超声造影在肾占位血流动力学中的基础和临床研究
摘要
第一部分超声造影在肾占位血流动力学中的基础研究
第一章超声引导建立VX2兔肾肿瘤模型及可行性研究
目的探讨超声引导经皮穿刺建立兔肾移植肿瘤模型的方法。方法25只新西兰白兔,在B超引导下经皮穿刺兔双侧肾脏,分别注入肿瘤组织块,术后超声随访观察肿瘤的生长情况。结果25只兔中22只穿刺成功,穿刺成功率88.0%(22/25)。22只兔共40个肾脏进行了穿刺接种,其中20只兔的35个肾脏有肿瘤发生,肿瘤种植成功率87.5%(35/40)。穿刺术后两周肿瘤生长平均直径大于11.8mm,易于超声观察。结论超声引导经皮穿刺建立兔双肾肿瘤模型适合于动物实验研究模型的建立和超声观察。
第二章VX2兔肾肿瘤的超声造影表现及检出率的研究
目的探讨高频超声造影在检测VX2兔肾肿瘤中的意义。方法10只新西兰白兔,在超声引导下接种VX2肿瘤,分别进行常规超声检查及高频超声造影。仪器选用百胜DU6增强型,具有实时谐波超声造影技术。造影剂选用SonoVue,观察肿瘤的增强表现,比较造影前后检出的肿瘤数,并与病理对照。结果10只兔肾接种成功,病理大体标本共发现24个肿瘤(包括播散灶),超声造影前发现11个,造影后发现21个,检出最小肿瘤为5mm,检出率分别为45.8%(11/24)和87.5%(21/24)(P=0.006)。超声造影显示兔肾肿瘤的典型表现为同步或缓慢增强,但增强强度较肾实质低且多呈不均匀,很快消退呈低回声改变。病理显示兔肾肿瘤超声造影增强的区域均为肿瘤存活区,而未增强区域均为坏死组织。结论高频超声造影能很好地反映VX2兔肾肿瘤血供和坏死情况,对提高肾肿瘤检出率有很大意义。
第二部分超声造影在肾占位血流动力学中的临床研究
第一章肾占位的超声造影表现
目的探讨超声造影在肾脏占位诊断中的价值。方法2004年6月至2010年2月超声检查432个肾占位,均经手术及病理证实。每个肿块均行常规超声和超声造影检查,其中恶性肿瘤共346个病灶,良性肿块共86个病灶。先行常规超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。结果造影时恶性组增强率高于良性组(P=0.000)。良恶性肾占位的造影时相之间的差异无统计学意义(P>0.05)。恶性组以同步增强为主,良性组以缓慢增强居多,两组在增强表现上的差异有显著的统计学意义(P=0.000)。恶性组以快速减退居多,良性组以同步或缓慢减退居多,两组在减退表现上的差异有显著的统计学意义(P=0.000)。恶性组超声造影达峰时不均匀居多,良性组超声造影达峰时均匀居多,两组差异有显著的统计学意义(P=0.000)。超声造影达峰时恶性组以高回声居多,良性组以等回声居多,两组差异有显著的统计学意义(P=0.006)。实质期恶性组见假包膜19.4%(67/346),良性组见假包膜3.5%(3/86),两组差异有显著的统计学意义(P=0.000)。结论超声造影通过显示肾脏占位的增强表现和均匀度,有助于诊断和鉴别诊断良恶性占位。
第二章常规超声与超声造影在肾占位血流检测中的对比研究
目的比较彩色多普勒超声和超声造影显示肾占位血供的能力。方法2004年6月至2010年2月超声检查432个肾占位,均经手术及病理证实。每个肿块均行彩色多普勒超声和超声造影检查,其中恶性肿瘤共346个病灶,良性肿块共86个病灶。先行彩色多普勒超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,肾占位血管按其多寡分为0-Ⅳ级。超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。结果彩色多普勒超声的恶性组血流显示率高于良性组(P=0.000),其动脉血流信号显示率也高于良性组(P=0.000)。恶性组以Ⅲ～Ⅳ级为主,而良性组以0级或Ⅲ级为主,两组血流信号分级表现的差异有显著的统计学意义(P=0.000)。无论肾占位血流信号的总显示率还是对于恶性肾占位或良性肾占位的血流信号显示率,超声造影均高于彩色多普勒超声(P<0.05)。结论超声造影充分反映病灶内部的血供,提高血流的检出率,优于彩色多普勒超声。
第三章常规超声与超声造影检测肾脏占位均匀度的对比研究
目的比较常规超声和超声造影反映肾占位内部结构的能力。方法2004年6月至2010年2月超声检查432个肾占位,均经手术及病理证实。每个肿块均行彩色多普勒超声和超声造影检查,其中恶性肿瘤共346个病灶,良性肿块共86个病灶。先行彩色多普勒超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。。肾占位的大小按其最大径线的超声测值以1 cm间隔分为Ⅰ～Ⅵ级。结果彩色多普勒超声显示恶性组中囊实性占位的比例高于良性组,而恶性组囊性占比却低于良性组,两组病灶内部的回声表现差异有显著的统计学意义(P=0.000)。恶性组中73.4%(254/346)超声造影达峰值时显示为部分不增强区或增强不均匀、分隔样增强或蜂窝状结构；良性组中33.7%(29/86)超声造影达峰值显示为部分不增强区或不均匀增强、分隔样增强或蜂窝状结构,两组差异有显著的统计学意义(P=0.000)。除Ⅰ级病灶外,良性组超声造影后内部回声均匀的病灶百分率明显高于恶性组(P=0.000)。恶性组超声造影后内部回声均匀的病灶百分率与病灶大小呈负相关(P=0.000)。结论超声造影能充分反映肾占位的内部结构,优于彩色多普勒超声。
第四章超声造影对提高小肾癌诊断率的价值
目的探讨超声造影在小肾癌诊断中的应用价值。方法2004年6月至2010年1月常规超声和超声造影检查最大直径测值≤3 cm的小肾癌共120个肿瘤,均经手术及病理证实。常规超声显示低回声肿瘤、高回声瘤周环状无回声、高回声瘤内无回声或低回声,作为诊断小肾癌标准；按超声造影皮质期不同增强方式分为2组,造影时肿瘤同步增强并达峰值呈高回声或等回声、缓慢增强并达峰值呈低回声,作为诊断小肾癌标准。结果常规超声显示低回声肿块21个,高回声瘤周环状无回声14个,高回声瘤内无回声或低回声31个,常规超声的诊断阳性率为53.3%(64/120,重叠按1个计算)。造影皮质期不同增强方式两组达峰时内部回声差异有显著的统计学意义(P=0.000),两组实质期造影表现差异有统计学意义(P=0.021),但达峰值内部回声均匀病灶的百分率和假包膜出现率的差异没有统计学意义(P＞O.05)。造影时肿瘤同步增强并达峰值高回声或等回声103个,缓慢增强并达峰值低回声7个,超声造影的诊断阳性率为91.7%(110/120)。结论超声造影诊断小肾癌的诊断阳性率高于常规超声。
第五章超声造影在肾细胞癌亚型鉴别诊断中的价值
目的探讨超声造影在肾细胞癌亚型鉴别诊断中的应用价值。方法2004年6月至2010年2月常规超声和超声造影检查肾细胞癌346个,均经手术及病理证实。先行常规超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。结果经手术和病理证实304个为透明细胞肾癌,23个为乳头状肾癌,19个为嫌色细胞肾癌。不同亚型肾细胞癌常规超声的表现没有明显差异。不同亚型肾细胞癌的增强时相没有显著性差异(P>0.05)。乳头状肾癌与透明细胞肾癌比较,两组病灶皮质期的表现差异有显著的统计学意义(P=0.000),两组病灶达峰值回声表现差异有显著的统计学意义(P=0.000),两组病灶实质期表现差异有显著的统计学意义(P=0.000)；嫌色细胞肾癌与透明细胞肾癌比较,两组病灶皮质期表现差异有显著的统计学意义(P=0.000),两组病灶达峰值病灶回声表现差异有显著的统计学意义(P=0.000),两组病灶实质期表现差异有显著的统计学意义(P=0.001)。结论超声造影使鉴别肾细胞癌亚型成为可能。
第六章超声造影诊断良恶性囊性肾占位的价值探讨
目的探讨超声造影诊断良恶性囊性肾占位的价值。方法2004年6月至2010年2月常规超声和超声造影检查良恶性囊性肾占位共103个,均经手术及病理证实。参照Bosniak CT分级标准,造影前后按照囊性肾占位的囊壁、分隔数目、钙化及囊内结节、血流信号及增强等特征进行分级。结果良恶性囊性肾占位造影时相比较差异没有统计学意义(P>0.05)。两组囊性肾占位均以同步增强为主。良性病灶达峰值时增强程度以等于肾皮质多见,而恶性肿瘤增强程度有等回声、高回声及低回声,两组达峰值表现差异有显著的统计学意义(P=0.002)。恶性组达峰值均匀增强的病灶占1.4%(1/69),良性组占26.1%(6/23),恶性组明显低于良性组(P=0.001)。恶性组实质期29.0%(20/69)病灶有假包膜,良性组均未见假包膜,两组间差异有显著的统计学意义(P=0.004)。常规超声对恶性囊性肾占位的诊断敏感性为55.1%(38/69),特异性为85.3%(29/34),准确性为65.0%(67/103),阳性预测值为88.4%(38/43),阴性预测值为48.3%(29/60),阳性似然比为3.7。超声造影对恶性囊性肾占位的诊断敏感性为69.6%(48/69)、特异性为97.1%(33/34),准确性为78.6%(81/103),阳性预测值为98.0%(48/49),阴性预测值为61.1%(33/54),阳性似然比为23.7。结论超声造影对良恶性囊性肾占位的诊断优于常规超声。
第七章超声造影对提高肾错构瘤诊断率的价值
目的探讨超声造影在提高肾错构瘤诊断准确率中的价值。方法2004年8月至2009年11月常规超声和超声造影检查肾错构瘤52个,均经手术及病理证实。先行常规超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,然后根据肿瘤高低回声不同分成两组,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。造影时缓慢向心增强和达峰值均匀等回声或高回声作为诊断肾错构瘤的特征。结果术前常规超声诊断肾错构瘤灵敏度为65.4%(34/52)。超声造影皮质期42个病灶见缓慢增强,达峰值呈等回声或高回声并均匀增强40个。高低回声肾错构瘤超声造影时相比较差异没有统计学意义(P>0.05)。两组肾错构瘤的超声造影皮质期和实质期的表现差异没有统计学意义(P=1.000,P=0.162),达峰值表现差异有显著的统计学意义(P=0.009)。两组错构瘤超声造影达峰值时均匀病灶百分率和实质期包膜出现率差异没有统计学意义(P=0.545,P=0.083)。超声造影诊断。肾错构瘤的灵敏度为76.9%(40/52)。结论超声造影能反映肾错构瘤的血流灌注特点,对提高诊断准确性有较大的帮助。
第八章超声造影提高疑难肾肿瘤检出率的研究
目的探讨超声造影提高疑难肾肿瘤检出率的临床价值。方法2004年10月至2010年1月常规超声显示困难的36个肾肿瘤行超声造影检查,均经手术及病理证实。先行彩色多普勒超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。建立肾肿瘤造影前后病灶明显性评分标准并计算。结果常规超声显示27个肿瘤边界欠清或不清,内部等回声18个,19个显示内部或周边血流信号,余无明显彩色血流信号。疑难肾肿瘤超声造影后在病灶的边界、内部回声和血供明显性方面大有改善,造影前后差异有显著的统计学意义(P<0.05)。造影后疑难肾肿瘤病灶的明显性积分高于造影前(P=0.000)。结论超声造影能显著提高疑难肾肿瘤病灶的检出率,优于常规超声。
第九章超声造影和增强CT在肾占位诊断中的对比研究
目的比较超声造影和增强CT两者诊断肾占位的价值。方法2007年3月至2010年2月超声造影及增强CT检查281个肾占位,均经手术及病理证实。将超声造影的表现与增强CT的表现进行分析与比较,并以病理诊断作为金标准,将两者在肾占位中的诊断价值相关指标进行统计分析与比较。结果本组恶性肾占位超声造影峰值期表现为不均匀的病灶所占百分比和增强CT的差异没有统计学意义(P=0.605)。恶性肾占位超声造影诊断的敏感性97.3%(218/224),特异性70.2%(40/57),阳性预测值92.8%(218/235),阴性预测值87.0%(40/46),准确率为91.8%(258/281)；增强CT诊断的敏感性87.9%(197/224),特异性64.9%(37/57),阳性预测值90.8%(197/217),阴性预测值57.8%(37/64),准确率为83.3%(234/281)。结论超声造影诊断肾肿瘤的准确率略优于增强CT。
Part One:The basic research of hemodynamics in renal lesions with contrast-enhanced ultrasonography
Chapter One
Ultrasound-guided implantation of VX2 renal tumors in rabbits and its feasibility study
Objective To evaluate the feasibility of establishing VX2 renal tumor model in rabbits with Ultrasound-guided implantation and ultrasonograpy. Methods Ultrasound-guided implantation was performed in bilateral kidneys of 25 New Zealand rabbits. Ultrasonography imaging was applied to observe the growth of VX2 tumor. The occurrence and the size of renal neoplasm was observed during the follow-up examination. Results The success rate of VX2 tumor implantation in rabbits was 88.0%(22/25) after operation. The occurrence rate of VX2 tumor in rabbit kidneys was 87.5%(35/40) after operation. The average size of VX2 tumor was more than 12 mm in diameter after growing of two weeks and was easy to observe with Ultrasound. Conclusion Ultrasound-guided implantation is successful to establish bilateral VX2 renal tumor model for experimental study and feasibility study with Ultrasound.
Chapter Two
High-frequency contrast-enhanced ultrasonography of VX2 renal tumors in rabbits
Objective To explore the value of high-frequency contrast-enhanced ultrasonography (HF-CEUS) in the vascularity and detection rate of VX2 renal tumors. Methods Ten New Zealand rabbits with implanted VX2 renal tumors were scanned by the conventional Ultrasound (US) and contrast-enhanced ultrasonography (CEUS). The VX2 renal tumors in rabbits were studied between 10 and 25days after implantation. The instrument in this experimental study was the Esaote DU6 with linear transducer. The contrast agent used was SonoVue (Bracco, Italy). Necropsies and histopathologic assessment were performed in comparing CEUS with pathology. Results The detection tumors of pathology, the conventional US and CEUS were 24,11 and 21 respectively. The least tumor detected by HF-CEUS was 5 mm. The detection rate for VX2 renal tumors were 45.8% (11/24) and 87.5%(21/24) respectively between conventional Ultrasound and HF-CEUS (P=0.006). The typical performance of VX2 renal tumors in rabbits was isochronous enhancement and delayed enhancement with CEUS. The enhancement strength of VX2 tumors was less than renal parenchyma and uneven enhancement was the mostly type. The VX2 tumors were displayed hypoechoic comparing with renal parenchyma after fast washout of contrast agent. The enhancement area on CEUS was confirmed viable tumor area by pathology, on the contrary the unenhancement area being confirmed the necrotic region. Conclusion HF-CEUS has higher sensitivity than the conventional Ultrasound in detecting blood supply and improving the detection rate of VX2 renal tumors.
Part Two:The clinical research of hemodynamics in renal lesions with contrast-enhanced ultrasonography
Chapter One The performance of contrast-enhanced ultrasonography in renal lesions
Objective To assess the value of contrast-enhanced ultrasonography (CEUS) in diagnosing the renal lesions. Methods Four hundred and thirty two renal lesions were scanned by conventional Ultrasound (US) and CEUS between Jun, 2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal and its location in tumors were observed by conventional US. The modality and phase of enhancement including the arrival time, the peak time, the washout time and enhancement appearance of lesions were investigated by CEUS. Results After CEUS, the proportion of enhanced tumors in malignant group was higher than the proportion in benign group (P=0.000). The change of enhancement phase of renal lesions was not statistically significant between malignant and benign groups(P>0.05). The isochronous enhancement was the mainly type in malignant group, on the contrary delayed enhancement being the mostly type in benign group. The change of enhancement modality was statistically significant between malignant and benign groups (P=0.000). The fast washout was the mostly type in malignant group, on the contrary isochronous or delayed washout being the mostly types in benign group. The change of washout modality was statistically significant between malignant and benign groups (P=0.000). The uneven enhancement and hyperechoic in peak time was the mostly type in malignant group, on the contrary uniform enhancement and isoechoic in peak time being the mostly type in benign group. The change of enhancement uniformity or intensity was statistically significant between malignant and benign groups respectively (P=0.000, P=0.006). In parenchymal phase,19.4%(67/346) cases were showed pseudocapsule in malignant group, on the contrary only 3.5%(3/86) cases being showed pseudocapsule in benign group. The change of display rate of pseudocapsule was statistically significant between malignant and benign groups (P=0.000)
Conclusion CEUS might be useful in the diagnosis and differentiation between malignant and benign renal lesions by enhancement modality and uniformity.
Chapter Two
The comparative study of blood detection in renal lesions between conventional Ultrasound and contrast-enhanced ultrasonography
Objective To compare the display rate of blood supply in renal lesions between color Doppler flow imaging (CDFI) and CEUS. Methods Four hundred and thirty two renal lesions were scanned by CDFI and CEUS between Jun,2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal of tumors and its location were observed by CDFI. The degree of tumor vascularity was subjectively graded from 0 to IV. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of lesions in CEUS were investigated and analyzed. Results The display rate of blood signal and arterial blood signal in malignant group were higher than the display rate in benign group respectively by CDFI. The grade III and IV were the mostly types in malignant group, as well as the grade 0 and III being the mostly types in benign group. The change of grade of tumor vascularity was statistically significant between malignant and benign groups (P=0.000). The total display rate of blood signal in renal lesions by CEUS was higher than the total display rate by CDFI, as well as display rate of blood signal in malignant group or benign group respectively (P<0.05). Conclusion CEUS has obvious advantages over CDFI in showing blood supply and improving the detection rate of blood signal.
Chapter Three
The comparative study of uniformity detection in renal lesions between conventional Ultrasound and contrast-enhanced ultrasonography
Objective To compare the uniformity detection in renal lesions between CDFI and CEUS. Methods Four hundred and thirty two renal lesions were scanned by CDFI and CEUS between Jun,2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal of tumors and its location were observed by CDFI. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of lesions were studied by CEUS. Renal lesions'size as determined from ultrasonography was stratified into six subgroups with a 1-cm interval. Results The proportion of solid-cystic masses in malignant group was higher than that in benign group by CDFI, but the proportion of cystic masses in malignant group lower than the proportion in benign group. The change of internal echoes of renal lesions was statistically significant between malignant and benign groups (P=0.000). In peak time,73.4%(254/346) cases were showed partly non-enhancement, uneven enhancement, septum enhancement or cellular enhancement in malignant group, on the contrary only 33.7%(29/86) cases being showed these features in benign group by CEUS. The change of uniformity detection was statistically significant between malignant and benign groups (P=0.000). The percentage of uniformity in benign group, except grade I, was higher than the percentage in malignant group by CEUS. The percentage of uniformity in malignant group was a negative correlation with tumor size (P=0.000). Conclusion CEUS is better than CDFI in fully displaying internal structure of renal lesions.
Chapter Four
The value of contrast-enhanced ultrasonography in improving the diagnostic rate of small renal cell carcinoma
Objective To investigate the value of CEUS in diagnosis of small renal cell carcinoma (SRCC). Methods One hundred and twenty SRCCs (≤3 cm in maximum diameter) were scanned by conventional US and CEUS between Jun, 2004 and Jan,2010. All tumors were confirmed by operation and pathology sequentially. The images, including hypoechoic tumor, hyperechoic tumor with dark-ring or intratumoral anechoic or intratumoral hypoechoic, were seen as the diagnostic criteria of SRCC by conventional US. SRCC as determined from different cortical enhancement modality was stratified into two groups by CEUS. The images, including isochronous enhancement with hyperechoic or isoechoic in peak time, delayed enhancement with hypoechoic in peak time, were seen as the diagnostic criteria of SRCC by CEUS. Results On conventional US, renal tumors were hypoechoic masses(n=21), hyperechoic tumor with dark-ring(n=14) or hyperechoic tumor with intratumoral anechoic or intratumoral hypoechoic(n=31). The positive rate of diagnosis was 5.3.3%(64/120, regarded as one tumor if the overlap) by conventional US. The change of inner echoes of SRCC in peak time was statistically significant between two groups by CEUS (P=0.000), as well as the change of performance of SRCC in parenchymal phase between two groups by CEUS (P =0.021). The change of percentage of uniformity in peak time and detection rate of pseudocapsule was not statistically between two groups by CEUS (P>0.05). Renal tumors were displayed isochronous enhancement with hyperechoic or isoechoic in peak time(n=103), delayed enhancement with hypoechoic in peak time (n=7). The positive rate of diagnosis was 91.7%(110/120) by CEUS. Conclusion The positive rate of diagnosis of SRCC by CEUS is higher than that of conventional US.
Chapter Five
The value of contrast-enhanced ultrasonography in differentiation of subtypes of renal cell carcinoma
Objective To investigate the value of CEUS in differentiation of subtypes of renal cell carcinoma (RCC). Methods Three hundred and forty six RCCs were scanned by conventional US and CEUS between Jun,2004 and Feb,2010. All tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. Result Renal tumors were diagnosed as clear cell renal cell carcinoma (CRCC, n=304), papillary renal cell carcinoma(PRCC, n=23) and chromophobe cell renal cell carcinoma(ChRCC, n=19) by operation and pathology. The change of performance among subtypes of RCC was not obvious by conventional US. The change of enhancement phase among subtypes of RCC was not statistically significant by CEUS (P>0.05). The change of performance in cortical phase, peak time and parenchymal phase was statistically significant between CRCC and PRCC by CEUS (P＜0.05), as well as the change of performance between CRCC and ChRCC by CEUS (P<0.05). Conclusion CEUS makes it possible to differentiate subtypes of RCC.
Chapter Six
The study of contrast-enhanced ultrasonography in diagnosis of malignant and benign cystic renal lesions
Objective To investigate the value of CEUS in diagnosis of malignant and benign cystic renal lesions. Methods One hundred and three cystic renal lesions were scanned by conventional US and CEUS between Jun,2004 and Feb, 2010. All cystic tumors were confirmed by operation and pathology sequentially. Each cystic tumor, which was evaluated by wall, number of septa, calcification, intratumoral nodule, blood signal and enhancement, was categorized by using Bosniak classification system before and after CEUS. Results The change of enhancement phase was not statistically between malignant and benign groups by CEUS (P>0.05). The isochronous enhancement was the mainly type between malignant and benign groups. The isoechoic in peak time was the mostly type in benign group, but isoechoic, hyperechoic and hypoechoic in peak time being the common types in malignant group. The change of enhancement in peak time was statistically significant between malignant and benign groups (P=0.002). In peak time,1.4%(1/69) cases were showed uniform in malignant group, on the contrary 26.1%(6/23) cases being showed uniform in benign group by CEUS. The change of uniformity was statistically significant between malignant and benign groups (P =0.001). In parenchymal phase,29.0%(20/69) cases were displayed pseudocapsule in malignant group, on the contrary non-case being showed pseudocapsule in benign group. The change of pseudocapsule was statistically significant between malignant and benign groups (P=0.004). The diagnostic sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio by conventional US were 55.1%(38/69),85.3%(29/34),65.0%(67/103),88.4% (38/43),48.3%(29/60),3.7 in malignant group respectively. The diagnostic sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio by CEUS were 69.6%(48/69),97.1%(33/34),78.6% (81/103),98.0%(48/49),61.1%(33/54),23.7 in malignant group respectively. Conclusion CEUS is better than conventional US for cystic renal lesions in differential diagnosis of malignant and benign.
Chapter Seven
The value of contrast-enhanced ultrasonography in improving the diagnostic sensitivity of renal angiomyolipoma
Objective To investigate the value of CEUS in improving the diagnostic sensitivity of renal angiomyolipoma (AML). Methods Fifty two renal AMLs were scanned by conventional US and CEUS between Aug,2004 and Nov, 2009. All tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. Tumors as determined from hyperechoic or hypoechoic was divided into two groups. The modality and phase of enhancement in two groups, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. The images, including delayed enhancement with uniform isoechoic or hyperechoic in peak time, were seen as the diagnostic criteria of AML by CEUS. Results The preoperative sensitivity of renal AML was 65.4%(34/52) by conventional US. In cortical phase, forty two cases were displayed delayed enhancement by CEUS. In peak time, forty cases were showed uniform isoechoic or hyperechoic enhancement. The change of enhancement phase was not statistically between hyperechoic and hypoechoic groups (P>0.05). The change of performance in cortical and parenchymal phase was not statistically between hyperechoic and hypoechoic groups (P= 1.000,.P=0.162), on the contrary the change of performance in peak time being statistically significant in two groups by CEUS (P=0.009). The change of uniformity in cortical time or pseudocapsule in parenchymal phase was not statistically in two groups by CEUS respectively (P=0.545, P=0.083). The diagnostic sensitivity of renal AML was 76.9%(40/52) by CEUS. Conclusion CEUS might be useful for the diagnosis in reflecting the internal structure of renal AML.
Chapter Eight
The study of contrast-enhanced ultrasonography in improving the detection rate of difficult renal tumors
Objective To investigate the value of CEUS in improving the detection rate of difficult renal tumors. Methods Thirty six difficult renal tumors by conventional US were scanned by CEUS between Oct,2004 and Jan,2010. All difficult tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. The assessment criteria of visibility of difficult renal tumors was established and calculated before and after CEUS. Results Twenty seven renal tumors of ill-defined margin and 18 isoechoic tumors were displayed by conventional US. Intratumoral or peritumoral blood signal was observed in 19 cases, while the rest cases did not been showed any blood signal. The visibility of difficult renal tumors, including boundary, inner echoes and blood supply, was better identified after CEUS. The change of visibility of difficult renal tumors was statistically significant before and after CEUS(P<0.05). The score of visibility of difficult renal tumors after CEUS was higher than the score of visibility before CEUS (P=0.000). Conclusion CEUS is better than the conventional US in significantly improving the detection rate of difficult renal tumors.
Chapter Nine
The comparative study of diagnostic accuracy in renal lesions between contrast-enhanced ultrasonography and contrast-enhanced computed tomography
Objective To compare the value in diagnosis of renal tumors between CEUS and contrast-enhanced computed tomography(CECT). Methods Two hundred and eighty one renal tumors were scanned by CEUS and CECT between Mar, 2007 and Feb,2010. All renal tumors were confirmed by operation and pathology sequentially. Results The change of percentage of uneven renal tumors was not statistically between CEUS and CECT in peak time. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy by CEUS were 97.3%(218/224),70.2%(40/57),92.8%(218/235),87.0%(40/46),91.8% (258/281) in malignant group respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy, by CECT were 87.9% (197/224),64.9%(37/57),90.8%(197/217),57.8%(37/64),83.3%(234/281) in malignant group respectively. Conclusion The diagnostic accuracy of CEUS is slightly better than that of CECT in renal tumors.
第一章超声引导建立VX2兔肾肿瘤模型及可行性研究
目的探讨超声引导经皮穿刺建立兔肾移植肿瘤模型的方法。方法25只新西兰白兔,在B超引导下经皮穿刺兔双侧肾脏,分别注入肿瘤组织块,术后超声随访观察肿瘤的生长情况。结果25只兔中22只穿刺成功,穿刺成功率88.0%(22/25)。22只兔共40个肾脏进行了穿刺接种,其中20只兔的35个肾脏有肿瘤发生,肿瘤种植成功率87.5%(35/40)。穿刺术后两周肿瘤生长平均直径大于11.8mm,易于超声观察。结论超声引导经皮穿刺建立兔双肾肿瘤模型适合于动物实验研究模型的建立和超声观察。
第二章VX2兔肾肿瘤的超声造影表现及检出率的研究
目的探讨高频超声造影在检测VX2兔肾肿瘤中的意义。方法10只新西兰白兔,在超声引导下接种VX2肿瘤,分别进行常规超声检查及高频超声造影。仪器选用百胜DU6增强型,具有实时谐波超声造影技术。造影剂选用SonoVue,观察肿瘤的增强表现,比较造影前后检出的肿瘤数,并与病理对照。结果10只兔肾接种成功,病理大体标本共发现24个肿瘤(包括播散灶),超声造影前发现11个,造影后发现21个,检出最小肿瘤为5mm,检出率分别为45.8%(11/24)和87.5%(21/24)(P=0.006)。超声造影显示兔肾肿瘤的典型表现为同步或缓慢增强,但增强强度较肾实质低且多呈不均匀,很快消退呈低回声改变。病理显示兔肾肿瘤超声造影增强的区域均为肿瘤存活区,而未增强区域均为坏死组织。结论高频超声造影能很好地反映VX2兔肾肿瘤血供和坏死情况,对提高肾肿瘤检出率有很大意义。
第二部分超声造影在肾占位血流动力学中的临床研究
第一章肾占位的超声造影表现
目的探讨超声造影在肾脏占位诊断中的价值。方法2004年6月至2010年2月超声检查432个肾占位,均经手术及病理证实。每个肿块均行常规超声和超声造影检查,其中恶性肿瘤共346个病灶,良性肿块共86个病灶。先行常规超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。结果造影时恶性组增强率高于良性组(P=0.000)。良恶性肾占位的造影时相之间的差异无统计学意义(P>0.05)。恶性组以同步增强为主,良性组以缓慢增强居多,两组在增强表现上的差异有显著的统计学意义(P=0.000)。恶性组以快速减退居多,良性组以同步或缓慢减退居多,两组在减退表现上的差异有显著的统计学意义(P=0.000)。恶性组超声造影达峰时不均匀居多,良性组超声造影达峰时均匀居多,两组差异有显著的统计学意义(P=0.000)。超声造影达峰时恶性组以高回声居多,良性组以等回声居多,两组差异有显著的统计学意义(P=0.006)。实质期恶性组见假包膜19.4%(67/346),良性组见假包膜3.5%(3/86),两组差异有显著的统计学意义(P=0.000)。结论超声造影通过显示肾脏占位的增强表现和均匀度,有助于诊断和鉴别诊断良恶性占位。
第二章常规超声与超声造影在肾占位血流检测中的对比研究
目的比较彩色多普勒超声和超声造影显示肾占位血供的能力。方法2004年6月至2010年2月超声检查432个肾占位,均经手术及病理证实。每个肿块均行彩色多普勒超声和超声造影检查,其中恶性肿瘤共346个病灶,良性肿块共86个病灶。先行彩色多普勒超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,肾占位血管按其多寡分为0-Ⅳ级。超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。结果彩色多普勒超声的恶性组血流显示率高于良性组(P=0.000),其动脉血流信号显示率也高于良性组(P=0.000)。恶性组以Ⅲ～Ⅳ级为主,而良性组以0级或Ⅲ级为主,两组血流信号分级表现的差异有显著的统计学意义(P=0.000)。无论肾占位血流信号的总显示率还是对于恶性肾占位或良性肾占位的血流信号显示率,超声造影均高于彩色多普勒超声(P<0.05)。结论超声造影充分反映病灶内部的血供,提高血流的检出率,优于彩色多普勒超声。
第三章常规超声与超声造影检测肾脏占位均匀度的对比研究
目的比较常规超声和超声造影反映肾占位内部结构的能力。方法2004年6月至2010年2月超声检查432个肾占位,均经手术及病理证实。每个肿块均行彩色多普勒超声和超声造影检查,其中恶性肿瘤共346个病灶,良性肿块共86个病灶。先行彩色多普勒超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。。肾占位的大小按其最大径线的超声测值以1 cm间隔分为Ⅰ～Ⅵ级。结果彩色多普勒超声显示恶性组中囊实性占位的比例高于良性组,而恶性组囊性占比却低于良性组,两组病灶内部的回声表现差异有显著的统计学意义(P=0.000)。恶性组中73.4%(254/346)超声造影达峰值时显示为部分不增强区或增强不均匀、分隔样增强或蜂窝状结构；良性组中33.7%(29/86)超声造影达峰值显示为部分不增强区或不均匀增强、分隔样增强或蜂窝状结构,两组差异有显著的统计学意义(P=0.000)。除Ⅰ级病灶外,良性组超声造影后内部回声均匀的病灶百分率明显高于恶性组(P=0.000)。恶性组超声造影后内部回声均匀的病灶百分率与病灶大小呈负相关(P=0.000)。结论超声造影能充分反映肾占位的内部结构,优于彩色多普勒超声。
第四章超声造影对提高小肾癌诊断率的价值
目的探讨超声造影在小肾癌诊断中的应用价值。方法2004年6月至2010年1月常规超声和超声造影检查最大直径测值≤3 cm的小肾癌共120个肿瘤,均经手术及病理证实。常规超声显示低回声肿瘤、高回声瘤周环状无回声、高回声瘤内无回声或低回声,作为诊断小肾癌标准；按超声造影皮质期不同增强方式分为2组,造影时肿瘤同步增强并达峰值呈高回声或等回声、缓慢增强并达峰值呈低回声,作为诊断小肾癌标准。结果常规超声显示低回声肿块21个,高回声瘤周环状无回声14个,高回声瘤内无回声或低回声31个,常规超声的诊断阳性率为53.3%(64/120,重叠按1个计算)。造影皮质期不同增强方式两组达峰时内部回声差异有显著的统计学意义(P=0.000),两组实质期造影表现差异有统计学意义(P=0.021),但达峰值内部回声均匀病灶的百分率和假包膜出现率的差异没有统计学意义(P＞O.05)。造影时肿瘤同步增强并达峰值高回声或等回声103个,缓慢增强并达峰值低回声7个,超声造影的诊断阳性率为91.7%(110/120)。结论超声造影诊断小肾癌的诊断阳性率高于常规超声。
第五章超声造影在肾细胞癌亚型鉴别诊断中的价值
目的探讨超声造影在肾细胞癌亚型鉴别诊断中的应用价值。方法2004年6月至2010年2月常规超声和超声造影检查肾细胞癌346个,均经手术及病理证实。先行常规超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。结果经手术和病理证实304个为透明细胞肾癌,23个为乳头状肾癌,19个为嫌色细胞肾癌。不同亚型肾细胞癌常规超声的表现没有明显差异。不同亚型肾细胞癌的增强时相没有显著性差异(P>0.05)。乳头状肾癌与透明细胞肾癌比较,两组病灶皮质期的表现差异有显著的统计学意义(P=0.000),两组病灶达峰值回声表现差异有显著的统计学意义(P=0.000),两组病灶实质期表现差异有显著的统计学意义(P=0.000)；嫌色细胞肾癌与透明细胞肾癌比较,两组病灶皮质期表现差异有显著的统计学意义(P=0.000),两组病灶达峰值病灶回声表现差异有显著的统计学意义(P=0.000),两组病灶实质期表现差异有显著的统计学意义(P=0.001)。结论超声造影使鉴别肾细胞癌亚型成为可能。
第六章超声造影诊断良恶性囊性肾占位的价值探讨
目的探讨超声造影诊断良恶性囊性肾占位的价值。方法2004年6月至2010年2月常规超声和超声造影检查良恶性囊性肾占位共103个,均经手术及病理证实。参照Bosniak CT分级标准,造影前后按照囊性肾占位的囊壁、分隔数目、钙化及囊内结节、血流信号及增强等特征进行分级。结果良恶性囊性肾占位造影时相比较差异没有统计学意义(P>0.05)。两组囊性肾占位均以同步增强为主。良性病灶达峰值时增强程度以等于肾皮质多见,而恶性肿瘤增强程度有等回声、高回声及低回声,两组达峰值表现差异有显著的统计学意义(P=0.002)。恶性组达峰值均匀增强的病灶占1.4%(1/69),良性组占26.1%(6/23),恶性组明显低于良性组(P=0.001)。恶性组实质期29.0%(20/69)病灶有假包膜,良性组均未见假包膜,两组间差异有显著的统计学意义(P=0.004)。常规超声对恶性囊性肾占位的诊断敏感性为55.1%(38/69),特异性为85.3%(29/34),准确性为65.0%(67/103),阳性预测值为88.4%(38/43),阴性预测值为48.3%(29/60),阳性似然比为3.7。超声造影对恶性囊性肾占位的诊断敏感性为69.6%(48/69)、特异性为97.1%(33/34),准确性为78.6%(81/103),阳性预测值为98.0%(48/49),阴性预测值为61.1%(33/54),阳性似然比为23.7。结论超声造影对良恶性囊性肾占位的诊断优于常规超声。
第七章超声造影对提高肾错构瘤诊断率的价值
目的探讨超声造影在提高肾错构瘤诊断准确率中的价值。方法2004年8月至2009年11月常规超声和超声造影检查肾错构瘤52个,均经手术及病理证实。先行常规超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,然后根据肿瘤高低回声不同分成两组,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。造影时缓慢向心增强和达峰值均匀等回声或高回声作为诊断肾错构瘤的特征。结果术前常规超声诊断肾错构瘤灵敏度为65.4%(34/52)。超声造影皮质期42个病灶见缓慢增强,达峰值呈等回声或高回声并均匀增强40个。高低回声肾错构瘤超声造影时相比较差异没有统计学意义(P>0.05)。两组肾错构瘤的超声造影皮质期和实质期的表现差异没有统计学意义(P=1.000,P=0.162),达峰值表现差异有显著的统计学意义(P=0.009)。两组错构瘤超声造影达峰值时均匀病灶百分率和实质期包膜出现率差异没有统计学意义(P=0.545,P=0.083)。超声造影诊断。肾错构瘤的灵敏度为76.9%(40/52)。结论超声造影能反映肾错构瘤的血流灌注特点,对提高诊断准确性有较大的帮助。
第八章超声造影提高疑难肾肿瘤检出率的研究
目的探讨超声造影提高疑难肾肿瘤检出率的临床价值。方法2004年10月至2010年1月常规超声显示困难的36个肾肿瘤行超声造影检查,均经手术及病理证实。先行彩色多普勒超声观察肿瘤的大小、回声、边界、有无彩色血流信号、血管位置等表现,超声造影观察病灶的增强方式和增强时相,包括起始时间、达峰时间、消退时间及病灶的增强表现。建立肾肿瘤造影前后病灶明显性评分标准并计算。结果常规超声显示27个肿瘤边界欠清或不清,内部等回声18个,19个显示内部或周边血流信号,余无明显彩色血流信号。疑难肾肿瘤超声造影后在病灶的边界、内部回声和血供明显性方面大有改善,造影前后差异有显著的统计学意义(P<0.05)。造影后疑难肾肿瘤病灶的明显性积分高于造影前(P=0.000)。结论超声造影能显著提高疑难肾肿瘤病灶的检出率,优于常规超声。
第九章超声造影和增强CT在肾占位诊断中的对比研究
目的比较超声造影和增强CT两者诊断肾占位的价值。方法2007年3月至2010年2月超声造影及增强CT检查281个肾占位,均经手术及病理证实。将超声造影的表现与增强CT的表现进行分析与比较,并以病理诊断作为金标准,将两者在肾占位中的诊断价值相关指标进行统计分析与比较。结果本组恶性肾占位超声造影峰值期表现为不均匀的病灶所占百分比和增强CT的差异没有统计学意义(P=0.605)。恶性肾占位超声造影诊断的敏感性97.3%(218/224),特异性70.2%(40/57),阳性预测值92.8%(218/235),阴性预测值87.0%(40/46),准确率为91.8%(258/281)；增强CT诊断的敏感性87.9%(197/224),特异性64.9%(37/57),阳性预测值90.8%(197/217),阴性预测值57.8%(37/64),准确率为83.3%(234/281)。结论超声造影诊断肾肿瘤的准确率略优于增强CT。
Part One:The basic research of hemodynamics in renal lesions with contrast-enhanced ultrasonography
Chapter One
Ultrasound-guided implantation of VX2 renal tumors in rabbits and its feasibility study
Objective To evaluate the feasibility of establishing VX2 renal tumor model in rabbits with Ultrasound-guided implantation and ultrasonograpy. Methods Ultrasound-guided implantation was performed in bilateral kidneys of 25 New Zealand rabbits. Ultrasonography imaging was applied to observe the growth of VX2 tumor. The occurrence and the size of renal neoplasm was observed during the follow-up examination. Results The success rate of VX2 tumor implantation in rabbits was 88.0%(22/25) after operation. The occurrence rate of VX2 tumor in rabbit kidneys was 87.5%(35/40) after operation. The average size of VX2 tumor was more than 12 mm in diameter after growing of two weeks and was easy to observe with Ultrasound. Conclusion Ultrasound-guided implantation is successful to establish bilateral VX2 renal tumor model for experimental study and feasibility study with Ultrasound.
Chapter Two
High-frequency contrast-enhanced ultrasonography of VX2 renal tumors in rabbits
Objective To explore the value of high-frequency contrast-enhanced ultrasonography (HF-CEUS) in the vascularity and detection rate of VX2 renal tumors. Methods Ten New Zealand rabbits with implanted VX2 renal tumors were scanned by the conventional Ultrasound (US) and contrast-enhanced ultrasonography (CEUS). The VX2 renal tumors in rabbits were studied between 10 and 25days after implantation. The instrument in this experimental study was the Esaote DU6 with linear transducer. The contrast agent used was SonoVue (Bracco, Italy). Necropsies and histopathologic assessment were performed in comparing CEUS with pathology. Results The detection tumors of pathology, the conventional US and CEUS were 24,11 and 21 respectively. The least tumor detected by HF-CEUS was 5 mm. The detection rate for VX2 renal tumors were 45.8% (11/24) and 87.5%(21/24) respectively between conventional Ultrasound and HF-CEUS (P=0.006). The typical performance of VX2 renal tumors in rabbits was isochronous enhancement and delayed enhancement with CEUS. The enhancement strength of VX2 tumors was less than renal parenchyma and uneven enhancement was the mostly type. The VX2 tumors were displayed hypoechoic comparing with renal parenchyma after fast washout of contrast agent. The enhancement area on CEUS was confirmed viable tumor area by pathology, on the contrary the unenhancement area being confirmed the necrotic region. Conclusion HF-CEUS has higher sensitivity than the conventional Ultrasound in detecting blood supply and improving the detection rate of VX2 renal tumors.
Part Two:The clinical research of hemodynamics in renal lesions with contrast-enhanced ultrasonography
Chapter One The performance of contrast-enhanced ultrasonography in renal lesions
Objective To assess the value of contrast-enhanced ultrasonography (CEUS) in diagnosing the renal lesions. Methods Four hundred and thirty two renal lesions were scanned by conventional Ultrasound (US) and CEUS between Jun, 2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal and its location in tumors were observed by conventional US. The modality and phase of enhancement including the arrival time, the peak time, the washout time and enhancement appearance of lesions were investigated by CEUS. Results After CEUS, the proportion of enhanced tumors in malignant group was higher than the proportion in benign group (P=0.000). The change of enhancement phase of renal lesions was not statistically significant between malignant and benign groups(P>0.05). The isochronous enhancement was the mainly type in malignant group, on the contrary delayed enhancement being the mostly type in benign group. The change of enhancement modality was statistically significant between malignant and benign groups (P=0.000). The fast washout was the mostly type in malignant group, on the contrary isochronous or delayed washout being the mostly types in benign group. The change of washout modality was statistically significant between malignant and benign groups (P=0.000). The uneven enhancement and hyperechoic in peak time was the mostly type in malignant group, on the contrary uniform enhancement and isoechoic in peak time being the mostly type in benign group. The change of enhancement uniformity or intensity was statistically significant between malignant and benign groups respectively (P=0.000, P=0.006). In parenchymal phase,19.4%(67/346) cases were showed pseudocapsule in malignant group, on the contrary only 3.5%(3/86) cases being showed pseudocapsule in benign group. The change of display rate of pseudocapsule was statistically significant between malignant and benign groups (P=0.000)
Conclusion CEUS might be useful in the diagnosis and differentiation between malignant and benign renal lesions by enhancement modality and uniformity.
Chapter Two
The comparative study of blood detection in renal lesions between conventional Ultrasound and contrast-enhanced ultrasonography
Objective To compare the display rate of blood supply in renal lesions between color Doppler flow imaging (CDFI) and CEUS. Methods Four hundred and thirty two renal lesions were scanned by CDFI and CEUS between Jun,2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal of tumors and its location were observed by CDFI. The degree of tumor vascularity was subjectively graded from 0 to IV. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of lesions in CEUS were investigated and analyzed. Results The display rate of blood signal and arterial blood signal in malignant group were higher than the display rate in benign group respectively by CDFI. The grade III and IV were the mostly types in malignant group, as well as the grade 0 and III being the mostly types in benign group. The change of grade of tumor vascularity was statistically significant between malignant and benign groups (P=0.000). The total display rate of blood signal in renal lesions by CEUS was higher than the total display rate by CDFI, as well as display rate of blood signal in malignant group or benign group respectively (P<0.05). Conclusion CEUS has obvious advantages over CDFI in showing blood supply and improving the detection rate of blood signal.
Chapter Three
The comparative study of uniformity detection in renal lesions between conventional Ultrasound and contrast-enhanced ultrasonography
Objective To compare the uniformity detection in renal lesions between CDFI and CEUS. Methods Four hundred and thirty two renal lesions were scanned by CDFI and CEUS between Jun,2004 and Feb,2010. All lesions were confirmed by operation and pathology sequentially, including 346 malignant tumors and 86 benign tumors. The size, inner echoes, boundary, blood signal of tumors and its location were observed by CDFI. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of lesions were studied by CEUS. Renal lesions'size as determined from ultrasonography was stratified into six subgroups with a 1-cm interval. Results The proportion of solid-cystic masses in malignant group was higher than that in benign group by CDFI, but the proportion of cystic masses in malignant group lower than the proportion in benign group. The change of internal echoes of renal lesions was statistically significant between malignant and benign groups (P=0.000). In peak time,73.4%(254/346) cases were showed partly non-enhancement, uneven enhancement, septum enhancement or cellular enhancement in malignant group, on the contrary only 33.7%(29/86) cases being showed these features in benign group by CEUS. The change of uniformity detection was statistically significant between malignant and benign groups (P=0.000). The percentage of uniformity in benign group, except grade I, was higher than the percentage in malignant group by CEUS. The percentage of uniformity in malignant group was a negative correlation with tumor size (P=0.000). Conclusion CEUS is better than CDFI in fully displaying internal structure of renal lesions.
Chapter Four
The value of contrast-enhanced ultrasonography in improving the diagnostic rate of small renal cell carcinoma
Objective To investigate the value of CEUS in diagnosis of small renal cell carcinoma (SRCC). Methods One hundred and twenty SRCCs (≤3 cm in maximum diameter) were scanned by conventional US and CEUS between Jun, 2004 and Jan,2010. All tumors were confirmed by operation and pathology sequentially. The images, including hypoechoic tumor, hyperechoic tumor with dark-ring or intratumoral anechoic or intratumoral hypoechoic, were seen as the diagnostic criteria of SRCC by conventional US. SRCC as determined from different cortical enhancement modality was stratified into two groups by CEUS. The images, including isochronous enhancement with hyperechoic or isoechoic in peak time, delayed enhancement with hypoechoic in peak time, were seen as the diagnostic criteria of SRCC by CEUS. Results On conventional US, renal tumors were hypoechoic masses(n=21), hyperechoic tumor with dark-ring(n=14) or hyperechoic tumor with intratumoral anechoic or intratumoral hypoechoic(n=31). The positive rate of diagnosis was 5.3.3%(64/120, regarded as one tumor if the overlap) by conventional US. The change of inner echoes of SRCC in peak time was statistically significant between two groups by CEUS (P=0.000), as well as the change of performance of SRCC in parenchymal phase between two groups by CEUS (P =0.021). The change of percentage of uniformity in peak time and detection rate of pseudocapsule was not statistically between two groups by CEUS (P>0.05). Renal tumors were displayed isochronous enhancement with hyperechoic or isoechoic in peak time(n=103), delayed enhancement with hypoechoic in peak time (n=7). The positive rate of diagnosis was 91.7%(110/120) by CEUS. Conclusion The positive rate of diagnosis of SRCC by CEUS is higher than that of conventional US.
Chapter Five
The value of contrast-enhanced ultrasonography in differentiation of subtypes of renal cell carcinoma
Objective To investigate the value of CEUS in differentiation of subtypes of renal cell carcinoma (RCC). Methods Three hundred and forty six RCCs were scanned by conventional US and CEUS between Jun,2004 and Feb,2010. All tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. Result Renal tumors were diagnosed as clear cell renal cell carcinoma (CRCC, n=304), papillary renal cell carcinoma(PRCC, n=23) and chromophobe cell renal cell carcinoma(ChRCC, n=19) by operation and pathology. The change of performance among subtypes of RCC was not obvious by conventional US. The change of enhancement phase among subtypes of RCC was not statistically significant by CEUS (P>0.05). The change of performance in cortical phase, peak time and parenchymal phase was statistically significant between CRCC and PRCC by CEUS (P＜0.05), as well as the change of performance between CRCC and ChRCC by CEUS (P<0.05). Conclusion CEUS makes it possible to differentiate subtypes of RCC.
Chapter Six
The study of contrast-enhanced ultrasonography in diagnosis of malignant and benign cystic renal lesions
Objective To investigate the value of CEUS in diagnosis of malignant and benign cystic renal lesions. Methods One hundred and three cystic renal lesions were scanned by conventional US and CEUS between Jun,2004 and Feb, 2010. All cystic tumors were confirmed by operation and pathology sequentially. Each cystic tumor, which was evaluated by wall, number of septa, calcification, intratumoral nodule, blood signal and enhancement, was categorized by using Bosniak classification system before and after CEUS. Results The change of enhancement phase was not statistically between malignant and benign groups by CEUS (P>0.05). The isochronous enhancement was the mainly type between malignant and benign groups. The isoechoic in peak time was the mostly type in benign group, but isoechoic, hyperechoic and hypoechoic in peak time being the common types in malignant group. The change of enhancement in peak time was statistically significant between malignant and benign groups (P=0.002). In peak time,1.4%(1/69) cases were showed uniform in malignant group, on the contrary 26.1%(6/23) cases being showed uniform in benign group by CEUS. The change of uniformity was statistically significant between malignant and benign groups (P =0.001). In parenchymal phase,29.0%(20/69) cases were displayed pseudocapsule in malignant group, on the contrary non-case being showed pseudocapsule in benign group. The change of pseudocapsule was statistically significant between malignant and benign groups (P=0.004). The diagnostic sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio by conventional US were 55.1%(38/69),85.3%(29/34),65.0%(67/103),88.4% (38/43),48.3%(29/60),3.7 in malignant group respectively. The diagnostic sensitivity, specificity, accuracy, positive predictive value, negative predictive value, positive likelihood ratio by CEUS were 69.6%(48/69),97.1%(33/34),78.6% (81/103),98.0%(48/49),61.1%(33/54),23.7 in malignant group respectively. Conclusion CEUS is better than conventional US for cystic renal lesions in differential diagnosis of malignant and benign.
Chapter Seven
The value of contrast-enhanced ultrasonography in improving the diagnostic sensitivity of renal angiomyolipoma
Objective To investigate the value of CEUS in improving the diagnostic sensitivity of renal angiomyolipoma (AML). Methods Fifty two renal AMLs were scanned by conventional US and CEUS between Aug,2004 and Nov, 2009. All tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. Tumors as determined from hyperechoic or hypoechoic was divided into two groups. The modality and phase of enhancement in two groups, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. The images, including delayed enhancement with uniform isoechoic or hyperechoic in peak time, were seen as the diagnostic criteria of AML by CEUS. Results The preoperative sensitivity of renal AML was 65.4%(34/52) by conventional US. In cortical phase, forty two cases were displayed delayed enhancement by CEUS. In peak time, forty cases were showed uniform isoechoic or hyperechoic enhancement. The change of enhancement phase was not statistically between hyperechoic and hypoechoic groups (P>0.05). The change of performance in cortical and parenchymal phase was not statistically between hyperechoic and hypoechoic groups (P= 1.000,.P=0.162), on the contrary the change of performance in peak time being statistically significant in two groups by CEUS (P=0.009). The change of uniformity in cortical time or pseudocapsule in parenchymal phase was not statistically in two groups by CEUS respectively (P=0.545, P=0.083). The diagnostic sensitivity of renal AML was 76.9%(40/52) by CEUS. Conclusion CEUS might be useful for the diagnosis in reflecting the internal structure of renal AML.
Chapter Eight
The study of contrast-enhanced ultrasonography in improving the detection rate of difficult renal tumors
Objective To investigate the value of CEUS in improving the detection rate of difficult renal tumors. Methods Thirty six difficult renal tumors by conventional US were scanned by CEUS between Oct,2004 and Jan,2010. All difficult tumors were confirmed by operation and pathology sequentially. The size, inner echoes, boundary, blood signal of tumors and its location were observed by conventional US. The modality and phase of enhancement, including the arrival time, the peak time, the washout time and enhancement appearance of tumors were studied by CEUS. The assessment criteria of visibility of difficult renal tumors was established and calculated before and after CEUS. Results Twenty seven renal tumors of ill-defined margin and 18 isoechoic tumors were displayed by conventional US. Intratumoral or peritumoral blood signal was observed in 19 cases, while the rest cases did not been showed any blood signal. The visibility of difficult renal tumors, including boundary, inner echoes and blood supply, was better identified after CEUS. The change of visibility of difficult renal tumors was statistically significant before and after CEUS(P<0.05). The score of visibility of difficult renal tumors after CEUS was higher than the score of visibility before CEUS (P=0.000). Conclusion CEUS is better than the conventional US in significantly improving the detection rate of difficult renal tumors.
Chapter Nine
The comparative study of diagnostic accuracy in renal lesions between contrast-enhanced ultrasonography and contrast-enhanced computed tomography
Objective To compare the value in diagnosis of renal tumors between CEUS and contrast-enhanced computed tomography(CECT). Methods Two hundred and eighty one renal tumors were scanned by CEUS and CECT between Mar, 2007 and Feb,2010. All renal tumors were confirmed by operation and pathology sequentially. Results The change of percentage of uneven renal tumors was not statistically between CEUS and CECT in peak time. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy by CEUS were 97.3%(218/224),70.2%(40/57),92.8%(218/235),87.0%(40/46),91.8% (258/281) in malignant group respectively. The diagnostic sensitivity, specificity, positive predictive value, negative predictive value, accuracy, by CECT were 87.9% (197/224),64.9%(37/57),90.8%(197/217),57.8%(37/64),83.3%(234/281) in malignant group respectively. Conclusion The diagnostic accuracy of CEUS is slightly better than that of CECT in renal tumors.
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