發(fā)布時間：2018-06-29 14:57

  本文選題：乳腺癌 + 腋窩淋巴結�。� 參考：《河北北方學院》2017年碩士論文

【摘要】：乳腺癌已成為女性發(fā)病率最高的惡性腫瘤,而腋窩淋巴結有無轉移作為一項重要相關因素,關系著患者治療方式的選擇及預后的療效評估,因此正確診斷淋巴結性質(zhì)非常重要。以往淋巴結清掃術為診斷淋巴結是否發(fā)生轉移的最可靠方法,但因具有創(chuàng)傷性及術后并發(fā)癥被前哨淋巴結活檢術漸趨替代,但仍為有創(chuàng)方法。因而如何術前無創(chuàng)性準確評估腋窩淋巴結狀態(tài)非常重要,并成為了研究的熱點,本研究旨在提出超聲與磁共振多因素綜合分析并對比評價以求探尋可靠的無創(chuàng)性診斷方法,提高診斷效能。選擇2015.4~2016.8在中國人民解放軍第307醫(yī)院確診的188例乳腺癌患者,其中2例患者為雙側病變,術前行同側腋窩淋巴結超聲檢查,共190例,術后病理證實淋巴結發(fā)生轉移127例,未發(fā)生轉移63例。超聲檢查內(nèi)容包括:二維超聲檢查并記錄淋巴結長短徑之比、形態(tài)是否規(guī)則、皮質(zhì)厚度及淋巴結門結構是否存在;彩色多普勒超聲觀察淋巴結血流類型、血流分級、收縮期最高血流速度(peak systolic velocity,PSV)、血流阻力指數(shù)(resistance index,RI);彈性成像檢查記錄淋巴結的彈性評分、彈性應變率比值(elastic strain rate,SR)。以術后病理結果為標準,彈性成像在二維超聲分級中的作用通過ROC曲線進行分析,常規(guī)超聲及彈性成像各單因素分析采用卡方檢驗,多因素建立二分類Logistic回歸模型并采用ROC曲線評估效能;并對同時行乳腺線圈聯(lián)合體線圈冠狀位掃描的60例腋窩淋巴結進行超聲與磁共振診斷的對比分析,其中轉移淋巴結34例,未轉移淋巴結26例,磁共振掃描后經(jīng)工作站進行薄層重建觀察記錄淋巴結長徑、短徑、內(nèi)部信號、輪廓邊緣、形態(tài)。采用卡方檢驗對體線圈掃描的價值及磁共振各因素進行分析,各因素與病理結果的一致性采用Kappa檢驗;常規(guī)超聲、彈性成像與磁共振三者對比診斷的ROC曲線行Z檢驗。研究結果顯示,彈性評分及SR聯(lián)合應用于單純依靠皮質(zhì)厚度及淋巴結門結構的二維淋巴結分級有著重要的作用,兩種方法診斷的ROC曲線下面積(Area under curve,AUC):二維分級為0.742,聯(lián)合彈性成像后分級為0.869,兩者相比具有統(tǒng)計學意義(P0.05);超聲各單因素分析結果顯示,淋巴結長短徑之比、形態(tài)、皮質(zhì)厚度和淋巴結門結構、血流類型、PSV、RI、彈性評分、SR為診斷淋巴結性質(zhì)的相關因素,而淋巴結的血流分級為不相關因素(P0.05),對8項相關因素進行二分類Logistic回歸,結果顯示,血流類型、彈性評分及SR被納入模型,其OR(odd ratio)值分別為5.896,10.272,9.729,95%可信區(qū)間分別為1.214~28.642,1.805~58.461,1.751~54.072,回歸模型為Logist(P)=-2.221+1.774X4+2.329X7+2.275X8,模型診斷的靈敏度為93.75%,特異度為88.7%,繪制多參數(shù)回歸模型的ROC曲線,AUC為0.952(S.E.=0.015,P0.001,95%CI=0.922~0.982),該模型對于診斷淋巴結性質(zhì)具有較好的擬合度;將體線圈聯(lián)合乳腺線圈冠狀位掃描有助于淋巴結的檢出與診斷,與單獨乳腺線圈對于腋窩淋巴結的檢出兩者相比具有統(tǒng)計學意義(p0.05);磁共振征象與診斷淋巴結性質(zhì)相關的因素有短徑10mm、長短徑之比、內(nèi)部信號是否均勻、輪廓邊緣是否規(guī)則及形態(tài)是否為類圓形,Kappa值分別為0.321,0.225,0.607,0.435,0.485;三種方法診斷的ROC曲線下面積:常規(guī)超聲0.781,彈性成像0.937,磁共振0.834,彈性成像與常規(guī)超聲、磁共振診斷效能相比均具有統(tǒng)計學意義(p0.05),體線圈聯(lián)合乳腺線圈的冠狀位掃描較常規(guī)超聲的診斷效能有所提高,但兩者相比不具有統(tǒng)計學意義(P0.05)。綜上所述,彈性成像在乳腺癌腋窩淋巴結的診斷分析中占有優(yōu)勢,而與常規(guī)超聲多因素綜合分析可進一步提高診斷效能;體線圈應用于乳腺癌腋窩淋巴結的掃描具有一定的臨床意義,能夠彌補乳腺線圈單獨用于腋窩淋巴結掃描及診斷中的不足;超聲與磁共振兩種診斷方法為臨床無創(chuàng)評估腋窩淋巴結性質(zhì)提供了很好的價值,以減少不必要的前哨淋巴結活檢,為指導臨床治療起到了重要的意義。
[Abstract]:Breast cancer has become the highest incidence of malignant tumors in women, and whether or not the axillary lymph node metastasis is an important related factor is related to the choice of the treatment and the evaluation of the prognosis of the patients. Therefore, it is very important to correctly diagnose the properties of the lymph nodes. The method, however, is gradually replaced by sentinel lymph node biopsy because of its traumatic and postoperative complications, but it is still a invasive method. Therefore, it is very important to evaluate the status of axillary lymph nodes without invasive and accurate preoperation, and it has become a hot spot of research. This study aims to propose a comprehensive analysis and comparison of multiple factors of ultrasound and magnetic resonance in order to seek for reliability. 188 cases of breast cancer diagnosed by 2015.4~2016.8 in No.307 Hospital of PLA of Chinese people were selected, of which 2 cases were bilateral lesions, and 190 cases were examined by ultrasonic examination of the ipsilateral axillary lymph nodes before operation. 127 cases of lymph node metastases were confirmed by pathology after operation, and 63 cases were not metastasize. The volume included: two-dimensional ultrasound examination and recording the ratio of length and diameter of lymph nodes, morphological rules, cortical thickness and lymph node portal structure; color Doppler ultrasound observation of lymph node blood flow type, blood flow classification, peak systolic velocity, PSV, resistance index, RI; elastography. The elasticity score of the lymph nodes, the ratio of elastic strain rate (elastic strain rate, SR). The role of the postoperative pathological results as the criterion, the role of elastic imaging in the two-dimensional ultrasound classification was analyzed by the ROC curve. The chi square test was used in the analysis of the single factor analysis of conventional ultrasound and elastography, and the two classification Logistic regression models were established by multiple factors. The ROC curve was used to evaluate the effectiveness. The diagnosis of 60 cases of axillary lymph node with the coronal scan of the coils of the breast coils was analyzed by ultrasound and magnetic resonance. 34 cases of metastatic lymph nodes and 26 cases of non metastatic lymph nodes were observed. The length of lymph nodes, short diameter and internal letter were recorded by TLC reconstruction after magnetic resonance scanning. The value of the body coil scanning and the factors of magnetic resonance were analyzed by chi square test. The consistency of the factors and the pathological results was examined by Kappa test; the ROC curve of the three contrasts, conventional ultrasound, elastic imaging and magnetic resonance imaging, was tested by Z test. The thickness of the cortex and the two-dimensional lymph node classification of the lymph node portal structure were important. The area under the ROC curve (Area under curve, AUC) diagnosed by the two methods: the two-dimensional classification was 0.742 and the combined elastography was 0.869, compared with the two methods (P0.05). The results of the single factor analysis of ultrasound showed that the length and diameter of the lymph nodes were long. Ratio, morphology, cortical thickness and lymph node gate structure, blood flow type, PSV, RI, elastic score, SR as the related factors for the diagnosis of lymph node properties, and the blood flow classification of lymph nodes was uncorrelated (P0.05), and the 8 related factors were classified by two Logistic regression. The results showed that the type of blood flow, the elasticity score and SR were included in the model, and the OR (odd ratio). The value of 5.896,10.272,9.729,95% confidence interval is 1.214~28.642,1.805~58.461,1.751~54.072 respectively, the regression model is Logist (P) =-2.221+1.774X4+2.329X7+2.275X8, the sensitivity of the model diagnosis is 93.75%, the specificity is 88.7%, the ROC curve of multi parameter regression model is drawn, AUC is 0.952 (S.E.=0.015, P0.001,95%CI=0.922~0.982), and the model is 0.952. It has a good fitting degree for the diagnosis of lymph node properties, and the coronal scan of the body coil combined with the breast coils is helpful to the detection and diagnosis of the lymph nodes, and is statistically significant compared with the detection of the axillary lymph nodes in the solitary breast coils (P0.05). The factors associated with the diagnosis of the magnetic resonance imaging and the diagnosis of the properties of the lymph nodes have a short diameter 10mm, The ratio of the length to diameter, the internal signal is uniform, the contour edge is regular and the shape is round, the Kappa value is 0.321,0.225,0.607,0.435,0.485, the area under the ROC curve diagnosed by the three methods is 0.781, the elastic imaging 0.937, the magnetic resonance 0.834, the elastic imaging and the conventional ultrasound, the magnetic resonance diagnosis efficiency are all compared. P0.05, the coronal scan of body coil combined with breast coils is more effective than conventional ultrasound, but they are not statistically significant (P0.05). To sum up, elastography has the advantage in the diagnosis and analysis of the axillary lymph nodes of breast cancer, and the comprehensive analysis of multiple factors can be further improved. The application of body coil to the axillary lymph nodes of breast cancer has a certain clinical significance, which can make up for the deficiency of the breast coils for axillary lymph node scanning and diagnosis. The two diagnostic methods of ultrasound and magnetic resonance provide good value for the noninvasive evaluation of the axillary lymph nodes in clinical noninvasive evaluation in order to reduce unnecessary outposts. Lymph node biopsy plays an important role in guiding clinical treatment.
【學位授予單位】：河北北方學院
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R737.9;R445

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