【摘要】：研究背景肺癌(lung cancer)是全球發(fā)病率和死亡率最高的惡性腫瘤。目前已成為世界范圍內(nèi)腫瘤相關(guān)死亡的主要原因。在我國肺癌的死亡率在過去幾十年內(nèi)迅速增長,盡管過去20年內(nèi)肺癌的診治水平有大幅度的提高,但肺癌的5年生存率仍較低,不足15%。肺癌準(zhǔn)確的TNM分期對于疾病的治療和預(yù)后判斷非常重要。僅部分極早期的患者可能會出現(xiàn)超過15%的五年生存率。肺癌患者縱膈分期和生存率密切相關(guān),此外最佳治療方案的選擇、臨床藥物實(shí)驗(yàn)的篩選以及療效判斷等都是建立在準(zhǔn)確的縱膈分期基礎(chǔ)上。因此研究者一直在探索能準(zhǔn)確評估肺門縱膈淋巴結(jié)是否轉(zhuǎn)移的縱膈分期工具。氣道內(nèi)超聲引導(dǎo)下的經(jīng)支氣管針吸活檢(Endobronchial ultrasound guided transbronchial needle aspiration,EBUS-TBNA)已廣泛應(yīng)用于肺癌患者的縱膈分期及診斷。但是在發(fā)生轉(zhuǎn)移的淋巴結(jié)中可能會有壞死、液化、良惡性共存等病理表現(xiàn),而穿刺活檢僅能代表穿刺局部的病變,使其診斷的準(zhǔn)確性受到一定限制�；贓BUS-TBNA在縱膈分期中的重要作用,如何提高診斷的準(zhǔn)確性引起學(xué)者的關(guān)注。超聲彈性成像(ultrasound Elastography,UE)是近年來發(fā)展起來的一項(xiàng)新的超聲診斷技術(shù),可以測量組織的彈性,所反映的是病灶內(nèi)的硬度情況。通過分析病灶軟硬度的不同來判斷病灶的性質(zhì)。超聲彈性成像技術(shù)在臨床上應(yīng)用較為成熟,主要用于乳腺、前列腺、甲狀腺等淺表器官病變良惡性鑒別,并取得較好的研究成果。結(jié)果均表明惡性病變較周圍組織硬度增加,可以通過硬度特征來鑒別病變的良惡性。內(nèi)鏡下超聲彈性成像技術(shù)主要應(yīng)用于消化系統(tǒng)疾病的診治,對于胰腺包塊、淋巴結(jié)良惡性的診斷敏感度、特異度較高。氣道內(nèi)超聲內(nèi)鏡下彈性成像技術(shù)對肺門和縱膈淋巴結(jié)及肺部腫塊良惡性的鑒別目前研究較少。本研究的目的為評估氣道內(nèi)超聲內(nèi)鏡下彈性成像技術(shù)對肺門縱膈淋巴結(jié)及肺部腫塊良惡性的診斷價值,對68個肺門縱膈淋巴結(jié)及57個肺部腫塊進(jìn)行氣道內(nèi)超聲彈性成像檢查,通過彈性評分、應(yīng)變率比值分析,并與常規(guī)超聲圖像特征比較,探討氣道內(nèi)超聲彈性成像技術(shù)在肺部腫塊及肺門縱膈淋巴結(jié)中的應(yīng)用價值。第一章氣道內(nèi)超聲彈性成像技術(shù)對肺癌患者肺門縱膈淋巴結(jié)轉(zhuǎn)移的診斷價值目的1.研究氣道內(nèi)超聲彈性成像技術(shù)診斷肺門縱膈淋巴結(jié)轉(zhuǎn)移的可行性及良惡性淋巴結(jié)的彈性成像特征及應(yīng)變率比值。2.探討氣道內(nèi)超聲彈性成像技術(shù)對肺癌患者肺門縱膈淋巴結(jié)轉(zhuǎn)移的診斷價值,并與常規(guī)超聲結(jié)果進(jìn)行比較。方法選取從2014年01月-2015年06月期間,在我院就診的門診和住院患者,經(jīng)胸部X線、CT檢查疑似肺癌的40例患者共68枚淋巴結(jié)。所有患者予以超聲支氣管鏡檢查,常規(guī)行淋巴結(jié)氣道內(nèi)超聲及彈性成像檢查,并予以支氣管內(nèi)超聲引導(dǎo)下的經(jīng)支氣管針吸活檢(EBUS-guided transbronchial needle aspiration, EBUS-TBNA)。以病理學(xué)結(jié)果為金標(biāo)準(zhǔn),通過比較良惡性淋巴結(jié)的超聲彈性成像特征及彈性成像評分法、應(yīng)變率比值法與常規(guī)超聲影像學(xué)特征診斷惡性淋巴結(jié)準(zhǔn)確性差異,評估氣道內(nèi)超聲彈性成像技術(shù)鑒別淋巴結(jié)良惡性的價值。結(jié)果1、常規(guī)超聲影像學(xué)特征中鑒別良惡性淋巴結(jié)差異有顯著統(tǒng)計(jì)學(xué)意義的指標(biāo)包括低回聲、回聲不均、邊界清楚、短徑大于1cm(均P0.01)。2、氣道內(nèi)超聲彈性成像評分在良惡性淋巴結(jié)中差異有顯著統(tǒng)計(jì)學(xué)意義(P0.01)。彈性評分法的曲線下面積(area under the curve,AUC)為0.852,其對良惡性淋巴結(jié)的鑒別價值明顯優(yōu)于常規(guī)超聲圖像特征中的任何一種。以彈性評分≥2.5分為診斷界值,其診斷惡性淋巴結(jié)的特異度、敏感度、陽性預(yù)測值及陰性預(yù)測值分別為76.9%,85.7%,85.7%及76.9%,診斷的準(zhǔn)確率為82.3%。在彈性評分和常規(guī)超聲圖像聯(lián)合診斷指標(biāo)中以彈性評分聯(lián)合低回聲、邊緣清晰、直徑大于1cm診斷價值最大,AUC 0.911,其診斷惡性淋巴結(jié)的特異度、敏感度、陽性預(yù)測值及陰性預(yù)測值分別為84.6%,88.1%,90.2%及81.5%,診斷的準(zhǔn)確率為86.8%。3、良惡性淋巴結(jié)應(yīng)變率比值(strain ratio,SR)(87.69±49.15 VS 20.60±17.14)差異具有統(tǒng)計(jì)學(xué)意義(P=0.000)。良惡性淋巴結(jié)SR和彈性評分間具有顯著的相關(guān)性(r=0.561,P=0.000)。SR診斷惡性淋巴結(jié)AUC為0.933,高于常規(guī)超聲及彈性評分的曲線下面積(AUC=0.662,0.705,0.561,0.732及0.852)。SR法對良惡性淋巴結(jié)的鑒別明顯優(yōu)于彈性評分法及常規(guī)超聲圖像特征中的任何一種。取約登指數(shù)最大值時的界值,確定SR診斷良惡性淋巴結(jié)的最佳界值為32.07,此時診斷惡性淋巴結(jié)敏感性為88.1%,特異性為80.8%,準(zhǔn)確性為85.3%,陽性預(yù)測值為88.1%,陰性預(yù)測值為80.8%。結(jié)論1、超聲支氣管鏡下彈性成像技術(shù)能有效實(shí)現(xiàn)對肺癌患者肺門縱膈淋巴結(jié)良惡性的鑒別,比傳統(tǒng)的EBUS圖像準(zhǔn)確率高。作為傳統(tǒng)EBUS圖像的補(bǔ)充,可指導(dǎo)EBUS-TBNA。2、應(yīng)變率比值法對良惡性淋巴結(jié)的鑒別明顯優(yōu)于彈性評分法及常規(guī)超聲圖像特征中的任何一種。第二章氣道內(nèi)超聲彈性成像技術(shù)對中央型肺部腫塊的診斷價值目的探討氣道內(nèi)超聲彈性成像技術(shù)對中央型肺部腫塊良惡性的鑒別診斷價值。方法選取57例中央型肺部腫塊患者,常規(guī)行超聲支氣管鏡及彈性成像檢查,并行EBUS-TBNA。通過比較良惡性肺部腫塊的超聲彈性成像特征與常規(guī)超聲影像學(xué)特征診斷惡性肺部腫塊準(zhǔn)確性的差異,評估氣道內(nèi)超聲彈性成像技術(shù)在鑒別中央型肺部腫塊良惡性的價值。結(jié)果(1)常規(guī)超聲影像學(xué)特征中鑒別良惡性肺部腫塊差異有顯著統(tǒng)計(jì)學(xué)意義的指標(biāo)包括低回聲、回聲不均、邊界清晰、支氣管充氣征(均PO.01)。(2)氣道內(nèi)超聲彈性成像評分及應(yīng)變率比值在良惡性肺部腫塊中差異有顯著統(tǒng)計(jì)學(xué)意義(P0.01)。(3)應(yīng)變率比值法對良惡性肺部腫塊的鑒別明顯優(yōu)于彈性評分法及常規(guī)超聲圖像特征中的任何一種。應(yīng)變率比值受試者工作曲線(ROC)曲線下面積(AUC)最大,為0.841。以應(yīng)變率比值≥9.785作為診斷界值,其診斷惡性肺部腫塊的特異度、敏感度、陽性預(yù)測值及陰性預(yù)測值分別為76.2%,83.4%,86.1%及72.7%,診斷的準(zhǔn)確率為82.5%。結(jié)論超聲支氣管鏡下彈性成像技術(shù)能有效實(shí)現(xiàn)對中央型肺部腫塊良惡性的鑒別,比傳統(tǒng)的EBUS圖像準(zhǔn)確率高。
[Abstract]:The study of lung cancer is the highest incidence of global morbidity and mortality. At present, it has become the main cause of tumor-related death in the world. The mortality of lung cancer in China has increased rapidly over the last few decades, although the diagnosis and treatment of lung cancer in the past 20 years has been greatly improved, but the 5-year survival rate of lung cancer is still lower and less than 15%. The accurate TNM staging of lung cancer is very important for the treatment and prognosis of the disease. Only part of the very early patients may have a five-year survival rate of more than 15%. The mediastinal stage and survival rate of the patients with lung cancer are closely related, and the selection of the best treatment plan, the screening of the clinical drug experiment and the judgment of the curative effect are based on the accurate mediastinal stage. So the researchers have been exploring the mediastinal staging tools that can accurately assess the metastasis of the mediastinal lymph nodes of the hilar. Endobronchial needle aspiration (EBUS-TBNA), guided by ultrasound in the airway, has been widely used in the mediastinal staging and diagnosis of lung cancer patients. However, there may be necrosis, liquefaction, benign and malignant co-existence and other pathological manifestations in the metastatic lymph nodes, and the puncture biopsy can only represent the local lesion, and the accuracy of the diagnosis is limited. Based on the important role of EBUS-TBNA in the stage of mediastinum, how to improve the accuracy of diagnosis can cause the attention of the scholars. Ultrasonic elastography (UE) is a new ultrasonic diagnostic technique developed in recent years. It can be used to measure the elasticity of tissue. The nature of the lesion was determined by analyzing the different soft-hardness of the lesion. The ultrasonic elastography is more mature in the clinical application, and is mainly used for the benign and malignant differentiation of superficial organs such as the breast, the prostate, the thyroid and the like, and has good research results. The results showed that the hardness of the surrounding tissue of the malignant lesion was increased, and the good and malignant of the lesion could be identified by the characteristics of hardness. Endoscopic ultrasound elastography is mainly used in the diagnosis and treatment of digestive system diseases. The differential diagnosis of benign and malignant tumors of the hilar and the mediastinal lymph nodes and the lung mass is less than that of the endoscopic elastic imaging in the airway. The purpose of this study was to evaluate the diagnostic value of the elastic imaging in the airway for benign and malignant mediastinal lymph nodes and lung masses. The value of the ultrasonic elastography in the lung and the mediastinal lymph nodes of the hilar was discussed by the ratio analysis of the strain rate and compared with the conventional ultrasound image. The first chapter is to evaluate the value of ultrasonic elastography in the diagnosis of mediastinal lymph node metastasis in patients with lung cancer. To study the feasibility of the ultrasonic elastography in the diagnosis of the mediastinal lymph node metastasis and the ratio of the elastic imaging and the strain rate of the benign and malignant lymph nodes. To study the diagnostic value of the ultrasonic elastography in the treatment of the mediastinal lymph node metastasis in patients with lung cancer, and to compare with the conventional ultrasound. Methods From January 2014 to June 2015,68 lymph nodes of 40 patients with suspected lung cancer were examined by chest X-ray and CT. All patients were subjected to an ultrasonic bronchoscopy, an intra-bronchial ultrasound and an elastic imaging examination, and a bronchial needle aspiration biopsy (EBUS-TBNA) under the guidance of intra-bronchial ultrasound. Based on the pathological results, the difference of the accuracy of the malignant lymph nodes was diagnosed by comparing the ultrasonic elastic imaging characteristics of the benign and malignant lymph nodes with the elastic imaging scoring method, the ratio of the strain rate and the conventional ultrasound imaging. To evaluate the value of intra-airway ultrasonic elastography in differentiating benign and malignant lymph nodes. Results 1. There was a significant difference in the differentiation of benign and malignant lymph nodes in the conventional ultrasound imaging features, including the low echo, the non-uniformity of the echo, the clear boundary and the short diameter of more than 1 cm (all P0.01). The difference of ultrasonic elastography in the airway was significantly different in the benign and malignant lymph nodes (P0.01). The area under the curve (AUC) of the elastic scoring method is 0.852, and the differential value of the benign and malignant lymph nodes is obviously superior to any one of the conventional ultrasound image features. The sensitivity, positive predictive value and negative predictive value were 76.9%, 85.7%, 85.7% and 76.9%, respectively, and the diagnostic accuracy was 82.3%. The sensitivity, positive predictive value and negative predictive value were 84.6% and 88.1%, respectively, in the combination of the elastic score and the conventional ultrasonic image in the combination of the elastic score and the low echo, the edge was clear, the diagnosis value of the diameter was greater than 1 cm, the AUC was 0.911, the specificity, the sensitivity, the positive predictive value and the negative predictive value of the malignant lymph node were 84.6% and 88.1%, respectively. 90.2% and 81.5%, the accuracy of the diagnosis was 86.8%, the ratio of the strain rate of benign and malignant lymph nodes (strin ratio, SR) (87.69-49.15 VS 20.60-17.14) was statistically significant (P = 0.000). There was a significant correlation between the SR and the elastic scores of benign and malignant lymph nodes (r = 0.561, P = 0.000). The AUC of the SR in the diagnosis of the malignant lymph node was 0.933, and the area under the curve (AUC = 0.662, 0.705, 0.561, 0.732, and 0.852) above the normal and elastic scores. The identification of benign and malignant lymph nodes by SR method is superior to any one of the elastic scoring method and the conventional ultrasound image feature. The best margin for the diagnosis of benign and malignant lymph nodes was 32.07. The sensitivity of the diagnostic malignant lymph nodes was 88.1%, the specificity was 80.8%, the accuracy was 85.3%, the positive predictive value was 88.1%, and the negative predictive value was 80.8%. Conclusion 1. The ultrasonic bronchoscopy is effective in the differential diagnosis of the mediastinal lymph nodes in the lung of patients with lung cancer, which is higher than that of the traditional EBUS. As a supplement to the traditional EBUS image, the differential diagnosis of benign and malignant lymph nodes by EBUS-TBNA.2 and strain rate ratio method is superior to any one of the elastic scoring method and the conventional ultrasound image feature. In the second chapter, the value of ultrasonic elastography in the diagnosis of central pulmonary mass is discussed in this paper. Methods A total of 57 patients with central lung mass were selected, and the normal lines were examined by ultrasonic bronchoscope and elastic imaging, and the parallel EBUS-TBNA was used. To evaluate the value of ultrasonic elastography in the differential diagnosis of benign and malignant lung masses by comparing the ultrasonic elastic imaging features of benign and malignant lung masses with the accuracy of the conventional ultrasound imaging features in the diagnosis of malignant lung masses. Results (1) There was a significant difference in the differentiation of benign and malignant lung masses in the conventional ultrasound imaging features, including low echo, uneven echo, clear boundary, and bronchial inflation (all PO.01). (2) The ratio of ultrasonic elastography and strain rate in the airway was significantly different in the benign and malignant lung masses (P0.01). (3) The method of the ratio of strain rate to the benign and malignant lung mass is obviously superior to any one of the elastic scoring method and the conventional ultrasonic image feature. The area under the curve of the strain rate ratio (ROC) curve (AUC) was the maximum at 0.841. The specificity, sensitivity, positive predictive value and negative predictive value of the malignant lung mass were 76.2%, 83.4%, 86.1% and 72.7%, respectively, and the accuracy of the diagnosis was 82.5%. Conclusion The ultrasonic bronchoscope can be used to differentiate the benign and malignant in the central pulmonary mass, and it is more accurate than the traditional EBUS image.
【學(xué)位授予單位】：南京醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2016
【分類號】：R734.2

【參考文獻(xiàn)】

相關(guān)期刊論文 前1條

1 羅建文,白凈;超聲彈性成像的研究進(jìn)展[J];中國醫(yī)療器械信息;2005年05期

，

本文編號：2493668