發(fā)布時(shí)間：2018-06-03 05:17

  本文選題：高強(qiáng)度聚焦超聲消融術(shù) + 子宮腺肌病��； 參考：《重慶醫(yī)科大學(xué)》2017年碩士論文

【摘要】：子宮腺肌病是婦科常見病,它是子宮內(nèi)膜腺體和間質(zhì)侵入子宮肌層而形成的一種良性病變。它多發(fā)生于30~50歲的婦女,但近些年逐漸呈年輕化的趨勢(shì),這可能與剖宮產(chǎn)、人工流產(chǎn)術(shù)、宮內(nèi)節(jié)育環(huán)的應(yīng)用增多有關(guān)。根據(jù)病灶的范圍,將子宮腺肌病分為彌漫型子宮腺肌病和局限型子宮腺肌病。傳統(tǒng)治療子宮腺肌病的方法包括手術(shù)和藥物治療。高強(qiáng)度聚焦超聲消融術(shù)(High-intensity Focused Ultrasound,HIFU)是近年來興起的一種治療子宮腺肌病的非侵入性技術(shù),其優(yōu)勢(shì)是可以準(zhǔn)確破壞靶細(xì)胞,而不損傷周圍組織,從而達(dá)到無創(chuàng)治療的目的。但對(duì)于兩種病變類型的子宮腺肌病是否均適用于HIFU治療,目前仍值得關(guān)注,除此之外,靶組織的生物學(xué)特點(diǎn)也會(huì)影響超聲能量的沉積,因此本研究旨在通過分析不同病變類型的子宮腺肌病對(duì)超聲消融劑量、安全性及有效性的影響,為臨床病例篩選及預(yù)后提供參考。同時(shí)探索不同灌注特征的子宮腺肌病對(duì)超聲消融劑量的影響規(guī)律,對(duì)優(yōu)化超聲消融子宮腺肌病的臨床方案具有重要意義。目的1.通過分析超聲消融子宮腺肌病患者治療中和治療后不良反應(yīng)的發(fā)生情況,以及治療后痛經(jīng)及月經(jīng)量過多癥狀改善情況,比較超聲消融彌漫型與局限型子宮腺肌病的可行性、安全性和有效性。2.通過彩色多普勒超聲及超聲造影評(píng)價(jià)子宮腺肌病的血流灌注特征,探討血流灌注特征的指標(biāo)與超聲消融劑量之間的相關(guān)性。方法1.回顧性分析重慶醫(yī)科大學(xué)附屬第一醫(yī)院2012年1月至2014年12月經(jīng)超聲消融治療的子宮腺肌病患者297例,其中彌漫型子宮腺肌病(彌漫組)177例,局限型子宮腺肌病(局限組)120例,并于治療后1天行MRI檢查,隨訪于治療后1、3、6、12、24、36個(gè)月進(jìn)行,評(píng)估并比較兩組的消融結(jié)果、治療中及治療后不良反應(yīng)發(fā)生情況以及兩組患者治療前、后痛經(jīng)及月經(jīng)量情況。2.2015年7月至2016年9月經(jīng)重慶醫(yī)科大學(xué)附屬第一醫(yī)院確診并接受超聲消融治療的子宮腺肌病患者109例,入院時(shí)采用彩色多普勒超聲評(píng)價(jià)子宮腺肌病的血流分布狀態(tài),治療前行超聲造影并儲(chǔ)存圖像,采用聚焦超聲消融系統(tǒng)自帶軟件定量分析超聲造影資料并記錄增強(qiáng)時(shí)間及增強(qiáng)灰度,確定灌注模式,治療后1天行MRI檢查計(jì)算消融率及能效因子(EEF),比較不同血流動(dòng)力學(xué)指標(biāo)及不同灌注模式對(duì)治療劑量的影響,并分析EEF與血流分布狀態(tài)、增強(qiáng)時(shí)間、增強(qiáng)灰度、灌注模式的相關(guān)性。結(jié)果1.297例患者均順利完成HIFU治療,消融發(fā)生率為99.33%(295/297),隨訪時(shí)間3~50個(gè)月,其中彌漫組177例、局限組120例。彌漫組及局限組消融率分別為25.38±13.39%和44.30±19.93%,差異有統(tǒng)計(jì)學(xué)意義(P0.01)。HIFU治療中彌漫組較局限組發(fā)生皮膚燙的風(fēng)險(xiǎn)增加1.82倍,局限組較彌漫組發(fā)生腹股溝區(qū)痛的風(fēng)險(xiǎn)增加2.00倍。297例中,64例(64/297,21.15%)因并發(fā)癥接受簡單治療[國際介入放射治療學(xué)會(huì)(SIR)-B級(jí)],其中彌漫組與局限組分別為38例(38/177,21.47%)和26例(26/120,21.67%),差異無統(tǒng)計(jì)學(xué)意義(P0.05)。兩組均未發(fā)生SIR-C~SIR-F級(jí)并發(fā)癥。兩組患者治療后痛經(jīng)及月經(jīng)量評(píng)分與治療前比較均有明顯降低(P0.05)。痛經(jīng)癥狀總緩解率在治療后12個(gè)月、24個(gè)月及36個(gè)月分別為73.51%(197/268)、60.71%(136/224)及46.83%(59/126);且在治療后24個(gè)月及36個(gè)月局限組痛經(jīng)緩解率均高于彌漫組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。月經(jīng)量過多癥狀總緩解率在治療后12個(gè)月、24個(gè)月及36個(gè)月分別為68.63%(140/204)、63.64%(105/165)及45.92%(45/98);兩組相比較差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。2.109例患者均順利完成HIFU治療,消融發(fā)生率為100%(109/109)。所有患者在HIFU治療中及治療后均未發(fā)生SIR C~F級(jí)并發(fā)癥。109例患者中血流分級(jí)為0級(jí)的患者有5例,Ⅰ級(jí)有60例,Ⅱ級(jí)有39例,Ⅲ級(jí)有5例,其病灶體積及平均功率分別為85.05±81.17cm3、150.39±107.24cm3、218.08±147.91cm3、246.82±164.46cm3和360.80±59.78W、383.77±25.24W、391.95±20.17W、400±0W,四組相比較差異有統(tǒng)計(jì)學(xué)意義(P0.05),而不同血流分級(jí)的治療劑量、能效因子(EEF),以及病灶周邊及內(nèi)部的平均血流速度(Vmean)、收縮期峰值血流速度(PSV)、搏動(dòng)指數(shù)(PI)和阻力指數(shù)(RI)相比較差異均無統(tǒng)計(jì)學(xué)意義(P0.05)。經(jīng)相關(guān)性分析,血流分級(jí)與EEF無線性相關(guān)性(P=0.345);109例患者中同步增強(qiáng)型有67例,緩慢向心型有42例,兩種灌注模式下的無灌注區(qū)體積(NPV)、始增時(shí)間、增強(qiáng)灰度分別為63.96±53.61cm3、15.36±6.83s、43.04±17.69和41.89±39.57cm3、18.23±6.26s、35.79±16.18,兩組比較差異有統(tǒng)計(jì)學(xué)意義(P0.05),而不同灌注模式下的治療劑量和EEF相比較差異無統(tǒng)計(jì)學(xué)意義(P0.05)。經(jīng)相關(guān)性分析,灌注模式、增強(qiáng)時(shí)間、增強(qiáng)灰度與EEF無線性相關(guān)性(P=0.102、0.686、0.418)。結(jié)論1.在嚴(yán)格控制消融范圍的情況下,對(duì)彌漫型與局限型子宮腺肌病同樣行超聲消融是安全、可行的。超聲消融子宮腺肌病療效顯著,局限型與彌漫型近期療效相當(dāng),遠(yuǎn)期療效局限型優(yōu)于彌漫型。2.彩色多普勒超聲與超聲造影用于評(píng)價(jià)子宮腺肌病的血流灌注特征是安全的。子宮腺肌病血流分級(jí)越高,超聲消融所需平均功率越大;同步增強(qiáng)型較緩慢向心型灌注時(shí)間短,強(qiáng)度較大,但消融結(jié)果及劑量均無明顯差異;子宮腺肌病的血流分級(jí)、血流動(dòng)力學(xué)指標(biāo)、增強(qiáng)時(shí)間、增強(qiáng)灰度、灌注模式對(duì)超聲消融劑量無影響。
[Abstract]:Adenomyosis is a common disease in gynecology. It is a benign lesion of the Endometrium Glands and intrauterine intruding the myometrium of the uterus. It often occurs in women aged 30~50, but in recent years it is becoming younger. This may be related to the increase in cesarean section, abortion, and intrauterine contraception. Myopathy is divided into diffuse adenomyosis and localized adenomyosis. The traditional methods for the treatment of adenomyosis include surgery and drug treatment. High intensity focused ultrasound (High-intensity Focused Ultrasound, HIFU) is a noninvasive technique for the treatment of adenomyosis in recent years. Its advantage is that it can be destroyed accurately. Target cells do not damage the surrounding tissue to achieve the goal of noninvasive treatment. But it is still worth paying attention to whether the two types of adenomyosis of the uterus are suitable for HIFU treatment. In addition, the biological characteristics of the target tissues also affect the deposition of ultrasonic energy. This study aims to analyze the uterus of different types of lesions. The effect of adenomyosis on the dosage, safety and effectiveness of ultrasound ablation to provide reference for the screening and prognosis of clinical cases. At the same time, it is of great significance to explore the effect of different perfusion characteristics on the dosage of ultrasonic ablation, and to optimize the clinical scheme of ultrasonic ablation of adenomyosis. 1. The incidence of ADR in patients with adenomyosis after treatment and after treatment, as well as the improvement of dysmenorrhea and excessive menstrual volume after treatment, the feasibility of ultrasonic ablation diffuse and localized adenomyosis was compared, and the safety and effectiveness of.2. were evaluated by color Doppler ultrasound and ultrasonography to evaluate the blood perfusion characteristics of adenomyosis. The correlation between the indexes of blood flow perfusion characteristics and the dosage of ultrasonic ablation. Method 1. retrospective analysis of 297 cases of uterine adenomyosis in First Affiliated Hospital of Chongqing Medical University from January 2012 to 2014 in 12 menstruation, including 177 cases of diffuse adenomyosis (diffuse group), and 120 cases of localized adenomyosis (limited group). MRI examination was performed on 1 days after treatment, followed up for 1,3,6,12,24,36 months after treatment. Evaluation and comparison of two groups of ablation results, adverse reactions during and after treatment, and two groups of patients before and after treatment, dysmenorrhea and menstrual volume were confirmed and accepted by First Affiliated Hospital of Chongqing Medical University from July to September 2016.2.2015. 109 patients with adenomyosis treated with ultrasound ablation were treated with color Doppler ultrasound to evaluate the distribution of the blood flow of adenomyosis. The ultrasound imaging was performed and the image was stored before treatment. The ultrasound imaging data were quantitatively analyzed by the focused ultrasound ablation system and the enhancement time and gray level were recorded, and the perfusion mode was determined. After 1 days of treatment, the ablation rate and energy efficiency factor (EEF) were calculated by MRI examination. The effects of different hemodynamic indexes and different perfusion modes on the treatment dose were compared, and the distribution of EEF and blood flow, the enhancement time, the enhancement of the gray level and the correlation of perfusion mode were analyzed. The results of the 1.297 patients were successfully treated with HIFU, and the rate of ablation was 99.33% (295/29 7), the time of follow-up was 3~50 months, of which 177 were in the diffuse group and 120 in the limited group. The ablation rates of the diffuse group and the limited group were 25.38 + 13.39% and 44.30 + 19.93% respectively. The difference was statistically significant (P0.01), the risk of skin ironing in the diffuse group was 1.82 times more than the limited group, and the risk of the inguinal pain in the limited group was increased by 2. In 64 times.297 cases, 64 cases (64/297,21.15%) received simple treatment for complications [International Interventional Radiology Society (SIR) -B level], of which 38 cases (38/177,21.47%) and 26 cases (26/120,21.67%) in the diffuse group and the limited group were respectively, the difference was not statistically significant (P0.05). The two groups had no SIR-C~SIR-F grade complications. The two group had dysmenorrhea and menstruation after treatment. The total remission rate of dysmenorrhea was 73.51% (197/268), 60.71% (136/224) and 46.83% (59/126) at 12 months after treatment, and 60.71% (136/224) and 46.83% (59/126) after treatment, and the reduction rate of dysmenorrhea in the limited group was higher than that in the diffuse group (P0.05). The difference was statistically significant (P0.05). The amount of menstrual period was too much. The total remission rate was 68.63% (140/204), 63.64% (105/165) and 45.92% (45/98) at 12 months, 24 months and 36 months after treatment. There was no statistical difference between the two groups (P0.05).2.109 patients successfully completed HIFU treatment, the rate of ablation was 100% (109/109). All patients had no SIR C~F grade in HIFU treatment and after treatment. There were 5 cases of blood flow classification in.109 patients with grade 0, 60 cases in grade I, 39 in grade II and 5 in grade III. The volume and average power of the lesions were 85.05 + 81.17cm3150.39 + 107.24cm3218.08 + 147.91cm3246.82 + 164.46cm3 and 360.80 + 59.78W respectively, 383.77 + 25.24W, 391.95 + 20.17W, 400 + 0W, and the difference between the four groups was statistically different. The therapeutic dose (P0.05), and the therapeutic dose of different blood flow classification, energy efficiency factor (EEF), the average velocity of blood flow (Vmean), peak systolic blood velocity (PSV), pulsatile index (PI) and resistance index (RI) in the peripheral and internal lesions of the focus (P0.05). The correlation analysis showed that there was no linear correlation between the blood flow classification and EEF (P=0). .345): of the 109 patients, there were 67 cases of synchronous enhancement, 42 cases of slow heart type, and two kinds of perfusion mode without perfusion zone volume (NPV), and the increase time was 63.96 + 53.61cm3,15.36 + 6.83s, 43.04 + 17.69 and 41.89 + 39.57cm3,18.23 + 6.26s, 35.79 + 16.18, and there were statistically significant differences between groups (P0.05), but the different perfusion models were different. There was no significant difference between the treatment dose and the EEF phase (P0.05). The correlation analysis, perfusion model, enhancement time, and enhanced gray level and EEF had no linear correlation (P=0.102,0.686,0.418). Conclusion 1., ultrasound ablation is safe and feasible for diffuse and localized adenomyosis under strict control of the ablation range. The curative effect of ultrasonic ablation of adenomyosis is significant. The limitation type is equivalent to the diffuse type. The long-term effect limitation is better than that of the diffuse.2. color Doppler ultrasound and the ultrasound contrast. The higher the blood flow classification of the adenomyosis, the greater the average power of the ultrasonic ablation; The perfusion time was shorter and the intensity was larger, but there was no significant difference between the ablation results and the dose. The blood flow classification, the hemodynamic index, the enhanced time, the enhanced gray level, and the perfusion mode had no effect on the dosage of ultrasonic ablation.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R711.71

【參考文獻(xiàn)】

相關(guān)期刊論文 前10條

1 黃偉容;趙仁峰;胡曉霞;吳玉英;封意蘭;韋利英;;第二代子宮內(nèi)膜去除術(shù)諾舒治療子宮腺肌病月經(jīng)過多的臨床分析[J];中國婦產(chǎn)科臨床雜志;2016年06期

2 蘇慧明;徐燕;黎穎雄;朱明慧;黃銘兒;;諾舒子宮內(nèi)膜去除術(shù)治療子宮腺肌病致月經(jīng)過多的臨床研究[J];中國計(jì)劃生育和婦產(chǎn)科;2014年03期

3 葉明珠;薛敏;;影響子宮腺肌病超聲消融療效相關(guān)因素分析[J];中國實(shí)用婦科與產(chǎn)科雜志;2013年09期

4 陳春林;祝江紅;劉萍;馬奔;王黎;唐怡欣;徐玉靜;;子宮動(dòng)脈栓塞治療子宮腺肌病中長期療效觀察[J];中國實(shí)用婦科與產(chǎn)科雜志;2013年06期

5 祝江紅;劉萍;;子宮動(dòng)脈栓塞治療子宮腺肌病的研究進(jìn)展[J];婦產(chǎn)與遺傳(電子版);2013年01期

6 陳錦云;陳文直;朱麗;唐良萏;鄧勇斌;劉映江;鄒建中;白晉;王智彪;;子宮肌瘤的血液供應(yīng)特征對(duì)超聲消融治療劑量的影響[J];中華婦產(chǎn)科雜志;2011年06期

7 李國政;苑敏;吳子芳;劉增強(qiáng);劉麗艷;;子宮肌瘤與子宮腺肌病超聲造影鑒別診斷的價(jià)值[J];首都醫(yī)科大學(xué)學(xué)報(bào);2011年02期

8 周敏;陳錦云;唐良萏;張蓉;陳文直;王智彪;;子宮腺肌病超聲消融有效性及安全性研究[J];第三軍醫(yī)大學(xué)學(xué)報(bào);2010年10期

9 孫立群;鄒建中;陳文直;王智彪;;縮宮素對(duì)子宮良性病變滋養(yǎng)血管頻譜變化的超聲觀察[J];第三軍醫(yī)大學(xué)學(xué)報(bào);2008年22期

10 陳春林;劉萍;曾北藍(lán);馬奔;張浩;;子宮動(dòng)脈栓塞術(shù)治療子宮腺肌病的中遠(yuǎn)期臨床療效觀察[J];中華婦產(chǎn)科雜志;2006年10期

，

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