子宫腺肌病病变类型及灌注特征对超声消融剂量、安全性、有效性的影响

发布时间：2018-06-03 05:17

本文选题：高强度聚焦超声消融术 + 子宫腺肌病　；参考：《重庆医科大学》2017年硕士论文

【摘要】：子宫腺肌病是妇科常见病,它是子宫内膜腺体和间质侵入子宫肌层而形成的一种良性病变。它多发生于30~50岁的妇女,但近些年逐渐呈年轻化的趋势,这可能与剖宫产、人工流产术、宫内节育环的应用增多有关。根据病灶的范围,将子宫腺肌病分为弥漫型子宫腺肌病和局限型子宫腺肌病。传统治疗子宫腺肌病的方法包括手术和药物治疗。高强度聚焦超声消融术(High-intensity Focused Ultrasound,HIFU)是近年来兴起的一种治疗子宫腺肌病的非侵入性技术,其优势是可以准确破坏靶细胞,而不损伤周围组织,从而达到无创治疗的目的。但对于两种病变类型的子宫腺肌病是否均适用于HIFU治疗,目前仍值得关注,除此之外,靶组织的生物学特点也会影响超声能量的沉积,因此本研究旨在通过分析不同病变类型的子宫腺肌病对超声消融剂量、安全性及有效性的影响,为临床病例筛选及预后提供参考。同时探索不同灌注特征的子宫腺肌病对超声消融剂量的影响规律,对优化超声消融子宫腺肌病的临床方案具有重要意义。目的1.通过分析超声消融子宫腺肌病患者治疗中和治疗后不良反应的发生情况,以及治疗后痛经及月经量过多症状改善情况,比较超声消融弥漫型与局限型子宫腺肌病的可行性、安全性和有效性。2.通过彩色多普勒超声及超声造影评价子宫腺肌病的血流灌注特征,探讨血流灌注特征的指标与超声消融剂量之间的相关性。方法1.回顾性分析重庆医科大学附属第一医院2012年1月至2014年12月经超声消融治疗的子宫腺肌病患者297例,其中弥漫型子宫腺肌病(弥漫组)177例,局限型子宫腺肌病(局限组)120例,并于治疗后1天行MRI检查,随访于治疗后1、3、6、12、24、36个月进行,评估并比较两组的消融结果、治疗中及治疗后不良反应发生情况以及两组患者治疗前、后痛经及月经量情况。2.2015年7月至2016年9月经重庆医科大学附属第一医院确诊并接受超声消融治疗的子宫腺肌病患者109例,入院时采用彩色多普勒超声评价子宫腺肌病的血流分布状态,治疗前行超声造影并储存图像,采用聚焦超声消融系统自带软件定量分析超声造影资料并记录增强时间及增强灰度,确定灌注模式,治疗后1天行MRI检查计算消融率及能效因子(EEF),比较不同血流动力学指标及不同灌注模式对治疗剂量的影响,并分析EEF与血流分布状态、增强时间、增强灰度、灌注模式的相关性。结果1.297例患者均顺利完成HIFU治疗,消融发生率为99.33%(295/297),随访时间3~50个月,其中弥漫组177例、局限组120例。弥漫组及局限组消融率分别为25.38±13.39%和44.30±19.93%,差异有统计学意义(P0.01)。HIFU治疗中弥漫组较局限组发生皮肤烫的风险增加1.82倍,局限组较弥漫组发生腹股沟区痛的风险增加2.00倍。297例中,64例(64/297,21.15%)因并发症接受简单治疗[国际介入放射治疗学会(SIR)-B级],其中弥漫组与局限组分别为38例(38/177,21.47%)和26例(26/120,21.67%),差异无统计学意义(P0.05)。两组均未发生SIR-C~SIR-F级并发症。两组患者治疗后痛经及月经量评分与治疗前比较均有明显降低(P0.05)。痛经症状总缓解率在治疗后12个月、24个月及36个月分别为73.51%(197/268)、60.71%(136/224)及46.83%(59/126);且在治疗后24个月及36个月局限组痛经缓解率均高于弥漫组,差异有统计学意义(P0.05)。月经量过多症状总缓解率在治疗后12个月、24个月及36个月分别为68.63%(140/204)、63.64%(105/165)及45.92%(45/98);两组相比较差异均无统计学意义(P0.05)。2.109例患者均顺利完成HIFU治疗,消融发生率为100%(109/109)。所有患者在HIFU治疗中及治疗后均未发生SIR C~F级并发症。109例患者中血流分级为0级的患者有5例,Ⅰ级有60例,Ⅱ级有39例,Ⅲ级有5例,其病灶体积及平均功率分别为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,四组相比较差异有统计学意义(P0.05),而不同血流分级的治疗剂量、能效因子(EEF),以及病灶周边及内部的平均血流速度(Vmean)、收缩期峰值血流速度(PSV)、搏动指数(PI)和阻力指数(RI)相比较差异均无统计学意义(P0.05)。经相关性分析,血流分级与EEF无线性相关性(P=0.345);109例患者中同步增强型有67例,缓慢向心型有42例,两种灌注模式下的无灌注区体积(NPV)、始增时间、增强灰度分别为63.96±53.61cm3、15.36±6.83s、43.04±17.69和41.89±39.57cm3、18.23±6.26s、35.79±16.18,两组比较差异有统计学意义(P0.05),而不同灌注模式下的治疗剂量和EEF相比较差异无统计学意义(P0.05)。经相关性分析,灌注模式、增强时间、增强灰度与EEF无线性相关性(P=0.102、0.686、0.418)。结论1.在严格控制消融范围的情况下,对弥漫型与局限型子宫腺肌病同样行超声消融是安全、可行的。超声消融子宫腺肌病疗效显著,局限型与弥漫型近期疗效相当,远期疗效局限型优于弥漫型。2.彩色多普勒超声与超声造影用于评价子宫腺肌病的血流灌注特征是安全的。子宫腺肌病血流分级越高,超声消融所需平均功率越大;同步增强型较缓慢向心型灌注时间短,强度较大,但消融结果及剂量均无明显差异;子宫腺肌病的血流分级、血流动力学指标、增强时间、增强灰度、灌注模式对超声消融剂量无影响。
[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.
【学位授予单位】：重庆医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R711.71

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