本文選題：甲狀腺癌 + 超聲診斷��； 參考：《蘇州大學(xué)》2014年碩士論文

【摘要】：背景 近年來甲狀腺癌發(fā)病率呈逐年上升的趨勢，是最常見的內(nèi)分泌腫瘤，目前已成為女性最常見的惡性腫瘤；甲狀腺癌約占全身惡性腫瘤的1%~2%，臨床發(fā)現(xiàn)的甲狀腺結(jié)節(jié)中有5％～10％為甲狀腺癌。分化型甲狀腺癌占所有甲狀腺癌的90%，包括甲狀腺乳頭狀癌（PTC）和濾泡癌。近幾年來，從我國統(tǒng)計(jì)資料表明PTC發(fā)病率呈逐年上升趨勢。因此，對甲狀腺結(jié)節(jié)的鑒別診斷是臨床關(guān)注的一個(gè)重點(diǎn)問題。目前，甲狀腺疾病的檢查方法很多，影像學(xué)檢查主要包括超聲檢查、核素掃描、CT、核磁共振顯像，各種方法都有其各自的優(yōu)缺點(diǎn)。近年來，隨著超聲顯像技術(shù)的不斷革新和應(yīng)用，探頭頻率不斷提高，顯示屏分辨率不斷上升，圖像后處理技術(shù)不斷進(jìn)步，淺表器官的顯像得到了飛躍發(fā)展，更多的小病灶得以顯示，顯示病灶內(nèi)微小結(jié)構(gòu)的能力明顯提高，日常工作中，我們甚至能夠檢出1mm的小結(jié)節(jié)，甚至可以判斷其良惡性，堪比病理診斷；此外，能量多普勒(PDI)技術(shù)也在改進(jìn)中，它使得血流信號的顯示較彩色多普勒血流圖更加敏感，很少依賴角度，已能兼顧反映血流方向及完整地顯示血管走行，給我們進(jìn)一步提供了研究腫瘤血管的可能性。目前，國內(nèi)外超聲學(xué)者已在不斷的探索中總結(jié)了一些鑒別甲狀腺良惡性病變的經(jīng)驗(yàn)，大量的研究表明，甲狀腺腫塊病理類型復(fù)雜，聲像圖表現(xiàn)也呈多樣性，且同一患者，甲狀腺腫塊可為多種來源超聲影像表現(xiàn)反映了病變組織的病理學(xué)改變，，甲狀腺結(jié)節(jié)的聲像圖表現(xiàn)與病理改變之間的關(guān)系也一直是學(xué)者們討論的問題。 第一部分甲狀腺癌聲像圖特征分析 目的深入研究甲狀腺病變的二維圖像特征、血流分布情況及各項(xiàng)血流參數(shù)，對照病理結(jié)果，對甲狀腺超聲診斷的聲像圖特征進(jìn)行進(jìn)一步分析，篩選出鑒別診斷力強(qiáng)的指標(biāo)，供臨床應(yīng)用。 資料與方法本研究選擇2012年3月~2013年12月因甲狀腺結(jié)節(jié)在本院手術(shù)的患者201例共226個(gè)甲狀腺結(jié)節(jié)。對226個(gè)甲狀腺結(jié)節(jié)的各項(xiàng)聲像圖表現(xiàn)進(jìn)行單因素分析，篩選出與診斷惡性腫瘤相關(guān)的因素，包括：結(jié)果顯示，對診斷甲狀腺癌有意義的聲像圖表現(xiàn)有邊界模糊、縱橫比＞1、低回聲、鈣化、后方衰減及頸部淋巴結(jié)腫大。之后進(jìn)行Logistic多因素回歸分析。 結(jié)果226個(gè)甲狀腺結(jié)節(jié)的超聲表現(xiàn)：①226例患者經(jīng)術(shù)后病理證實(shí)，確定為良性59例，包括結(jié)節(jié)性甲狀腺腫20例，甲狀腺腺瘤49例；甲狀腺癌167例，包括乳頭狀癌131例，濾泡癌23例，髓樣癌7例，未分化癌4例，轉(zhuǎn)移癌1例，淋巴瘤1例。與手術(shù)、病理結(jié)果對照，超聲定位診斷符合率為100％，定性診斷符合率為83.6%(189/226)。超聲的漏診率為4.9%（11/226）、誤診率為11%(37/226)。其中12例濾甲狀腺泡癌誤診為腺瘤，3個(gè)甲狀腺癌誤診為結(jié)甲，11個(gè)微小型甲狀腺癌因病灶小或結(jié)節(jié)性甲狀腺腫掩蓋而漏診，6個(gè)結(jié)節(jié)性甲狀腺腫誤診為腺瘤，1個(gè)甲狀腺淋巴瘤誤診為未分化癌，4個(gè)髓樣癌誤診為甲狀腺乳頭狀癌。②超聲診斷甲狀腺癌的單因素分析：依據(jù)226個(gè)甲狀腺結(jié)節(jié)的聲像圖表現(xiàn)，按照結(jié)節(jié)大小、數(shù)目、邊界、有無聲暈、結(jié)節(jié)內(nèi)部回聲、有無砂粒樣鈣化、后方回聲衰減、頸部有無可疑淋巴結(jié)進(jìn)行分組分析，用卡方檢驗(yàn)作統(tǒng)計(jì)學(xué)分析。結(jié)果顯示，對診斷甲狀腺癌有意義的聲像圖表現(xiàn)有邊界模糊、縱橫比＞1、低回聲、鈣化、后方衰減及頸部淋巴結(jié)腫大。③經(jīng)單因素分析后，選出P0.05的因素進(jìn)行多因素Logistic回歸分析，結(jié)果顯示，有統(tǒng)計(jì)學(xué)意義的超聲表現(xiàn)指標(biāo)為：邊界不清、縱橫比＞1、低回聲、鈣化及頸部淋巴結(jié)腫大。 結(jié)論 1.經(jīng)Logistic多因素相關(guān)回歸分析顯示，低回聲、鈣化、邊界模糊、頸部可疑淋巴結(jié)為診斷甲狀腺癌的主要依據(jù)。 2.彩色多普勒超聲對甲狀腺良惡性結(jié)節(jié)的鑒別診斷具有重要意義，能為臨床診斷及治療提供準(zhǔn)確信息。 第二部分鈣化在甲狀腺癌超聲診斷中的價(jià)值 目的本研究旨在通過分析不同分型鈣化與甲狀腺結(jié)節(jié)的關(guān)系，探討鈣化在甲狀腺結(jié)節(jié)超聲診斷中的應(yīng)用價(jià)值。 方法選擇2012年3月~2013年12月因甲狀腺結(jié)節(jié)在本院手術(shù)的患者201例共226個(gè)甲狀腺結(jié)節(jié)。所有患者術(shù)前均行彩色多普勒超聲檢查，二維超聲重點(diǎn)觀察結(jié)節(jié)內(nèi)鈣化灶的數(shù)目、形態(tài)、大小、分布。將鈣化模式分為定Ⅰ型微小點(diǎn)狀鈣化，Ⅱ型粗鈣化，Ⅲ型周邊鈣化三類。采用卡方檢驗(yàn)比較甲狀腺惡性結(jié)節(jié)與甲狀腺良性結(jié)節(jié)的鈣化率差異，比較I型、Ⅱ型、Ⅲ型鈣化在甲狀腺良惡性結(jié)節(jié)中的發(fā)生率差異。 結(jié)果226個(gè)甲狀腺結(jié)節(jié)經(jīng)術(shù)后病理證實(shí)，確定為良性59例，包括結(jié)節(jié)性甲狀腺腫20例，甲狀腺腺瘤39例；甲狀腺癌167例�？傮w鈣化發(fā)生率50.44%（114/226）,其中167甲狀腺惡性結(jié)節(jié)的鈣化率為59.88%（100/167），59個(gè)甲狀腺良性結(jié)節(jié)的鈣化率23.72%（14/59），具有顯著性統(tǒng)計(jì)學(xué)差異意義（χ2=35.216，P＜0.01）。Ⅰ型微小點(diǎn)狀鈣化在甲狀腺惡性結(jié)節(jié)中的發(fā)生率為52.69%（88/167），高于其在甲狀腺良性結(jié)節(jié)中的發(fā)生率5%（3/59），且差異有顯著性統(tǒng)計(jì)學(xué)意義（χ2=39.523，P＜0.01）；Ⅱ型粗鈣化在甲狀腺良惡性結(jié)節(jié)中的發(fā)生率差異無統(tǒng)計(jì)學(xué)意義[4.79%（8/167）vs5.08%（3/59），χ2=7.216，P＞0.05]；Ⅲ型周邊鈣化在甲狀腺良性結(jié)節(jié)中的發(fā)生率為8.47%（5/59），高于其在甲狀腺惡性結(jié)節(jié)中的發(fā)生率4.19%（7/167），但差異無統(tǒng)計(jì)學(xué)意義（χ2=11.581，P＞0.05）。 結(jié)論甲狀腺結(jié)節(jié)惡性病變相對于良性病變更容易出現(xiàn)鈣化，不同類型的鈣化均存在一定惡性風(fēng)險(xiǎn)，對甲狀腺良惡性結(jié)節(jié)的鑒別診斷有一定的參考價(jià)值。
[Abstract]:background
In recent years, the incidence of thyroid cancer is increasing year by year. It is the most common endocrine tumor, and it has become the most common malignant tumor in women. Thyroid cancer accounts for about 1%~2% of the malignant tumor of the whole body, and 5% to 10% of thyroid nodules are found to be thyroid cancer. Differentiated thyroid cancer accounts for 90% of all thyroid cancers. Papillary thyroid carcinoma (PTC) and follicular carcinoma. In recent years, the statistical data from China show that the incidence of PTC is increasing year by year. Therefore, the differential diagnosis of thyroid nodules is a key issue of clinical concern. At present, there are many methods of examination of thyroid diseases. Imaging examinations include ultrasound examination, radionuclide scan, CT, NMR In recent years, with the continuous innovation and application of the ultrasonic imaging technology, with the continuous improvement and application of ultrasonic imaging technology, the frequency of the probe is increasing, the resolution of the display screen is rising, the image post-processing technology is progressing, the imaging of the superficial organs has been leaps and bounds, and more small foci are displayed, and the micro nodules in the focus are shown. In the daily work, we can even detect the small nodules of 1mm, even to determine its benign and malignant, comparable to the pathological diagnosis; in addition, the energy Doppler (PDI) technology is also improved, which makes the display of the blood flow signal more sensitive than the color Doppler flow map, and is less dependent on the angle, which has been able to reflect the blood flow. We have further provided us with the possibility of studying the tumor vessels. At present, the scholars at home and abroad have summarized some experience in the differential diagnosis of thyroid benign and malignant lesions. A large number of studies have shown that the pathological type of the thyroid gland is complex and the image of the thyroid is diverse, and the same disease is the same. The thyroid mass can reflect the pathological changes of the pathological tissue for various sources of ultrasound, and the relationship between the ultrasonographic representation of the thyroid nodules and the pathological changes has been a problem that has been discussed by the scholars.
Analysis of ultrasonographic features of thyroid carcinoma in the first part
Objective to study the two-dimensional image characteristics of thyroid diseases, the distribution of blood flow and the parameters of blood flow, and to further analyze the ultrasonographic features of thyroid ultrasound diagnosis by comparing the pathological results, and to screen out the indicators of strong differential diagnosis for clinical application.
Materials and methods this study selected 226 thyroid nodules in 201 patients with thyroid nodules in our hospital in March 2012 ~2013. A single factor analysis of the ultrasonographic features of 226 thyroid nodules was carried out to screen out factors associated with the diagnosis of malignant tumors, including: the results showed that it was meaningful for the diagnosis of thyroid cancer. The sonograms showed blurred boundaries, aspect ratio > 1, hypoechoic, calcification, posterior attenuation and cervical lymph node enlargement. Logistic regression analysis was performed.
Results the ultrasonographic findings of 226 thyroid nodules: (1) 226 patients confirmed by postoperative pathology confirmed that 59 cases were benign, including 20 cases of nodular goiter, 49 thyroid adenoma, 167 thyroid carcinoma, 131 cases of papillary carcinoma, 23 follicular carcinoma, 7 cases of medullary carcinoma, 4 undifferentiated carcinoma, 1 metastatic carcinoma, 1 cases of lymphoma, operation, pathological results. The diagnostic coincidence rate of ultrasonic localization was 100%, the diagnostic coincidence rate of qualitative diagnosis was 83.6% (189/226). The rate of missed diagnosis was 4.9% (11/226) and the misdiagnosis rate was 11% (37/226). 12 cases of thyroid carcinoma were misdiagnosed as adenoma, 3 thyroid cancer was misdiagnosed as nail, and 11 small thyroid adenocarcinoma was missed because of small or nodular goiter. 6 A nodular goiter was misdiagnosed as adenoma, 1 thyroid lymphoma was misdiagnosed as undifferentiated carcinoma and 4 medullary carcinomas were misdiagnosed as papillary thyroid carcinoma. (2) single factor analysis of thyroid carcinoma diagnosed by ultrasonography: according to the image of 226 thyroid nodules, according to the size, number, boundary, nonacoustic halo, internal echo of nodules, and no sand particles Sample calcification, posterior echo attenuation, or not suspicious lymph nodes in the neck were analyzed, and statistical analysis was performed with chi square test. The results showed that the significance of the diagnosis of thyroid cancer was blurred by the boundary, the longitudinal and transverse ratio > 1, the low echo, the calcification, the posterior attenuation and the cervical lymph node enlargement. 3. After single factor analysis, the factors of P0.05 were selected. The results of multifactor Logistic regression analysis showed that the statistically significant ultrasonographic indicators were unclear boundary, vertical and horizontal ratio > 1, hypoechoic, calcification, and cervical lymph node enlargement.
conclusion
1. multivariate regression analysis of Logistic showed that low echo, calcification, blurred border and suspicious cervical lymph nodes were the main basis for the diagnosis of thyroid cancer.
2. color Doppler ultrasound is of great significance in the differential diagnosis of benign and malignant thyroid nodules. It can provide accurate information for clinical diagnosis and treatment.
The second part of the value of calcification in ultrasound diagnosis of thyroid carcinoma
Objective the purpose of this study was to evaluate the diagnostic value of calcification in thyroid nodules by analyzing the relationship between different types of calcification and thyroid nodules.
Methods 226 thyroid nodules were selected in 201 patients with thyroid nodules in December ~2013 March 2012. All patients underwent color Doppler ultrasonography before operation. The number, shape, size and distribution of calcified focal nodules were observed by two-dimensional ultrasound. The calcification mode was divided into type I microcalcification and type II coarse calcification. Three types of type III peripheral calcification. The calcification rates of thyroid malignant nodules and thyroid benign nodules were compared by chi square test. The difference in the incidence of type I, type II and type III calcification in benign and malignant thyroid nodules was compared.
Results 226 thyroid nodules were confirmed by postoperative pathology, and 59 cases were confirmed as benign, including 20 cases of nodular goiter, 39 thyroid adenoma, 167 thyroid carcinoma, 50.44% (114/226), 167 malignant nodule calcification rate 59.88% (100/167), 59 thyroid benign nodule calcification rate 23.72% (14/59), with 59 thyroid nodules 23.72% (14/59). There was significant statistical difference (x 2=35.216, P < 0.01). The incidence of type I microcalcification in thyroid malignant nodules was 52.69% (88/167), higher than that in benign thyroid nodules (5% (3/59)), and the difference was statistically significant (x 2= 39.523, P < 0.01); type II coarse calcification in benign and malignant thyroid nodules. There was no statistically significant difference in the incidence of [4.79% (8/167) vs5.08% (3/59), X 2=7.216, P > 0.05], and the incidence of type III peripheral calcification in benign thyroid nodules was 8.47% (5/59), higher than that in the malignant thyroid nodules (4.19% (7/167)), but the difference was not statistically significant (x 2=11.581, P > 0.05).
Conclusion the malignant lesions of thyroid nodules are more prone to calcification than benign lesions, and there are certain malignant risks in different types of calcification. It is of certain reference value for the differential diagnosis of benign and malignant thyroid nodules.
【學(xué)位授予單位】：蘇州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R736.1;R445.1

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