循证医学诊断案例分析

1、科別：口腔颌面外科住院号:38871入院日期:2014.3.6报告者姓名：职务：住院医师基地医师实习医师完成时间:2014.4.11病例摘要患者，女，31岁。因“右上腭肿块2年余，伴胀痛3个月”之主诉于2014年3月16日收 住我科。查体：患者一般情况良好，右眶下隆起，鼻道无异常分泌物，开口度：3. 0cm牙列完整无叩痛，右上腭部明显隆起，内界接近中线，后界达软腭前部，黏膜光滑无溃疡，触之中 等硬度，无明显压痛，上颌瓦氏位片示，右上颌窦内有一半球形软组织阴影。MRI与CT扫描见右上颌窦内有一半球形软组织阴影，上颌窦底骨质无规则破坏。肿块穿刺液涂片发现异形细胞， 血尿常规、生化检验无异常。初步诊

2、断右上颌骨恶性肿瘤，侵犯上颌窦。于2014年3月13日在经鼻气管插管全麻下。行右上颌骨次全切除术。手术进行顺利，术后恢复良好。术后病理报 告：腺样囊性癌。由修复科行上颌贋复体修复，恢复上颌形态及咀嚼功能，于2014年4月7日出院。提出可回答的临床问題(Asking)P：唾液腺腺样囊性癌患者I:CT或者MRI诊断C:病理诊断0:诊断正确率的评价检索最有用的证据(Acquire)关键词(Key word ): oral ade noid cystic carci noma，CT or MRI数据库来源(Database ): PubMed Clinical Queries主要內容：Per in e

3、ural spread of ade noid cystic carc inoma in the oral and maxillofacialregi ons: evaluati onwith con trast-e nhanced CT and MRIObjectives: The objective of this study was to compare the accuracy of con trast-e nhanced CT(CECT) and con trast-e nha need MRI (CEMRI) in the detection of peri neural spre

4、ad (PNS) of ade noid cystic carci noma (ACC) in the oral and maxillofacial regi ons.Methods: This study consisted of 13 ACCsfrom 13 patients,all of which were histopathologicallydiag no sed. Both CECT and CEMRI were performed in all patie nts before the treatme nt. The images of each patient were re

5、trospectivelyevaluated for the detection of PNS. The definitionsof PNSincludedabnormal density/signalintensity,contrastenhancement or widening of the pterygopalatinefossa,palati ne forame n, in cisive can al, man dibular forame n and man dibular can al, and en largeme nt or excessive con trast enhan

6、 ceme nt of a n erve.Results: 11 out of 13 cases were prove n to exhibit PNS histopathologically. 8 of the 11 casesfor which PNS was histopathologically proven exhibited PNS on MR images. Six of the eight casesfor which PNSwas exhibited on MRimages also exhibited PNSon CTimages. The sensitivity,spec

7、ificityand accuracy for the detection of PNS were 55%, 100% and 62% on CT images and 73%, 100% and 77%on MRimages, respectively. Although the accuracy of PNSon MRimages was slightly superior to that on CT images, there were no statistically sig ni fica nt differe nces betwee n the detect ion of PNS

8、on CT images and on MR images.Con clusi ons: CT and MR images are equally useful for the detect ion of PNS of ACC in the oral and maxillofacial regi ons.证据评价(Appraisal )证据等級：DWorksheet:一、标准诊断方法的确定：组织病理学检查的神经侵犯(the prese nee of PNS by the histopathological diag nosis)二、诊断对象的选择：The study sample was de

9、rived from the populatio n of patie nts who prese nted to Osaka Un iversity Den tal Hospital, and were histopathologically diag no sed with ACC betwee nJune 2000 and December 2007.此研究中病例组指的是患有腺样囊性癌有神经侵犯的病例。病例组和对照组的确定是根据标准诊断方法，即组织病理学检查的神经侵犯(the presenee ofPNS by the histopathological diag no sis)的阴阳性

10、来决定的。阳性为病例组，阴性为非病例组。1. 病例组包括该病的各种类型：神经侵犯(PNS有一个标准(the basis of Ginsberg scriteria of PNS ),包括不正常牙的密度，翼腭窝的增强，腭孔、切牙管上颌管和孔神经侵犯 性(abno rmal den sity/sig nal in ten sity, con trast enhan ceme nt or wide ning of the pterygopalat ine fossa, palat ine forame n, i ncisive can al, man dibular forame n andman

11、dibular can al, and enl argeme nt or excessive con trast enhan ceme nt of a n erve)，其多样性体现了病例组的多样性。2. 对照组是未表现为神经侵犯的病例，由于此研究重点对CT和MRI的诊断比较，没有包括易与该病混淆的其他病例。CT和MRI相互对比。三、列出评价诊断试验的四格表：标准诊断病例组非病例组诊断试验CT+60652711213四、计算各项诊断试验的评价指标：1. CT灵敏度(真阳性率)55%漏诊率(假阴性率)45% 特异性(真阴性率)100%误诊率(假阳性率)0% 预测值，阳性100%阴性29%似然比LR

12、,试验阳性无穷大，实验阴性 45%病例组非病例组诊断试 验MRI+80832511213神经侵犯疾病概率85%神经侵犯疾病比率550%验前比550%验后比，阳性无穷大，阴性 278%验后概率，阳性27%阴性74%2. MRI灵敏度（真阳性率）73%漏诊率（假阴性率）27%特异性（真阴性率）100%误诊率（假阳性率）0%预测值，阳性100%阴性40%似然比LR,试验阳性无穷大，实验阴性 72%神经侵犯疾病概率85%神经侵犯疾病比率550%验前比550%验后比，阳性无穷大，阴性 396%验后概率，阳性20%阴性80%3. 处理综合实验结果阴性验后比=178%五、诊断试验的评估：1. 真实性：采用盲

13、法： Thesefi ndings were in depe nden tly evaluated on the CT and MR images by two radiologists who did not know the results of the histopathological exam in ati on and the n consen sus readi ngs for in terpretati on discrepa ncies was performed.诊断试验包含适当的病谱诊断试验的检测结果不会影响参考标准的运用存在相同真实性由于样本量不够大，对于其数值的真实性

14、存在质疑2. 重要性：特异性较强，能够诊断疾病，但是敏感性不够没有进行分层似然比3. 实用性由于样本量不够大，对于其数值的可能存在偏倚但是实用性必须得到重视。由于腺样囊性癌具有极强的神经侵犯性，其相较于其他唾液腺肿瘤比较保守的方法，手术范围 必须扩大，并且果断牺牲各种神经。所以术前诊断室非常重要的，有利于手术方案的确定。 可以在本单位开展，因为 CT和MRI的运用。验前概率估计该病发生神经侵犯的概率，可以作为估算验后概率得到相对可靠的神经侵犯的概率，为手术方案的确定作指导。证据解读及证据应用（Apply ）由于腺样囊性癌具有极强的神经侵犯性，其相较于其他唾液腺肿瘤比较保守的方法，手术范围 必须扩大，并且果断牺牲各种神经。所以术前诊断室非常重要的，有利于手术方案的确定。病 人在追求治愈疾病的同时，也注重术后的生活质量。基于可能牺牲神经，导致病人许多感觉运 动功能丧失，例如面瘫等严重影响其生存治疗。病人的志愿更希望术前有明确的诊断防止过多 的切除组织，不管是诊断有无此神经侵犯，还是诊断神经侵犯的范围。同时也让患者有自信心