【作者】 李平；

【导师】 王学梅；

【作者基本信息】 中国医科大学 ， 影像医学与核医学， 2003， 硕士

【摘要】 前言 子宫肌瘤是妇科的常见病和多发病，治疗症状性子宫肌瘤的传统方法主要有激素治疗、肌瘤核除、子宫切除等，但每种方法均有一定的缺陷。 子宫动脉栓塞（uterine artery embolization UAE）治疗子宫肌瘤是近年来发展起来的一种新疗法，自从1995年开展以来，国内外已有不少报道。影像学在UAE前后的应用，集中于MRI及超声，MRI在国外应用较多。两者主要用于术前协助诊断及就肌瘤大小、子宫体积进行术前、术后的比较，而对栓塞前后子宫肌瘤的血运变化研究得甚少。本研究应用彩色多普勒超声对子宫肌瘤动脉栓塞治疗的患者进行随访观察，旨在探讨肌瘤栓塞后血运变化的特点，与体积变化的相关性，及彩色多普勒超声在UAE治疗子宫肌瘤疗效观察中的应用价值。 材料与方法 1．研究对象： 选取子宫肌瘤UAE治疗，治疗前后经超声检查和复查的患者29例，年龄29～55岁，平均42.6岁。术前均有月经过多、紊乱、贫血、腹痛等临床症状，由专科医生检查确诊并排除其他妇科疾病。 2．仪器与方法： 使用ATL-HDI5000、GE-LOGIQ700型彩色多普勒超声诊断仪，经阴道或经腹超声检查。测量肌瘤的大小（三径线D₁、D₂、D₃，多发性肌瘤以最大的一个或两个为主），记录肌瘤的部位与回声。启动彩色多普勒能量图（CDE）对肌瘤内部及周边的血流分布作重点观察。将肌瘤的血流分为四个等级：0级(无血流入I级(血流稀少入川级(血流较丰富X皿级（血流丰富人脉冲多普勒检测肌瘤动脉的收缩期最大峰值流速（PSV入舒张末期流速KDV）及阻力指数（RI人术后1周、术后3个月在个月进行超声随访观察。 肌瘤体积的变化用配对t检验、肌瘤血流的变化用秩和检验进行统计学分析；肌瘤体积变化与血流变化的关系用 SPe－an等级相关分析，P＜O．05有统计学意义。 结 果 1．术前超声所见： 本组栓塞治疗的29名妇女中，共包括32个主要肌瘤，术前体积 10．90－364．50 cm＼平均 100．18 cm＼二维超声所见为低回声或等回声结节，轮廓清晰。CDE显示肌瘤血流皿级者13个；I级者17个；I级者2个；0级者0个。血流丰富或较丰富者（皿级＋11级）占 93．75呢。术前肌瘤动脉 PSV 18．83。10．90CudS，EDV8．03土5．75Crn／S，RI．61土0．18。 2．术后随访： O）肌瘤体积的变化：栓塞术后1周随访的＊个肌瘤，其体积与术前比较无显著差异瞩＞0·05入肌瘤体积平均缩小4．77％；术后3个月在个月肌瘤体积与术前比较有显著性差异（P＜O．of人栓塞后3个月肌瘤体积平均缩小50．06％，栓塞后6个月肌瘤体积平均缩小63．70％。 p）肌瘤血流的变化：术后1周3个月为个月肌瘤血流与术前比较，明显减少（P＜O．01入术后1周＊个月在个月血流信号稀少或消失者分别占83．33阮、86．36呢、77．78％。 一2 一 o）肌瘤体积变化与血流变化的关系：Speannan等级相关分析结果显示，术后3个月肌瘤体积的缩小与术后二周肌瘤血流的减少呈等级相关（r。＝0．65，P＜0．05）。 k）肌瘤回声的变化：术后1周随访，肌瘤回声发生变化者8个门八，66．7％L瘤内出现强光点或强光条；术后3个月随访，肌瘤回声发生变化者8个抢o2，36．4％厂瘤内出现强光点、强光条、液性暗区或回声增高；术后6个月随访，肌瘤回声发生变化者3个（3／9，33．3％）。 讨 论 一、术前子宫肌瘤的声像图特征： 子宫肌瘤二维超声所见为实质性球体，边界光滑，周围常可见含血管的结缔组织形成的低回声晕－假包膜。CDE显示肌瘤血流多丰富或较丰富，周围为主，肌瘤动脉表现为中低流速、中等阻力指数（m＞0．4）的血流。肌瘤C＊E超声所见与子宫动脉造影表现相符，为CDE观察子宫肌瘤的血流变化提供了客观依据。 二、彩色多普勒超声对＊＊ 疗效的评价： 1．肌瘤体积的缩小：本研究中，栓塞后3个月肌瘤体积平均缩／J’50．06％，栓塞后6个月肌瘤体积平均缩小63．70％，与文献报导的40－70％相符，证明近期效果明显。而栓塞后互周肌瘤体积与术前比较无显著差异。栓塞术后3个月显示了更快的体积缩小，3个月至6个月较慢但持续的体积缩小，表明瘤体的缩小是一个缓慢、渐进的过程。 2．肌瘤血流的变化：栓塞后1周子宫肌层血流略减少或无变化而肌瘤血流显著减少。83．33％的肌瘤血流信号稀少甚至消失，说明肌瘤处于严重的缺血缺氧状态中，这时肌瘤无明显缩小，甚至是增大的，可能处于急性水肿期。栓塞后3个月为个月肌层 一3 一血流同栓塞前水平，而肌瘤血流与术前相比仍明显减少(P＜0．of入周边及内部血流稀少或消失者分别占 86．36％及 77．78％。说明子宫动脉栓塞治疗对子宫正常组织血液的阻断可通过侧枝循环很快得到恢复，而对肌瘤血供的阻断作用是持续存在的。通过SPe－an等级相关分析证实：肌瘤血供的减少或消失与肌瘤的缩小相一致更多还原

【Abstract】 PrefaceUterine myoma is a disease commonly seen in gynecology. The traditional methods used to treat symptomatic uterine myoma include hormone therapy, myomectomy and hysterectomy, but each of the methods has certain defects.Uterine artery embolization ( UAE) is a newly developed method used to treat uterine myoma. Since 1995, there have been many associated reports inland and abroad. MRI and ultrasound are the two main radiological tools used before and after UAE. MRI is preferred in overseas. They help to make diagnosis for myoma before operation and compare the size and volume of myoma and uterus pre - operation and post - operation. But there is a little of report about the change of blood flow in myoma after embolization. In this study, color Doppler ultrasound was used to follow up the patients who underwent UAE and we discussed the characteristic of the change of blood flow after embolization, its correlation with the change of myoma volume and the practical value of color Doppler ultrasound in observing the curative effect of UAE for uterine myoma.Patients and Methods1. Patients:We randomly selected 29 patients with uterine myoma who underwent UAE therapy. These patients were 29 to 55 years old ( mean age: 42. 6 years old) . All of them had hypermenorrhea, menstruation disturbance, anemia or abdominal pain. The final diagnosis of uterine myoma were made by Gynecologic doctors and other gynecologic diseases were excluded.2. Equipments and methods;All the patients had underwent Color Doppler ultrasonography before UAE using ATL - HDI 5000 or GE - LOGIQ 700 with convex or transvaginal probes. In each case, we measured the size of myoma (the three dimensions: D1, D2 and D3. If there were multiple myo-mas, we mainly measured the largest one or two) and recorded the location and echo of them. Color Doppler Energy (CDE) were used to observe the vascular distribution inside the myoma and at its peripheral areas. The pattern of blood flow in myoma was graded as follows; Pattern 0-presence of no blood flow. Pattern I -presence of sparse blood flow. Pattern II -presence of moderate blood flow. Pattern III-presence of abundant blood flow. Pulsed Doppler was used to test the PSV, EDV and RI of myoma artery. All the patients were followed up by ultrasonography 1 week, 3 months, 6 months after operation. The indexes above were all respectively recorded.The chang of myoma in volume was analyzed by paired t - test; The change in blood flow was analyzed by rank sum test. The relationship between the chang of myoma in volume and in blood flow wasstudied by using Spearman rank correlation coefficent.Results1. sonographical results before operation;32 myomas were included in this study, whose volume was 10. 9 - 364. 5cm3 ( mean volume 100. 18cm3). all the myomas were hypoe-choic or echogenetic nodes with distinct margin. CDE showed the blood flow pattern of myoma, in which pattern III 13 cases, pattern II 17 cases, pattern I 2 cases and pattern 0 no case. Myoma with abundant or moderate blood flow ( pattern III + pattern II ) occupied 93. 75% of all cases. Before operation, PSV of Myoma artery was 18. 83 10.9cm/s, EDV was 8.03 5.75cm/s, RI was 0.61 0.18.2. Following - up after operation(1) Change of the myoma volume: 1 week after embolization, there was no significant difference between pre - operation and post -operation in the volume of the 12 myomas (p >0.05) , whose volume decreased by 4. 77% ; while there was significant difference after 3 months and 6 months ( p <0. 01). The volume decreased by 50. 06% after 3 months and 63. 7% after 6 months.(2 ) Change of blood flow in myoma: The blood flow of the myoma decreased significantly and even diseapeared after embolization ( p <0. 01 ). The sparse or disappeared type of blood flow 1 week, 3 months and 6 months after embolization was respectively 83. 33% , 86.36% and 77.78%.(3.) The relationship between the change of volume and the change of blood flow: Spearman rank correlation analysis showed that the decrease in更多还原