本文選題：超聲造影 + 甲狀腺微小乳頭狀癌��； 參考：《遵義醫(yī)學院》2014年碩士論文

【摘要】：目的：分析常規(guī)超聲、超聲造影以及聯合常規(guī)超聲和超聲造影三種方法，，對鑒別甲狀腺微小良惡性病變的診斷價值。評價超聲造影的定性診斷及定量診斷兩種方法在甲狀腺微小良惡性病變診斷中的作用。 方法：102例甲狀腺結節(jié)納入標準：①甲狀腺內孤立性低弱回聲結節(jié)，②甲狀腺背景為實質回聲均勻的正常甲狀腺組織，③結節(jié)最大直徑≤10mm，④TI-RADS分類為3類和4類；排除標準：①結節(jié)直徑＞10mm的低弱回聲結節(jié)，②高回聲或等回聲結節(jié)，③伴有多發(fā)結節(jié)，④結節(jié)內粗大鈣化致使不能顯示結節(jié)實性成份的結節(jié)，⑤FNA診斷分型中取材不滿意不能診斷的結節(jié)。儀器采用意大利百勝公司的Mylab90超聲診斷儀。造影劑選用意大利Bracco公司生產的聲諾維（SonoVue），經肘正中靜脈團注造影劑1.0ml。采用目測法觀察甲狀腺內微小結節(jié)的增強特點，并應用Qontrast4.0分析軟件進行時間-強度曲線（TIC）定量參數分析，并與手術病理為金標準進行對照。超聲造影操作人員要求由三個固定的具有造影經驗3年以上的醫(yī)師操作，以達到標準統(tǒng)一。統(tǒng)計學數據應用Binary Logistic回歸分析以及診斷性試驗方法中ROC曲線，得出ROC曲線下面積，進行比較分析。 結果：1、單因素分析，患者一般情況中甲狀腺微小乳頭狀癌患者的平均年齡（40.69±10.67）歲低于良性組患者的平均年齡（49.52±13.21）歲、惡性組患病年齡多在30-50歲之間，年齡在良惡性組間差異性比較中有統(tǒng)計學意義（P㩳0.05），性別在良惡性組間比較中無統(tǒng)計學意義（P＞0.05）；常規(guī)超聲檢查中，甲狀腺微小乳頭狀癌的結節(jié)多顯示為不規(guī)則形態(tài)、邊界不清晰、縱橫比（A/T）≥1、結節(jié)內微鈣化以及頸部查見可疑異常腫大淋巴結在良惡性組間差異性比較中有統(tǒng)計學意義（P㩳0.05）；超聲造影定性指標中，甲狀腺微小乳頭狀癌的超聲造影特征多表現為慢進、向心性增強、不均勻性增強、達峰時呈等增強或低增強、增強后結節(jié)徑線改變、邊界不清晰、結節(jié)周邊無環(huán)狀增強，以上指標中除不均勻性增強外良惡性組間差異性比較有統(tǒng)計學意義（P㩳0.05）；超聲造影時間-強度曲線（TIC）定量參數中，峰值強度（PEAK）、局部血流量（RBF）、最大灌注強度（SImax）、平均灌注強度（SImean）、相對峰值強度、相對峰值時間、相對局部血流量、相對局部血容量、相對平均灌注強度、相對最大灌注強度在良惡性組間差異性比較中有統(tǒng)計學意義（P㩳0.05）； 2、多因素分析，常規(guī)超聲及患者一般情況多因素分析中：①縱橫比A/T，②形態(tài)是否規(guī)則，③結節(jié)內微鈣化，④頸部有無可疑異常淋巴結進入Logistic多因素回歸方程，預測甲狀腺微小乳頭狀癌的準確性、敏感性及特異性分別為82.4%、80.0%、84.6%；超聲造影定性指標多因素分析中：①造影增強時間，②有無環(huán)狀增強進入多因素回歸方程，運用Logistic回歸方程預測甲狀腺微小乳頭狀癌的準確性、敏感性及特異性分別為87.3%、86.0%、88.5%；超聲造影定量指標中僅有相對最大灌注強度（相對SImax）一項參數進入Logistic回歸方程，其預測甲狀腺微小乳頭狀癌的準確性、敏感性及特異性分別為66.7%、60.0%、73.1%；聯合常規(guī)超聲以及超聲造影定性定量的多因素分析中：①縱橫比A/T，②微鈣化，③頸部有無可疑異常淋巴結，④造影灌注方式，⑤有無環(huán)狀增強及⑥SImax進入Logistic回歸方程，其預測甲狀腺微小乳頭狀癌的準確性、敏感性及特異性分別為93.1%、92.0%、94.2%。 3.ROC曲線分析，常規(guī)超聲診斷方法、超聲造影定性診斷和定量診斷方法以及聯合常規(guī)超聲和超聲造影定性定量診斷方法產生的ROC曲線下面積分別為90.0%、90.7%、99.0%。由此可見，聯合應用常規(guī)超聲和超聲造影定性定量兩種診斷方法，其診斷能力明顯優(yōu)于單獨應用前兩者；分別由超聲造影的定性診斷方法和定量診斷方法獲得的ROC曲線，其曲線下面積分別為90.7%、69.7%。由此可見，超聲造影的定性診斷能力明顯優(yōu)于超聲造影定量診斷方法的診斷能力。 結論：對甲狀腺微小乳頭狀癌的診斷能力而言，超聲造影定性診斷方法的準確性、敏感性和特異性均高于超聲造影的定量診斷方法。聯合應用常規(guī)超聲以及超聲造影定性及定量各項指標和參數對甲狀腺微小良惡性結節(jié)的鑒別診斷能力明顯優(yōu)于單獨運用前兩者，值得在臨床上推廣應用。
[Abstract]:Objective: to analyze the diagnostic value of three methods of conventional ultrasound, ultrasound contrast and conventional ultrasound and ultrasound contrast in the differential diagnosis of benign and malignant thyroid lesions. To evaluate the role of two methods of qualitative diagnosis and quantitative diagnosis of contrast ultrasound in the diagnosis of thyroid microbenign and malignant lesions.
Methods: 102 cases of thyroid nodules were included: (1) isolated hypoechoic nodules in the thyroid gland, (2) thyroid background as parenchyma and homogeneous normal thyroid tissue, (3) the maximum diameter of the nodules were less than 10mm, and (4) TI-RADS classified as 3 and 4 categories; the exclusion criteria: (1) the low and weak echo nodules with the diameter of the nodule > 10mm, and the hyperechoic or equal echo Nodules, (3) with multiple nodules, (4) nodular calcification that can not show nodular solid components, (5) FNA diagnostic typing that is dissatisfied with undiagnosed nodules. The instrument adopts the Mylab90 ultrasonic diagnostic instrument of Italy Baisheng company. The contrast agent is selected from the SonoVue of the Bracco male division in Italy and the median vein of the elbow. The contrast agent 1.0ml. was observed by visual method to observe the enhancement of small nodules in the thyroid gland. The quantitative parameters of time intensity curve (TIC) were analyzed with Qontrast4.0 analysis software and compared with the gold standard of surgical pathology. The operators of ultrasound contrast operators were required to be operated by three fixed doctors with more than 3 years of angiography. In order to achieve standard unification, statistical data is used in the Binary Logistic regression analysis and the diagnostic test method of ROC curve to obtain the area under the ROC curve, and to make a comparative analysis.
Results: 1, single factor analysis, the average age of the patients with thyroid small papillary carcinoma (40.69 + 10.67) was lower than that of the benign group (49.52 + 13.21). The age of the malignant group was 30-50 years old, and the age was statistically significant between the benign and malignant groups (P? 0.05), and the sex was in the benign and malignant group. There was no statistical significance in the comparison (P > 0.05); in the routine ultrasound examination, the nodules of the thyroid micropapillary carcinoma showed irregular shape, the boundary was not clear, the longitudinal and transverse ratio (A/T) was more than 1, the microcalcification in the nodules and the suspicious abnormal lymph nodes in the neck were statistically significant (P? 0.05) in the benign and malignant groups; The contrast-enhanced ultrasound features of thyroid micropapillary carcinoma were characterized by slow progress, centripetal enhancement, inhomogeneity enhancement, enhanced or low enhancement in the peak, enhanced posterior nodular diameter, unclear boundary, non circular enhancement in the periphery of nodules, and the differences among the above groups in addition to non uniformity and non uniformity. Statistical significance (P? 0.05); in the quantitative parameters of the time intensity curve (TIC), the peak intensity (PEAK), the local blood flow (RBF), the maximum perfusion intensity (SImax), the average perfusion intensity (SImean), the relative peak intensity, the relative peak time, relative local blood flow, relative local blood volume, relative mean perfusion intensity, relative maximum perfusion intensity, and relative maximum perfusion were observed. There was a significant difference in the intensity between the benign and malignant groups (P? 0.05).
2, multifactor analysis, conventional ultrasound and patient general analysis of multifactor analysis: (1) the accuracy of the thyroid micropapillary carcinoma is 82.4%, 80%, and 84.6%, respectively, whether the longitudinal and transverse A/T, the second shape is regular, the third is the microcalcification in the nodules, and the suspicious abnormal lymph nodes in the neck are entered into the multiple regression equation of the multiple factors of the thyroid papillary carcinoma. The multiple factor analysis of ultrasound contrast qualitative indexes: (1) contrast enhancement time, or ring enhancement into multiple regression equation, using Logistic regression equation to predict the accuracy of thyroid small papillary carcinoma, the sensitivity and specificity were 87.3%, 86%, 88.5%, respectively, and only the relative maximum perfusion intensity in the hyper contrast quantitative index. Relative SImax) a parameter entered the Logistic regression equation, and its accuracy was 66.7%, 60%, and 73.1% for the prediction of thyroid small papillary carcinoma, respectively, and the qualitative and quantitative analysis of combined conventional ultrasound and ultrasound contrast: (1) the longitudinal and transverse ratio A/T, the second microcalcification, and the neck without suspicious abnormal lymph nodes; (4) angiography The accuracy of the thyroid micropapillary carcinoma was predicted with 93.1%, 92%, 94.2%., respectively, with no annular enhancement and 6 SImax into the Logistic regression equation.
3.ROC curve analysis, conventional ultrasonic diagnosis, qualitative diagnosis and quantitative diagnosis of contrast-enhanced ultrasound and qualitative and quantitative diagnosis of combined conventional ultrasound and ultrasound contrast ROC curves are 90%, 90.7%, 99.0%., respectively. The combined use of conventional ultrasound and ultrasound contrast qualitative and quantitative diagnosis of two methods, the diagnosis The ability of the ROC curve obtained by qualitative diagnosis and quantitative diagnosis of ultrasound contrast, respectively, is 90.7% and 69.7%., respectively. The qualitative diagnosis ability of ultrasound contrast is better than that of the quantitative diagnostic method of ultrasound contrast.
Conclusion: for the diagnosis of thyroid small papillary carcinoma, the accuracy, sensitivity and specificity of the qualitative diagnosis are higher than the quantitative diagnostic methods of contrast-enhanced ultrasound. The differential diagnosis of thyroid small benign and malignant nodules by combined use of conventional ultrasound and ultrasound contrast medium and quantitative parameters and parameters The force is obviously better than the former two. It is worth popularizing in clinic.
【學位授予單位】：遵義醫(yī)學院
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R736.1;R445.1

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