超聲造影對橋本甲狀腺炎背景惡性結(jié)節(jié)鑒別診斷修改

尚旭周琦姜玨馬文琦雷小【摘要】目的評價超聲造影對橋本甲狀腺炎背景下良惡性結(jié)節(jié)的鑒別診斷價值。方法 對82例經(jīng)手術(shù)病理證實的橋本甲狀腺炎背景下的單發(fā)性結(jié)節(jié)應(yīng)用超聲造影檢查，應(yīng)用TomTec軟件繪制超聲造影時間-強度曲線，比較良惡性結(jié)節(jié)超聲造影參數(shù)的差異，并應(yīng)用ROC曲線進行分析。結(jié)果 82例橋本甲狀腺炎背景下的單發(fā)性結(jié)節(jié)中，良性56個，惡性26個。①良性結(jié)節(jié)注射造影劑（P<0.05；（P>0.0596.2%75%、46.43%。結(jié)論超聲造影對橋本甲狀腺炎背景下良惡性結(jié)節(jié)的鑒別診斷有【】橋本甲狀腺炎；甲狀腺結(jié)節(jié)；超聲造Valueofcontrast-enhancedultrasonographyinthedifferentialdiagnosisofbenignandmalignantthyroidnodulesunderthebackgroundofHashimoto'sthyroiditisSHANGXu,ZHOUQi,JIANGJue,WANGHua,MAWen-qi,LEIXiao-ying.DepartmentofMedicalUltrasound，the2ndAffiliatedHospital，SchoolofMedicine，Xi’anJiaotongUniversity，Xi’an710004ChinaCorrespondingauthor:ZHOUQi,: 】ObjectiveToevaluatethevalueofthe通信作者：周琦， diagnosisofbenignandmalignantthyroidnodulesunderthebackgroundofHashimoto'sthyroiditis(HT)usingcontrast-enhancedultrasonography(CEUS).MethodsEighty-twosinglethyroidnoduleswithHTconfirmedbyoperationsandpathologyweregivenCEUSexamination,andtime-intensitycurvesweredrawnbyusingTomTecyzingsoftware.Theparametersasfollows:risetime(RT),timetopeak(TTP),meantransittime(mTT)andumintensity(IMAX)werecomparedbyindependent-samplesttest,andthediagnosticvalueofparameterswereyzedbyreceiveroperatingcharacteristic(ROC)curve.ResultsIn82nodules,therewere56benignthyroidnodules,and26malignantthyroidnodules.①Afterinjectionofcontrastmedia，theenhancementandwash-outinbenignnodulesweremostlythesamewithperipheralgland,aswellastheenhanceintensity.Malignantnodulespresentedlowerenhancement,withlaterrisetimeandearlierwash-outcomparedtoperipheralgland.②mTTwaslonger,whileIMAXwashigherinbenignnodulesthanthoseinmalignantnodules(P＜0.05).ButtherewerenosignificantdifferencesinRTorTTPbetweenthetwogroups.③Thecut-offvalueindiagnosisofbenignandmalignantthyroidnoduleswithHTassessedbyROCcurveweremTT22.69s,IMAX86.41%.WhenmTT,IMAX,andcombinationofthetwoparameterswereusedforthediagnosisofmalignantthyroidnoduleswithHT,thesensitivitywere84.6%、76.9%、96.2%andthespecificitywere66.1%75%46.43%,respectively.ConclusionsCEUSishelpfultoidentifythebenignandmalignantthyroidnodulesunderthebackgroundofHashimoto'sthyroiditis.【】Hashimoto'sthyroiditis；thyroidenhanced橋本甲狀腺炎(Hashimoto'sthyroiditis,HT)是一種常見的自身免疫性疾腺自身抗體升高[1]。HT發(fā)結(jié)節(jié)樣病變，其病理結(jié)果可為良性或惡性。近年來HT合并甲狀的呈現(xiàn)上升趨勢，多數(shù)為甲狀腺狀癌，極少數(shù)為濾泡癌、等[4-7]。甲狀HT胞增生與甲狀腺濾泡上皮細(xì)胞相混雜而類似淋轉(zhuǎn)移癌濾泡上皮細(xì)胞常有嗜酸性變和鱗狀化生易誤診為因此細(xì)胞學(xué)診斷的不確定性可能使甲狀腺遭誤切導(dǎo)致永久性甲狀腺功能低減。超聲檢查是診斷甲狀腺結(jié)節(jié)的重要，但18]度曲線(time-intensitycurve，TIC)HT資料與方2011420121，HT頭狀癌。男9例，女73例，19~65歲，平均46歲。AcusonSequoia512超聲診斷儀，15L8W寬頻線陣探頭，頻率7~14MHz。超聲造影劑選用德國Bracco公司生產(chǎn)的第二代聲學(xué)造影劑超聲造影檢查方法2.4ml，隨后迅速注入5ml生理鹽水沖管。同時啟動計時器，持續(xù)動態(tài)圖像約5min，觀造影圖像分析后期應(yīng)用TomTec軟件分析造影動態(tài)圖像，獲取始增時間、達的粗大血管，對于囊實灶盡可能使ROI處于實性部位內(nèi)。病灶外甲狀腺實質(zhì)ROI盡量與病灶ROI等大，并與其處于同一深度。應(yīng)用SPSS17.0統(tǒng)計軟件（xst檢驗，P0.05曲線，選取診斷惡性結(jié)節(jié)敏感性與特異性之和最高的診斷界點。結(jié)果40個結(jié)節(jié)為低回聲，13個結(jié)節(jié)可見等回聲，3個結(jié)節(jié)為混合回聲，其內(nèi)可見點惡性組：4個結(jié)節(jié)邊界尚清形態(tài)尚規(guī)則，22個結(jié)節(jié)邊界不清形態(tài)不規(guī)則，無完整包膜。21個結(jié)節(jié)為低回聲，2個結(jié)節(jié)為等回聲，3個結(jié)節(jié)為混合回聲，其15良性組：49例可見造影劑均勻進入甲狀腺實質(zhì)，結(jié)節(jié)與周圍甲狀腺組織增強程度基本一致（1。見造影劑進入為弱增強僅見少量造影劑進入；2例結(jié)節(jié)整體明顯弱增強，僅見極少量造影劑進入（2。三、時間-良性組：時間-強度曲線（TI）6（3平均渡越時間、峰值強度與周邊甲狀腺組織基本接近。惡性組：TIC26個結(jié)節(jié)始增時間多晚于周邊甲狀腺組織，增強程度低較弱的特點（4。（P<0.05（P>0.051。以各變量診斷惡性結(jié)節(jié)的敏感性為縱坐標(biāo)，1-ROC曲線（5、622.69s86.41%22.69s時，84.6%66.1%。當(dāng)峰值強度≤86.41%時，診斷為橋本甲狀腺炎伴惡性結(jié)節(jié)的敏感性為76.9%，特異性為75%。聯(lián)合兩者進行判斷，診斷為橋本甲狀腺炎伴惡性結(jié)節(jié)的敏感性為96.2%，46.43%。討論認(rèn)為是由遺傳因素與環(huán)境因素相互作用而成的。HT發(fā)展的最終趨勢是甲狀腺功HT癥和甲狀腺自身抗體升高[]臨診斷T的指標(biāo)一般有游離甲狀腺素(FT4)降低、促甲狀腺激素(TS)升高、甲狀腺球蛋白抗體(T-)、甲狀腺過氧化物酶抗體(TPO-)升高等然而T的臨床表現(xiàn)及學(xué)檢查結(jié)果經(jīng)常呈14%T患者TP-b2%T患者未發(fā)現(xiàn)T-b1]。診斷中有著重要價值[021。根據(jù)甲狀腺內(nèi)低回聲的范圍、分布及結(jié)節(jié)形成狀況，TT最常HT盡管存在爭議，仍有表明HT患者并發(fā)甲狀腺狀癌的風(fēng)險增加[4-7]。HTHT的超聲表現(xiàn)的研究尚不充分。在Langer等的回顧性研究中，由細(xì)針穿刺證實的21個孤立性甲狀腺結(jié)節(jié)（20HT患者）中，多表現(xiàn)為邊緣不規(guī)則的實性回聲14%（3/21）的結(jié)節(jié)伴囊性改變，24%（5/21）的結(jié)節(jié)內(nèi)伴鈣化點，無特定模式[8]Anderson61HT64個甲狀腺結(jié)節(jié)的研究成型HT的超聲表現(xiàn)無固定模式其中良性結(jié)節(jié)與惡性結(jié)節(jié)的表現(xiàn)有部分[9]。（77%[10/13]12（7/69界及血流對比均沒有顯著性差異[2]56HT(54%30/56)與惡性結(jié)節(jié)表現(xiàn)近似。WangL64腺狀癌的超聲聲像圖進行回顧性分析計算出惡性結(jié)節(jié)超聲聲像圖特征的聯(lián)部分，對聲像圖特征的判斷易受檢查者影響，故僅根據(jù)二維及彩色多普勒超聲聲像圖鑒別HT背景下的良惡性結(jié)節(jié)存在一定。、[24-26]。SonoVue作為第二代微泡造影劑，比第一代造影劑更穩(wěn)定，通過提高聲波反射增加了小血管的可視性。以往研究已證明CEUS使用第二代微泡造影劑SonoVue鑒別良惡性甲狀腺結(jié)節(jié)的可行性[18,27]。與傳統(tǒng)不穩(wěn)定的觀察結(jié)節(jié)形態(tài)和血管的超聲診斷方法相比，CEUS可通過定量分析結(jié)節(jié)的微血管灌注模式為鑒別甲狀腺結(jié)節(jié)提供有用的附加信息[28-29]。HT背景下良性結(jié)節(jié)在血管數(shù)量、病理研究中良性組56例結(jié)節(jié)均與周圍甲狀腺組織增強程度基本一致，多數(shù)結(jié)節(jié)表現(xiàn)為與周圍組織同時增強。HT在病理發(fā)展過程中，存在進行性的葉間纖維化，甲周圍組織同時增強，且增強強度一致。而26例HT合并惡性結(jié)節(jié)多為弱增強，TIC“慢進快出可能因為甲狀腺惡性結(jié)節(jié)內(nèi)新生血管較細(xì)血管分布雜亂， 造影劑難以進入的現(xiàn)象。然而，良惡性結(jié)節(jié)之間的超聲表現(xiàn)同樣一定程度上限制了CEUS增強模式對結(jié)節(jié)內(nèi)微血管形態(tài)的解釋、利用TomTec軟件分析造影動態(tài)圖像，得到相關(guān)參數(shù)，有利于對造影圖像進行定量分析，進一步減少因素的影響。本研究顯示，良性組與惡性組相比，TIC曲線越平坦。甲狀腺惡性結(jié)節(jié)內(nèi)大多血流豐富，多見穿入性血流，動脈血流速度高[30]HT96.2%，說明兩者聯(lián)合判斷有利于對惡性本研究顯示良性組與惡性組之間始增時間、達峰時間比較均無統(tǒng)計學(xué)意義，I的選取有關(guān)，應(yīng)進一步優(yōu)化超聲造影及分析TIC以提高超聲造影TIC曲線的應(yīng)用價值。PearceEN,FarwellAP,BravermanLE.Thyroiditis.NEnglJMed,2003,348:YehHC,FutterweitW,GilbertP.Micronodulation:ultrasonographicsignofHashimotothyroiditis.JUltrasoundMed,1996,15:813–819.PedersenOM,AardalNP,LarssenTB,VarhaugJE,MykingO,Vik-MoH.Thevalueofultrasonographyinpredictingautoimmunethyroiddisease.Thyroid,2000,10:KimKH,SuhKS,KangDW,etal.MutationsoftheBRAFgeneinpapillarythyroidcarcinomaandinHashimoto'sthyroiditis.PathologyInternational,2005,55(9):540–545.GulK，DirikocA，KiyakG.TheassociationbetweenthyroidcarcinomaandHashimoto'sthyroiditis:theultrssonographicandhistopathologiccharacteristicsofmalignantnodules.Thyroid:OfficialJournaloftheAmericanThyroidAssociation,2010,20:873-878.KwakJY,KimEK,KoKH,etal.Primarythyroidlymphoma:roleofguidedneedlebiopsy.JUltrasoundMed,2007,26:CipollaC,SandonatoL,GraceffaG.Hashimotothyroiditiscoexistentwithpapillarycarcinoma.AmSurg,2005,71:874–878.LangerJE,KhanA,NisenbaumHL,etal.Sonographicappearanceoffocalthyroiditis.AJR,2001,176:751–754.AndersonL,MiddletonWD,TeefeySAetal.Hashimotothyroiditis:Part1,sonographicysisofthenodularformofHashimotothyroiditis.[J].AJR,2010,195(1):208-215.AnilC,GokselS,GursoyA.Hashimoto'sthyroiditisisnotassociatedwithincreasedriskofthyroidcancerinpatientswiththyroidnodules:asingle-centerprospectivestudy.Thyroid,2010,20(6):601-6.MukasaK,NohJY,KuniiY,MatsumotoM,SatoS,YasudaS,SuzukiM,ItoK,K.Prevalenceofmalignanttumorsandadenomatouslesionsdetectedbyultrasonographicscreeninginpatientswithautoimmunethyroiddiseases.Thyroid,2011,21(1):37-41.DietrichCF.Characterisationoffocalliverlesionswithcontrastenhancedultrasonography.EurJRadiol,2004,51:9-17.SchneiderAG,HofmannL,WuerznerG,GlatzN,MaillardM,MeuwlyJY,EggimannP,BurnierM,VogtB.Renalperfusionevaluationwithcontrast-enhancedultrasonography.NephrolDialTransplant,2012,27(2):674-81.SongY,YangJ,LiuZ,ShenK.Preoperativeevaluationofendometrialcarcinomabycontrast-enhancedultrasonography.BJOG,2009,116(2):294-8;discussion298-9.LindnerJR.Molecularimagingofcardiovasculardiseasewithcontrast-ultrasonography.NatRevCardiol,2009,6(7):475-ThoreliusL.Emergencyreal-timecontrast-enhancedultrasonographyfordetectionofsolidorganinjuries.EurRadiol,2007,17:107-11.HornungM,JungEM,GeorgievaM,SchlittHJ,StroszczynskiC,AghaDetectionofmicrovascularizationofthyroidcarcinomasusinglinearhighresolutioncontrast-enhancedultrasonography(CEUS).ClinHemorheolMicrocirc,2012,52(2):197-203.ZhangB,JiangYX,LiuJB,YangM,DaiQ,ZhuQL,GaoP.Utilityofcontrast-enhancedultrasoundforevaluationofthyroidnodules.Thyroid,2010,GilmourJ,BrownleeY,FosterP,GeekieC,KellyP,RobertsonS,WadeE,HB,StaubU,MichelG,LazarusJH,ParkesAB.ThetativemeasurementofautoantibodiestothyroglobulinandthyroidperoxidasebyautomatedmicroparticlebasedimmunoassaysinHashimoto'sdisease,Graves'diseaseandafollow-upstudyonpostpartumthyroiddisease.ClinLab,2000,46(1-2):57-61.PedersenOM,AardalNP,LarssenTB,VarhaugJE,MykingO,Vik-MoH.Theofultrasonographyinpredictingautoimmunethyroiddisease.Thyroid,2000,BischofP.[Updateendocrinology:Thyroidsonography].Praxis(Bern1994),2004,21;93(17):695-700.AndersonL,MiddletonWD,TeefeySA,ReadingCC,LangerJE,DesserT,MM,MandelSJ,HildeboltCF,CronanJJ.Hashimotothyroiditis:Part2,sonographicysisofbenignandmalignantnodulesinpatientswithdiffuseHashimotothyroiditis.AJRAmJRoentgenol.2010Jul;195(1):216-22.WangL,XiaY,JiangYX,DaiQ,LiXY.Likelihoodratio-baseddifferentiationofnodularhashimotothyroiditisandpapillarythyroidcarcinomainpatientssonographicallyevidentdiffusehashimotothyroiditis:preliminarystudy.JUltrasoundMed.2012Nov;31(11):1767-75.EisenbreyJR,ForsbergF.Contrast-enhancedultrasoundformolecularimagingofangiogenesis.EurJNuclMedMolImaging.2010Aug;37:S138-46.DelormeS,KrixM.Contrast-enhancedultrasoundforexaminingtumorbiology.CancerImaging.2006Sep27;6:148-52.WilsonSR,BurnsPN.Microbubble-enhancedUSinbodyimaging:whatrole?Radiology.2010Oct;257(1):24-39.NemecU,NemecSF,NovotnyC,WeberM,Czerny