子宫腺肌症治疗

湖北省妇幼保健院Maternity and child care centers in hubei province王燕Wang Yan,project date 20/09/2007,高强度聚焦超声治疗子宫腺肌症的临床研究The Clinical Study Of Ultrasound-guided High-intensity Focused UltrasoundAblation For Adenomyosis,概念onception,02,子宫腺肌病( adenomyosis, AM )一种常见妇科疾病，多发生在30-50岁经产妇。本病的发病机制尚不清楚Adenomyosis is a common Gynecological disease that usually affect multiparas of 30-to-50 year-olds.The pathogenesis of this disease is not clear 现状：发病率升高，发病年龄呈下降趋势, 对患者生活质量的影响也越来越大The current situation: The incidence rates rised while the age of onset declined, the influence on the quality of life of patients are getting more and more serious,文献资料：literature & information :可能与人工流产、宫内放置节育器、输卵管结扎、诊断性刮宫、分娩等因素相关常损伤子宫内膜及浅肌层，导致基底层子宫内膜侵入子宫肌层内生长Adenomyosis may be related to the factors of induced abortion 、IUD、tubal ligation 、curettage、childbirth,etc-which usually damage the endometrium and shallow myometrium,caused the basal layer of endometrium invade into myometrium,观察 observation 手术治疗 surgery药物治疗 drugs,治疗therapy,症状Symptoms 年龄 Age生育要求Desire of fertility,根治性手术Radical surgery 子宫+双附件切除术Hysterectomy and bilateral salpingo-oophorectomy (BSO),手术治疗surgical treatment,保守性手术：Conservative operation 子宫内膜去除术（Transcervical esection of endometrium ,TCRE）介入（Uterine Arterial Embolization,UAE）腹腔镜子宫动脉结扎术（Laparoscopic Uterine Artery Ligation ,LBUAB）超声聚焦治疗（High Intensity Focused Ultrasound,HIFU）电消融治疗electrical ablation子宫腺肌瘤挖除术myomectomy for uterine myoma +腹腔镜子宫动脉阻断术（Laparoscopic uterine artery blockage,LBUAB） +腹腔镜子宫神经去除术（Laparoscopy uterine nerve ablation,LUNA）,根治性手术：1% Radical surgery保守性手术：80-95% Conservative operation,治疗方式的选择The choice of treatments,手术治疗的不足之处the defects of surgical treatment,不能处理微小病灶复发Cant deal with the small lesions-Relapse 不能去除病因复发Have been unable to remove the causes-Relapse,增加患者的压力和负担Increasing the pressure and burdenof patients,保留子宫Preservation of the uterus 非侵入性 Non-invasive 不需麻醉No anesthesia 并发症、副作用少There were few side effects and complications保留生育功能Conserve fertility 可重复性好Well repeatability,理想治疗方式The ideal treatmants,研究方法 Research methods,High Intensity Focused Ultrasound Ablation by Haifus Model JC200,skin,非月经期、非妊娠期、非哺乳期Non-menstrual ，un-pregnant， nonpuerperal women.经妇检和B超确定为子宫腺肌病患者Gynecological examination and Type-B ultrasonic scan evidence of typical features of adenomyosis.所有病例均有渐进性痛经、经量增多、经期延长以及下腹部坠胀、腰酸、腹痛等症状All the cases with the clinical symptoms of progressive dysmenorrhea,menorrhagia,menostaxis,next abdominal pain and swelling, lumbar acid,abdominal pain.无实施镇静镇痛的禁忌证，治疗前均签署知情同意书同意超声消融治疗Without the contraindications to sedative and analgesic,sign a consent form before treatment.,病例选择case selection,下腹部瘢痕致明显声衰减或有放射治疗病史 The abdomen scar led to obvious acoustic attenuation or received radiation treatment.急性感染性疾病未控制、慢性盆腔感染至盆腔器官 Uncontrolled acute infective disease ,the chronic pelvic infection to pelvic organs.下腹部多次大手术、严重粘连者 Reccived repeatedly abdomina major surgery with seriously adhesions. 盆腔内有金属植入物 There are metal implants in pelvic.严重心肺疾病史及患者不能俯卧2h者 With history of seriously prior heart and lung disease,inability to lie in a prone position for 2 hours.合并子宫外脏器内膜异位者未纳入本研究 With the internal organs of the uterus endometriosis.,病例排除标准Excluding criterion,Patient data：Characteristics病例基本资料,Patient data：accompanying symptoms患者资料：伴随症状,预处理：皮肤脱脂、脱气，膀胱及肠道准备pretreatment： degreasing，degassing，intestinal and bladder preparation镇静镇痛方案：芬太尼、咪唑安定 Sedation and analgesia :midazolam,fentanyl.治疗前、后超声造影 Receive contrast-enhanced ultrasound before and after treatment.,治疗方法therapeutic method,治疗参数Treatment parameter,Frequency频率：1MHzFocal length焦距：134mmDiameter of trasnducer 治疗头直径：220mmScanning mode扫描模式：single exposure点扫描 Thickness 层面距离：4-5mmStarting power 开始功率：250w-300wMaximal power 最大功率：400w,评估方法 Methods of evaluation： 超声造影 contrast-enhanced ultrasound 彩色超声定期随访检查（治疗后1、3、6个月）Regular follow-up by Color Doppler Sonography (after treatment 1month,3month,6month) 临床症状评分the clinical symptom grades评估内容evaluating content : 消融定量评估 quantitative ablation evaluation 腺肌瘤及子宫消融前后声像图变化 compared the changing of the acoustic image of uterus and endometrioma before and after treatment. 临床症状改善the improvement of symptoms,腺肌病消融后的疗效评估内容The evaluations of efficacy after,应用超声造影计算腺肌病的消融疗效computie the effective in ablating by contrast-enhanced ultrasound,病例插图1 The 1th illustration of cases,腺肌瘤体积（FV）=消融体积（NPV）=体积消融比率=NPV/FV100%=,应用超声造影计算腺肌病的消融疗效computie the effective in ablating by contrast-enhanced ultrasound,病例插图2The 2th illustration of cases,腺肌瘤体积（FV）=消融体积（NPV）=体积消融比率=NPV/FV100%=,应用超声造影计算腺肌病的消融疗效computie the effective in ablating by contrast-enhanced ultrasound,病例插图3The 3th illustration of cases,腺肌瘤体积（FV）=消融体积（NPV）=体积消融比率=NPV/FV100%=,治疗前后各指标变化情况 The change of indexs before and after treatment,结果results,在40例腺肌病患者中，32例(80%)治疗后即刻出现团块状灰度变化，5例(12.5%)出现整体灰度变化，3例(7.5% )治疗中未观察到灰度变化In the 40 case of adenomysis,there are 32cases (80%) appeared lumpish grayscale change immediately after treatment, 32cases (80%) appeared lumpish lumpish change immediately after treatment,5cases (12.5%) appeared holistic grayscale change immediately after treatment, treatment,3cases (7.5%) did not appeare grayscale change immediately after treatment.,治疗后变化The change after treatment,治疗前后超声造影检查腺肌瘤灭活部分造影剂充盈缺损，呈无回声 The contrast-enhanced ultrasound after treatment show that no contrast medium and hyperechoic in nactivated adenomysis 每个腺肌病均有不同程度的灭活，灭活率为20%95%，平均75%左右，其中灭活率90.0%以上的腺肌瘤占37.5% (15/40)，灭活率75.0%以上的腺肌病占70% (28/40) All the adenoymisis there were certain degree of inactivation,the deactivation rate is 20%-95%, the average deactivation rate about 75%,the cases of rate greater than 90.0% accounts for 37.5%(15/40), the cases of rate greater than 75.0% accounts for 70%(28/40),治疗后变化The change after treatment,月经量增多改善 the improvement of menstruation,临床症状改善clinically improvement in symptoms,痛经症状改善the improvement of dysmenorrhea,临床症状改善clinically improvement in symptoms,HIFU治疗后行彩超随访，39例患者治疗中均可见腺肌瘤区域内回声增强，部分出现小的团状强回声The follow-up after HIFU treatment show that there 39 patients the treat area echoes of high amplitude,some one appear strong echo .,影像学随访follow-up of Imaging,治疗1个月：腺肌瘤体积无明显变化，3例体积略增大，瘤体内回声较前增强、不均，边界逐渐模糊，血流信号明显减少（8例开始出现坏死液化）after treatment 1month:there are not significant change of Uterine myoma volume,3 cases volume increased,the echo of myoma enhanced and unevenness. the borders are blurring gradually, the blood flow signals significantly decreased(Of the 8 patients with liquefaction necrosis )治疗3个月6个月：腺肌瘤体积逐渐缩小；血流信号稀少或未见血流信号，瘤体周边见较细的血流信号存在after treatment 1-3month: Uterine myoma volume decreased gradually; there are few or no blood flow signals, there are some smaller blood flow signals para-tumors .,影像学随访follow-up of Imaging,HIFU治疗子宫腺肌病的安全性The safety of HIFU ablae adenomyosis,治疗中Durning the treatment： 疼痛（盆腔内治疗区、骶尾部、会阴、下肢，疼痛评分2-3分，患者均诉可耐受） pain(treatment areas in pelvic cavity ,Sacrococcygeal region ,perineum,legs, pain score was 2-3 points,all the patients could tolerance.) 皮肤灼伤：未见 Skin Burns: no,治疗后after treatment： 骶尾部胀痛2例（治疗次日既缓解）Sacrococcygeal region pain 2 case (disapperd next day ) 治疗区皮肤压痛3例（2-4天即缓解）pressing pain of the skin of treatment area(disapperd in 2-4 days ) 皮肤水泡（未见）no skin hydroncus bubble ache 下肢痛麻（未见）no leg pain 低热1例（治疗次