循证医学诊断案例分析

1、； 循证医学实践教学案例分析 2014年2月18日修訂科別: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 þ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：30cm，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

2、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。由修复科行上颌赝复体修复，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O:诊断正确率的评价检索最有用的证据(Acquire)关键词( Key word )：oral adenoid cystic carcinoma，CT or MRI数据库来源 ( Database )：PubMe

3、d Clinical Queries主要內容：Perineural spread of adenoid cystic carcinoma in the oral and maxillofacial regions: evaluation with contrast-enhanced CT and MRIObjectives: The objective of this study was to compare the accuracy of contrast-enhanced CT (CECT) and contrast-enhanced MRI (CEMRI) in the detectio

4、n of perineural spread (PNS) of adenoid cystic carcinoma (ACC) in the oral and maxillofacial regions.Methods: This study consisted of 13 ACCs from 13 patients, all of which were histopathologically diagnosed. Both CECT and CEMRI were performed in all patients before the treatment. The images of each

5、 patient were retrospectively evaluated for the detection of PNS. The definitions of PNS included abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal, and enlargement or excessive

6、contrast enhancement of a nerve.Results: 11 out of 13 cases were proven to exhibit PNS histopathologically. 8 of the 11 cases for which PNS was histopathologically proven exhibited PNS on MR images. Six of the eight cases for which PNS was exhibited on MR images also exhibited PNS on CT images. The

7、sensitivity, specificity and accuracy for the detection of PNS were 55%, 100% and 62% on CT images and 73%, 100% and 77% on MR images, respectively. Although the accuracy of PNS on MR images was slightly superior to that on CT images, there were no statistically significant differences between the d

8、etection of PNS on CT images and on MR images.Conclusions: CT and MR images are equally useful for the detection of PNS of ACC in the oral and maxillofacial regions.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 presence of PNS by the histopathological diagnosis）二、诊断对象的选择：The study sa

9、mple was derived from the population of patients who presented to Osaka University Dental Hospital, and were histopathologically diagnosed with ACC between June 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 presence of PNS by the histopathological diagnosis）的

10、阴阳性来决定的。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 Ginsbergs criteria 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（abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal,

11、 and enlargement or excessive contrast enhancement of a nerve），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病例组非病例组诊断试验CT+606诊断试验MRI+8085273251121311213四、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

12、%似然比LR，试验阳性无穷大，实验阴性45%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：采用盲法：Thesefindings were

13、 independently evaluated on the CT and MR images by two radiologists who did not know the results of the histopathological examination and then consensus readings for interpretation discrepancies 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

14、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