超声造影对胰腺囊性占位的诊断价值—与内镜超声、核磁共振的前瞻性对照研究

发布时间：2018-08-29 12:25

【摘要】：目的:1.探讨经腹超声造影(Contrast-enhanced ultrasonography, CEUS)对胰腺浆液性囊腺瘤(Serous cystadenomas,SCAs )与粘液性囊腺瘤(Mucinous cystadenomas,MCAs)的诊断价值。2.研究经腹超声(Conventional ultrasonography, US)、CEUS 与内镜超声(Endoscopic ultrasonography,EUS )、内镜下超声造影(Contrast-enhanced endoscopic ultrasonography,CH-EUS )对胰腺常见囊性肿瘤不同病种的诊断及鉴别诊断价值。3.对比 CEUS、EUS 及增强核磁(Contrast-enhanced magnetic resonance imaging,CE-MRI)对区分良性与潜在恶性/恶性胰腺囊性占位的诊断效能。资料与方法:1.2015年4月到2017年2月期间,共83例患者纳入本研究,包括47例SCAs与36例MCAs。其中67例为病理学诊断,16例为临床综合诊断。所有病灶完成US检查后,行CEUS检查,记录所有病灶的CEUS特征:大小、部位、形态、囊壁特征(囊壁厚度及增强模式)、分隔(分隔厚度及增强模式)、是否呈蜂窝状、结节等,以临床最终诊断作为金标准,分析依据CEUS不同特征对SCAs和MCAs的诊断效能。2. 2015年4月到2017年2月期间,共105例患者纳入本研究,包括42例SCAs,34例MCAs,18例胰腺导管内粘液性乳头状瘤(Intraductal papillary mucinous neoplasms,IPMNs),11 例实性假乳头状瘤(Solid pseudopapillary neoplasms,SPNs)。其中85例为病理学诊断,20例为临床综合诊断。所有患者均行经US、CEUS,EUS及CH-EUS检查。以临床最终诊断作为金标准,分析US、CEUS、EUS、CH-EUS 对 SCAs、MCAs、IPMNs 和 SPNs 的诊断效能。3. 2015年4月到2017年2月期间,共110例患者纳入本研究,包括SCAs38例,MCAs31例,IPMNs16例,SPNs8例,假性囊肿8例,神经内分泌肿瘤3例,囊肿2例,囊腺癌2例,腺泡细胞癌1例,淋巴管瘤1例。所有患者均行US、CEUS、EUS、MRI及CE-MRI检查。其中84例为病理学诊断,26例为临床综合诊断。将病灶分为良性(SCAs、假性囊肿、囊肿、淋巴管瘤)和潜在恶性/恶性(MCAs、IPMNs、神经内分泌肿瘤、囊腺癌、腺泡细胞癌)两组。所有患者均行经CEUS、EUS及CE-MRI检查。以临床最终诊断作为金标准,区分CEUS、EUS及CE-MRI对区分胰腺囊性占位良性和潜在恶性/恶性的诊断效能。将胰腺囊性病灶按照胰头(钩突) 3cm、胰头(钩突)≥3cm;胰体(颈) 3cm、胰体(颈)≥3cm;胰尾 3cm、胰尾≥3cm分为六组,比较三种影像在不同组别中对区分胰腺囊性占位良性和潜在恶性/恶性的诊断效能。结果:1.部位(p=0.026)、形态(p=0.001)、囊壁厚度(p=0.024)、分隔数目(p=0.003)、蜂窝状结构(p=0.002)对区分SCAs和MCAs具有统计学差异。其中,病灶位于头颈部、呈分叶状外形、内部蜂窝状结构、囊壁小于3mm对诊断SCAs有显著意义;当此四种特征中的两种相结合时诊断SCAs的敏感度为74.5%,特异度为77.8%;三种特征相结合时诊断SCAs的特异度为91.6%,敏感度63.8%。病灶位于体尾部、呈圆/椭圆状外形,内部具有0-2条分隔,囊壁厚度大于等于3mm在诊断MCAs方面有显著意义;当此四种特征中的两种特征相结合时诊断MCAs的敏感度为86.1%,特异度为63.8%;当三种特征相结合时敏感度为80.5%,特异度为80.8%。2. US、CEUS、EUS、CH-EUS对四种疾病的总体诊断准确率分别为60.0%、73.3%、80.0%、82.9%。对于 SCAs、MCAs、IPMNs、SPNs 四类疾病,US 的诊断准确率分别为54.8%、73.5%、55.6%、45.5%; CEUS的诊断准确率分别为76.2%、79.4%、61.1%、63.6%、; EUS 的诊断准确率分别为 81.0%、85.3%、77.8%、63.6%;CH-EUS 的诊断准确率分别为 81.0%、91.2%、77.8%、72.7%。与 US 相比,CEUS在诊断SCAs时的诊断准确率显著提高(P=0.012),诊断全部病种时的诊断准确率显著提高(P=0.013 ) ; EUS与CH-EUS在诊断SCAs时准确率均为81.0%,诊断IPMNs时准确率均为77.8%,对两种疾病的诊断具有完全一致性(κ=1.000);CEUS相比于EUS在诊断四类疾病时的敏感度及特异度均无显著差异(P0.05)。3.对于胰腺囊性占位,CEUS、EUS和CE-MRI在区分良性与潜在恶性/恶性病灶时的敏感度分别为73.8%、86.9%、80.3%,特异度分别为69.4%、81.6%、83.7%,准确率分别为71.8%、84.5%、81.8%,其中任两种影像学在良恶性鉴别诊断中的诊断效能无显著差异。当病灶位于胰头(钩突)部3cm时,CEUS与EUS的诊断效能P值接近0.05( P=0.065 ),CEUS与CE-MRI诊断效能无差异(P=0.267 ),EUS与CE-MRI的诊断效能无差异(P=0.453 );当病灶位于胰尾部 3cm时,CEUS与EUS的诊断效能有显著差异(P=0.039 ) , CEUS与CE-MRI诊断效能P值接近0.05 (P=0.057) ,EUS与MRI诊断效能无差异(P=1.000);位于其余部位及大小的病灶,三种影像两两之间均无统计学差异。结论:1 .经腹超声造影所示肿瘤部位、形态、囊壁厚度、分隔数目、蜂窝状结构在对SCAs和MCAs的鉴别诊断上有一定价值。CEUS不同图像特征结合有助于超声医师更好地鉴别诊断SCAs和MCAs。2.在对胰腺常见囊性肿瘤进行病种诊断时,经腹超声造影优于常规二维超声,尤其对于浆液性囊腺瘤的诊断;内镜下超声造影与内镜二维超声的诊断效能无明显差异;经腹超声造影与内镜二维超声的诊断效能无明显差异,两者在诊断实性假乳头状瘤方面一致性最好,在诊断IPMNs方面的一致性较差。3.对于胰腺囊性占位病灶,CEUS、EUS和CE-MRI在区分潜在恶性/恶性病灶和良性病灶方面诊断效能相当。但对于位于胰尾部最大径 3cm的病灶,EUS的诊断效能明显优于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..
【学位授予单位】：中国人民解放军医学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R445;R735.9

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