本文選題：乳腺X線攝影 + 磁共振��； 參考：《河北醫(yī)科大學》2017年碩士論文

【摘要】：目的:本課題旨在于通過分析乳腺X線檢出的BI-RADS分類3-5類微鈣化病變的形態(tài)和分布特點以及對應部位的MRI表現特點,對比此兩種檢查手段對此類微鈣化病變的診斷效能,從而指導選擇合理的檢查方法并提高早期癌的診斷率,對臨床制定有效的檢查方法及診治方案提供幫助。方法:回顧性分析2015年3月-2016年12月在河北醫(yī)科大學第四醫(yī)院行乳腺X線攝影檢查及乳腺DCE-MRI檢查檢出的BI-RADS3-5類微鈣化性病變94例。依據美國放射學會(ACR)提出的乳腺影像報告和數據統(tǒng)計系統(tǒng)(BI-RADS)標準對X線和MRI圖像進行分析和評估。X線圖像的分析包括鈣化的形態(tài)和分布,MRI圖像分析依據BI-RADS-MRI標準:將病變分為腫塊樣強化和非腫塊樣強化,腫塊樣強化分析其腫塊的形態(tài)、邊緣及內部強化特征,非腫塊樣強化主要分析其形態(tài)學分布。依據病變大小,選取感興趣區(qū)(ROI)繪制病變時間-信號強度曲線(TIC),并與相應的組織病理學結果進行對比分析。采用SPSS21軟件進行統(tǒng)計學分析,分析內容包括:(1)乳腺X線攝影BI-RADS3-5類微鈣化的形態(tài)和分布表現的陽性預測值;(2)乳腺X線攝影BI-RADS 3,4,5類鈣化性病變的陽性預測值;(3)乳腺X線攝影BI-RADS 3-5類微鈣化灶相對應的MRI強化表現及陽性預測值;(4)良、惡性病變動態(tài)增強曲線類型比較;(5)以BI-RADS 3,4a類病變?yōu)楦叨瓤赡芰夹詷藴?以BI-RADS 4b,4c及5類為高度可能惡性標準,分別分析X線和MRI對BI-RADS3-5類微鈣化的病變診斷的敏感性(sensibility)、特異性(specificity)、陽性預測值(PPV)、陰性預測值(NPV)和準確性(accuracy);(6)分析不同乳腺腺體類型的X線和MRI檢查的敏感性(sensibility)和特異性(specificity)。結果:1病理結果94例X線表現為BI-RADS 3-5類微鈣化性病變中,經術后病理證實86例。其中55例惡性,病理結果分別為:乳腺粘液腺癌2例、浸潤性導管癌12例、低分化腺癌2例、浸潤癌29例、導管原位癌1例、乳腺導管上皮不典型增生伴癌變1例、乳頭Peget病伴大導管癌1例、非浸潤性導管內癌1例、浸潤性-小葉癌混合癌2例、重度不典型增生伴癌變1例、高核級導管內癌2例、高核級導管內癌peget病1例。良性病變31例,病理結果分別為:乳腺腺病伴上皮不典型增生1例、乳腺腺病10例、乳腺腺病伴柱狀細胞改變及平坦上皮增生2例、正常腺體組織4例、乳腺腺病伴纖維脂肪組織3例、乳腺腺病伴導管擴張5例、柱狀上皮不典型增生1例、乳腺導管擴張伴脂肪壞死及炎性改變1例、乳腺腺病伴纖維瘤1例、乳腺腺病伴鈣化1例。另外8例經1年以上X線檢查隨訪復查,經過三個月、六個月及一年復查,對比原片病變未見明顯變化,故考慮為良性病變。2 X線形態(tài)學表現、分布與陽性預測值:94例病變中,X線上BI-RADS3類微鈣化形態(tài)表現以圓點狀為主(83%),分布以彌散和成簇為主(均41%);4a類微鈣化形態(tài)表現以無定形模糊為主(56%),分布以成簇分布為主(64%);4b類微鈣化形態(tài)以粗糙不均質為主(46%),分布以成簇分布為主(73%);4c類微鈣化形態(tài)以細微多形性為主(67%),分布以段樣分布為主(48%);5類微鈣化形態(tài)以分枝狀、蠕蟲樣為主(60%),分布以段樣分布為主(45%)。鈣化形態(tài)呈圓點狀其PPV值為11.1%,無定形模糊其PPV值38.1%,粗糙不均質其PPV值為18.1%,細微多形性其PPV值為96.1%,分支狀、蠕蟲樣其PPV值為100%;鈣化分布呈彌散分布其PPV值為11.1%;區(qū)域分布其PPV值為60%;線樣、導管樣分布PPV值為70%;段樣分布PPV值為82%;成簇分布PPV值為54%。通過以上數據對微鈣化的形態(tài)及分布分析得出,高度惡性的鈣化形態(tài)為細微多形性及分支狀、蠕蟲樣狀鈣化,二者均高于點狀、模糊不定形及粗糙不均質鈣化,關于鈣化的分布特點,段樣分布的陽性預測值(PPV)均高于其他類型分布。3 MRI影像學表現與陽性預測值:(1)在MRI上BI-RADS3-5類微鈣化性病變相對應的腫塊型強化表現:其中BI-RADS 3類病變多表現為邊緣光滑的腫塊(100%),內部強化特點為環(huán)形強化(100%);BI-RADS 4a類病變多表現為邊緣光滑(50%)或呈淺分葉的腫塊(50%),內部強化特點為均勻強化(100%);BI-RADS 4b類病變多表現為邊緣不光滑(60%)圓型、卵圓型的腫塊(80%),內部強化特點為不均勻強化(80%);BI-RADS4c類鈣化性病變多表現為邊緣呈毛刺(40%)的圓型或橢圓形腫塊(81.3%),內部強化特點多呈不均勻強化(60%);BI-RADS 5類病變多表現為邊緣不光滑(44.4%)或呈毛刺狀(44.4%)的圓型或類圓形腫塊(52.5%),內部強化特點多為不均勻強化(100%)。腫塊呈圓型或橢圓形PPV值為96.4%,分葉狀PPV值為86.7%,不規(guī)則型PPV值為100%;腫塊邊緣光滑PPV值為0.0%,不光滑PPV值為100%,毛刺狀PPV值為100%,淺分葉為90.9%。病變內部強化特點,均勻強化PPV值為66.7%,不均勻強化PPV值為96.8%,環(huán)形強化PPV值為0.0%,間隔強化PPV值為83.3%;(2)BI-RADS 3-5類鈣化性病變表現為非腫塊型病變強化表現:其中3類及4a類病變多表現為局灶樣強化(63%)、(42.9%);4b類多表現為線樣、導管樣(66.7%);4c類病變多表現為線樣、導管樣及段樣強化(50%);5類病變多表現為段樣強化(66.7%)。在非腫塊型強化類型中,點狀強化PPV值為60%,局灶樣強化PPV值為12.5%,線樣、導管樣強化PPV值為85.7%,段樣強化PPV值為85.7%,區(qū)域樣強化PPV值為25%,斑片樣強化的PPV值為0.0%。4結果分析(1)呈腫塊樣強化的病變中,高度惡性的強化形式為邊緣不光滑的不規(guī)則腫塊,內部強化呈不均勻強化;非腫塊樣強化的病變中,高度惡性的強化形式為線樣、導管樣強化及段樣強化。(2)在MRI動態(tài)增強掃描中,良性病變MRI強化曲線多表現為Ⅰ型(80.6%),惡性病變MRI強化曲線多表現為Ⅲ型(50.9%),良、惡性病變在MRI動態(tài)增強強化曲線之間差異具有統(tǒng)計學意義(P0.05)。(3)本研究中X線診斷為3類鈣化性病變的PPV為0.0%,4a類鈣化性病變的PPV值為32%,4b類鈣化性病變的PPV值為63.7%,4c類鈣化性病變的PPV值為95.2%,5類鈣化性病變的PPV值為100%。(4)X線對BI-RADS 3-5類微鈣化性病變診斷的敏感性、特異性、準確率、陽性預測值、陰性預測值、分別為:92.3%,38%,69.7%,67.6%,78%。(5)MRI對BI-RADS 3-5類微鈣化性病變診斷的敏感性、特異性、準確率、陽性預測值、陰性預測值、分別為:92.3%,73%,84.3%,82.8%,87%。5乳腺腺體類型與鈣化顯示的關系關于鈣化性病變在不同乳腺腺體類型中X線和MRI檢查的敏感性和特異性,其中脂肪型腺體(a型)和散在纖維腺體型(b型)中X線和MRI檢查敏感性和特異性均為100%;不均質型腺體(c型)中X線檢查的敏感性為91%,特異性為31%,MRI檢查的敏感性為91%,特異性為69.7%。兩種檢查方法對于腺體類型呈不均質致密型的BI-RADS 3-5類鈣化性病變其敏感性相同,而MRI檢查的特異性遠高于乳腺X線檢查。對于極度致密型(d型)腺體X線檢查的敏感性為100%,特異性為33%,MRI檢查的敏感性和特異性均為100%。因此對于不均勻致密型腺體及致密型腺體MRI檢查占優(yōu)勢。結論:1 MRI難以顯示乳腺的微小鈣化,但能顯示對應微小鈣化區(qū)域病變的組織形態(tài)學及血流動力學改變。2 MRI檢查的特異性、準確率、陽性預測值、陰性預測值均高于X線檢查。3乳腺鈣化性病變,特別是中間性(良、惡性鑒別困難)鈣化是X線上診斷難點,雖然MRI不能直觀地顯示鈣化,但對鈣化性病變的良、惡性鑒別診斷具有較高的價值,可在一定程度上避免X線診斷上對鈣化性病變的高估或低估4 MRI對典型惡微鈣化灶的判定沒有優(yōu)勢。此類鈣化性病變若在MRI表現為線樣導管樣強化及節(jié)段性強化特征時,應行活檢明確病理結果。5動態(tài)增強曲線對于含成簇鈣化病變具有一定的診斷效能。6在MRI上表現為彌漫性強化的病灶仍存在惡性病灶的可能性。鈣化性病變在MRI上無強化時,要求隨訪復查。由于X線攝影檢查對微鈣化病灶的高敏感性及簡便易行是乳腺癌篩查的首選方法,MRI雖然難以顯示乳腺的微小鈣化,但根據其極高的分辨率、動態(tài)強化特點能很好的顯示對應病變微鈣化區(qū)域的組織形態(tài)學及血流動力學改變,對乳腺早期病灶的顯示及診斷具有重要的意義。
[Abstract]:Objective: the purpose of this study is to analyze the morphological and distribution characteristics of 3-5 types of microcalcification in the BI-RADS classification of mammary glands and the characteristics of the MRI manifestations of the corresponding sites, and compare the diagnostic efficacy of these two methods for this kind of microcalcification, so as to guide the selection of reasonable examination methods and to improve the diagnosis rate of early cancer. Methods: a retrospective analysis of 94 cases of BI-RADS3-5 microcalcifications found in the fourth hospital of Hebei Medical University in December, March 2015, and breast DCE-MRI examination in fourth hospital of Hebei Medical University. The breast imaging report and data statistics based on the American Institute of Radiology (ACR) The X-ray and MRI images were analyzed and evaluated by the system (BI-RADS) standard. The analysis of X - ray images included the morphology and distribution of calcification. The MRI image analysis was based on the BI-RADS-MRI standard: the lesions were divided into lump like enhancement and non lump like enhancement. The mass sample enhancement was used to analyze the shape of the lumps, the edge and the internal intensification features, and the non lump like strengthening main points. According to the size of the lesion, we selected the region of interest (ROI) to draw the time signal intensity curve (TIC), and compared with the corresponding histopathological results. The statistical analysis was carried out by SPSS21 software. The contents included: (1) the positive precondition of the morphology and distribution of BI-RADS3-5 type microcalcification in mammography. Test values; (2) the positive predictive value of BI-RADS 3,4,5 calcified lesions in mammography; (3) MRI enhancement and positive predictive value of BI-RADS 3-5 microcalcifications in mammography; (4) good, malignant lesions dynamic enhancement curve type comparison; (5) BI-RADS 3,4 a lesion as a highly possible benign standard, BI-RADS 4b, 4C and 5 groups High possible malignant criteria, the sensitivity (sensibility), specificity (specificity), positive predictive value (PPV), negative predictive value (NPV) and accuracy (accuracy) of X-ray and MRI for the diagnosis of BI-RADS3-5 microcalcification (accuracy); (6) sensitivity (sensibility) and specificity (specificI) for the analysis of different mammary gland types (specificI) and specificity (specificI). Results: (TY) results: 1 the pathological results of 94 cases were found in the BI-RADS 3-5 type of microcalcification, and 86 cases were confirmed by postoperative pathology. 55 cases were malignant. The pathological results were 2 cases of mucous adenocarcinoma of the breast, 12 cases of invasive ductal carcinoma, 2 cases of low differentiated adenocarcinoma, 29 cases of invasive carcinoma, 1 cases of ductal carcinoma and 1 cases of ductal epithelial hyperplasia with canceration. 1 cases of head Peget disease, 1 cases of non invasive intraductal carcinoma, 2 cases of mixed carcinoma of infiltrative lobular carcinoma, 1 cases of severe atypical hyperplasia with canceration, 2 cases of high nuclear grade intraductal carcinoma, 1 cases of high nuclear grade intraductal carcinoma, 31 cases of benign lesions, 1 cases of atypical hyperplasia of mammary glands, 10 cases of mammary gland adenosis, mammary gland adenopathy, 2 cases of columnar cell change and flat epithelial hyperplasia, 4 cases of normal gland tissue, 3 cases of mammary gland disease with fibrous adipose tissue, 5 cases of mammary gland disease with catheter dilatation, 1 cases of columnar epitheliosis, 1 cases of mammary duct dilatation with necrosis and inflammatory changes, 1 cases of breast adenosis with fibrous tumor, 1 cases of mammary gland disease with calcification, and 8 cases after 1 years. After three months, six months and one year reexamination, there was no obvious change in the original lesion, so it was considered as the.2 X - ray morphology, distribution and positive predictive value: in 94 cases, the X-ray microcalcification was mainly (83%) on X - ray microcalcification, and distributed to diffuse and cluster mainly (41%); 4A The morphology of microcalcification is dominated by amorphous fuzzy (56%) and cluster distribution mainly (64%); 4B microcalcification is dominated by rough heterogeneity (46%), and the distribution is dominated by cluster distribution (73%); 4C microcalcification is mainly (67%) with microcalcification (67%), and the 5 type of microcalcification is branched and worm like Main (60%), distribution mainly in segment distribution (45%). Calcification is a circular shape with a PPV value of 11.1%, an amorphous fuzzy PPV value of 38.1%, a rough and uneven PPV value of 18.1%, a fine pleomorphic PPV value of 96.1%, a branch, and a worm like PPV value of 100%; the distribution of calcification is a dispersion and a PPV value of 11.1%; the distribution of its PPV value is 60%; line sample, guide The PPV value of the tube distribution is 70%, the PPV value of the segment distribution is 82%, and the cluster distribution PPV value is that 54%. through the above data analyses the morphology and distribution of microcalcification. The highly malignant calcification forms are fine polymorphic and branched, and worm like calcification, two are higher than the point, fuzzy and rough uneven calcification, and the distribution of calcification is special. Point, the positive predictive value (PPV) of the segment distribution (PPV) was higher than that of other types of.3 MRI imaging and positive predictive value: (1) the enhanced manifestation of the lump type corresponding to the BI-RADS3-5 microcalcification in MRI, among which, the BI-RADS 3 lesions were mostly marginal smooth masses (100%), and the internal intensification was characterized by annular enhancement (100%); BI-RADS 4a. Most of the lesions showed a smooth (50%) or shallow lobular mass (50%), and the internal enhancement was homogeneous (100%), and BI-RADS 4B lesions were characterized by irregular edge (60%) round, oval type mass (80%), inhomogeneous enhancement (80%), and BI-RADS4c calcified lesions as a circle of marginal burr (40%). Type or oval mass (81.3%) with inhomogeneous enhancement (60%); BI-RADS 5 lesions were mostly circular or circular mass (52.5%) with unsmooth edge (44.4%) or burr like (44.4%). The internal strengthening features were mostly uneven enhancement (100%). The mass was round or oval PPV value 96.4%, and the lobulated PPV value was 86.7%, no The regular PPV value was 100%, the smooth PPV value of the lump edge was 0%, the unsmooth PPV value was 100%, the burr shape PPV value was 100%, the superficial lobule was the internal strengthening characteristic of the 90.9%. lesion, the uniform strengthening PPV value was 66.7%, the unevenly strengthened PPV value was 96.8%, the annular enhanced PPV value was 0%, the interval strengthened PPV value 83.3%, and (2) BI-RADS 3-5 calcified pathological changes showed non The enhanced manifestation of lump type lesions: 3 and 4A lesions were characterized by focal enhancement (63%) and (42.9%); 4B was characterized by line samples and catheter like (66.7%); class 4C lesions were characterized by lines, catheter like and segmental enhancement (50%); the 5 types of lesions were characterized by segmental intensity (66.7%). In non lump type intensification types, punctate PPV value was 60%, focal lesion was found. The PPV value was 12.5%, the line sample, the catheter like enhancement PPV value was 85.7%, the segment enhancement PPV value was 85.7%, the regional sample enhanced PPV value was 25%, the PPV value of the patch sample intensification was 0.0%.4 result analysis (1) in the lump like enhancement lesion, the highly malignant enhancement form was the irregular edge not smooth mass, the internal strengthening was inhomogeneous strengthening; non - mass In the lesion of sample enhancement, the highly malignant form of enhancement was line sample, catheter like enhancement and segmental enhancement. (2) in MRI dynamic enhanced scan, the MRI enhancement curve of benign lesions was type I (80.6%), and the MRI intensification curve of malignant lesions was type III (50.9%), and the difference between good and malignant lesions was statistically significant in the dynamic enhancement curve of MRI. (P0.05) (3) (3) the X-ray diagnosis of 3 types of calcified lesions in this study was 0%, the PPV value of 4A calcified lesions was 32%, the PPV value of 4B calcified lesions was 63.7%, the PPV value of 4C calcified lesions was 95.2%, and the PPV value of 5 calcified lesions was 100%. (4) in the sensitivity and specificity of the diagnosis of BI-RADS 3-5 microcalcifications. Accuracy, positive predictive value, negative predictive value: 92.3%, 38%, 69.7%, 67.6%, 78%. (5) MRI for the diagnosis of BI-RADS 3-5 microcalcification, specificity, accuracy, positive predictive value, negative predictive value, respectively: 92.3%, 73%, 84.3%, 82.8%, 87%.5 mammary gland type and calcification display in different calcification lesions in different The sensitivity and specificity of X - ray and MRI examination in the mammary gland type were 100%. The sensitivity and specificity of the X - ray and MRI examination were 100% in the fatty gland (type A) and in the fibrous gland type (type b). The sensitivity of the X - ray examination in the heterogeneous gland (type C) was 91%, the specificity was 31%, the sensitivity of the MRI examination was 91%, and the specificity was 69.7%. two kinds of examination. The sensitivity of the method was the same to the BI-RADS 3-5 type calcified lesions of the inhomogeneous and dense glandular type, but the specificity of the MRI examination was much higher than that of the mammography. The sensitivity of the X-ray examination of the highly dense (D type) gland was 100%, the specificity was 33%, the sensitivity and specificity of the MRI examination were 100%., therefore, for the inhomogeneous density. Conclusion: 1 MRI can not show small calcification of the mammary gland, but it is difficult to show the Microcalcification of the breast, but it can show the specificity, accuracy, positive predictive value and negative predictive value of the.2 MRI examination for the changes of the lesions in the small calcification region, and the negative predictive values are higher than those of the X-ray examination of the.3 mammary calcification, especially in the middle of the.2. Intersex (benign, malignant differential difficulty) calcification is the difficult point in X-ray diagnosis. Although MRI can not display calcification intuitively, it is of high value for the differential diagnosis of calcified lesions. To some extent, it can avoid the overestimation or underestimation of calcified lesions by X - ray diagnosis. The 4 MRI has no advantage on the determination of typical malignant microcalcifications. Calcified lesions, if MRI appears as a line like catheter like enhancement and segmental enhancement, should undergo biopsy clear pathological results, the.5 dynamic enhancement curve has a certain diagnostic efficacy for cluster calcification, and the possibility of malignant Focus still exists in the diffuse enhancement of.6 on MRI. Calcified lesions have no enhancement on MRI. Gao Min's susceptibility to microcalcification is the first choice for screening of breast cancer. Although MRI is difficult to show small calcification of the breast, the dynamic strengthening features can show the histomorphology and hemodynamics of the corresponding microcalcification region, according to its high resolution. The change of learning is of great significance for the diagnosis and diagnosis of early breast lesions.
【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R737.9;R445.2;R730.44

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5 蔣紅兵;何健龍;張方t，

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