【作者】 孙长坤；

【导师】 汪龙霞； 汪伟；

【作者基本信息】 中国人民解放军军医进修学院 ， 影像医学与核医学， 2008， 硕士

【摘要】 背景和目的高强度聚焦超声(HIFu)是近年来兴起的一种非侵入性外科技术,已应用于临床消融治疗子宫肌瘤,被证明是安全有效的治疗方法。如何正确判断治疗后靶区病灶消融范围,是客观评价治疗效果的关键。采用增强计算机断层扫描(CT)、增强磁共振显像(MRI)可区分灌注和非灌注组织,但由于放射性、价格昂贵等因素,广泛应用于消融疗效评价及随访受到限制。超声成像切面灵活、无放射性,且二维超声(2DUS)能够进行实时监控,超声造影(CEUS)检查能够确定肌瘤无灌注区、敏感地显示残存的细小血流信号,国内有文献报导CEUS可以作为判断肌瘤坏死和残存的指标,所以本研究将CEUS作为对照,评价经济易行的2DUS、彩色多普勒血流显像(CDFI)和三维彩色能量图(3D-CPA)在判断HIFU治疗子宫肌瘤消融疗效中的应用价值。方法选择HIFU消融治疗47例(52个肌瘤)患者为观察对象,治疗前、后24h内均进行2DUS、CDFI和3D-CPA检查并存储图像,评价HIFU治疗疗效。2DUS参照子宫肌壁回声将子宫肌瘤的回声分为低回声、等回声、高回声和强回声四个等级,CDFI和3D-CPA根据子宫肌瘤的血供丰富度将血流分为0级、Ⅰ级、Ⅱ级和Ⅲ级,并行以CEUS检查观察血流灌注情况,以CEUS结果为对照,分别判断2DUS、CDFI和3D-CPA评价消融疗效的价值;疗效评价方法:CEUS肌瘤无灌注区确定为有效消融区,2DUS肌瘤治疗区回声至少增强1级为治疗有效区,CDFI及3D-CPA血流消失或至少减少1级为治疗有效。2DUS、CDFI和3D-CPA随访6个月,观察肌瘤回声、血流、体积(二维超声肌瘤体积=π×纵径×横径×厚径/6,三维超声用VOCAL软件计算肌瘤体积)及患者症状变化情况。结果治疗前CEUS检查呈不同程度增强的52个肌瘤于治疗后24h内复查时20个肌瘤无灌注、32个见残存灌注,2DUS、CDFI和3D-CPA结果并与CEUS比较如下:(1)2DUS检查:治疗前显示51个不均匀低回声、1个等回声的共52个肌瘤回声于治疗后均呈不同程度增强:48.1%(25/52)的肌瘤回声增强;51.9%(27/52)的肌瘤增强回声中见回声无变化区;以回声无变化区为“阳性”,以回声增强为“阴性”,2DUS判断残存病灶的灵敏度为62.5%(20/32),特异度为65.0%(13/20)。(2)CDFI检查:治疗前显示血流呈Ⅰ级的14个、Ⅱ级的18个、Ⅲ级的20个共52个肌瘤于治疗后消失或血流明显减少(除1例血流减少呈Ⅱ级外,其余均呈0级或Ⅰ级):48.1%(25/52)的肌瘤内未见血流;51.9%(27/52)的肌瘤见残存血流;以残存血流为“阳性”,以无血流为“阴性”,CDFI判断残存病灶的灵敏度为68.8%(22/32),特异度为75.0%(15/20)。(3)3D-CPA检查:治疗前显示血流呈Ⅰ级的11个、Ⅱ级的19个、Ⅲ级的22个共52个肌瘤于治疗后血流消失或明显减少(除1例血流减少呈Ⅱ级外,其余均呈0级或Ⅰ级):46.2%(24/52)的肌瘤内未见血流;53.8%(28/52)的肌瘤见残存血流;3D-CPA判断残存病灶的灵敏度为75.0%(24/32),特异度为80.0%(16/2 0)。治疗后24h内CDFI和3D-CPA显示残存血流呈Ⅱ级的1个肌瘤,被CEUS证实残存血流灌注较多,随访3个月肌瘤体积虽有缩小,但残存血流有增加,于是进行了第二次HIFU补充治疗。HIFU治疗52个肌瘤(包括1个补充治疗肌瘤),随访6个月,肌瘤增强的回声逐渐减弱,血流未见增加,2DUS体积由治疗前的102.3±58.2cm~3(三维超声体积为115.9±63.7cm~3)缩小为随访末的42.5±28.3cm~3(三维超声体积为50.8±31.6cm~3),体积缩小率为21%～95%。47例患者治疗后有16例症状消失,31例症状有不同程度改善。治疗后47例患者中有3例治疗部位皮肤出现小水泡,2例患者治疗后原下腹部腹壁手术瘢痕处肿胀,均在1月内缓解。未见严重不良反应。结论(1)2DUS可观察治疗区回声强度变化评价消融疗效,CDFI观察治疗区内部及周边血供评价消融疗效,与CEUS比较灵敏性和特异性虽不是很高,但经济易行,长期随访对及时发现肌瘤体积或血流有增加趋势而需要HIFU补充治疗的病例具有重要意义;(2)3D-CPA能够立体显示子宫肌瘤的血供状态,清楚区分肌瘤内外血流,较CDFI灵敏和特异,方法简捷可行,可作为HIFU治疗子宫肌瘤疗效评价的新方法。更多还原

【Abstract】 Background and Objective High intensity focused ultrasound(HIFU),as a new minimally invasive technique,has been used successfully in treatment of uterine leiomyomas.The key to evaluating therapeuic efficacy is to identify lesion extent ablated.Although both CT and MRI were able to identify blood per fusion region in lesion,their usage were often limited due to radiation injury and large consume and so on.This aim of study was to evaluate two-dimensional ultrasound(2DUS), color Doppler flow imaging(CDFI)and three-dimensional color power angiography(3D-CPA)in therapeutic efficacy of uterine leiomyomas treated with high intensity focused ultrasound(HIFU).Contrast-enhanced ultrasound(CEUS), as a diagnostic technique,compared with other ultrasound imaging in this study. Methods Forty-seven patients with 52 leiomyomas were treated with HIFU. 2DUS,CDFI,3D-CPA and CEUS was performed and the echo and the blood flow was observed before and after HIFU treatment respectively within twenty-four hours,Taking myometrium echo as reference,leiomyomas were divided into hypoecho,isoecho,hyperechogenicity and hyperecho by 2DUS,and blood flow was divided into 0,Ⅰ,Ⅱ,Ⅲgrade by CDFI and 3D-CPA.The CEUS results were taken as criterion,the sensitivity and specificity of 2DUS,CDFI,3D-CPA were calculated to assess treatment efficacy.The efficacy standard:no contrast perfusion on CEUS,hyperechoic region on 2DUS and blood flow signs disappearing or on CDFI and 3D-CPA indicated HIFU therapy was effective. and leiomyomas’ flow was classified by vascularity using 3D-CPA.Blood perfusion was observed with CEUS before and after HIFU treatment.Echo,blood flow,volumes of leiomyomas and symptoms were observed during 6 months of follow-up.Results Twenty in 52 leiomyomas treated with HIFU were demonstrated no blood flow,32 no blood flow in the center.Leiomyomas showed hyperecho in 2DUS,of which 25 showed hyperechogenicity while 27 showed hyperechogenicity with hypoecho.The sensitivity and spectivity of commenting survival focus was 65%and 62.5%,respectively.Blood supply was decreased completely or significantly in CDFI,25 appeared as no blood flow,27 survival blood flow,the sensitivity and spectivity was 75%and 68.8%.Twenty-four leiomyomas were detected no blood flow in 3D-CPA,28 were left blood flow,the sensitivity and specitivity was 80%and 75%.One leiomyoma’s remained blood flow appeared as gradeⅡby CDFI and 3D-CPA in 24h post-therapy,which was proved abundant blood perfusion with CEUS.Although the volume of the leiomyoma was decreased during 3-month follow-up,the blood flow increased, thus another complementary HIFU was carried out.During the 6-month-follow-up,the echo of leiomyomas decreased gradually,blood flow showed no increase,the volume decreased by 21%～95%from(102.3±58.2)cm~3 before treatment to(42.5±28.3)cm~3 after treatment.The symptoms were disappeared in 16 cases and improved in 31 after HIFU treatment.No outstanding adverse event was in 42 cases,skin vesicles in 3 cases and local swelling at skin scar in 2 cases.Conclusions The ablation efficacy could be evaluated by echo intensity of 2DUS,by central and peripheral blood supply of CDFI.The sensitivity and specitivity of 2DUS and CDFI are lower than that of 3D-CPA.But it is much more economic and convenient of 2DUS and CDFI,which is of great importance to patients needed long-term followup or complementary HIFU treatment.3D-CPA could demonstrate the blood supply of uterine leiomyomas stereoly,differentiate blood flow inside leiomyomas from outside clearly,more sensitive and specitive than CDFI.As an easy-performed and effective method,3D-CPA would be a new method to evaluate uterine leiomyomas treated with HIFU.更多还原