【作者】 王勇；

【导师】 陈文直； 汪伟；

【作者基本信息】 重庆医科大学 ， 肿瘤学， 2017， 硕士

【摘要】 子宫肌瘤是常见的妇科疾病,为平滑肌细胞良性增生所致,可引起女性经量增多、盆腔压迫、不孕、贫血等症状,严重影响女性的身心健康。子宫全切除术被公认为是根治子宫肌瘤的方式,但该手术对女性生理上及心理上均有较大影响,且不适合有保留生育愿望的患者。子宫肌瘤剔除术有术后复发、瘢痕子宫及妊娠期子宫破裂的风险。高强度聚焦超声(High Intensity Focused Ultrasound,HIFU)作为一种完全非侵入性肿瘤热消融技术,具有并发症少、治疗后恢复快、保留器官完整性等优点,已越来越多应用于子宫肌瘤的治疗。大量临床研究表明HIFU可显著缩小肌瘤体积,缓解经量多、贫血等相关症状。热效应是HIFU治疗的主要机制,肌瘤的血流灌注是影响超声能量热沉积的重要因素,因此HIFU术前了解子宫肌瘤的血流灌注特征对于超声消融治疗子宫肌瘤具有重要意义。超声造影(Contrast-enhanced Ultrasound,CEUS),是目前临床中常用的评价血流灌注的方法,其所使用的超声造影剂(Ultrasound Contrast Agent,UCA)是由脂质包裹的氟化碳气体形成的微气泡,该微泡在体内血流动力特征与红细胞相似,可通过毛细血管而不进入组织间隙,是一种良好的血管显像剂。本研究旨通过术前对子宫肌瘤进行造影检查定量评价子宫肌瘤血流灌注特征,探讨与hifu消融效果的关系及其对预测超声消融效果的价值。目的通过分析超声造影定量参数与消融效果的关系以及探索定量参数对预测超声消融效果的价值,为临床超声消融治疗子宫肌瘤临床方案制定提供帮助。方法对63例子宫肌瘤患者术前行超声造影检查,采用jc型超声消融治疗系统内置灰度测量软件获得子宫肌瘤血流灌注定量参数。术后根据增强mri将消融结果分为消融满意组(消融率≥70%)和部分消融组(消融率<70%),比较两组造影参数差异,分析造影参数与消融率的关系,并采用受试者工作特征曲线(roc)评价造影参数对消融效果的预测价值。结果部分消融组造影剂注射后的始增时间(at)、峰值时间(pt)、增强时间(et)分别为(13.20±4.09)s、(20.86±5.38)s、(7.66±2.19)s,明显快于消融满意组的(16.77±3.50)s、(26.95±4.98)s、(10.18±2.58)s;部分消融组的增强强度值(ei)、增强速率值(er)分别为(62.44±27.86)、(8.54±4.56),明显高于消融满意组的(29.77±16.72)、(3.02±1.67)。相关性分析显示:at、pt、et与消融率呈正相关(p<0.01),ei、er与消融率呈负相关(p<0.01),其中与er相关性最大(r=-0.724)。at、pt、et、ei、er作为预测指标的roc曲线下面积(auc)分别为0.806、0.820、0.767、0.841、0.935,对应预测消融效果满意的最佳截点值分别为AT>13.50s、PT>20.50s、ET>9.50s、EI<34.55、ER<5.23。结论1.在不同HIFU消融效果间,超声造影参数存在显著差异:部分消融组在始增时间、峰值时间、增强时间方面明显快于消融满意组,在增强强度、增强速率方面明显大于消融满意组。2.超声造影定量参数与消融率存在相关性,始增时间、峰值时间、增强时间与消融率呈正相关,增强强度、增强速率与消融率呈负相关。增强速率与消融率相关性最高。3.子宫肌瘤超声造影定量参数可用于预测HIFU消融效果,其中增强速率预测准确率较高。增强速率越慢,预示着消融效果越好,增强速率可作为预测HIFU效果的良好指标。更多还原

【Abstract】 Uterine fibroids is a common gynecological disease,caused by benign hyperplasia of smooth muscle cells,can lead to an increase in the amount of menstruation,pelvic compression,infertility,anemia and other symptoms,seriously affecting women’s physical and mental health.Hysterectomy is recognized as a way to cure uterine fibroids,however,the operation has a greater impact on women’s physical and psychological health,and is not suitable for patients with fertility desire.Myomectomy has the risk of postoperative recurrence,uterine scar and uterine rupture during pregnancy.High intensity focused ultrasound(HIFU)as a completely non-invasive technique for tumor thermal ablation,due to its less complications,quick recovery after treatment and retains the advantages of organic integrity,has been more and more used in the treatment of uterine fibroids.A large number of clinical studies have shown that HIFU can significantly reduce the volume of fibroids,relieve the symptoms of anemia and other symptoms.The thermal effect is the main mechanism of HIFU treatment,blood perfusion of uterine fibroids is important factor influencing the deposition of ultrasonic energy.Therefore,it is of great significance for us to understand the characteristics of blood perfusion of uterine fibroids before HIFU treatment.Contrast enhanced ultrasound(CEUS)is a commonly used method for the evaluation of blood perfusion in clinic,and the ultrasound contrast agent(UCA)used in this study is a microbubble formed by lipid-coated carbon fluoride,which is similar to the red blood cells in vivo,and is a good blood vessel imaging agent.The purpose of this study was to quantitatively evaluate the characteristics of uterine fibroids perfusion by CEUS before operation and to explore the relationship with HIFU and its predictive value on the ablation effect.ObjectiveThrough the analysis of the relationship between the quantitative parameters and the ablation effect to explore the value of quantitative parameters to predict the effect of ultrasound ablation,and to provide help for the clinical treatment of uterine fibroids.MethodsSixty-three patients with uterine fibroids underwent contrast-enhanced ultrasound before operation.The software of gray level measurement in JC HIFU system was used to obtain quantitative parameters of uterine fibroids perfusion.According to postoperative enhanced MRI examination,the results were divided into satisfactory group(NPV ratio ≥70%)and partial ablation group(NPV ratio < 70%).CEUS parameters of two groups were compared,and the correlation between parameters and ablation rate was analyzed.The predictive value was evaluated by ROC curve.ResultsThe arrival time(AT),peak time(PT),enhancement time(ET)of partial ablation group after the injection of contrast agent were(13.20 ± 4.09)s,(20.86 ± 5.38)s,(7.66 ± 2.19)s,significantly faster than those in satisfactory group(16.77 ± 3.50)s,(26.95 ± 4.98)s,(10.18 ± 2.58)s;The enhancement intensity(EI),enhancement rate(ER)of partial ablation group were(62.44 ± 27.86),(8.54 ± 4.56),significantly higher than those in satisfactory group(29.77 ± 16.72),(3.02 ± 1.67).Correlation analysis showed that the AT、PT and ET were positively correlated with the NPV ratio(P < 0.01),and the EI and ER were negatively correlated with the NPV ratio(P < 0.01),and the correlation between ER and NPV ratio was the largest(r=-0.724).Using AT,PT,ET,EI,ER for predictors,the area under ROC was 0.806、0.820、0.767、0.841、0.935,respectively.The corresponding optimal cut-off of predicting ablation were AT>13.50 s,PT>20.50 s,ET>9.50 s,EI<34.55,ER<5.23,respectively.Conclusion1.In different HIFU ablation effect,there are significant differences in the parameters of CEUS: In partial ablation group,The arrival time,peak time and enhancement time were significantly faster than that of the satisfactory ablation group,and the enhancement intensity,enhancement rate were significantly higher than those of the ablation group.2.There was a correlation between the quantitative parameters of CEUS and the ablation rate.The arrival time,peak time and enhancement time were positively correlated with the ablation rate,and the enhancement intensity and the enhancement rate were negatively correlated with the ablation rate.The correlation between enhancement rate and ablation rate was the highest.3.The quantitative parameters of contrast-enhanced ultrasound in uterine fibroids can be used to predict the effect of HIFU ablation,and the predictive value of enhancement rate is high.The slower the enhancement rate,the better the ablation effect,and the enhancement rate can be used as a good indicator to predict the effect of HIFU.更多还原