子宫肌瘤栓塞前后mr临床表现课件

子宫肌瘤栓塞前后MR表现,医学百事通转载,临床意义 Leiomyomas, also known as fibroids or myomas, are the most common gynecologic neoplasm, occurring in 20%30% of women of reproductive age.子宫肌瘤是妇产科最常见的肿瘤，生育期女性发病率约20%-30%。 It has been reported that up to 80% of women with leiomyomas are asymptomatic and require no treatment. By other accounts, 20%50% of women with leiomyomas present with symptoms such as menorrhagia, dysmenorrhea, pressure, urinary frequency, pelvic and back pain, dyspareunia, constipation, or obstipation. 子宫肌瘤患者多无症状，无需治疗。但部分可表现为月经过多，痛经，尿频，臀背部疼痛，性交困难，便秘。 Hysterectomy and myomectomy are the traditional surgical treatments for symptomatic leiomyomas. For well over a decade, uterine fibroid embolization (UFE) has been a popular and effective minimally invasive treatment for symptomatic fibroids. 子宫切除和肌瘤切除术是子宫肌瘤的传统治疗方法。子宫肌瘤栓塞术（UFE）是一种新兴、有效的微创治疗方式，用于治疗有症状的肌瘤患者。 Magnetic resonance (MR) imaging is the most accurate imaging modality for detection and localization of leiomyomas. 磁共振能清楚显示肌瘤特征，是首选的检查方法。 Preprocedure MR imaging is the diagnostic tool of choice for determining patient eligibility for UFE and for assessing potential procedural risk . Furthermore, MR imaging is also a useful tool for determining treatment outcome and for diagnosing potential complications after UFE. MR可在术前评价患者是否适合做栓塞，也可于术后评价疗效和发现并发症。,Histopathologic Features病理 Uterine leiomyomas are benign neoplasms composed of whorled fascicles of smooth muscle and fibrous connective tissue anchored in the muscular wall of the uterus. Although there is no true capsule, these tumors are well circumscribed and surrounded by a pseudocapsule.子宫肌瘤由旋涡状平滑肌束和纤维结缔组织组成。有假包膜。 As leiomyomas enlarge, they may outgrow their blood supply. The type of degenerative change depends on the degree and rapidity of the onset of vascular insufficiency. The result is various types of degeneration: hyaline or myxoid degeneration, calcification, cystic degeneration, red (hemorrhagic) degeneration, or fatty degeneration. In most patients, findings of degeneration are rarely related to the clinical symptoms; however, acute degeneration may be associated with pelvic pain or abnormal uterine bleeding. 肌瘤增大快于血管生长时会发生变性。变性类型：透明或黏液样变性，钙化，囊变，红色（出血样）变性，脂肪变性。对大多数病人，变性与临床症状无关。但急性变性可导致疼痛和异常子宫出血。,Classification分型 Submucosal leiomyomas粘膜下肌瘤 Although submucosal leiomyomas are the least common, representing only approximately 5% of uterine leiomyomas, they are commonly associated with dysmenorrhea, menorrhagia, or infertility. 粘膜下肌瘤最少见，但最容易引起症状，如痛经、月经过多和不孕。 Intramural leiomyomas肌壁间肌瘤 Intramural leiomyomas, which are the most common, are usually asymptomatic.However, they can occasionally be associated with menorrhagia and infertility. 肌壁间肌瘤最常见，但常无症状。少数可致月经过多和不孕。 Subserosal leiomyomas浆膜下肌瘤 Subserosal leiomyomas are usually asymptomatic; however, pedunculated subserosal leiomyomas may undergo torsion, resulting in infarction accompanied by pain. Rarely, a pedunculated leiomyoma may become attached to an adjacent structure, from which it may derive a new blood supply, and become detached from the uterus (parasitic leiomyoma) . 浆膜下肌瘤常无症状。但有蒂的肌瘤可发生扭转，导致梗死及疼痛。一种少见情况是浆膜下肌瘤附着于临近组织器官，获得新的血供，最终从子宫分离（寄生性子宫肌瘤）。,Symptoms症状 Bleeding.The most frequent symptom of leiomyomas is abnormal uterine bleeding. The bleeding pattern most characteristic of leiomyomas is menorrhagia or menometrorrhagia, excessively heavy or prolonged menstruation. The heavy bleeding can cause medical problems, particularly iron-deficiency anemia. Submucosal leiomyomas are often associated with ulceration of the overlying endometrium and are most likely to cause menorrhagia. 出血：子宫肌瘤最常见的症状是不规则阴道流血。最常表现为月经过多，进而导致缺铁性贫血。粘膜下肌瘤因其可损伤子宫内膜、致内膜溃疡，最可能导致月经过多。 Pressure on Adjacent Organs and Pain.As leiomyomas enlarge, they may produce pressure on surrounding structures. Specific symptoms can arise from leiomyomas in particular locations. Urinary symptoms can arise from anterior leiomyomas and constipation from those that are posterior. Broad ligament leiomyomas may compress the ureter along the pelvic wall, resulting in hydroureter or hydronephrosis. 压迫临近器官和疼痛：前壁肌瘤可致排尿异常，后壁肌瘤可致便秘，阔韧带肌瘤压迫输尿管，导致积水。 There is acute pain in the rare cases in which degeneration occurs or there is torsion of a pe- dunculated leiomyoma. Pain occurs in approximately 30% of women with uterine leiomyomas and is usually the result of acute degeneration. Red degeneration, which is most commonly observed during pregnancy, results from hemorrhagic infarction of a leiomyoma. Such degeneration may result in systemic symptoms, such as abdominal pain, low-grade fever, and leukocytosis. 急性疼痛主要原因是肌瘤变性（30%）和扭转。红色变性是由于血管栓塞所致，最常见于妊娠期，除腹痛外，还可有全身症状（腹痛，低热，白细胞升高）。 Reproductive Dysfunction.Leiomyomas are an infrequent primary cause of infertility. Infertility may be caused by compromise of the patency of the fallopian tube, irritation of the endometrium preventing implantation, or distortion of the endometrial cavity. Tubal obstruction may be caused by intramural leiomyomas located in the cornual regions of the uterus and obstructing the interstitial portions of the tube, or the tube may be obstructed because of extrinsic compression by leiomyomas located in the broad ligament. 子宫肌瘤是导致不孕的少见原因。位于宫角或阔韧带的肌瘤可压迫输卵管。,MR Imaging Appearance of Leiomyoma子宫肌瘤MR表现 Nondegenerated uterine leiomyomas have a typical appearance at MR imaging: well-circumscribed masses with homogeneously decreased T2-weighted signal intensity compared with that of the outer myometrium, and demonstrate homogeneous enhancement on contrast-enhanced images 未变性肌瘤表现为边界清楚的肿块，T2呈均匀低信号（与外肌层相比），明显均匀强化。 Degenerated leiomyomas have variable appearances on T1-weighted, T2-weighted, and contrast-enhanced images. Low T2-weighted signal intensity is seen in leiomyomas with hyaline or calcific degeneration, an appearance similar to that of standard leiomyomas. Conversely, high T2-weighted signal intensity is seen in leiomyomas with cystic degeneration, and the cystic areas do not enhance. Extremely high T2-weighted signal intensity and minimal contrast enhancement are seen in leiomyomas with myxoid degeneration. Variable T1-weighted signal intensity and low T2-weighted signal intensity are seen in necrotic leiomyomas that have not liquefied (ie, those with hyaline or coagulative necrosis) .变性的肌瘤表现各异。玻璃样变性和钙化T2信号减低， 信号可与未变性肌瘤相近。肌瘤囊变T2高信号，无强化。粘液样变性T2信号极高而无明显强化。T2低信号而T1信号各异见于还未液化的坏死组织（玻璃样变性，凝固性坏死）。 Red degeneration (hemorrhagic necrosis) can have an unusual appearance at MR imaging: peripheral or diffuse high signal intensity on T1-weighted images and variable signal intensity with or without low signal intensity on T2-weighted images.In red degeneration, methemoglobin or the proteinaceous content of blood results in increased T1-weighted signal intensity. When high signal intensity is isolated to the rim of the leiomyoma, it has been hypothesized that the blood products are confined to thrombosed vessels that surround the tumor. 红色变性表现特殊：T1边缘性或弥漫性高信号，高信号来自高铁血红蛋白和蛋白成分，肿块周边高信号环被认为是肌瘤周边血管血栓形成所致。T2信号各异。 Cellular leiomyomas, which are composed of compact smooth muscles cells with little or no collagen, can have relatively increased T2-weighted signal intensity and demonstrate homogeneous enhancement on contrast-enhanced images. 富细胞性肌瘤（平滑肌细胞排列致密，含胶原少）T2信号增高，但强化均匀。 Some leiomyomas have a high-signal-intensity rim on T2-weighted images, which represents a pseudocapsule of dilated lymphatic vessels, dilated veins, or edema and corresponds to peritumoral rim enhancement. 某些肌瘤有T2高信号环包绕，代表由扩张淋巴管、静脉、水肿组成的假包膜。,Degenerated submucosal leiomyoma in a 46-year-old woman. Axial (a), coronal (b), oblique coronal (c), and sagittal (d) T2-weighted images show a degenerated leiomyoma (SM) that is located below the mucosal surface and protrudes into the endometrial cavity (arrows). Also note the nondegenerated submucosal leiomyoma (L) in b. 变性的粘膜下肌瘤（SM），T2信号不均，突入宫腔（箭） 未变性的粘膜下肌瘤（L），T2均匀低信号,Multiple intramural leiomyomas in a 50-year-old woman. Axial (a) and sagittal (b) T2- weighted images show multiple intramural (IM) and submucosal (SM) leiomyomas with decreased signal intensity. 未变性的肌瘤 肌壁间肌瘤（IM）和粘膜下肌瘤（SM），T2低信号,Subserosal leiomyoma. Axial T2-weighted.Myometrial claws (arrows) are noted at the base of the leiomyoma. 浆膜下肌瘤（L） T2低信号，子宫肌层呈“爪”样包绕肌瘤（箭）。,Pedunculated leiomyoma. Axial (a) and sagittal (b) T2-weighted and contrast-enhanced fat-suppressed T1-weighted GRE (c) images show a pedunculated subserosal leiomyoma (P) of the posterior uterine fundus. The leiomyoma is attached by a short stalk (arrow).,有蒂的浆膜下肌瘤 宫底后壁未变性浆膜下肌瘤（P），有蒂（箭）与肌层相连。T2低信号，明显均匀强化。,Broad ligament leiomyoma in a 43-year-old woman. Coronal T2-weighted image shows a surgically proved leiomyoma (arrows) of the broad ligament. Although it is difficult to separate the leiomyoma from the uterus, it appears to be centered in the left broad ligament. Differential diagnostic considerations included an exophytic leiomyoma and a broad ligament leiomyoma. 阔韧带肌瘤（箭）,Leiomyomas in a 43-year-old woman being evaluated for UFE. (a, b) Transverse (a) and sagittal (b) transabdominal pelvic US images show a heterogeneously enlarged myomatous uterus. The margins of the leiomyomas (L) are not well visualized. (c, d) Axial (c) and sagittal (d) T2-weighted images show multiple intramural leiomyomas (L), as well as an exophytic subserosal leiomyoma (S in d) arising from the fundus. The sub- serosal leiomyoma was not identified at US secondary to the limited field of view. The endometrial canal (arrow in c) can be seen sandwiched between two of the intramural leiomyomas. MR显示肌瘤优于超声 超声（ab）显示两个肌瘤（L），边界不清。 MR（cd）显示两个肌壁间肌瘤（L）和一个外生性浆膜下肌瘤（S），边界清晰，宫腔受压（c箭）。,Pathologically proved cellular leiomyoma in a 35-year-old woman. (a) Axial T2- weighted image shows a large heterogeneous uterine mass with areas of increased signal intensity. (b) Axial contrast-enhanced fat-suppressed T1-weighted GRE image shows predominantly homogeneous enhancement of the mass. 富细胞性肌瘤T2信号增高（a），强化均匀（b）。,Cellular leiomyoma in a 42-year-old woman being evaluated for UFE. (ac) Sagittal (a) and axial (b) T2-weighted and sagittal contrast-enhanced fat-suppressed T1-weighted GRE (c) images show a large, enhancing, exophytic uterine mass (M in a and b) with extensive collateral vessels (arrows in b). Also note the nonviable uterine leiomyoma (L in a and c).,富细胞性肌瘤（M）T2信号增高，强化均匀。侧枝血管（b箭）。无活性肿瘤（L）无强化。,医学百事通,Leiomyomas with hyaline degeneration. Sagittal T2-weighted image shows two intramural leiomyomas with decreased signal intensity, a finding consistent with hyaline degeneration. 肌瘤玻璃样变 肌壁间肌瘤玻璃样变，T2信号减低。,Leiomyoma with cystic degeneration. Sagittal T2-weighted (a) and contrast-enhanced fat-suppressed T1-weighted GRE (b) images show an intracavitary leiomyoma that has undergone cystic degeneration. Note that the area of cystic degeneration (C) does not enhance after intravenous administration of gadolinium contrast material. The enlarged uterus causes mass effect on the urinary bladder (B). 肌瘤囊变 宫腔内肌瘤囊变（c）T2高信号，增强扫描无强化。,Leiomyoma with red degeneration in a 32-year-old pregnant woman. (a, b) Axial (a) and sagittal (b) T2-weighted images show variable low signal intensity in a large leiomyoma (L) of the posterior lower uterine segment. Note the distortion and lengthening of the lower uterine segment and cervix (arrows in b) caused by the large leiomyoma. (c, d) Axial nonenhanced (c) and sagittal contrast-enhanced (d) fat-suppressed T1-weighted GRE images of the degenerated leiomyoma (L) show peripheral increased signal intensity (arrowheads) and a lack of contrast enhancement.,肌瘤红色变性 子宫后下壁肌瘤（L），致宫体下部及宫颈受压伸长（b箭）。肌瘤T1边缘性高信号（cd白箭头），未见明显强化。,Differential Diagnosis鉴别诊断 Adenomyosis子宫内膜异位症 Ectopic endometrial glands and stroma within the myometrium with reactive hypertrophy of the surrounding myometrial smooth muscle characterize adenomyosis. 子宫内膜腺体和基质异位致子宫肌层，致周围平滑肌肥大。 Adenomyosis occurs in focal and diffuse forms, the latter being the more common appearance. 子宫内膜异位症分为局限型和弥漫型。后者更常见。 At MR imaging, the diffuse form of adenomyosis appears as a thickened junctional zone (inner myometrium) on T2-weighted images. A junctional zone 12 mm thick or thicker is highly predictive of adenomyosis. The low signal intensity of adenomyosis on T2-weighted images is due to the reactive, dense smooth muscle hypertrophy that surrounds the imbedded endometrial glands. Small foci of high signal intensity on T2-weighted images represent the ectopic endometrial glands. Some of these ectopic endometrial glands also have corresponding high signal intensity on T1-weighted images, a finding that corresponds to hemorrhage. 弥漫型子宫内膜异位症MR表现为结合带（内肌层）增厚，12mm。因平滑肌肥大致T2低信号。结合带低信号中斑点状高信号代表内膜腺体。 In its focal form, adenomyosis appears as an ill-defined, poorly marginated area of low signal intensity within the myometrium on T2-weighted images, whereas leiomyomas often appear as well-circumscribed masses. 局限型子宫内膜异位症表现为肌层内边界不清的T2低信号灶。而子宫肌瘤边界清晰。 Similar treatment options for adenomyosis and leiomyomas have differing success rates, emphasizing the importance of distinction at preprocedure imaging. MR imaging allows easy differentiation between adenomyosis and leiomyomas. It is important to note that these conditions can coexist. MR较易区分子宫内膜异位症和子宫肌瘤，两者治疗相似，但预后不同。两者可同时存在。,弥漫性子宫内膜异位症 结合带增厚，T2低信号，其内斑点状高信号代表内膜腺体（a箭头），T1高信号结节代表内膜腺体内出血。,医学百事通，在线医生咨询,局灶性子宫内膜异位症 宫体厚壁结合带局限性增厚（A），边界不清，T2低信号，其内斑点状高信号代表内膜腺体（ab箭头），T1高信号结节代表内膜腺体内出血（d箭头）。,子宫内膜异位症和子宫肌瘤共存 子宫内膜异位症（a中A）。肌瘤（L），带蒂肌瘤（P，蒂-箭）,Solid Adnexal Mass附件实性肿块 Adnexal masses and pedunculated leiomyomas can be detected and characterized with MR imaging. If MR imaging can demonstrate continuity of an adnexal mass with the myometrium, even if only by the presence of bridging vessels, then a diagnosis of leiomyoma can be established. 附件实性肿块需与带蒂的肌瘤鉴别。如果发现附件区肿块与子宫肌层相连（哪怕只是靠血管相连），即可将其诊断为子宫肌瘤。 Ovarian fibromas and Brenner tumors are benign ovarian neoplasms that have a large fibrous component and can have signal intensity similar to that of a pedunculated leiomyoma. MR imaging can show fibromas and Brenner tumors surrounded by ovarian stroma and follicles, thus establishing the ovarian origin of the mass and allowing exclusion of a diagnosis of leiomyoma . 卵巢纤维瘤和Brenner瘤是卵巢的良性肿瘤，内含大量纤维成分，可类似子宫肌瘤。但这些肿瘤位于卵巢内，周围环绕卵泡和基质。 Differentiation between leiomyomas and ovarian adnexal masses is particularly important in pregnant patients because confident diagnosis of a leiomyoma may eliminate the need for surgery during pregnancy. 对怀孕妇女来说，附件肿瘤可能需要手术切除，而子宫肌瘤则可能暂时不需要手术。 Focal Myometrial Contraction子宫局限性收缩 Uterine contractions can appear as transient hypointense T2-weighted masses and may simulate leiomyomas or focal adenomyosis at MR imaging. Because the contractions are transient, resolution of the mass at subsequent imaging allows the diagnosis to be established. 子宫局限性收缩可表现为T2低信号肿块，因为子宫收缩是暂时的，所以过一段时间扫描可见肿块消失。 Uterine Leiomyosarcoma子宫平滑肌肉瘤 Leiomyosarcomas may arise from the connective tissue of uterine blood vessels, in a preexisting leiomyoma, or de novo from uterine musculature. The prevalence of sarcomatous change in benign uterine leiomyomas is reported to be 0.1%0.8%. 子宫平滑肌肉瘤起源于子宫血管间质、已存在的肌瘤和子宫肌肉组织。约 0.1%0.8%子宫肌瘤恶变成肉瘤。 Leiomyosarcoma usually manifests as massive uterine enlargement with irregular central zones of extensive hemorrhage and necrosis. Foci of calcification may be present. It has been suggested that an irregular margin of a uterine leiomyoma at MR imaging is suggestive of sarcomatous transformation, but the specificity of this finding has not been established. 子宫明显增大，肿块边界不清，内见出血和坏死，可见钙化。,浆膜下肌瘤（L） 与子宫间有血管相连（箭），可与附件实性肿块鉴别,卵巢纤维瘤 纤维瘤（箭）旁见卵泡（箭头），可判断其在卵巢内。,子宫局限性收缩 表现为T2低信号肿块（a箭），过一段时间扫描可见肿块消失（b）。,子宫平滑肌肉瘤 子宫明显增大，肿块（LMS）边界不清，内见坏死（b箭）,Treatment Options for Leiomyomas治疗方法 Surgical Treatments手术 Hysterectomy子宫切除术 The surgery can be performed via the vaginal or abdominal route. In selected cases, the uterus can be removed with a laparoscopic approach. 手术可经腹或经阴道做，部分病人可行腹腔镜子宫切除术。 Myomectomy肌瘤切除术. Myomectomy is indicated in women with a history of second-trimester fetal loss, anemia secondary to hypermenorrhea, or pelvic pain.The risk of recurrence after myomectomy has been estimated to be 27% after 10 years. 肌瘤切除术适用于有孕中期胎儿流产史、月经过多继发贫血及腹痛的病人。切除后肌瘤10年内复发率约27%。,Nonsurgical Treatments非手术治疗 Gonadotropin-releasing Hormone Analogs促性腺激素释放激素类似物 Gonadotropin-releasing hormone agonists are often used as preoperative adjunctive therapy to surgery. They cause down-regulation of estrogen receptors, which decreases growth of leiomyomas. However, after cessation of treatment, there is rapid regrowth of the tumor. 促性腺激素释放激素类似物治疗常于术前应用，可下调雌激素受体水平，抑制肌瘤生长。但停药后肌瘤会迅速长大。 Uterine Fibroid Embolization（UFE）子宫肌瘤栓塞术 UFE is a popular and effective method of treating symptomatic leiomyomas. The procedure involves delivery of embolic particles via the uterine arteries to occlude end-arterioles that perfuse the leiomyomas, thus causing necrosis of the leiomyomas. Symptom relief as well as a decrease in the size of the leiomyomas and the uterus overall occur in a majority of patients. UFE通过子宫动脉注入颗粒，栓塞肌瘤血管，致肌瘤坏死。术后多数患者症状减轻，肿瘤体积缩小。 MR Imagingguided Focused Ultrasound MR介导的超声聚焦治疗 It is intended for premenopausal women who have completed childbearing. Other than medical management, this is the only completely noninvasive treatment option available. The therapy is extremely accurate, as real-time MR imaging is performed during the procedure to map out and confirm that the ultrasound waves are targeting the leiomyoma precisely. Because this is a new technique, long-term outcomes have not been studied. 用于绝经前妇女，超声聚焦治疗可精确彻底地切除肿瘤。,MR Imaging Findings Pertinent to Success of UFE ，MR筛选适合子宫肌瘤栓塞的患者 Pedunculated Leiomyomas.带蒂肌瘤 Initially, it was believed that a pedunculated leiomyoma in a subserosal location was a relative contraindication to UFE because of the risk of separation from the uterus. That is, the potential for stalk necrosis and detachment of the leiomyoma could lead to peritonitis, persistent pain, or infection. However, it has been shown that for pedunculated subserosal leiom