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术前MRI对早期子宫内膜癌的诊断及分期价值
张平平 唐雯 杨翔 陈汉威

Cite this article as: Zhang PP, Tang W, Yang X, et al. Value of preoperative MRI in the diagnosis of early endometrial carcinoma[J]. Chin J Magn Reson Imaging, 2022, 13(1): 123-125, 129.本文引用格式:张平平, 唐雯, 杨翔, 等. 术前MRI对早期子宫内膜癌的诊断及分期价值[J]. 磁共振成像, 2022, 13(1): 123-125, 129. DOI:10.12015/issn.1674-8034.2022.01.025.


[摘要] 目的 探讨术前MRI对子宫内膜癌肌层浸润深度及宫颈侵犯的诊断价值。材料与方法 回顾性分析经手术病理证实的162例子宫内膜癌患者病例,年龄25~72 (53.29±8.35)岁。采用MR多序列评估子宫肌层浸润深度及宫颈侵犯情况,并以病理结果为金标准,利用诊断试验公式计算MRI诊断的敏感度、特异度、准确度。采用Kappa检验评估术前MRI检查结果和手术病理结果之间的一致性。结果 经手术病理证实的162例子宫内膜癌患者,Ⅰ期137例,Ⅱ期25例。MRI诊断子宫浅肌层浸润的敏感度、特异度、准确度分别为94.7%、93.3%、94.4%,诊断子宫深肌层浸润的敏感度、特异度、准确度分别为93.3%、94.7%、94.4%,MRI术前评估子宫肌层浸润与手术病理结果的一致性好(k=0.83)。诊断宫颈侵犯的敏感度、特异度、准确度分别为48.0%、94.2%、87.0%,MRI术前评估宫颈侵犯与手术病理结果的一致性中等(k=0.46)。结论 术前MRI对早期子宫内膜癌肌层浸润和宫颈侵犯具有重要的诊断价值,对制订个性化治疗方案有一定的指导作用。
[Abstract] Objective To investigate the diagnostic value of preoperative MRI in the depth of muscular invasion and cervical invasion of endometrial carcinoma.Meterials and Methods: One hundred and sixty two cases of endometrial carcinoma confirmed by operation and pathology were retrospectively included, aged 25 to 72 years old, median age 53-year-old. The depth of myometrial invasion and cervical involvement were evaluated by MR multisequence. And using pathological results as the gold standard, the sensitivity, specificity and accuracy of MRI diagnosis were calculated by diagnostic test formula. The Kappa test was used to evaluate the consistency between preoperative MRI results and surgical pathology results.Results There were 162 cases of endometrial carcinoma confirmed by surgical pathology, including 137 cases of stage Ⅰ and 25 cases of stage Ⅱ. The sensitivity, specificity and accuracy of superficial myometrial infiltration were 94.7%, 93.3% and 94.4%, respectively. The sensitivity, specificity and accuracy of the diagnosis of deep myometrial invasion were 93.3%, 94.7% and 94.4%, respectively. The preoperative MRI evaluation of myometrial invasion was consistent with the operative pathological results (k=0.83). The sensitivity, specificity and accuracy of cervical invasion diagnosis were 48.0%, 94.2% and 87.0%, respectively. Preoperative MRI evaluation of cervical invasion had moderate consistency with surgical pathology results (k=0.46).Conclusions Preoperative MRI plays an important role in the diagnosis of myometrium invasion and cervical invasion of early endometrial carcinoma, and has a certain guiding role in the development of personalized treatment plan.
[关键词] 子宫内膜癌;磁共振成像;宫颈;子宫肌层
[Keywords] endometrial cancer;magnetic resonance imaging;the cervix;myometrium

张平平 1   唐雯 2   杨翔 3   陈汉威 1*  

1 广州市番禺区中心医院放射科,广州 511400

2 广东省妇幼保健院放射科,广州 510010

3 广州市番禺区中心医院妇科,广州 511400

陈汉威,E-mail:docterwei@sina.com

全部作者均声明无利益冲突。


收稿日期:2021-07-12
接受日期:2021-11-18
中图分类号:R445.2  R737.33 
文献标识码:A
DOI: 10.12015/issn.1674-8034.2022.01.025
本文引用格式:张平平, 唐雯, 杨翔, 等. 术前MRI对早期子宫内膜癌的诊断及分期价值[J]. 磁共振成像, 2022, 13(1): 123-125, 129. DOI:10.12015/issn.1674-8034.2022.01.025

       子宫内膜癌(endometrial cancer,EC)是发达国家最为普遍的妇科恶性肿瘤。在发展中国家,由于生活方式受西方发达国家的影响以及人均寿命的不断延长,近年来,EC的发病率稳步上升并且越来越年轻化[1, 2, 3]。大部分EC诊断时都处于早期(Ⅰ、Ⅱ期)[4]。目前早期EC最好的治疗方式是手术治疗,而手术方式的选择与病理组织学类型、分化程度、肌层浸润程度及有无宫颈侵犯有关。尽管宫腔镜和阴道超声术前能够诊断早期EC,但对盆腔结构的全貌具有局限性,并且主观因素的影响较大。MRI具有软组织分辨率高的特点,能够区分子宫肌层、结合带及内膜,对判断肿瘤位置、肌层浸润程度及宫颈侵犯均有优势,同时可以确定是否有淋巴结转移,对早期EC的诊断及分期具有重要价值。本文回顾性分析术前MRI对早期EC诊断及分期的准确性。

1 资料与方法

1.1 研究对象

       本研究获得了广州市番禺区中心医院伦理委员会的批准(批准文号:PYRC-2021-079),免除受试者知情同意。回顾性分析2019年1月至2020年12月期间在广州市番禺区中心医院高度怀疑EC患者病例220例。纳入标准:术前均行MRI检查并经病理证实为早期EC患者。排除标准:既往有子宫外科手术史者并伴有其他方面妇科肿瘤者;临床及影像学资料不完整者;选择保守治疗者。最终共纳入162例患者,其中Ⅰ期137例,Ⅱ期25例,浅肌层浸润132例,深肌层浸润30例,年龄25~72 (53.29±8.35)岁,未绝经者89例,绝经者73例。

1.2 检查方法

       采用德国西门子Express 1.5 T MRI扫描仪,相控阵盆腔线圈。T2WI压脂矢状位:TR 4830 ms,TE 61 ms,层厚4 mm,间隔0.8 mm,视野(FOV) 250 mm×250 mm,矩阵224×320;T2WI轴位:TR 3000 ms,TE 110 ms,层厚4 mm,间隔0.8 mm,FOV 250 mm×250 mm,矩阵256×320;T1WI轴位:TR 640 ms,TE 20 ms,层厚4 mm,间隔0.8 mm,视野(FOV) 250 mm×250 mm,矩阵272×320;动态对比增强磁共振成像(DCE-MRI):TR 3.84 ms,TE 1.53 ms,层厚3.0 mm,FOV 260 mm×260 mm,矩阵179×224,预扫描后第二个时相高压注射器注射对比剂钆喷酸葡胺注射液(Gd-DTPA,生产厂家Bayer AG,生产批号KT07B54,规格:469.01 mg/mL×15 mL),剂量16~18 mL,流率2.0 mL/s,之后注入相等剂量生理盐水,共扫描时相20期,时间240 s。

1.3 图像分析

       两位高年资放射科医生各自复阅162例EC患者的MR图像,当意见不统一时协商确定。术前对早期EC的分期参照2009年国际妇产科联盟(International Federation of Gynecology and Obstetrics,FIGO)手术病理分期标准[5]:Ⅰa期,无或<1/2肌层浸润;Ⅰb期,≥1/2肌层浸润;Ⅱ期,肿瘤累积宫颈间质,未超出子宫体外。Ⅰ、Ⅱ期EC MRI表现为:Ⅰa期,T2WI上肿瘤突破结合带,导致结合带部分中断,动态增强扫描显示浸润肌层边缘欠光滑,范围<1/2全肌层厚度;Ⅰb期,肿瘤累及结合带使其完全中断,范围≥1/2全肌层厚度;Ⅱ期,肿瘤侵犯宫颈时,T2WI上低信号宫颈带模糊不清或信号中断。

1.4 统计分析

       使用SPSS 25.0统计学软件对数据进行统计处理,以手术病理结果为参照标准,根据诊断试验公式计算MRI诊断EC宫颈浸润和肌层浸润程度的敏感度、特异度、准确度。采用Kappa检验评估术前MRI检查结果和手术病理结果的一致性:0.01<k≤0.20,表示一致性差;0.21<k≤0.40,一致性一般;0.41<k≤0.60,一致性中等;0.61<k≤0.80,一致性较好;0.81<k≤0.99一致性好[6,7]

2 结果

2.1 手术病理结果

       162例EC患者最终手术病理结果显示典型子宫内膜样腺癌153例,浆液细胞性癌6例,透明样细胞癌1例,恶性癌肉瘤2例。组织学分级:1级为72例,2级为64例,3级为26例。对于子宫肌层浸润程度和宫颈侵犯诊断中,浅肌层浸润132例,深肌层浸润30例,有宫颈侵犯25例,无宫颈侵犯137例。

2.2 MRI图像结果

       术前MRI诊断子宫浅肌层受累时矢状位T2WI序列示病灶区子宫内膜增厚,示局部结合带模糊不清或中断,动态增强扫描时黏膜下强化带局部模糊,浸润<1/2全肌层厚度;深肌层受侵时矢状位T2WI序列示病灶区子宫内膜明显增厚,结合带与肌层分界不清,动态增强扫描时黏膜下强化带中断,呈明显强化,浸润≥1/2全肌层厚度(图1,图2)。162例患者中,MRI正确预测了153例肌层浸润,误诊9例,肌层浸润被高估2例,低估7例,诊断子宫浅肌层浸润的敏感度、特异度、准确度分别为94.7% (125/132)、93.3% (28/30)、94.4% (153/162),诊断子宫深肌层浸润的敏感度、特异度、准确度分别为93.3% (28/30)、94.7% (125/132)、94.4% (153/162),在准确诊断子宫肌层浸润深度方面,MRI与手术病理结果的Kappa值为0.83,详见表1。当EC浸润宫颈时,T2WI示低信号宫颈纤维基质环被中等信号肿瘤所取代;动态增强扫描显示肿瘤的强化程度略低于正常宫颈(图3)。162例患者中,MRI正确预测了12例宫颈侵犯,误诊21例,其中宫颈浸润被高估8例,低估13例,诊断宫颈侵犯的敏感度、特异度、准确度分别为48.0% (12/25)、94.2% (129/137)、87.0% (141/162)。在诊断宫颈侵犯方面,MRI与手术病理结果的Kappa值为0.46,详见表2

图1  女,55岁,手术病理证实为中分化子宫内膜样腺癌,侵犯浅肌层,FIGO分期为Ⅰa期。A:矢状位T2WI压脂序列示子宫前壁低信号结节灶,与子宫结合带分界不清,侵犯浅肌层(箭);B:矢状位动态增强扫描早期前壁黏膜下强化带完整性欠连续(箭)。
图2  女,68岁,手术病理证实为中分化子宫内膜样腺癌,侵犯深肌层,FIGO分期为Ⅰb期。A:矢状位T2WI压脂序列示子宫内膜明显增厚并见一结节灶,后壁结合带模糊不清,侵犯深肌层(箭);B:矢状位动态增强扫描早期后壁黏膜下强化带完全中断,呈明显显著强化(箭)。
图3  女,56岁,手术病理证实为中低分化子宫内膜样腺癌,侵犯宫颈,FIGO分期为Ⅱ期。A:矢状位T2WI压脂序列示宫腔内见一长形肿块,宫颈低信号消失,肿块与阴道前后唇分界清楚(箭);B:矢状位动态增强扫描宫腔至宫颈见肿块,强化程度低于子宫肌层(箭)。
表1  术前MRI和病理学诊断子宫肌层浸润的结果(例)
表2  术前MRI和病理学诊断宫颈浸润的结果(例)

3 讨论

       本研究采用盆腔DCE-MRI及矢状位T2WI压脂序列对早期EC (Ⅰ、Ⅱ期)进行评估发现对Ⅰ期EC的敏感度、特异度及准确度都比较高,与最终病理结果的一致性比较高;而对Ⅱ期EC的敏感度不高,特异度及准确度较高,与最终病理结果的一致性中等。目前早期EC标准的治疗是全子宫切除术和双侧输卵管卵巢切除术,术前准确诊断和分期直接关系手术方式,与患者的预后密切相关[8, 9]。本研究通过术前MRI对Ⅰ、Ⅱ期EC准确性的分析,对临床医生选择合适的手术方式,提高患者的生存率起着积极作用。

3.1 术前MRI判断Ⅰ期EC的准确性

       常规T2WI是判断EC肌层浸润深度的基础;动态增强时子宫肌层比肿瘤更早强化,也可以鉴别肌层是否浸润[10]。以往研究表明[11, 12]在Ⅰ期EC中,深部肌层浸润与淋巴结转移密切相关,这直接关系着患者后期生存率。本研究结果显示术前MRI诊断浅肌层浸润的敏感度为94.7%、93.3%、94.4%,其对深肌层浸润的敏感度、特异度及准确度分别为93.3%、94.7%、94.4%,与既往文献13, 14, 15, 16结果接近。尽管常规T2WI联合动态增强对Ⅰ期EC的诊断准确性较高,但本研究中肌层浸润深度被高估的为2例,低估的为7例。高估原因可能是患者为绝经期女性,肿瘤的体积较大推压子宫肌层,使其变薄,导致正常子宫肌层与肿瘤在MRI信号强度一致;低估的原因可能是:(1)合并子宫内膜良性病变如增生、息肉或肌瘤、腺肌症等,导致肌层信号不均影响观察;(2)由于1.5 T MRI分辨力较低,术前MRI判断为浅肌层浸润,术后病理结果为深肌层浸润。

3.2 术前MRI判断Ⅱ期EC的准确性

       宫颈间质浸润是Ⅱ期EC不良预后的高危因素,即使宫颈间质浸润患者术后采取放化疗等辅助治疗,术后远处转移发生风险仍高于无宫颈间质浸润患者[17]。本研究中,MRI诊断宫颈侵犯的发生率为12.3% (20/162),而在MRI图像中,正常宫颈在T2WI序列上呈低信号,当EC侵袭宫颈时,正常低信号会被高信号或中等信号的肿瘤所取代[18, 19, 20]。本组对162例EC患者进行宫颈是否侵犯的评估中,敏感度为48.0%,Kappa值为0.46,低于既往文献报道[21],可能原因如下:(1)一般对宫颈微小浸润方面都是最终病理确诊的,在MRI上很难发现这一阳性征象;(2)不同医生对宫颈与宫体的解剖界限存在差异;(3)当慢性炎症、宫颈良性病变如纳氏囊肿及子宫峡部的良性肿瘤对宫颈黏膜信号影响时,也可能会干扰我们对宫颈侵犯的判断。总之,MRI术前诊断的重要性在于MRI图像上对宫颈内口的定位。在如何解决这一问题上,国内学者[22]研究发现宫体肌层与宫颈肌层在动态增强扫描过程中强化程度会出现明显的分界面,这一差异可作为定位宫颈内口的方法。在临床工作中,特别是那些年龄较大的EC患者,由于子宫萎缩,对于宫颈内口的定位会相当困难,如果一旦发现肿瘤累及子宫下段,要警惕宫颈内口的侵犯。在确定宫颈内口解剖位置,前期扫描也非常关键,国外学者在其研究中[23]指出对宫颈间质浸润检测的敏感性较低,这促使我们在必要时改变MRI扫描方案,即采取垂直于宫颈管的高分辨率T2序列扫描。

3.3 本研究的局限性

       (1)样本含量较少;(2)国外学者[24, 25, 26]验证了DWI的ADC值在早期EC应用方面的效能,本研究仅对MRI信号综合观察后得出诊断结果,未比较MRI不同序列各自对子宫内膜肌层浸润及宫颈间质侵犯的诊断价值及优势,未测ADC值和动态增强定量参数值,在今后的工作中将会扩大样本量进一步研究。

       总之,术前MRI能够准确判断Ⅰ、Ⅱ期EC,为临床医师正确分期、从而选择合理手术方式及治疗方法提供重要依据。

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