化，增强扫描后可见“强化残圈征”或“蟹足状强化”。以上的特征性表现在甲状腺良恶性结节之间差异均有统计学差异（p<0.05）。增强CT可以成为鉴别甲状腺良恶性结节的有用方法（p<0.05）,诊断的灵敏度、特异度和准确度分别为82.9%，83.7%，83.3%。结论：增强CT是诊断甲状腺结节良恶性的有效和可靠的检查方法,掌握各种甲状腺病变的CT表现特点能有效的提高诊断的准确性，为临床制定治疗方案提供重要依据。第二部分双能量扫描中碘图对于甲状腺结节良恶性鉴别诊断中的应用价值目的：探讨双能CT扫描中碘图对于甲状腺结节良恶性的鉴别诊断中的应用价值方法：除8例完全囊性变的结节因病变囊壁较薄，无法准确选择结节实性成分作为感兴趣区，未入组本研究外，其它同第一部分。将平扫的两组双能量数据传入西门子双源CT的工作站上的Dual—Energy软件中，选择“Thyroid”模式，得到碘图，测量平扫时甲状腺结节实性成分以及病灶周围正常正常甲状腺组织的碘含量。结果：在平扫时甲状腺良恶性结节内实性成分之间的碘含量差异有统计学意义（p<0.05），良性结节的碘含量明显高于恶性结节。良恶性结节结节周边正常甲状腺组织的碘含量差异无统计学意义(p>0.05)。利用SPSS软件中受试者工作特征曲线（receiver operator characteristic,ROC曲线）法选取碘含量最佳灵敏度及特异度时的临界值，界值为0.20mg/ml时，灵敏度为65.7%，特异度为97.6%；界值为0.35mg/ml时，灵敏度为71.4%，特异度为90.2%。结论：双能量CT的碘图能够成为鉴别甲状腺结节良恶性的有用工具。第三部分双能量扫描中能谱分析对于甲状腺结节良恶性的鉴别诊断中的应用价值目的：探讨双能CT扫描中能谱分析对于甲状腺结节良恶性的鉴别诊断中的应用价值方法：除8例完全囊性变的结节因病变囊壁较薄，无法准确选择结节实性成分作为感兴趣区，未入组本研究外，其它同第一部分。将平扫的两组双能量数据传入西门子双源CT的工作站上的Dual—Energy软件中，选择“Monoenergetic”模式进行能谱分析，得到不同Kev（40Kev-190Kev区间）下的图像，产生病变的能谱曲线。结果：良性结节的能谱曲线均表现为“下降型”，恶性结节的能谱曲线既可以表现为“上升型”（57.1%），又可以表现为“下降型”（42.9%），曲线类型在甲状腺良恶性结节之间具有统计学意义（p<0.05）。能谱分析诊断甲状腺结节的灵敏度、特异度和准确度分别57.1%，100.0%，80.3%。碘含量测定利用SPSS软件中ROC曲线法与能谱分析软件诊断甲状腺结节的良恶性，均具有较高的诊断的特异度，明显高于常规增强CT的诊断特异度。结论：双能量CT的能谱分析软件可以成为鉴别甲状腺结节良恶性的有用工具。更多还原

【Abstract】 Part One The clinical utility of CT enhancement scanningin the differentiation of benign and malignant thyroid noduleObjective: To discuss the clinical utility of CT enhancement scanningin the differentiation of benign and malignant thyroid nodule.Methods:64cases with thyroid nodule accepted the thyroid enhancedCT examination were selected. All the cases were confirmed bypathohistology,operation or puncture biopsy.All64cases including19female and45male,whose mean age is48years. There are totally84nodules of these patients,diameters from0.5cm to8.8cm, which mean diameters is3.3cm.84thyroid nodules were divided intotwo groups,35malignant nodules (which included25papillary carcinoma,7focus papillary carcinoma,2follicular carcinoma,1medullary carcinoma) and49benign nodules (which included36nodular goiter, of the total19case withadenomatoid hyperplasia,11adenomas,2hashimoto’s thyroiditis).Firstly, all patients were performed routine non-enhanced scan(tubevoltage80KV and140KV,slice thickness is5mm)using DSCT with dualenergy mode, then underwent the enhanced scanning with dual energy modeafter injection of iodinated contrast material (iohexol,300mg/ml,1.5-2ml/kg,injective rate3ml/s,at30s,60s).To observe the shape, boundary appearance,cystic change;calcifications, micro-calcificatio，enhanced characteristics，andthe character of lymph node of cervical part.The SPSS for Windows version13.0software package was used forstatistical data analysis. The x2test was performed to numeration datacompare.If one or more of the expected count were less than5，Fisher’s ExactTest was used.P<0.05was considered with statistically significance.The pathology diagnosis was considered as the gold standard， thesensitivity,specificity and accuracy of all signs (including the shape,boundary appearance, cystic change; micro-calcification， enhancedcharacteristics) that was diagnosised thyroid cancer with CT enhancedscanning were calculated.Results: Malignant nodules were more often showed irregular shape,obscure boundary, contained micro-calcification， showed no completeenhanced ring around the tumor or crab-foot shaped enhancement. Differencesof the CT characteristics between the benign and malignant nodules of thethyroid gland showed statistical significance (P<0.05). Enhanced CT can beone implemental method for differentiate malignant thyroid nodules frombenign ones(x2=36.668,p=0.000,P<0.05).The sensitivity, specificity, accuracyof enhanced CT in the diagnosis of thyroid lesions were82.9%，83.7%，83.3%respectively.Conclusion: Enhanced CT is an efficient and reliable imaging methodfor detection and differential diagnosis of thyroid nodules. Mastering theenhanced CT features of various thyroid nodules can improve the accuracy ofdiagnosis. Part Two The clinical utility of iodine-enhanced image ofdual-energy computed tomography(CT) in evaluating the benignand malignant thyroid noduleObjective: To investigate the clinical utility of iodine-enhanced image ofdual-energy computed tomography(CT)in evaluating the benign and malignantthyroid nodule.Methods: Excepted8complete cystic change nodules,because ofnodules capsule wall was thin，impossible accurate choose nodules true component as region of interest，not enter this study,other the same to part One.Transfer the two groups dual energy data into Dual-Energy software of theworkstation,Choose “Thyroid” mode to obtained the iodine-enhancedimages.Iodine content of thyroid nodule as well as normal thyroid gland thatsurrounding lesion in nonenhanced weighted images were measured.Results: Iodine content between the benign and malignant thyroidnodules in nonenhanced weighted images showed statistical significance(P<0.05). Iodine content of benign thyroid nodules is more than that ofmalignant thyroid nodules.Iodine content of normal thyroid gland thatsurrounding lesion did not showed statistical significance (P>0.05).To utilizereceiver operator characteristic curve(ROCcurve)in SPSS software to selectcritical value of optimum sensitivity and specificity，when critical value is0.20mg/ml， sensitivity is65.7%,specificity is97.6%,critical value is0.35mg/ml，sensitivity is71.4%，specificity is90.2%.Conclusion: Iodine-enhanced images with DECT in nonenhancedweighted images may be a implemental tool for differential diagnosis ofbenign and malignant nodules of the thyroid gland. Part Three The clinical utility of dual-energy energy spectrumanalyzing technology in evaluating the benign and malignantthyroid nodulesObjective: To investigate the clinical utility of dual-energy computedtomography(CT) energy spectrum analyzing technology in evaluating thebenign and malignant thyroid nodules.Methods: Excepted8complete cystic change nodules,because ofnodules capsule wall was thin,impossible accurate choose nodules truecomponent as region of interest，not enter this study,other the same to part One. Transfer the two groups dual energy data of nonenhanced weighted imagesinto Dual-Energy software of the workstation,choose“Monoenergetic”mode toobtained images under different Kev(40Kev-190Kev), then make energyspectrum analysis, bring about energy spcetrum curve of different lesion.Results: Energy spectrum curve of benign thyroid nodules mainlyrepresent as “descent model”. Energy spcetrum curve of malignantthyroid nodules represent as either“rise model”(57.1%)or “descent model”(42.9%).Curve model between the benign and malignant thyroid nodules innonenhanced weighted images showed statistical significance (P<0.05).Thesensitivity,specificity,accuracy of curve model in the diagnosis of thyroidlesions were57.1%，100.0%，80.3%respectively.To utilize receiver operator characteristic curve(ROCcurve)in SPSSsoftware and energy spectrum analyzing technology, both have higherdiagnostic specificity,have an advantage compared routine CT enhancedscanning.Conclusion: Energy spectrum analyzing with DECT may be aimplemental tool for differential diagnosis of benign and malignant nodules ofthe thyroid gland.更多还原