腹膜后脂肪肉瘤(RLS)是一种来源于间叶组织最常见的软组织恶性肿瘤,病因尚不明确,成人多发,发病率占恶性肿瘤的10％～45％[1].脂肪肉瘤最常见的发生部位在腹膜后,因腹膜后解剖位置的特殊性,在肿瘤早期不易发现.本文通过对1例腹膜后巨大肿瘤且病理分型为黏液样脂肪肉瘤去分化成分为横纹肌肉的多种影像学联合及结合相关文献报道分析其影像学特殊性,归纳总结其特点并鉴别诊断,为后续临床诊断及治疗提供参考.

Multi-modal imaging technology was used to screen the cervical microlymph nodes of patients with head and neck squamous cell carcinoma. Based on the pathological results, radiotherapy was optimized to improve the quality of life of patients. CT or magnetic resonance imaging (MRI) examination before radiotherapy was performed in 36 patients with head and neck squamous cell carcinoma. Fifty-one microlymph nodes with ≤1 cm diameter were selected. Following the ultrasonic detection of relevant indicators, ultrasound-guided puncture biopsy was performed to confirm the pathology. Based on the multi-modal evaluation results, the target area and plan of radiotherapy was confirmed. We evaluated the dose to organs at risk before and after target optimization. The difference in the detection results was compared, and the 3-year local control rate of the lymph node region of interest was observed. The Dmean and V30 of the parotid (left and right) and submandibular gland (left and right) and the V50 of the mandibular gland (left and right) had significant differences before and after optimization in the microlymph node target area of the neck (p<0.05). After 3 years of follow-up, four patients had cervical lymph node recurrence in the high-dose irradiated field. The recurrence rate was 11.11%, and no local recurrence was observed in the microlymph node area of interest. Thus, multi-modal imaging technology is a safe and reliable method to further optimize radiotherapy target planning to distinguish between benign and malignant cervical microlymph nodes of head and neck squamous cell carcinoma.

目的:应用Q-T间期离散度、常规心脏超声、超声二维斑点追踪显像技术早期监测心肌损害的优势以及它们之间的相关性,来预测心脏不良事件的发生.方法:选择经病理证实的乳腺癌患者 62例在用药 2、4 周期后先获取Q-Tcd、常规超声、二维斑点追踪显像等各项数据,再根据任一化疗周期内心电图和心肌酶情况将乳腺癌化疗患者分为四组,对所有数据进行统计分析.结果:第二次用药后四组之间E/A、Q-Tcd差异有统计学意义(P<0.05),第四次用药后四组之间二尖瓣E峰、二尖瓣环e峰、GLPS-a2c、GLPS-avg差异有统计学意义(P<0.05).结论:心电图Q-T间期离散度、常规超声的E/A比值、二尖瓣E峰、二尖瓣环e峰以及二维斑点整体纵向峰值监测能早期较敏感地发现蒽环类药物亚临床阶段的心肌损伤,延长患者生存期,改善预后.

Objective:To analyze the clinicopathological characteristics of patients with false negative breast cancer diagnosed by ultrasound examination, and explore measures to reduce the missed diagnosis rate of breast cancer.Methods:According to the inclusion and exclusion criteria, the data of 68 cases of false-negative breast cancer diagnosed by ultrasound in the Tumor Hospital of Gansu Province from January 2011 to June 2016 were analyzed retrospectively. The relationship between clinicopathological factors (ultrasound blood flow type, Adler classification, etc) and BI-RADS ultrasound classification and the relationship between BI-RADS mammography classification and BI-RADS ultrasound classification were analyzed. The one-way ordered data and the two-way ordered rank data were analyzed by the Kruskal-wallis H test. The pairwise comparison between groups was performed by the Bonferroni-Dunn’s method.Results:The number of patients with BI-RADS category 1, 2 and 3 lesions was 2, 5 and 14; 0, 1 and 7; 1, 2 and 13; 4, 12 and 7 among the patients with peripheral, penetrating, internal and lacking blood flow types, respectively. The number of patients with BI-RADS category 1, 2 and 3 lesions was 2, 12 and 7; 3, 7 and 26; 2, 1 and 8 among the patients with Adler classification 0, 1, 2 lesions. There were significant differences in BI-RADS category of breast cancer missed by ultrasound among patients with different ultrasound blood flow types and different Adler classification (χ2=14.756, 6.829; P=0.002, 0.033). The patients with different BI-RADS mammography category showed significant difference in BI-RADS ultrasound category (χ2=9.574, P=0.023). After mammography, 17 patients were newly diagnosed with BI-RADS category 4 lesions and the cases of missed diagnosis declined by about 25%. The large majority of breast cancer missed by ultrasound was at early stage (Tis: 22 cases; T1mic: 14; T1c: 17; T2: 6).Conclusions:Early stage, small lesions, special pathological types and atypical blood flow features are main factors for misseddiagnosis of breast cancer by ultrasound. Additional mammography can improve the diagnostic accuracy of ultrasound to diagnose breast cancer, but it still has certain limitations.

患者女性,18岁,主因"月经紊乱5个月,下腹疼痛4 d"前来就诊.自述平素月经规律,末次月经2020年6月30日,2020年1月至5月每月出现阴道异常流血,持续3～4 d自行停止;2020年7月9日突然出现右下腹绞痛,呈持续性,尤其活动时疼痛明显,伴有恶心,无发热、阴道流血.遂入院治疗.

目的:研究心电图Q-T间期离散度和多普勒二维斑点追踪显像技术,对蒽环类药物化疗的乳腺癌患者进行心脏评估,探讨早期发现心脏功能亚临床损害的可行性及必要性.方法:选择初诊的乳腺癌患者60例,于化疗前、化疗每周期后24～48 h常规进行十二导联心电图描记,测量Q-T间期,测算出Q-T间期离散度值(Q-Tcd).于化疗前、化疗每周期后24～48 h行心脏常规超声及斑点追踪显像技术检查,测量左室射血分数(LVEF)、左室Tei指数、二尖瓣口舒张早期流速峰值E峰、二尖瓣口舒张晚期流速峰值A峰.组织多普勒测量二尖瓣环室间隔侧舒张期运动速度,E峰、A峰,计算E/A值、E/e值.计算左室收缩期心尖四腔心切面整体纵向峰值应变(GLPS-a4c)、二腔心切面整体纵向峰值应变(GLPS-a2c)、三腔心切面整体纵向峰值应变(GLPS-a3c)、左室平均整体纵向峰值应变(GLPS-avg).观察蒽环类药物用药前后及各个周期心电图Q-Tcd值和心脏常规超声及斑点追踪显像参数的变化.结果:研究发现不同次数用药后Q-Tcd差异有统计学意义(P<0.05).随着用药次数增加Q-Tcd延长,差异有统计学意义(P<0.05).Q-Tcd两两比较,各组间差异均有统计学意义(P<0.05).患者化疗前后常规超声心动图参数比较,差异无统计学意义(P>0.05).GLPS-a4c、GLPS-a3c、GLPS-a2c、GLPS-avg各参数随着用药次数的增加,各组差异均有统计学意义(P<0.05).结论:Q-T间期离散度和二维斑点追踪技术,有助于蒽环类药物致乳腺癌患者心脏毒性的早期发现,为及时改善化疗方案提供依据.

患者男,15岁,因"发现腹腔包块"入院. 患者一月余前无明显诱因出现上腹部胀满不适,无发热、黄疸,无泛酸、嗳气,无恶心、呕吐,无腹泻、便秘,无黑便、便血,无咳嗽、胸闷等不适. 其后上述上腹腹胀症状逐渐加重.查体:上腹部触之饱满,未及明显包块,全腹无明显压痛及反跳痛,莫非氏征阴性,余未见明显异常. 实验室检查:各项血液学检查未见明显异常.

目的:探讨双重超声造影在胃癌术前T分期判断中的价值.方法:选取2018年3月至11月我院收治的50例手术治疗胃癌患者,所有患者术前进行胃窗超声造影与双重超声造影检查,并根据检查结果进行T分期判断,以患者手术病理结果为标准,对两种方式的诊断价值进行探讨.结果:胃窗超声造影在患者术前T分期判断的准确率为80％,其中,T2、T3、T4分期判断准确率分别为72.7％、87.1％、62.5％;双重超声造影在患者术前T分期判断的准确率为92％,其中,T2、T3、T4分期判断准确率分别为90.9％、93.5％、87.5％.根据两种检查方式对术前T分期诊断准确率对比,差异具有统计学意义(P<0.05).结论:双重超声造影进行胃癌术前T分期判断准确率较高,具有临床应用价值.

患者,女,39岁,因"左侧颈部肿物3年"入院.3年前无明显诱因发现左侧颈部约"核桃"大小肿物,无任何不适,半月前出现呼吸费力伴饮食时哽咽感,患者自述肺结核病史30年,疾病史、婚育史及家族史无特殊.入院查体:气管右偏,左侧甲状腺下极可触及7cm×5cm肿物,活动度可,边界清,无触痛;右侧甲状腺未见异常. 周围皮肤无红肿. 双侧颈部未触及明显肿大淋巴结. 甲状腺功能及甲状旁腺素无异常. 红细胞沉降率26(0～20).超声检查结果(图1～4):左侧甲状腺下极下方至上纵隔混合性占位,淋巴结核?建议穿刺.双侧甲状腺未见异常. 左侧颈部V区淋巴结部分淋巴门结构消失. CT检查(图5)提示:颈部及胸上段局部食管管壁偏心性明显增厚,可见不规则肿物,边界不清,不均匀强化,内见更低密度无强化区,病变局部破溃,肿物向前、向左推挤左侧甲状腺及气管. 诊断:纵隔占位并溃疡形成考虑恶性. 术前在超声引导下行肿物穿刺组织活检:免疫组化结果(图6):肿瘤细胞S-100(+), SMA(-),Desmin(-),Caldesmon(-),CD34(-),BcL-2 (+),CD99(-),Ki-67(+5％),B-Catenin(+),CD117(-), Dog-1(-);结合HE切片及免疫组化结果,神经源性肿瘤. 术后大体标本所见:肿块位于颈段食管前外侧壁,类圆形,直径约5cm,质韧,呈厚壁囊性,内有少量黄色黏稠液,肿物下后方与食管腔相通,术后食管壁肿物免疫组化结果:肿瘤细胞S-100(+),SMA(-),Desmin(-), Caldesmon(-),CD34(-),BcL-2(+),CD99(-),Ki-67 (+10％),B-Catenin(+),CD117(-),Dog-1(-),CD5(-);结合HE切片及免疫组化结果,食管壁纤维瘤病样神经肿瘤,局部侵袭性.

目的 探究超声双重造影在胃癌TNM分期上的诊断价值及局限性.方法 从我院选取80例胃癌患者,对患者分别进行单纯胃窗超声造影检查以及超声双重造影检查和TNM分期,与术后病理结果进行比较.结果 与术后病理结果相比,使用胃窗超声造影对胃癌术前T分期的超声诊断符合率为78.75％,其中T1的超声诊断符合率为50.00％,T2为66.67％,T3为83.33％,T4为87.88％;与术后病理结果相比,使用超声双重造影在胃癌术前T分期的超声诊断符合率为85.00％,其中T1的超声诊断符合率为75.00％,T2为73.33％,T3为87.50％,T4为90.91％,两组数据存在明显差异(P<0.05).两种检查对淋巴转移的符合率不理想,都存在胃癌N分期低估的问题,远处转移符合率也比较低.结论 超声双重造影在胃癌T分期检查中有良好的效果,但对NM分期检查存在局限性.

结合近年来蒽环类药物心脏毒性的研究,总结出蒽环类药物心脏毒性的机制、毒性分类、心脏毒性的监测及中医药预防处理的研究进展,为蒽环类药物治疗的肿瘤患者早期监测心脏毒性提供依据和方向.

目的:探讨甲状腺超声规范化诊断及规范化报告在甲状腺结节分层管理中的价值.方法:应用2011年韩国学者Kwak提出的甲状腺超声影像数据报告系统(Thyroid Imaging Reporting and Data System,TI-RADS),回顾性分析2015年1月1日至2018年12月31日就诊于我院的11053例甲状腺疾病患者的彩色多普勒超声规范化诊断及报告,探讨甲状腺超声规范化诊断及报告系统在甲状腺结节分层管理中的价值.结果:对11053例患者共13333个结节进行规范化诊断及报告:TI-RADSⅠ类占8.63％;TI-RADSⅡ类占18.50％;TI-RADSⅢ类占47.25％;TI-RADSⅣa类11.75％;TI-RADSⅣb类9.83％;TI-RADSⅣc类2.32％;TI-RADSⅤ类1.72％.其中,对632例TI-RADS≥Ⅳ类且有手术指征的患者行外科手术治疗取得病理结果.结果 显示,随着TI-RADS分级增加,恶性率呈上升趋势.绘制ROC曲线后,曲线下面积为0.918,证明对于TI-RADS≥Ⅳ类甲状腺结节,该分层管理诊断方法具有一定价值.结论:甲状腺超声规范化诊断及报告,为临床诊断和治疗提供客观的影像学依据,有效将甲状腺疾病患者进行分层管理,可达到合理分流、有的放矢、精准诊疗的效果.

目的 探讨超声造影对甲状腺影像分析与数据报告4类(TI-RADS 4类)结节的校对价值.方法 选择经病理诊断证实甲状腺结节患者49例(50个病灶),其中男性19例;女性30例;年龄17～73岁,平均年龄48岁.应用超声造影方法对以上50个甲状腺影像分析与数据报告(TI-RADS)分类为4类结节进行再次评估,并重新分类:以术后病理诊断为“金标准”,分析并对比超声诊断甲状腺结节良恶性价值.结果 经病理诊断,甲状腺良性42个,恶性8个.通过建立Logistic回归方程和运用受试者工作特性(ROC)曲线证实,应用超声造影重新校对TI-RADS分类后,其诊断试验正确区分该疾病为良性和恶性的概率为0.823.同时,由曲线趋势及面积可见,相比于灰阶超声TI-RADS分类及超声造影两种方法联合诊断具有更高的准确度.采用灰阶超声和超声造影联合诊断法,纳入Logistic回归模型的变量,最终模型纳入了增强模式和纵横比两个变量,这两个变量可以预测良性或者恶性,模型公式:Logit(P)=-0.685+1.361×纵横比+(-2.271)×增强模式(等增强、无增强)+1.002×增强模式(高增强).结论 应用超声造影方法校对甲状腺TI-RADS 4类结节,并将两者结合,联合诊断具有较高灵敏度的同时又具有较好的特异度,该诊断方法可以进一步有效地预测良恶性分类.

Objective To investigate the learning curve of contrast-enhanced ultrasonography ( CEUS) in sentinel lymph node( SLN ) of breast cancer and provide a theoretical basis for leaners to learn SLN CEUS . Methods The multi-center study of SLN CEUS in breast cancer" was planned by Sichuan Cancer Hospital . According to the uniform inclusion and exclusion criteria , 511 patients with complete clinical data and follow-up results from 9 hospitals in Multi-center were included in this study . According to the inspection time ,the patients were divided into 3 groups named as group A ( 170 patients) ,group B ( 170 patients) and group C ( 171 patients ) ,respectively . The basic clinical data ,ultrasound imaging data , intraoperative and postoperative pathological findings of all patients were recorded . With the accumulation of cases examined ,analysis was performed to find the learning curve of the SLN CEUS examination time , SLN CEUS detection rate ,SLN CEUS surface marking accuracy rate and SLN CEUS diagnosis rate ,the learning curve was analyzed . Results ① There was no statistical significant difference in patients ages , tumors sizes ,tumors locations ,SLNs numbers and LCs numbers among the three groups( all P > 0 .05) . ②As the number of cases examined increases ,the examination time was reduced gradually ,but SLN detection rate ,surface marking accuracy and SLN diagnostic coincidence rate were increased gradually( F = 151 .75 , 1 .96 ,7 .49 ,5 .50 ; P = 0 .000 ,0 .143 ,0 .001 ,0 .005 ) . Conclusions The skill of the doctor is improved gradually when learning SLN CEUS . With the number of the cases increase ,the operating time of SLN CEUS is shorted ,and the SLN detection rate ,surface marking accuracy and SLN diagnostic coincidence rate of SLN-CEUS are gradually increased . It has an important clinical significance for beginners to learn the SLN CEUS technology .

患者女,51岁,主因"胸壁肿物进行性增大1年余,咳嗽、咳痰1个月"入院。患者曾于2009年接受右侧甲状腺巨大肿物切除术,术后诊断为甲状腺滤泡性腺瘤。超声:左侧甲状腺明显增大,气管受压右偏,双侧甲状腺内多发实性占位,部分伴液化、钙化,符合TI-RADSⅣb类（图1A）;双侧锁骨上、腋窝、胸壁皮下多发实性占位,其中较大者伴液化,甲状腺来源不除外（图1B）。进一步行CT检查提示:（1）双侧甲状腺占位,性质待定;（2）前胸壁多发软组织密度结节,恶性可能性大;（3）双肺多发占位,考虑为转移灶;（4）腋下、双侧锁骨上淋巴结肿大。遂行超

Objective:To investigate the influencing factors of thyroid and parathyroid function,thyroid ultrasonog-raphy and calcium and phosphorusions before and after radiotherapy in breast cancer,and to explore the influencing factors of thyroid and so on.Methods:From 2015－1 to 2017－1 120 cases of stageⅡ,Ⅲ,with postoperative radio-therapy indications of female breast cancer patients were collected.Before radiotherapy,at the end of radiotherapy,af-ter radiotherapy about 1 month,6 months,12 months,24 months,all indexes were detected.Results:After the end of radiotherapy T3 and T3 of 1 month and 6 months after the end of radiotherapy were[(2.01 ± 0.33)nmol/L,(2.05 ± 0.39)nmol/L,(2.05 ± 0.27)nmol/L]respectively,with statistical significance(P＜0.05).FT4 in the 1 month af-ter the end of radiotherapy was lower than that before radiotheray ,and the difference was statistically significant [(13.63 ± 1.67)pmol/L](P＜0.05).The level of A－TPO in the 12 months after the end of radiotherapy was sig-nificantly lower than that before radiotherapy[(5.38 ± 0.73)IU/L],with statistical significance(P＜0.05).After radiotherapy,the detection of calcium decreased after 12 months phosphorus and parathyroid hormone had no signifi-cant change.The proportion of thyroid nodules and nodules near the rich blood flow after the end of radiotherapy 6 months to reduce was more obvious.Conclusion:The postoperative supraclavicular radiotherapy for breast cancer has an effect on thyroid and thyroid function,but it has a limited impact.With the extension of time,the risk of hypothy-roidism is increased.There is no significant effect on parathyroid and phosphorus ions.Calcium ion radiotherapy has a trend of decreasing after 12 months.Thyroid nodules and blood flow decreased significantly 6 months after radiotherapy.

1 病例相关情况 患者,女性,52岁,肛门不适数月,偶有便血;直肠指诊发现:距肛门6厘米10点至1点处可触及一5×3 cm肿物,质硬,触血阴性;外院肠镜提示:直肠息肉.经直肠腔内双平面超声检查显示(见图1):距肛门6~7 cm直肠肛管9点至12点方向处自黏膜层至浆膜层见一不规则低回声区,范围5.0×2.7 cm,边界欠清晰,黏膜面凹凸不平,局部区域形成一基底0.7 cm、深1.4 cm的凹陷区,内附着耦合剂回声;瘤体区肠壁层次消失,局部区域向浆膜层凸出至周围脂肪层.彩色多普勒血流显示:瘤体内部见丰富穿入的血流信号.超声提示:直肠肛管自黏膜至浆膜层实性占位性病变,局部区域突破至脂肪层,局部区域溃疡形成,直肠恶性肿瘤不排外,T3期.

目的:分析超声弹性成像对甲状腺结节(直径>1cm)的鉴别诊断.方法:随机对107个直径>1cm甲状腺结节行超声弹性成像检查,并分级,结合超声弹性成像5分法,分析其在甲状腺结节良恶性诊断中的意义.结果:甲状腺良性病变中,弹性分级以≤3级居多,但仍有少部分结节分级为4级及以上;甲状腺恶性病变弹性分级较为分散,与诊断恶性分级标准拟合度低.超声弹性成像诊断甲状腺结节(>1cm)恶性病变的灵敏度29.41%,特异度66.67%.结论:甲状腺弹性成像评分对于直径>1cm结节其敏感性较低,在诊断过程中仍需与超声灰阶图像相结合.

Objective: To explore the identified and diagnostic values of percutaneous injection ultrasound contrast on negative axillary lymph node condition hinted by routine ultrasonography of patients with breast cancer. Methods: 109 patients with breast cancer were identified by pathological demonstration and routine ultrasound examination was performed, which hinted negative axillary lymph node, development conditions after ultrasound were judged, and compared with the results of surgical pathology. Results:Percutaneous ultrasound contrast showed 78 negative cases, pathological diagnosis presented 89 positive cases, sensitivity of percutaneous ultrasound contrast was 55%, specificity was 77.53%, and accuracy was 73.39%. Conclusion: Percutaneous ultrasound contrast for negative axillary lymph node of patients with breast cancer by routine ultrasound examination can improve diagnos-tic accuracy of routine ultrasound examination, lower false negative rate.

目的:探讨常规彩色多普勒超声、超声弹性技术、超声造影技术联合应用诊断乳腺癌的临床价值.方法:回顾性分析临床疑似乳腺癌的39例住院患者常规超声、超声弹性、超声造影检查的诊断准确率及联合应用的诊断准确率、敏感性及特异性,并与病理组织学相对照.结果:依据超声弹性5分法诊断乳腺癌准确率79.49％、灵敏度85.71％、特异度63.64％、假阳性率或误诊率36.36％;阳性预测值85.71％;阴性预测值63.64％;超声造影诊断乳腺癌的准确率87.18％、灵敏度92.86％、特异度72.73％、假阳性率或误诊率27.27％;阳性预测值89.66％;阴性预测值80％.将超声弹性技术和超声造影技术联合应用诊断乳腺癌的准确率89.74％,灵敏度85.71％,特异度100.00％,假阳性率或误诊率0.00％;阳性预测值100.00％;阴性预测值73.33％.结论:超声多项技术的联合应用明显提高乳腺癌的诊断特异性,降低了假阳性率,具有很好的临床应用价值.