气道内超声弹性成像技术对肺癌肺门纵膈淋巴结转移的诊断价值
发布时间：2019-06-05 16:44
【摘要】：研究背景肺癌(lung cancer)是全球发病率和死亡率最高的恶性肿瘤。目前已成为世界范围内肿瘤相关死亡的主要原因。在我国肺癌的死亡率在过去几十年内迅速增长,尽管过去20年内肺癌的诊治水平有大幅度的提高,但肺癌的5年生存率仍较低,不足15%。肺癌准确的TNM分期对于疾病的治疗和预后判断非常重要。仅部分极早期的患者可能会出现超过15%的五年生存率。肺癌患者纵膈分期和生存率密切相关,此外最佳治疗方案的选择、临床药物实验的筛选以及疗效判断等都是建立在准确的纵膈分期基础上。因此研究者一直在探索能准确评估肺门纵膈淋巴结是否转移的纵膈分期工具。气道内超声引导下的经支气管针吸活检(Endobronchial ultrasound guided transbronchial needle aspiration,EBUS-TBNA)已广泛应用于肺癌患者的纵膈分期及诊断。但是在发生转移的淋巴结中可能会有坏死、液化、良恶性共存等病理表现,而穿刺活检仅能代表穿刺局部的病变,使其诊断的准确性受到一定限制。基于EBUS-TBNA在纵膈分期中的重要作用,如何提高诊断的准确性引起学者的关注。超声弹性成像(ultrasound Elastography,UE)是近年来发展起来的一项新的超声诊断技术,可以测量组织的弹性,所反映的是病灶内的硬度情况。通过分析病灶软硬度的不同来判断病灶的性质。超声弹性成像技术在临床上应用较为成熟,主要用于乳腺、前列腺、甲状腺等浅表器官病变良恶性鉴别,并取得较好的研究成果。结果均表明恶性病变较周围组织硬度增加,可以通过硬度特征来鉴别病变的良恶性。内镜下超声弹性成像技术主要应用于消化系统疾病的诊治,对于胰腺包块、淋巴结良恶性的诊断敏感度、特异度较高。气道内超声内镜下弹性成像技术对肺门和纵膈淋巴结及肺部肿块良恶性的鉴别目前研究较少。本研究的目的为评估气道内超声内镜下弹性成像技术对肺门纵膈淋巴结及肺部肿块良恶性的诊断价值,对68个肺门纵膈淋巴结及57个肺部肿块进行气道内超声弹性成像检查,通过弹性评分、应变率比值分析,并与常规超声图像特征比较,探讨气道内超声弹性成像技术在肺部肿块及肺门纵膈淋巴结中的应用价值。第一章气道内超声弹性成像技术对肺癌患者肺门纵膈淋巴结转移的诊断价值目的1.研究气道内超声弹性成像技术诊断肺门纵膈淋巴结转移的可行性及良恶性淋巴结的弹性成像特征及应变率比值。2.探讨气道内超声弹性成像技术对肺癌患者肺门纵膈淋巴结转移的诊断价值,并与常规超声结果进行比较。方法选取从2014年01月-2015年06月期间,在我院就诊的门诊和住院患者,经胸部X线、CT检查疑似肺癌的40例患者共68枚淋巴结。所有患者予以超声支气管镜检查,常规行淋巴结气道内超声及弹性成像检查,并予以支气管内超声引导下的经支气管针吸活检(EBUS-guided transbronchial needle aspiration, EBUS-TBNA)。以病理学结果为金标准,通过比较良恶性淋巴结的超声弹性成像特征及弹性成像评分法、应变率比值法与常规超声影像学特征诊断恶性淋巴结准确性差异,评估气道内超声弹性成像技术鉴别淋巴结良恶性的价值。结果1、常规超声影像学特征中鉴别良恶性淋巴结差异有显著统计学意义的指标包括低回声、回声不均、边界清楚、短径大于1cm(均P0.01)。2、气道内超声弹性成像评分在良恶性淋巴结中差异有显著统计学意义(P0.01)。弹性评分法的曲线下面积(area under the curve,AUC)为0.852,其对良恶性淋巴结的鉴别价值明显优于常规超声图像特征中的任何一种。以弹性评分≥2.5分为诊断界值,其诊断恶性淋巴结的特异度、敏感度、阳性预测值及阴性预测值分别为76.9%,85.7%,85.7%及76.9%,诊断的准确率为82.3%。在弹性评分和常规超声图像联合诊断指标中以弹性评分联合低回声、边缘清晰、直径大于1cm诊断价值最大,AUC 0.911,其诊断恶性淋巴结的特异度、敏感度、阳性预测值及阴性预测值分别为84.6%,88.1%,90.2%及81.5%,诊断的准确率为86.8%。3、良恶性淋巴结应变率比值(strain ratio,SR)(87.69±49.15 VS 20.60±17.14)差异具有统计学意义(P=0.000)。良恶性淋巴结SR和弹性评分间具有显著的相关性(r=0.561,P=0.000)。SR诊断恶性淋巴结AUC为0.933,高于常规超声及弹性评分的曲线下面积(AUC=0.662,0.705,0.561,0.732及0.852)。SR法对良恶性淋巴结的鉴别明显优于弹性评分法及常规超声图像特征中的任何一种。取约登指数最大值时的界值,确定SR诊断良恶性淋巴结的最佳界值为32.07,此时诊断恶性淋巴结敏感性为88.1%,特异性为80.8%,准确性为85.3%,阳性预测值为88.1%,阴性预测值为80.8%。结论1、超声支气管镜下弹性成像技术能有效实现对肺癌患者肺门纵膈淋巴结良恶性的鉴别,比传统的EBUS图像准确率高。作为传统EBUS图像的补充,可指导EBUS-TBNA。2、应变率比值法对良恶性淋巴结的鉴别明显优于弹性评分法及常规超声图像特征中的任何一种。第二章气道内超声弹性成像技术对中央型肺部肿块的诊断价值目的探讨气道内超声弹性成像技术对中央型肺部肿块良恶性的鉴别诊断价值。方法选取57例中央型肺部肿块患者,常规行超声支气管镜及弹性成像检查,并行EBUS-TBNA。通过比较良恶性肺部肿块的超声弹性成像特征与常规超声影像学特征诊断恶性肺部肿块准确性的差异,评估气道内超声弹性成像技术在鉴别中央型肺部肿块良恶性的价值。结果(1)常规超声影像学特征中鉴别良恶性肺部肿块差异有显著统计学意义的指标包括低回声、回声不均、边界清晰、支气管充气征(均PO.01)。(2)气道内超声弹性成像评分及应变率比值在良恶性肺部肿块中差异有显著统计学意义(P0.01)。(3)应变率比值法对良恶性肺部肿块的鉴别明显优于弹性评分法及常规超声图像特征中的任何一种。应变率比值受试者工作曲线(ROC)曲线下面积(AUC)最大,为0.841。以应变率比值≥9.785作为诊断界值,其诊断恶性肺部肿块的特异度、敏感度、阳性预测值及阴性预测值分别为76.2%,83.4%,86.1%及72.7%,诊断的准确率为82.5%。结论超声支气管镜下弹性成像技术能有效实现对中央型肺部肿块良恶性的鉴别,比传统的EBUS图像准确率高。
[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.
【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R734.2
本文编号：2493668
[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.
【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R734.2
【参考文献】
相关期刊论文 前1条
1 罗建文,白净;超声弹性成像的研究进展[J];中国医疗器械信息;2005年05期
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