超声在妇科肿瘤方面的应用.doc

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1、以前看英文资料，都是泛泛而读，只要看懂意思就行，这次正儿八经的翻译全文，觉得有时咬文嚼字，排兵布阵还真有点麻烦，翻译的不好，请高手批评指正，感谢丁香园、感谢版主给我这个机会，尽管业务、行政工作都很忙，但是业务不能丢，觉得丁香园确实是学习提高的好地方，是我们超声医生的精神家园。Applications of Ultrasound in gynecologic OncologyDarcy J. Wolfman, MD*, Sandra J. Allison, MDKEYWORDS_ Gynecologic oncology _ Ultrasound_ Gynecologic imaging _ G

2、ynecologic malignancy超声在妇科肿瘤学方面的应用关键词：妇科肿瘤学 超声检查 妇科影像 妇科恶性肿瘤In patients with gynecologic malignancy, ultrasound (US) has many established applications, including the diagnosis and staging of ovarian cancer, endometrial cancer, and gestational trophoblastic disease (GTD); detection of recurrent and/o

3、r metastatic disease, including ovarian and cervical cancer and GTD; and diagnosis and guidance for treatment of postoperative complications.在妇科恶性肿瘤方面，超声已经得到了广泛的应用，包括：卵巢癌、子宫内膜癌和妇科滋养细胞疾病的诊断与分期；以及上述疾病的复发及转移的检测；术后并发症的诊断及引导下的治疗。 查看所有投票本贴已得 1 同行票!如果你赞同本文的内容, 可以给作者, 你在本周最多可以投6票, 今天可最多投6票. xgbddxgbdd edite

4、d on 2010-08-04 23:59 举报 【讨论】断指 是干燥冷藏 还是低温冷藏？ xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 18:35 DIAGNOSIS AND STAGING OF GYNECOLOGIC MALIGNANCYOvarian CancerUS is considered the initial imaging modality of choice to help distinguish a benign ovarian lesion from a malignant one

5、. Although a likely benign lesion can be followed or removed by a general gynecologist, suspicion of a malignant ovarian mass should initiate referral to a gynecologic oncologist who can better perform the more complex therapeutic and staging surgery for ovarian carcinoma. Morphologic features remai

6、n the primary US criteria for differentiating benign from malignant ovarian masses. Hence, transvaginal ultrasound (TVS) is the critical US imaging approach because of the improved spatial and soft tissue resolution afforded by the higher frequency endovaginal probe. Nonetheless, transabdominal US r

7、emains an important, complementary component of this US examination when a larger field of view is required. For example, if a lesion is displaced out of the pelvis or is so large that it is incompletely visualized by TVS. In addition, transabdominal imaging is required for evaluation of secondary f

8、indings in ovarian cancer, such as ascites, peritoneal implants, and hydronephrosis. These secondary findings are important not only because they can confirm the suspicion of a malignant ovarian mass, but these findings are also necessary for staging a malignant ovarian mass.妇科恶性肿瘤的诊断及分期卵巢癌超声被论为是鉴别卵

9、巢肿瘤良恶性的首选影像诊断方法，普通的妇产科医师可以随访或手术切除疑为良性的妇科肿瘤，但是，当疑为卵巢恶性肿瘤时，求教于妇科肿瘤方面的专家是首选，因为他们能够对卵巢恶性肿瘤施行更复杂的治疗及分期手术。肿瘤形态学特征仍然是超声鉴别卵巢肿瘤良恶性的主要标准。阴道超声探头具有更高的频率，从而具有更高的空间及软组织分辨率，因此经阴道超声是诊断妇科肿瘤关键性影像诊断方法。然而当需求更大的超声视野时，经腹超声仍然是阴道超声的重要补充。比如肿瘤被推移出了盆腔，或者肿瘤过大，阴道超声无法获得整个肿瘤的视野。此外，当要评估卵巢癌的次要征象，如有无腹水、腹膜种植、肾积水等时，仍然要求经腹超声检查。这些次要征象很重

10、要，因为它们不仅能够进一步确认恶性肿瘤的怀疑，而且对恶性卵巢肿瘤的分期也很重要。 举报 【讨论】断指 是干燥冷藏 还是低温冷藏？ xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 18:39 Numerous studies have reported that when strict US criteria and a pattern recognition approach for identification of benign ovarian masses are used, US has a near

11、ly 95% to 99% negative predictive value in excluding malignancy. 17 US features consistent with benign etiology include smooth, thin walls; few, thin septations; and absence of solid components or mural nodularity. Besides specific US features that suggest a benign etiology, several benign etiologie

12、s are diagnosed by pattern recognition. Simple cysts will be anechoic with a smooth, thin wall and posterior acoustic enhancement. Endometriomas often contain uniform low-level echoes but should still demonstrate a smooth, thin wall, increased through transmission, and no internal vascularity. Hemor

13、rhagic cysts may have characteristic lacelike internal echoes. The internal echogenicity of hemorrhagic cysts may be quite complex and even irregular; however, the appearance of the internal echoes will change over time and internal vascularity should never be noted. Several US patterns associated w

14、ith dermoid cysts have been escribed including uniform increased echogenicity with posterior acoustic attenuation, echogenic shadowing mural nodules, and layering with or without floating debris.许多研究已经报道：当应用严格的超声标准和模式识别法时，超声对卵巢恶性肿瘤的阴性预测值可以达到95%-99%，良性肿瘤的超声特征：光滑纤细的囊壁、少而纤细的分隔、缺少实性成分及壁结节。除了上述提示良性肿瘤的典型超

15、声特征外，几种良性肿瘤可以通过模式识别法进行诊断。单纯性囊肿，表现为无回声、囊壁纤细光滑、后方回声增强。子宫内膜异位囊肿，当提高发射功率时，内可见均匀一致的低水平的回声，同时囊壁仍然是纤细光滑的，内无血流信号。出血性囊肿内部可能见到特征性的条带状回声，内部回声可以复杂、不规则，而且可以随着时间而变化，内部无血流信号，皮样囊肿的几种超声特征包括：均匀一致的回声增多伴有后方回声衰减；伴有声音的高回声壁结节、有或无漂浮碎片的分层现象。 举报 【讲座】话说阴茎起勃器（也称阴茎假体） xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010

16、-08-04 18:41 Conversely, mural nodules, mural thickening or irregularity, solid components, and thick septations (3 mm) suggest malignancy (Fig. 1). Although these morphologic features have a high sensitivity for malignancy, the specificity is low.17 The low specificity reflects overlap in the imagi

17、ng appearance of benign and malignant lesions. For example, benign lesions such as emorrhagic cysts, cystadenomas, or cystadenofibromas may have thick septations and apparent mural nodules and Brenners tumors, fibromas, and fibrothecomas re solid but benign. Furthermore, pedunculated fibroids, dermo

18、ids, and endometriomas can masquerade as solid ovarian lesions. Even with the low specificity of these morphologic features, if US findings suggestive of a malignant ovarian mass are seen, further evaluation is mandatory.相反，壁结节、囊壁增厚不规则、瘤内实性成分、厚的分隔均提示恶性肿瘤。尽管这些形态学特征诊断恶性肿瘤具有很高的敏感性、但是特异性低。低特异性反映了良、恶性肿瘤的

19、影像学表现有重叠。良性肿瘤中，比如出血性囊肿、囊腺瘤、囊腺纤维瘤等均可有厚的分隔和明显的壁结节。例如勃勒氏瘤、纤维瘤、卵泡膜细胞瘤均是实性的但是它们均是良性肿瘤。还有带蒂的子宫肌瘤、皮样囊肿、子宫内膜异位囊肿均可被误论为卵巢实性肿瘤。尽管这些形态学特征特异性低，但是如果超声检查所见提示恶性卵巢肿瘤，则必须进一步检查。 举报 【共享】【活动】医学史中的第一人. xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:05 Fig. 1. Ovarian cancer. Transvaginal gray-scal

20、e (A) and color Doppler ( images demonstrating a cystic lesion with mural nodularity (white arrow in A) with color flow (.图一：卵巢癌，经阴道灰阶超声及彩色多普勒超声检查发现一囊性肿块，内有壁结节（白色箭头 图A），壁结节内探及彩色血流信号（图B） （缩略图，点击图片链接看原图） 举报国际临床专家/产品经理，影像专业背景xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:07 The u

21、se of color and pulse Doppler in the evaluation of ovarian masses is controversial. Some investigators consider blood flow characteristics to be merely confirmatory whereas others consider the Doppler examination to be a helpful discriminator.811 Increased number of often tortuous vessels with arter

22、iovenous shunts is characteristic of tumor neovascularity. Malignant neovascularity lacks the normal amount of smooth muscle cells in the vessel walls. Researchers had hoped that Doppler evaluation, which could potentially assess vascular compliance or resistance as well as vessel morphology, densit

23、y, and distribution, would be helpful in characterizing ovarian masses. Malignant lesions more often demonstrate increased vessel density and tortuosity than benign lesions, but significant overlap exists. Malignant ovarian lesions also tend to demonstrate higher peak systolic velocities and lower r

24、esistive indices than benign masses, but again, considerable overlap exists and no discriminatory cutoff values are ccepted.811彩色及脉冲多普勒超声在评价卵巢肿瘤方面尚有争议。一些调查者沦为肿瘤的血流特征只能起到进一步确证的作用，而一些专家论为多普勒在鉴别卵巢肿瘤良、恶性上有帮助。肿瘤内血流增加，血流紊乱伴有动静脉瘘是肿瘤新生血管的特征,恶性肿瘤的新生血管壁缺乏正常数量的平滑肌细胞。研究者认为：由于多普勒超声能够评估血管的顺应性和血流的阻力，还有血管的形态、密度以及分布

25、、因此应该在鉴别卵巢肿块的性质上有所帮助。同良性肿瘤相比，恶性肿瘤更经常地表现为血管密度的增加和血管的扭曲，但是良、恶性肿瘤的多普勒血流特征有明显的重叠。同良性肿瘤相比，恶性卵巢肿瘤倾向于表现为更高的峰值流速、更低的血流阻力指数，但是，有相当多的重叠存在，而且没有一个可以接受的界值。 举报 【课件】显微镜操作指导 xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:08 Three-dimensional (3D) US is a new imaging technique that may improve

26、 characterization of adnexal masses. Several studies have shown that 3D power Doppler US improved specificity and positive predictive value compared with conventional 2D US12,13; however, other studies have shown no added value with 3D power Doppler US compared with conventional 2D US.14 Further res

27、earch is needed with this technique to better define its role in the characterization of adnexal masses.三维超声是一个新的影像技术，它可能能够改善附件肿块的鉴别诊断。几项研究已经表明：同传统二维超声相比，三维能量多普勒超声提高了诊断的特异性和阳性预测值。然而，其他的研究表明：同传统二维超声相比，三维能量多普勒超声在鉴别诊断方面并没有额外的价值。对这项新的影像技术必须进一步研究，以更好地明确它在附件肿块鉴别诊断中的角色。 举报 【JAMA - 米国的住院医培训】米国住院医教育白皮书 - 200

28、9 - 2010. xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:09 Scoring systems have been proposed to standardize evaluation of ovarian masses in an attempt to improve specificity.1517 Brown and colleagues17 used a stepwise logistic regression analysis to determine the most discri

29、minating gray-scale and Doppler sonographic features of malignancy. They reported that a multiparameter approach, which assessed for nonhyperechoic solid components, central blood flow on color Doppler, ascites, and thick septations, had a 93% sensitivity and specificity for malignancy.To achieve 10

30、0% sensitivity, specificity dropped to 86% in this study.17 However, Timmerman and colleagues18 reported similar sensitivity and specificity and interobserver variability when readers used subjective criteria for evaluatingovarian masses rather than a standardized approach.有人建议用评分系统对卵巢肿瘤进行标准化的评估，以试图

31、提高鉴别诊断的特异性，布朗和他的同事应用分步逻辑回归分析法来决定恶性肿瘤最有鉴别诊断意义的灰阶和多普勒超声特征。他们报道应用多参数分析方法来诊断恶性肿瘤具有93%的敏感性和特异性，这多个参数包括肿瘤内非高回声实性成分、肿瘤中间的彩色多普勒血流信号、腹水和厚的分隔，在这个研究中要达到100%的敏感性，则特异性降低到83%。然而，Timmerman和他的同事们报道：当观察者应用主观标准而不是应用标准化的方法来评价卵巢肿瘤时，得到了相似的敏感性、特异性以及观察者之间的变异度。 举报 【讨论】考过执业医师后，你会继续考研吗？ xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线

32、丁当: 223 个人资料 发短消息 2010-08-04 23:11 US has a limited role in the staging of ovarian cancer; however, US can be used to detect the presence of ascites, peritoneal implants, and hydronephrosis. These findings are not only useful for the staging of ovarian cancer, they can be used to confirm the maligna

33、nt nature of an indeterminate adnexal mass. Transabdominal US is an excellent modality for identifying ascites (Fig. 2A) and hydronephrosis and can be used to guide biopsy, paracentesis, or renal collecting system stent placement; however, detection of peritoneal disease by transabdominal US is limi

34、ted (seeFig. 2. Although the specificity of US in documenting peritoneal spread of disease is slightly higher than CT or MR, the sensitivity for the detection of implants smaller than 2 cm is low.19,20 If an indeterminate adnexal mass is found, it is worthwhile to evaluate for peritoneal spread of d

35、isease with US because a positive finding will limit the need for further imaging and initiate referral to a gynecologic oncologist. A negative result,however, should not be taken as proof that peritoneal implants are not present.在卵巢癌分期诊断中超声作用有限。超声可以检测腹水、腹膜种植转移以及肾积水。这些发现不仅对肿瘤的分期诊断有价值，而且可以确证那些可疑的附件肿瘤

36、的恶性本质。经腹超声是鉴别腹水、肾积水的优秀影像诊断方式，而且能够引导穿刺活检及肾脏集合系统支架放置，然而经腹超声诊断腹膜疾病的作用有限。尽管，超声诊断疾病腹膜转移的特异性稍高于CT、MR，但是超声检测小于20mm转移病灶的敏感性较低.如果发现一个无法定性的附件肿块，利用超声来评估腹膜转移很有价值，因为如果超声检查有阳性发现，则没有必要再进一步的影像检查，需首先求教于妇科肿瘤专家。然而，超声检查如果没有阳性发现，则并不能排除腹膜种植转移。 举报深圳市人民医院龙华分院xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-0

37、4 23:13 Endometrial Cancer Endometrial biopsy and/or dilation and curettage has traditionally been the gold standard for histologic diagnosis of endometrial pathology.However, if routine endometrial sampling were performed in all women with postmenopausal bleeding, only 1 of every 10 samples would b

38、e expected to be positive. In addition, significant sampling error has been reported with falsenegative rates ranging from 2% to 6%.2126 To decrease unnecessary endometrial biopsies,screening patients with postmenopausal bleeding with TVS and/or ono-hysterography (SHG) has been advocated.2733子宫内膜癌子宫

39、内膜活检或刮宫术获取子宫内膜病理学诊断，是传统上诊断子宫内膜癌的金标准，但是如果对所有绝经后阴道流血的妇女进行常规的子宫内膜活检，仅仅1%10%的活检样本有阳性发现。还有，重大的样本诊断失误也已经有报道，样本的假阴性率达到2%-6%。为了减少不必要的子宫内膜活检，有人倡议应用阴道超声和最新发展的子宫收缩描记术筛查绝经后阴道流血的患者。 举报 【medical-news】古老病毒通过入侵重塑人类基因组 xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:14 Double-layer endometrial

40、thickness greater than 4 or 5 mm on TVS is used as the sole US criterion for determining whether endometrial sampling is warranted in postmenopausal patients (Fig. 3).27,28 This endometrial thickness is based on numerous trials that looked to establish a threshold endometrial thickness in postmenopa

41、usal patients below which endometrial pathology is unlikely. However, the specificity ofthis criterion is low, ranging from 59% to 63%.是否决定对绝经后阴道流血的患者进行子宫内膜取样，超声检查的唯一标准就是：阴超检查时，发现双层子宫内膜厚度大于4-5mm。这个子宫内膜厚度的数值是基于多项试验研究决定的，这些试验研究的目的就是建立对绝经后阴道流血的患者进行子宫内膜取样的界值，如果内膜厚度在这些界值以下，就不会有子宫内膜癌。然而这个标准的特异性低,在59%-63%之

42、间。 举报 【公告】EyeBook爱布客眼科杂志第期是起点，也许就是终点 xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:15 When endometrial thickness is greater then 5mm, endometrial sampling is suggested not only because of increased posttest probability of endometrial carcinoma but also because of the inabilit

43、y of TVS and/or SHG to differentiate accurately between benign and malignant causes of endometrial thickening.29,3538 In a meta-analysis of 35 articles including 5892 women, Smith-Bindman and colleagues28 reported that when using a cutoff of 5 mm for endometrial thickness, 96% of women with endometr

44、ial cancer had an abnormal TVS. Int his series, a woman with a 10% pretest probability of endometrial carcinoma and a negative TVS had a posttest probability of endometrial carcinoma of only 1%. They concluded that TVS is highly accurate in identifying a subgroup of patients at extremely low risk, o

45、bviating the needfor endometrial sampling in these patients.当子宫内膜超过5mm，建议进行子宫内膜活检，这不仅因为子宫内膜癌的概率增加，而且因为阴超和子宫收缩描技术并不能准确鉴别子宫内膜增厚的良、恶性病因。在一篇综合35篇论文，5928个患者的meta分析论文中，Smith-Bindman和他的同事报道：如果应用5mm作为子宫内膜增厚的标准，则96%的子宫内膜癌患者阴超检查都是异常的，在他的系列研究中，一个妇女如果预测其患子宫内膜癌的概率是10%，阴超检查结果正常，则这个妇女子宫内膜癌的可能性仅仅1%。他们推断：阴超在识别低危险的患者

46、准确性很高，这些患者没有必要进行子宫内膜活检。 举报健康管理中心超声医师_南方医科大学南方医院xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当: 223 个人资料 发短消息 2010-08-04 23:16 In women taking hormone replacement therapy (HRT), the specificity of the 5-mm cutoff is even lower, as HRT increases endometrial thickness.However, because the pretest probability

47、 of endometrial carcinoma is also likely increased in these patients, the same cutoff value of 4 or 5 mm is generally used. In women on sequential HRT regimens, scanning should be performed after the progesterone part of the cycle when the endometrium is expected to be at its thinnest.在激素替代治疗的患者中，5mm的界值的特异性太低，因为激素替代治疗可以增加内膜的厚度，然而这些患者子宫内膜癌的患病率也增加，因而，4-5mm的界值仍然普遍适用。应用激素替代周期治疗的妇女，在孕酮治疗后，患者的子宫内膜最薄，此时可以对这些妇女进行内膜取样活检进行筛查。 举报四川省肿瘤医院诚聘放疗科医师xgbddxgbdd发贴: 176 积分: 5 得票: 36 状态: 离线 丁当