摘要
前言
研究表明恶性肿瘤依赖它的血管系统生长和转移。三维能量多普勒超声是一种非损伤性评价盆腔器官血流灌注状态的方法。三维能量多普勒超声可定量计算和分析感兴趣区内的彩色亮度及灰阶值，是一种新的、客观的、定量的研究方法，并可以清楚地显示肿瘤内低速血流及血管构建和分布的变化。已有研究表明利用能量多普勒超声获得的能量多普勒血管指数来评估乳腺癌及卵巢肿瘤等血管，发现其与MVD有较好的相关性。
本研究利用三维能量多普勒超声定量分析的方法，检测早期宫颈癌组织、CIN(宫颈上皮内瘤样变)及正常宫颈组织内血流的相关参数值，比较三者之间血管参数的差异；并研究早期宫颈癌三维能量多普勒超声血管参数与MVD及临床病理参数的相关性。
材料与方法
2005年11月至2006年10月，选取我院以手术治疗为初治疗的早期宫颈癌(≤Ⅱb期)患者27名及CIN患者14名。对照组为同期在我院妇科因子宫良性病变行子宫全切术的患者15例。对照组术前妇科检查宫颈光滑且液基细胞学法测试均为阴性结果。全部病例术前1—3天内接受了三维能量多普勒超声检查。宫颈癌的患者按照FIGO(International Federation of Gynecology and Obstetrics)的标准进行临床分期。
我们所使用的超声仪器为GE VOLUSON 730 Expert超声诊断仪，阴式容积探头的频率为5-9MHz。
首先在灰阶模式下对宫颈部位进行经阴道二维超声检查，对有病变者仔细观察肿物特征，确定感兴趣区。然后切换至彩色能量多普勒模式测定收缩期峰值速度(PSV)和阻力指数(RI)。之后进行三维重建。使用VOCAL(Virtual Organ Compute-Aid Analysis)软件中的三维能量多普勒直方图进行分析，得到下列参数：VI(vascularization index)，FI(flow index)，VFI(vascularization-flow index)。
收集宫颈癌组患者的临床病理资料。详细记录宫颈癌患者年龄、绝经状况、临床分期、组织学类型、组织学分级、有无淋巴结转移情况。
术后选取患者宫颈部位的组织切片，采用SP(链霉素抗生物素蛋白-过氧化酶)免疫组化法染色。血管标记物为CD_(34)，以PBS(磷酸盐缓冲液)代替第一抗体作阴性对照，检测宫颈组织内微血管密度。
将计算得到的感兴趣区内各参数值结果与MVD及临床病理参数进行分析。所有数据使用SPSS 11.5统计软件包进行统计分析。各项数据进行正态分布检验，若数据呈正态分布，两组数据之间比较采用t检验，多组数据比较，进一步分析其是否符合方差齐性，是则采用方差分析。不符合正态分布的数据采用非参数检验。使用相关和回归分析，预测最佳值由受试者工作特征(ROC)曲线获取。P<0.05为差异有显著性。
实验结果
1、MVD与三维能量多普勒超声参数VI、VFI呈正相关(r=0.776，r=0.717)，RI、PSV、FI与MVD无显著相关性。
2、三维能量多普勒超声定量分析得到的宫颈癌组及CIN组的血管参数与对照组相比RI、VI、VFI值均有显著性差异。宫颈癌组与CIN组相比只有VI值有显著性差异。从对照组到C1N组再到宫颈癌组MVD值逐渐升高，差异有显著性意义。
3、早期宫颈癌临床病理参数与能量多普勒参数及MVD之间关系：
(1)宫颈癌Ⅰ期与Ⅱ期相比，Ⅰ期患者的VI值和MVD低于Ⅱ期患者，且有显著性差异。
(2)宫颈癌不同组织分级间的血管参数及MVD比较均没有显著性差异。
(3)宫颈癌有盆腔淋巴结转移LN(+)组和没有盆腔淋巴结转移LN(-)组相比血管参数RI、VI、VFI值和MVD值均有显著性差异。根据ROC曲线，VI、VFI、MVD、RI作为预测早期宫颈癌有盆腔淋巴结转移指标时，它们的诊断界点分别为8.0％，4.25，32.5，0.46；在此诊断界点时的阳性似然比(LR_+)分别为2.9，2.18，3.64，1.94。
结论
1、三维能量多普勒超声定量分析的参数VI、VFI与MVD值呈显著正相关，提示三维能量多普勒超声定量分析可用于术前活体评估宫颈癌肿瘤血管生成。
2、三维能量多普勒超声定量分析的参数VI、VFI在宫颈癌与CIN及正常宫颈间有差异，为宫颈癌的早期诊断提供了新的诊断信息。
3、三维能量多普勒超声定量分析的参数VI值与宫颈癌临床分期有关，为宫颈癌的术前分期提供了新的诊断信息。
4、三维能量多普勒超声定量分析的参数VI、VFI在术前预测宫颈癌盆腔淋巴结转移情况方面优于RI，可作为预测宫颈癌盆腔淋巴结转移的重要参数。
Preface
Malignant tumors are highly dependent on vascularization for their growth and spread. Three-dimensional (3D) power Doppler ultrasound is a non-invasive technology that evaluates the blood flow of pelvic organs. Three-dimensional power Doppler ultrasound is a relatively new technique that allows tumor vascularization assessment, both quantitatively by means of 3D-PDU-derived vascular indices and qualitatively by depicting three-dimensionally the tumor vascular network. Some studies have shown that Doppler assessment of tumor vascularization is related to microvessel density in ovary and breast cancer.
The aim of the present study was to evaluate whether differences exist in vascularization as assessed by 3D-PDU in early stage cervical carcinoma and in cervical intraepithelial neoplasm (CIN) and in normal controls; and to find the correlation between tumor angiogenesis assessed by 3D-power Doppler ultrasound and MVD in early stage cervical carcinoma.
Materials and Methods
From November 2005 to October 2006, an analysis was performed of 27 women with cervical carcinoma and 14 women with CIN at Second Hospital, China Medical University. During the study period, 15 women with normal uterine cervix agreed to undergo 3D power Doppler examinations and were selected as controls. All the patients underwent 3D power Doppler examination during one to three days prior to surgery. All the cervical carcinoma patients were staged clinically according to the staging system of the International Federation of Gynecology and Obstetrics (FIGO).
The equipment used in the study was GE VOLUSON 730 Expert with 5-9 MHz trans vaginal transducers.
Each patient underwent systematic gray-scale examination of uterus and ovaries with special emphasis on the cervix. Following B-mode evaluation, the two-dimensional power Doppler gate was activated to assess vascularization. Resistance Index (RI) and Peak Systolic Velocity (PSV, cm/s) were recorded automatically. And then the three-dimensional power Doppler mode was switched on. The Virtual Organ Computer-aided Analysis (VOCAL) program then automatically calculated gray-scale and color values. According to these values the indices were calculated: Vascularization Index (VI), Flow Index (FT), Vascularization Flow Index (VFI).
All clinicopathologic data were obtained. All the cervical tissue samples were obtained after operation. MVD of the tissue samples was assessed by immunohistochemical method (SP method).
All statistical analysis were performed using the SPSS 11.5 statistical package which involves Kolmogorov-Smirnov test, Kruskal-Wallis test, Mann-Whitney test and Spearman correlation analysis. A P-value < 0.05 was considered to be statistically significant.
Results
1. There was a significant positive correlation between MVD and VI, VFI(r=0.776, r=0.717).
2.Significant differences between means for normal controls and cervical carcinoma were found for following parameters: RI, VI, VFI, MVD. And significant differences between means for normal controls and CIN were found for the same parameters. The VI, VFI, MVD in cervical carcinoma were significantly higher than that in normal tissues and CIN, the RI in cervical carcinoma was significantly lower than that in normal tissues and CIN. Significantly higher VI and MVD values were noted in cervical carcinoma compared with CIN.
3.The relationship of clinicopathological characteristics and 3D-PDU parameters or MVD in early stage cervical carcinoma:
(1) Significantly higher VI and MVD values were noted in Stage II tumors compared with Stage I tumors.
(2) There were no significant differences in all values regard to histologic grades.
(3) Significant differences between means for tumors with pelvic lymph node metastases and tumors without pelvic lymph node metastases were found for following parameters: VI, VFI, MVD and RI. ROC curve showed cut off values were 8.0%, 4.25, 32.5, 0.46, respectively. The positive likelihood ratio (LR_+) of these cut off values were 2.9, 2.18, 3.64, 1.94, respectively.
Conclusions
1 .VI, VFI were significant correlated with MVD. Thus, VI and VFI could be used as useful in vivo indicators of tumor angiogenesis in cervical carcinoma.
2.The quantified indices using 3D power Doppler helped to differentiate cervical carcinoma from CIN and normal cervix.
3.The quantified indices using 3D power Doppler, corresponding with the stage in cervical carcinoma, helped to judge the stage of the tumors.
4.The quantified indices using 3D power Doppler showed more worthful than RI and PSV in predicting pelvic lymph node metastasis. VI, VFI could be used as new parameters for predicting pelvic lymph node metastasis potential before operation in cervical carcinoma.
引文
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