發(fā)布時(shí)間：2018-08-29 12:25

【摘要】：目的:1.探討經(jīng)腹超聲造影(Contrast-enhanced ultrasonography, CEUS)對(duì)胰腺漿液性囊腺瘤(Serous cystadenomas,SCAs )與粘液性囊腺瘤(Mucinous cystadenomas,MCAs)的診斷價(jià)值。2.研究經(jīng)腹超聲(Conventional ultrasonography, US)、CEUS 與內(nèi)鏡超聲(Endoscopic ultrasonography,EUS )、內(nèi)鏡下超聲造影(Contrast-enhanced endoscopic ultrasonography,CH-EUS )對(duì)胰腺常見(jiàn)囊性腫瘤不同病種的診斷及鑒別診斷價(jià)值。3.對(duì)比 CEUS、EUS 及增強(qiáng)核磁(Contrast-enhanced magnetic resonance imaging,CE-MRI)對(duì)區(qū)分良性與潛在惡性/惡性胰腺囊性占位的診斷效能。資料與方法:1.2015年4月到2017年2月期間,共83例患者納入本研究,包括47例SCAs與36例MCAs。其中67例為病理學(xué)診斷,16例為臨床綜合診斷。所有病灶完成US檢查后,行CEUS檢查,記錄所有病灶的CEUS特征:大小、部位、形態(tài)、囊壁特征(囊壁厚度及增強(qiáng)模式)、分隔(分隔厚度及增強(qiáng)模式)、是否呈蜂窩狀、結(jié)節(jié)等,以臨床最終診斷作為金標(biāo)準(zhǔn),分析依據(jù)CEUS不同特征對(duì)SCAs和MCAs的診斷效能。2. 2015年4月到2017年2月期間,共105例患者納入本研究,包括42例SCAs,34例MCAs,18例胰腺導(dǎo)管內(nèi)粘液性乳頭狀瘤(Intraductal papillary mucinous neoplasms,IPMNs),11 例實(shí)性假乳頭狀瘤(Solid pseudopapillary neoplasms,SPNs)。其中85例為病理學(xué)診斷,20例為臨床綜合診斷。所有患者均行經(jīng)US、CEUS,EUS及CH-EUS檢查。以臨床最終診斷作為金標(biāo)準(zhǔn),分析US、CEUS、EUS、CH-EUS 對(duì) SCAs、MCAs、IPMNs 和 SPNs 的診斷效能。3. 2015年4月到2017年2月期間,共110例患者納入本研究,包括SCAs38例,MCAs31例,IPMNs16例,SPNs8例,假性囊腫8例,神經(jīng)內(nèi)分泌腫瘤3例,囊腫2例,囊腺癌2例,腺泡細(xì)胞癌1例,淋巴管瘤1例。所有患者均行US、CEUS、EUS、MRI及CE-MRI檢查。其中84例為病理學(xué)診斷,26例為臨床綜合診斷。將病灶分為良性(SCAs、假性囊腫、囊腫、淋巴管瘤)和潛在惡性/惡性(MCAs、IPMNs、神經(jīng)內(nèi)分泌腫瘤、囊腺癌、腺泡細(xì)胞癌)兩組。所有患者均行經(jīng)CEUS、EUS及CE-MRI檢查。以臨床最終診斷作為金標(biāo)準(zhǔn),區(qū)分CEUS、EUS及CE-MRI對(duì)區(qū)分胰腺囊性占位良性和潛在惡性/惡性的診斷效能。將胰腺囊性病灶按照胰頭(鉤突) 3cm、胰頭(鉤突)≥3cm;胰體(頸) 3cm、胰體(頸)≥3cm;胰尾 3cm、胰尾≥3cm分為六組,比較三種影像在不同組別中對(duì)區(qū)分胰腺囊性占位良性和潛在惡性/惡性的診斷效能。結(jié)果:1.部位(p=0.026)、形態(tài)(p=0.001)、囊壁厚度(p=0.024)、分隔數(shù)目(p=0.003)、蜂窩狀結(jié)構(gòu)(p=0.002)對(duì)區(qū)分SCAs和MCAs具有統(tǒng)計(jì)學(xué)差異。其中,病灶位于頭頸部、呈分葉狀外形、內(nèi)部蜂窩狀結(jié)構(gòu)、囊壁小于3mm對(duì)診斷SCAs有顯著意義;當(dāng)此四種特征中的兩種相結(jié)合時(shí)診斷SCAs的敏感度為74.5%,特異度為77.8%;三種特征相結(jié)合時(shí)診斷SCAs的特異度為91.6%,敏感度63.8%。病灶位于體尾部、呈圓/橢圓狀外形,內(nèi)部具有0-2條分隔,囊壁厚度大于等于3mm在診斷MCAs方面有顯著意義;當(dāng)此四種特征中的兩種特征相結(jié)合時(shí)診斷MCAs的敏感度為86.1%,特異度為63.8%;當(dāng)三種特征相結(jié)合時(shí)敏感度為80.5%,特異度為80.8%。2. US、CEUS、EUS、CH-EUS對(duì)四種疾病的總體診斷準(zhǔn)確率分別為60.0%、73.3%、80.0%、82.9%。對(duì)于 SCAs、MCAs、IPMNs、SPNs 四類疾病,US 的診斷準(zhǔn)確率分別為54.8%、73.5%、55.6%、45.5%; CEUS的診斷準(zhǔn)確率分別為76.2%、79.4%、61.1%、63.6%、; EUS 的診斷準(zhǔn)確率分別為 81.0%、85.3%、77.8%、63.6%;CH-EUS 的診斷準(zhǔn)確率分別為 81.0%、91.2%、77.8%、72.7%。與 US 相比,CEUS在診斷SCAs時(shí)的診斷準(zhǔn)確率顯著提高(P=0.012),診斷全部病種時(shí)的診斷準(zhǔn)確率顯著提高(P=0.013 ) ; EUS與CH-EUS在診斷SCAs時(shí)準(zhǔn)確率均為81.0%,診斷IPMNs時(shí)準(zhǔn)確率均為77.8%,對(duì)兩種疾病的診斷具有完全一致性(κ=1.000);CEUS相比于EUS在診斷四類疾病時(shí)的敏感度及特異度均無(wú)顯著差異(P0.05)。3.對(duì)于胰腺囊性占位,CEUS、EUS和CE-MRI在區(qū)分良性與潛在惡性/惡性病灶時(shí)的敏感度分別為73.8%、86.9%、80.3%,特異度分別為69.4%、81.6%、83.7%,準(zhǔn)確率分別為71.8%、84.5%、81.8%,其中任兩種影像學(xué)在良惡性鑒別診斷中的診斷效能無(wú)顯著差異。當(dāng)病灶位于胰頭(鉤突)部3cm時(shí),CEUS與EUS的診斷效能P值接近0.05( P=0.065 ),CEUS與CE-MRI診斷效能無(wú)差異(P=0.267 ),EUS與CE-MRI的診斷效能無(wú)差異(P=0.453 );當(dāng)病灶位于胰尾部 3cm時(shí),CEUS與EUS的診斷效能有顯著差異(P=0.039 ) , CEUS與CE-MRI診斷效能P值接近0.05 (P=0.057) ,EUS與MRI診斷效能無(wú)差異(P=1.000);位于其余部位及大小的病灶,三種影像兩兩之間均無(wú)統(tǒng)計(jì)學(xué)差異。結(jié)論:1 .經(jīng)腹超聲造影所示腫瘤部位、形態(tài)、囊壁厚度、分隔數(shù)目、蜂窩狀結(jié)構(gòu)在對(duì)SCAs和MCAs的鑒別診斷上有一定價(jià)值。CEUS不同圖像特征結(jié)合有助于超聲醫(yī)師更好地鑒別診斷SCAs和MCAs。2.在對(duì)胰腺常見(jiàn)囊性腫瘤進(jìn)行病種診斷時(shí),經(jīng)腹超聲造影優(yōu)于常規(guī)二維超聲,尤其對(duì)于漿液性囊腺瘤的診斷;內(nèi)鏡下超聲造影與內(nèi)鏡二維超聲的診斷效能無(wú)明顯差異;經(jīng)腹超聲造影與內(nèi)鏡二維超聲的診斷效能無(wú)明顯差異,兩者在診斷實(shí)性假乳頭狀瘤方面一致性最好,在診斷IPMNs方面的一致性較差。3.對(duì)于胰腺囊性占位病灶,CEUS、EUS和CE-MRI在區(qū)分潛在惡性/惡性病灶和良性病灶方面診斷效能相當(dāng)。但對(duì)于位于胰尾部最大徑 3cm的病灶,EUS的診斷效能明顯優(yōu)于CEUS。
[Abstract]:Objective: 1. To evaluate the value of Contrast-enhanced ultrasonography (CEUS) in the diagnosis of serous cystadenomas (SCAs) and mucinous cystadenomas (MCAs) of the pancreas. 2. To study transabdominal ultrasonography (US), CEUS and endoscopic ultrasonography (EUS). Contrast-enhanced endoscopic ultrasonography (CH-EUS) in the diagnosis and differential diagnosis of different types of common cystic tumors of the pancreas. 3. Contrast-enhanced magnetic resonance imaging (CE-MRI) and CEUS in the diagnosis of benign and potential malignant / malignant cystic masses of the pancreas Materials and Methods: From April 2015 to February 2017, 83 patients including 47 SCAs and 36 MCAs were enrolled in this study. 67 of them were pathological diagnosis and 16 were comprehensive clinical diagnosis. All the lesions were examined by CEUS. The CEUS features of all lesions were recorded: size, location, shape, cystic wall characteristics (cystic wall thickness and cystic wall thickness). Enhanced mode, septation (septal thickness and enhancement mode), honeycomb shape, nodules and so on. The diagnostic efficacy of different CEUS features for SCAs and MCAs was analyzed. 2. From April 2015 to February 2017, 105 patients, including 42 SCAs, 34 MCAs, 18 intraductal mucinous breasts of the pancreas, were enrolled in this study. Intraductal papillary mucinous neoplasms (IPMNs) and solid pseudopapillary neoplasms (SPNs) were detected in 11 patients. 85 of them were pathological and 20 were clinically diagnosed. All the patients were examined by US, CEUS, EUS and CH-EUS. From April 2015 to February 2017, 110 patients were enrolled in this study, including 38 cases of SCAs, 31 cases of MCAs, 16 cases of IPMNs, 8 cases of SPNs, 8 cases of pseudocysts, 3 cases of neuroendocrine tumors, 2 cases of cystic adenocarcinoma, 2 cases of acinar cell carcinoma, 1 case of lymphangioma. The lesions were divided into benign (SCAs, pseudocysts, cysts, lymphangiomas) and potentially malignant / malignant (MCAs, IPMNs, neuroendocrine neoplasms, cystadenocarcinoma, acinar cell carcinoma) groups. All patients were examined by CEUS, EUS and CE-MRI. EUS, EUS and CE-MRI were used to differentiate benign and potentially malignant from malignant pancreatic cystic masses.The cystic lesions were divided into six groups according to the head of pancreas (uncinate process) 3 cm, head of pancreas (uncinate process) > 3 cm, body of pancreas (neck) > 3 cm, tail of pancreas 3 cm and tail of pancreas (> 3 cm). Results: 1. The location (p = 0.026), the shape (p = 0.001), the wall thickness (p = 0.024), the number of septations (p = 0.003), the honeycomb structure (p = 0.002) were significantly different in the diagnosis of SCAs and MCAs. The sensitivity and specificity were 74.5% and 77.8% respectively when two of the four features were combined, and 91.6% and 63.8% respectively when the three features were combined. The sensitivity and specificity were 86.1% and 63.8% respectively when the two features were combined, 80.5% and 80.8% respectively when the three features were combined. The diagnostic accuracy of CEUS was 76.2%, 79.4%, 61.1%, 63.6%, 81.0%, 85.3%, 77.8% and 63.6% respectively, and that of CH-EUS was 81.0%, 91.2%, 77.8% and 72.7% respectively. The diagnostic accuracy of EUS and CH-EUS was 81.0% and 77.8% respectively in the diagnosis of SCAs and IPMNs. The diagnostic accuracy of CEUS was consistent with that of EUS (kappa = 1.000). There was no significant difference in sensitivity and specificity between EUS and EUS in the diagnosis of four types of diseases (P 0.05). CEUS, EUS and CE-MRI were 73.8%, 86.9%, 80.3%, 69.4%, 81.6%, 83.7%, respectively. The accuracy rates were 71.8%, 84.5% and 81.8%, respectively. There was no significant difference in the diagnostic efficacy between benign and malignant lesions. The diagnostic efficacy of CEUS and EUS was close to 0.05 (P = 0.065) at 3 cm of protrusion, no significant difference between CEUS and CE-MRI (P = 0.267), and no significant difference between EUS and CE-MRI (P = 0.453); when the lesion was located at 3 cm of the tail of pancreas, the diagnostic efficacy of CEUS and EUS was significantly different (P = 0.039), CEUS and CE-MRI were close to 0.05 (P = 0.057), EUS and CE-MRI were close to 0.057 (P = 0.057). There was no significant difference in the diagnostic efficiency of MRI (P = 1.000), and there was no significant difference between the three images in the rest of the lesions (P = 1.000). Transabdominal contrast-enhanced ultrasonography is superior to conventional two-dimensional ultrasonography in the diagnosis of common cystic tumors of pancreas, especially for serous cystadenoma; endoscopic contrast-enhanced ultrasonography and endoscopic two-dimensional ultrasonography have no significant difference in diagnostic efficacy; transabdominal contrast-enhanced ultrasonography and endoscopic two-dimensional ultrasonography in the diagnosis of common cystic tumors of pancreas. The diagnostic efficacy of CEUS, EUS and CE-MRI was similar in differentiating potential malignant/malignant lesions from benign lesions, but for lesions with a maximum diameter of 3 cm in the tail of the pancreas, there was no significant difference between the two methods. The diagnostic efficiency of EUS is obviously better than that of CEUS..
【學(xué)位授予單位】：中國(guó)人民解放軍醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R445;R735.9

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9 郝純毅 北京腫瘤醫(yī)院肝膽胰外二科主任醫(yī)師;酗酒和吸煙最傷胰腺[N];大眾科技報(bào);2011年

10 記者 朱弼瑜　專業(yè)指導(dǎo) 劉玉坦 新安國(guó)際醫(yī)院普通外科副主任醫(yī)師 董波 嘉興學(xué)院醫(yī)學(xué)院營(yíng)養(yǎng)學(xué)科負(fù)責(zé)人、公共營(yíng)養(yǎng)師;健康生活,遠(yuǎn)離“癌癥之王”[N];嘉興日?qǐng)?bào);2011年

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