子宫恶性肿瘤术前MRI检查价值

1、子宫恶性肿瘤术前mri检查价值【摘要】目的 探讨mri检查在子宫内膜癌和子宫颈癌中 的诊断及术前分期中的应用价值。方法回顾分析2004年1 月至2010年1月在我院经病理证实为子宫内膜癌和子宫颈癌的患者各60例进行定量及定性分析，子宫颈癌患者中30例术前行mri检查，另30例未行mri检查。mri检查应用philips achieva 1.5t超导型双梯度磁共振仪，采用体部线圈, 常规行轴位 t1wi(se),t2wi use),矢状 t2wktse)及 t2wi 脂肪抑制序列，层厚为45mm、层间距1mm。成像范围:轴 位自双侧骼骨翼上缘至耻骨联合下缘,矢状位根据病变部位 及范围而定。结果子

2、宫内膜癌患者中,mri检查组:其判断分 期的准确性是83.3%(25/30);对肿瘤局限于内膜、浸润浅肌 层和浸润深肌层的敏感性分别为75.0%、82.4%和88.9%;特异性分别为96.2%、84.6%和90.5%;准确性分别为93.3%、83.3%和 90.0%;阳性预测值分别为 75.0%. 87.5% 和80.0%;阴性预测值分别为96.2%、78.6%和95.0%。非 mri检查组中，其判断分期的准确性是66.7%(20/30)o宫颈 癌患者中,mri检查组:判断分期的准确性是80.0%(24/30); 判断宫旁浸润的准确性、特异性、敏感性、阳性预测值和阴性预测值分别为 93.3%、

3、96.2%. 75.0%. 75.0%和 96.2%。非mri检查组:术前临床分期的准确性是66.7%(20/30);判断 宫旁浸润的准确率、特异性、敏感性、阳性预测值、阴性预 测值分别为 86.7%. 92.6%, 33.3%、33.3%和 92.6%。结论1.mri对术前子宫内膜癌，尤其是对肌层浸润深度方面的 准确分期具有很高价值。2. mri清楚显示癌灶大小、位置及 宫旁浸润，对术前宫颈癌分期明显优于临床分期。【关键词】子宫恶性肿瘤磁共振成像(mri)肿瘤分期浸润 深度【中图分类号】r737.3【文献标识码】a【文章编号】1004-7484(2010)08-00-03value of m

4、ri in preoperative assessment of uterine tumorsabstract objective to explore the value of mri in diagnosis and preoperative staging of endometrial carcinoma and cervical cancer, to analyze and summarize the differe nt stagi ngs of the mri findings of the com mon m alignant uteri ne tumor, guide the

5、mri exami nation in the field of gyn ecology applicatio n. methods to qua ntitative and qualitative analysis of the data of 60 cases of various were pathologically con firmed endometrial carcinoma and cervical cancer in our hospital between jan.2004 and jan.2010 similarly, 30 patients with cervical

6、cancer underwent mri sean before operation, another 30 patients were not underwent mri. all general in formation were comparable, who were not underwent mri were selected on randomly over the same period and all performed operation, then compared the preoperative mri stagings and clinical stagings w

7、ith the operation-pathologic stagings, separatly. mri with body coils of philips achieva 1.5t. the patients laid on back and were performed by axial(spin echo): t1wi, t2wi; saggital(tubor spin echo): t2wi and fat-saturation t2wi. the slice thickness was 4-5mm,the slice interval was 1mm. the sean fie

8、ld: the axial was from the iliac crest to the low rim of pubic symphysis; the saggital was decided by the location and the field of the leisions. results in en dometrial carci no ma, the mri group: the accuracy for judging stages was 83.3% (25/30). the sensitivity of mri assessment for tumor confine

9、d to endometrium, superficial myometrial and deep-myometrial invasion was 75.0%, 82.4% and 88.9%, respectively; specificity: 96.2%, 84.6% and 90.5%, respectively; accuracy: 93.3%, 83.3% and 90.0%; positive predictive value: 75.0%, 87.5% and 80.0%, respectively; negative predictive value: 96.2%, 78.6

10、% and 95.0%, respectively. in control group: the accuracy for judging stages was 66.7% (20/30). in cervical cancer, the mri group: which presented an accuracy of 80.0%(24/30) in determining stages of disease; the accuracy, specificity, sensitivity, positive predictive value and negative predictive v

11、alue of parametrial invasion were 93.3%, 96.2%, 75.0%, 75.0% and 96.2%, respective!y. in control group: the accuracy for judging stages was 66.7%(20/30); the accuracy, specificity, sensitivity, positive predictive value and negative predictive value of parametrial invasion were 86.7%, 92.6%, 33.3%,

12、33.3% and 92.6%, respectively.conclusion 1. mri is one of highly valuable methods in diagnosis and staging endometrial carcinoma, especiall in judging of myometrial invasion. 2. mri is superior to clinical evalution in the staging of cervical cancer, it can show the size, location and extension of t

13、he cervical cancer clearly.key words 1 uterine tumor; magnetic resonanceimaging(mri); neoplasm stagingqepth of invasion1资料与方法1.1 一般资料 收集2004年1月至2010年1月在我院经手术后病理证实的120例子宫恶性肿瘤资料完整的患者。子宫内膜癌60 例，年龄24-73(51.13±11.95)岁,主要临床症状包括:阴道不 规则流血或绝经后阴道流血、腹痛、腹胀等，其中30例患者 于术前1周行mri检查，另30例为随机抽取的同期资料完整 的未行mri检查患者。宫

14、颈癌60例，年龄2559(4200±9.71) 岁，主要临床症状包括:阴道不规则接触性或性生活后出血、 阴道排液等，其中30例于术前1周行mri检查，另30例为随 机抽取的同期资料完整的未行mri的患者。2 mri检查方法患者取仰卧位，适当充盈膀胱，应用philips achieva 1.5t 超导型双梯度磁共振仪，采用体部线圈，常规行轴位wi(se),t2wi(tse),矢状位 t2wktse)及 t2wi 脂肪抑制序列，层厚均为45mm、层间距1mmo必要时同时进行增 强检查，静注轧喷酸葡胺(gddtpa)15ml后行轴位、矢状位t1wi检查。成像范围:轴位自双侧酸骨翼上缘至耻骨

15、联合下缘,矢状位根据病变部位及范围而定。3资料分析及处理方法由我院mri室诊断经验丰富的医师采用双盲法进行分析, 并与术后病理结果进行比较。所得数据使用spss11.5软件包，进行卡方检验,p1/2;lla期2例,mri显示宫颈管明显增宽, 病灶呈菜花样突出宫颈口;lib期2例,mri显示间质内明显低 信号肿块影，宫颈低信号纤维环中断;illa期2例,mri表现子 宫肌层连续性中断，并突破浆膜层;lllc期2例,mri显示双侧 骼血管周围见多发增大融合的淋巴结。(2) 子宫内膜癌mri分期与术后病理分期的对照结果(见 表1)本组30例中肿瘤分期的准确度达83.3%(25/30)o运用 spss

16、13.0中的rxc表卡方检验分析得出:kappa值 =0.759>0.096;se(渐进标准误)二0.096,近似t=8284,近似概率p0"6;se(渐进标准误)二0"6,近似t=6006,近似概率p(2) mri在子宫内膜癌分期中的价值mri的主要价值是对肿瘤分期的准确评估,尤其是对子宫肌层浸润深度的判断。mri具有高组织分辨率和多方位成像 等特点，在t2wi上可明确区分宫体自内向外的三层结构，还 可敏感发现子宫内膜病变及判断肌层浸润程度，提高了术前 分期的准确性，为临床医师选择、制定合理的治疗方案提供了 客观依据。mri对子宫内膜癌诊断准确性为73% - 97%

17、，本 组30例mri检查患者，其分期的准确度达83.3%(25/30)o(3) 子宫内膜癌最常见的mri表现子宫内膜癌最常见的mri表现:子宫体积增大，子宫内膜腔增宽，部分可见局限性肿瘤信号影。病变于t1wi上多表现 为均匀一致的等信号，伴有出血时呈略高信号;于t2wi上均 呈高信号，高信号部分包含内膜、肿瘤、宫腔内分泌物和出血 等，有时仅能凭借内膜厚度来判断，一般绝经期前女性内膜厚 度超过9mm,绝经期后女性内膜厚度超过4mm为异常3。(4) mri对子宫内膜癌浸润深度的评估savci等应用mri对子宫内膜癌患者术前评价有无肌层浸润的准确性为90%;scoutt等发现常规mri鉴别深肌层浸

18、润lc和浅表浸润(la+lb)的准确性为78%,在区分la、lb、lc期 准确性为55%o vasconcelos4等人研究显示，阴道超声鉴别 深肌层浸润的准确性、敏感性和特异性分别为69%、50%和81%,而mri判断深肌层浸润的准确性、敏感性和特异性分 别为95%.89%和100%,要明显优于经阴道超声仃vus);kim 等人对26例病人比较,tvus、ct和mri评价深肌层的准 确性、敏感性和特异性分别为69%、50%、和81%,61%.40%和75%,89%. 90%和88%。发现mri在判断肌层浸润方面的敏感性和准确性明显优于tvus和ct(p=0.049)o本 组30例患者中，术前

19、mri正确诊断与术后病理结果诊断总体 符合率为83.3%o对于肿瘤的浸润深度结果表明，肿瘤局限于内膜、浸润浅肌层及浸润深肌层的准确率分别为93.3%、83.3%和90.0%,同文献报道相似5。(5) mri对宫颈受累及对淋巴结转移的评估mri具有很高的解剖分辨率，在t2wi上可以很好的显示宫颈间质受累情况，表现为宫颈管扩大，管内略高信号结构和 宫颈间质信号升高。本组30例患者中有4例mri表现为宫 颈受累，与术后病理一致,证实了 mri是一种较为准确的术前 评估宫颈有无受累的方法。多数学者认为淋巴结短径1cm时应考虑有淋巴结转移的可能，但准确率不高。cabrita等研究显示,mri判断淋巴 结转移的敏感性为17%,特异性为99%,准确性为89%。本组 病例中,mri平扫发现淋巴结增大20枚(短径邛.0cm),术后病 理证实转移淋巴结13枚，其它7枚为炎性改变，认为mri对 淋巴结的检出还有一定的局限性。5.2宫颈癌宫颈癌的临床分期 宫颈癌的临床分期主要通过妇科检查、宫颈细胞学并辅以宫颈活组织