1、子宫恶性肿瘤的子宫恶性肿瘤的MRI诊断诊断MRI of Uterine Malignant Neoplasm1子宫恶性肿瘤的MR I 诊断12子宫恶性肿瘤的流行病学现状子宫恶性肿瘤的流行病学现状Epidemiology of Uterine Malignant Neoplasm子宫恶性肿瘤包括子宫颈癌、子宫内膜癌、滋养细胞恶性肿瘤、子宫肉瘤等Uterine malignant neoplasm includes cervical carcinoma,endometrialcarcinoma,uterine sarcoma and malignant trophoblastic tumor,et
2、c.22子宫恶性肿瘤的流行病学现状23nnnn全球妇女恶性肿瘤发病率的第三位The No.3 female malignant tumor in the world我国妇科恶性肿瘤发病率的前两位The top two common female cancer in China女性恶性肿瘤死亡率的第二位The second mortality in female malignant tumor in China每年约有3万名妇女死于宫颈癌About 30,000 females died子宫颈癌子宫颈癌Cervical Carcinoma33 n 全球妇女恶性肿瘤发病率的第三位子宫颈癌34nnn
3、全球妇女恶性肿瘤发病率的第四位The fourth most common female cancer in the world每年的平均病例数是30 年前的40 倍之多The yearly average number of endometrial carcinoma is nearlyfourty times as much as those 30 years ago随着我国妇女内分泌代谢性疾病的增加，子宫内膜癌呈对数速度增长With endocrinopathy morbidity rising,the number of endometrialcarcinoma is increasi
4、ng according to logarithm fashion子宫内膜癌子宫内膜癌Endometrial carcinoma44 n 全球妇女恶性肿瘤发病率的第四位子宫内膜癌45nnn占子宫恶性肿瘤的2%4%Accounting for 2 4%of all uterine malignancies占生殖道恶性肿瘤的1%Accounting for 1%of all malignancies in female reproductive tract临床罕见、恶性程度较高A very rare and high malignancy in female reproductive tract子
5、宫肉瘤子宫肉瘤Uterine sarcoma55 n 占子宫恶性肿瘤的2%4%子宫肉瘤56子宫恶性肿瘤的临床检查方法子宫恶性肿瘤的临床检查方法Clinical examination of uterinemalignant neoplasm66 子宫恶性肿瘤的临床检查方法67临床检查临床检查Clinical examinationp普通妇科检查：简单，但具有明显的局限性Gynecological examination:simple&limitedp分期具有主观性：3439的患者分期错误Subjectivity on its staging:34%-39%of incorrect stagin
6、gp不能全面评价肿瘤侵犯深度和盆腔淋巴结转移Difficult to identify invasive extent and lymph node metastases77临床检查78临床检查临床检查-细胞学检查细胞学检查Clinical examination-Exfoliative cytologic examinationn检测来源于子宫内膜、子宫颈的恶性细胞Finding malignant cells from cervix and uterine endometriumn为子宫恶性肿瘤的诊断诊断提供直接依据Providing direct diagnosis for uterin
7、e malignant neoplasmn为子宫微生物感染提供诊断依据Finding foundation for uterine microbial infectionn在肿瘤的分期上无明显价值No value on its staging88临床检查-细胞学检查89临床检查临床检查-阴道宫腔镜阴道宫腔镜Clinical examination-hysteroscopynnn对子宫可疑病变进行定位活检Biopsy for suspected lesion明显提高子宫体、颈部早期癌的诊断率Higher diagnostic rate of uterine and cervical cancer
8、不能客观评价肿瘤侵犯深度和盆腔淋巴结转移Unable to evaluate invasive extent and lymphnodes metastasisaccurately99临床检查-阴道宫腔镜n 对子宫可疑病变进行定位活检910影像学方法影像学方法-超声检查超声检查Medical image examination-Ultrasonographyppp对子宫可疑病变进行定位活检The most common screen on uterine malignant tumor经腹超声在分期上应用价值较小Trans-abdominal ultrasound with few value
9、 on staging阴式超声可明显提高子宫恶性肿瘤的分期，其阳性、阴性预测值分别约62和92Improving staging by trans-vagina ultrasound with 62%forpositive predictive value and 92%for negative predictive value101 0影像学方法-超声检查p对子宫可疑病变进行定位活检1 011影像学方法影像学方法-CT检查检查Medical image examination-CTnnn平扫CT：子宫恶性肿瘤与子宫壁密度相似，难以显示癌肿的浸润深度和范围Non-CE CT:difficult
10、 to show tumor invasive depth and extent becauseof similar intensity between uterine tissues&malignant tissuesCT增强：子宫恶性肿瘤显示有局限性Showing uterine disease with some limitations by CE CTCT评价宫旁浸润假阳性较高，准确度仅3358Accuracy is 3358 on evaluating parametrical invasion by CTbecause of a high false-positive error1
11、11 1影像学方法-C T 检查n 平扫C T：子宫恶性肿瘤与子宫壁12影像学方法影像学方法-MRMedical image examination-MRInn上世纪80年代，MRI出现并应用于子宫肿瘤的诊断MRI used in uterine diagnosis in the last 80s当时，成像时间长、图像易受呼吸、血管搏动和肠蠕动的影响、磁场强度低等缺点使其应用受限At that time,longer imaging time&imaging quality easily disturbed bybreath,vessel pause,bowel movement,low ma
12、gnetic field strengt,etc.These disadvantages limited its application121 2影像学方法-MR n 上世纪8 0 年代，MR I 出现并应用于13nn随着MRI场强、梯度切换率的提高和多通道高密相控阵线圈的应用，使应用MRI技术对子宫恶性肿瘤进行准确诊断和客观评价成为可能With high-magnetic MR scanner,high-gradient switch ratio andmultiple phased array coils,it is possible to diagnose uterinemalignac
13、y accurately and evaluate it objectively by MRIMRI因其极高的软组织分辨力，能够清晰显示子宫的组织结构和信号的细微变化，近而准确评价子宫恶性肿瘤的大小和范围Clearly displaying uterine layers,signal changes,tumor size andextent on MRI image because of it high soft tissue resolution131 3 n 随着MR I 场强、梯度切换率的提高和多通道高1 314nn肿瘤分期达到b期以上，MRI的评价准确性、阳性和阴性预测值分别可达81
14、95%、100、90%Above IB staging,accuracy,positive predictive value and negativepredictive value of MRI evaluation:81%-95%,100%and 90%在显示子宫恶性肿瘤宫旁浸润和淋巴结转移等方面，其敏感度、特异度均较高High sensitivity and specificity in showing parametrical invasion andlympnode metastasis from uterine malignant neoplasm on MRI141 4 n 肿瘤
15、分期达到b 期以上，MR I 的评价准确性、阳性1 415影像学方法影像学方法-PETCT检查检查Medical image examination-PEC/CTnnn是评价子宫肿瘤良恶性的最佳影像方法之一One of the best evaluations on uterine malignancy对肿瘤及周围淋巴结转移进行客观评价，其特异性高，阳性预测值约75%-100%Objective view on tumor and lymph node metastasis with 75%-100%positive predictive value昂贵的价格制约了其广泛应用Applicati
16、on limited by expensive costing151 5影像学方法-P E T C T 检查n 是评价子宫肿瘤良恶性的最16MRI在子宫恶性肿瘤诊断上的价值在子宫恶性肿瘤诊断上的价值Diagnostic Value of MRI in UterineMalignant Neoplasm161 6 MR I 在子宫恶性肿瘤诊断上的价值1 617MRI成像的优势成像的优势Advantage of MRInnnn无损伤和辐射性No injury and radiation高的软组织分辨力和极高的敏感度High soft tissue resolution and sensitivit
17、yMRI三维成像使病灶定位更准确3D images with high accuracy in lesions检出子宫多灶性病变以及评价侵犯的范围、周围淋巴结转移区域有明显价值Identifying multiple lesions,invasive extending and lymph nodemetastasis171 7 MR I 成像的优势n 无损伤和辐射性1 718nn动态增强检查可了解病变的血流灌注情况,有助于病变性质的评价Exploring perfusion&evaluation of tumors by DCT为准确分期和临床治疗方案的制定提供可靠依据Providing a
18、ccurate staging and therapy planning181 8 n 动态增强检查可了解病变的血流灌注情况,有助于1 819子宫子宫MRI检查的适应症检查的适应症Indications of uterine MRI examinationnnnnn检出子宫隐匿性病灶、囊性病灶及多灶性病变Detecting occult,cystic and multiple lesions评价子宫恶性肿瘤的浸润范围和淋巴结转移Evaluating invasive extent and lympnode metastasis评价子宫恶性肿瘤的新辅助治疗疗效Evaluateing therap
19、y effect确定手术适应症Determining surgical indications监测子宫恶性肿瘤的术后复发Monitoring post-surgical recurrence191 9子宫MR I 检查的适应症n 检出子宫隐匿性病灶、囊性病灶及20子宫恶性肿瘤的子宫恶性肿瘤的MRI诊断、分期诊断、分期Diagnosing and Staging of UterineMalignant Neoplasm by MRI202 0 子宫恶性肿瘤的MR I 诊断、分期2 021（一）子宫内膜癌（一）子宫内膜癌Endometrial Carcinoma212 1（一）子宫内膜癌2 122
20、子宫内膜癌的临床特征子宫内膜癌的临床特征Clinical Characters of Endometrial Carcinomann临床表现：绝经后妇女阴道不规则流血、恶臭液体及烂肉,下腹疼痛、消瘦和贫血Clinical manifestations:postmenopausal women withirregular vaginal bleeding,foul liquid,necrotic tissue,abdominal pain,weight loss and anemia好发部位：子宫底和体后壁Occurrence sites:the posterior wall of uterus
21、 and itsbottom222 2子宫内膜癌的临床特征n临床表现：绝经后妇女阴道不规则23扩散方式The spreading ways直接播散Direct spreading淋巴转移Lymph node metastasis血行转移Hematogenous metastasis232 3 扩散方式 直接播散2 324子宫内膜癌的子宫内膜癌的MRI特征特征MRI Characters of Endometrial Carcinoma病变局限于内膜Lesions confined in endometrialnnnT1WI：癌肿信号稍低于内膜或与肌层信号一致T1WI:endometrial c
22、arcinoma signal is slightly lower than theendometrial signal or same as the myometrial signalT2WI：内膜局限/弥漫增厚，呈稍高信号T2WI:hyper-signal in limitations/diffuse thickening endometrial病变不强化或轻度强化，低于肌层Slightly or no enhanced contrast with a signal lower than myometrial242 4子宫内膜癌的MR I 特征n T 1 WI：癌肿信号稍低于内膜25病变侵
23、入肌层Invading myometrialnnn癌肿呈菜花状、息肉状突入宫腔lesions with cauliflower-like mass in the uterine cavityT2WI:低信号的结合带内出现高信号T2WI:hyper-signal in lower junctional zone增强时:肌层病变与内膜病变均呈低信号，强化的结合带不完整CE:lesion with low signals in both myometrial and endometriallayers,showing incompletely enhanced changes in the junc
24、tionalzone252 5 病变侵入肌层n 癌肿呈菜花状、息肉状突入宫腔2 526深肌层受侵Deep myometrial invasionnn子宫各层结构消失,局部肌层出现不规则低信号病灶，肌层变薄Disappearance uterine layers with focused,irregular low-signallesions in myometrium&thinning myometrium子宫增大,盆腔内组织器官广泛受侵Enlarged uterus,diffusion involvement in pelvic tissues&organs262 6 深肌层受侵n 子宫各层
25、结构消失,局部肌层出现不规则低信27nnnna:肿瘤仅局限于子宫内膜a:Tumor confined in endometriumb:子宫肌层受侵小于1/2b:invaded myometrial less than 1/2c:子宫肌层受侵大于1/2c:invased myometrial more than1/2a:宫颈内膜受侵a:invasion into cervical endometrial子宫内膜癌的临床分期子宫内膜癌的临床分期Staging of Endometrial Carcinoma采用国际妇产科联盟分期标准From International Federation of
26、Gynecology and Obstetrics,FIGO272 7 n a:肿瘤仅局限于子宫内膜子宫内膜癌的临床分期2 728nnnnnnb:肿瘤侵犯到宫颈基质外b:invasion into cervical stromal outsidea:附件受侵或穿出浆膜/腹腔积液细胞学()a:out of the annex or serosal invasion/peritoneal fluid cytology(+)b:阴道扩散b:the spread of the vaginac:盆腔或主动脉周围淋巴结转移c:pelvic lymph node metastasis around the
27、aortaa期:膀胱或直肠受侵a:involvement of bladder or rectumb期:远处转移或腹部、腹股沟淋巴结转移b:distant metastasis or the abdomen,groin lymphnode metastasis282 8 nb:肿瘤侵犯到宫颈基质外2 829292 9 2 930303 0 3 0肌层受侵小于肌层受侵小于 Cancer Institute and31子宫内膜癌子宫内膜癌Ib 期期 55岁岁-Stageb endometrial carcinoma in a 55-year-old womanT2WIT1WIT2WI1/2Liao
28、ningInvaded myometrial less than 1/231肌层受侵小于 C a n c e r I n s t i t u t e a n d 3 1Invased myometrial more than1/2T2WIT1WI32子宫内膜癌子宫内膜癌Ic期期 40岁岁-Stage Ic endometrial carcinoma in a 40-year-old womanCE:T1WICE:T1WI肌层受侵大于肌层受侵大于1/232I n v a s e d m y o m e t r i a l m o r e t h a n 1/33Copyright 2007 by
29、 the American Roentgen Ray Society子宫内膜癌子宫内膜癌IIa期期 78岁岁-Stage IIa endometrial carcinoma in a 78-year-old woman宫颈内膜受侵宫颈内膜受侵Invasion into cervical endometrialSala,E.et al.Am.J.Roentgenol.2007;188:1577-1587T2WIT2WI333 3子宫内膜癌I I a 期 7 8 岁宫颈内膜受侵I n v a34子宫内膜癌子宫内膜癌a期期-Stage a endometrial carcinoma双侧卵巢受侵双侧卵
30、巢受侵tumor invading the ovarieshttp:/T2WIT2WI343 4子宫内膜癌a 期双侧卵巢受侵T 2 WI T 2 WI 3 435子宫内膜癌子宫内膜癌b期期-Stage b endometrial carcinoma肌层受侵大于肌层受侵大于1/2伴阴道扩散伴阴道扩散Deep invasion 50%of the myometrialthickness of endometrial carcinoma(arrow).The spread of the vaginaT2WI353 5子宫内膜癌b 期(a r r o w).T h e s p r e a d36Ric
31、cardo et.al子宫内膜癌子宫内膜癌c期期-Stage c endometrial carcinoma肌层受侵大于肌层受侵大于1/2伴闭孔内淋巴结转移伴闭孔内淋巴结转移Deep invasion 50%of the myometrialthickness of endometrial carcinoma(arrow)and internal obturator lymph node metastasisT2WIRadiology 2004 18(10).1148363 6 R i c c a r d o e t.a l子宫内膜癌c 期t h i c37T2WI直肠受侵直肠受侵Involv
32、ement of rectumT2WI子宫内膜癌子宫内膜癌a期期-Stage a endometrial carcinomaT2WIT1WI373 7T 2 WI T 2 WI子宫内膜癌a 期T 1 WI 3 738Jpn Clinica lRadol 50（11）1514-1515Involvement of bladder子宫内膜癌子宫内膜癌a期期-Stage a endometrial carcinomaT2WIT2WI膀胱受侵膀胱受侵383 8 J p n C l i n i c a l R a d o l 5 0（1 1）1 5 139子宫内膜癌子宫内膜癌b期期-Stage b en
33、dometrial carcinoma宫颈受侵、腹部多发转移宫颈受侵、腹部多发转移Invasion into cervical and abdomenmetastasis393 9子宫内膜癌b 期3 940（二）子宫颈癌（二）子宫颈癌Cervical carcinoma404 0（二）子宫颈癌4 041nnn病因:尚不清，可能与妇女性生活、生育史、生殖道病毒或细菌感染、性病、种族、地理和营养状况等相关Etiology:not clearly,maybe related with sexual life,reproductive history,reproductive tract virus
34、or bacterial infection,sexually transmitteddiseases,race,geography and nutrition肿瘤来源:95%为宫颈鳞状上皮；5%为宫颈管腺上皮Oncology resource:95%from cervical squamous cell;5%from thecervical epithelium好发部位：鳞状上皮和柱状上皮间的移行区Ocurrence site:transitional zone between squamous epithelium andcolumnar epithelium子宫颈癌的临床特征子宫颈癌的临
35、床特征Clinical Characters of Cervical Carcinoma414 1 n 病因:尚不清，可能与妇女性生活、生育史、生殖道病子宫42nn临床表现：阴道出血是主要征象，可以是自然出血或接触性出血，合并感染时白带增多Clinical:the main symptom:vaginal bleeding with natural or contactbleeding,white discharge infection扩散方式：深部浸润、直接蔓延、淋巴转移，血行转移少The spreading:deep infiltration,direct spreading,lymph
36、nodemetastasis,hematogenous metastasis424 2 n 临床表现：阴道出血是主要征象，可以是自然出4 243n期：限于宫颈Stage confined to the cervixa:早期镜下浸润a-Diagnosed only by microscopy;no visible lesionsa1期:微灶浸润深度小于3mm,宽度小于7mma1-stromal invasion less than 3 mm in depth and7 mm or less in horizontal spreada2期:融合性浸润，深度在3-5mm，宽度7mma2-stroma
37、l invasion between 3 and 5 mm withhorizontal spread of 7 mm or less子宫颈癌的临床分期子宫颈癌的临床分期Staging of Cervical Carcinoma采用国际妇产科联盟分期标准From International Federation of Gynecology and Obstetrics,FIGO434 3 n 期：限于宫颈 a 1 期:微灶浸润深度小于3 m m,宽度44b期：浸润深度5mm，宽度7mmb-visible lesion or a microscopic lesion with more than
38、 5 mm ofdepth or horizontal spread of more than 7 mmb1期：病灶可视最大径40mmb2-visible lesion more than 4 cmn期：癌灶超越宫颈Stage involved in cervixa:癌肿未达到骨盆壁，累及阴道上部2/3a no parametrial invasion,but involved in upper 2/3 of vaginab:宫颈旁组织浸润b-parametrial invasion444 4 b 期：浸润深度 5 m m，宽度 7 m m n期：癌灶超45n期：癌肿累及阴道下1/3和/或达到
39、骨盆壁Stage III-extends to pelvic wall or lower third of the vaginaa期：癌肿累及阴道下1/3a-involves lower 1/3 of vaginab期：骨盆壁累和/或肾盂积水或无功能肾B-extends to pelvic wall and/or causes hydronephrosis or non-functioning kidneyn期：癌肿累及真骨盆以外部分或累及膀胱或直肠(a)，到达远处器官(b)a-invades mucosa of bladder or rectum and/or extends beyond
40、truepelvisb-distant metastasis454 5 n期：癌肿累及阴道下1/3 和/或达到骨盆壁a46464 6 4 647474 7 4 8 b e s t p r a c t i c e.b m j.c o m/b e s t-p r49http:/www.scielo.br/scielo.php?script=sci_arttext&pid=S0100 -39842007000300014&tlng=en&lng=en&nrm=iso494 9 h t t p:/w w w.s c i e l o.b r/s c i e l o.50nnnMRI轴位上显示为类圆形和不
41、规则形分叶肿块MRI:a round,irregular-shaped and lobulated mass on axial MRI矢状位显示宫颈增大为桶状，宫颈管腔消失Enlarged cervix with barrel shape on sgaiggtal imagingT1WI呈等信号，T2WI呈高信号the disappearance of cervical cannel iso-signal on T1WI;hyper-signal on T2WI子宫颈癌的子宫颈癌的MRI特征特征MRI Characters of Cervical Carcinoma癌肿的MRI表现MRI Ch
42、aracters of lesion505 0 n MR I 轴位上显示为类圆形和不规则形分叶肿块子宫颈癌51nnT2WI:癌肿与正常宫颈基质低信号及宫旁脂肪间隙有良好对比T2WI:good contrast between the tumor and normal cervicalstroma with low signal¶metrial space增强动态扫描，T1WI癌肿早期强化，可清晰显示病灶的形态、边界和宫颈基质受侵犯的深度CE:obviously showing enhanced tumor with shape and rimand the depth of cervi
43、cal stromal invasion515 1 n T 2 WI:癌肿与正常宫颈基质低信号及宫旁脂肪5 152癌肿侵犯深度的MRI评价Tumor invasion depth:evaluation by MRInn局限于粘膜内：浸润深度5mm，T1WI与T2WI呈中等信号，与正常粘膜接近;增强扫描可依据早期强化的癌肿清晰显示病灶的边缘及其浸润的深度Confined in mucosa:the invasion depth 5mm，宽度，宽度7mmStromal invasion more than5 mm in depth and morethan7 mm in horizontal sp
44、readT1WIT2WI545 4子宫颈癌I b 期 3 6 岁T 2 WI T 1 WI T 2 WI 5 455浸润深度浸润深度5mm，宽度，宽度7mmStromal invasion more than5 mm in depth and morethan7 mm in horizontal spread子宫颈癌子宫颈癌Ib期期-Stage b cervical carcinomaT2WIT2WI555 5 浸润深度 5 m m，宽度 7 m m子宫颈癌I b 期T 2 WI 556子宫颈癌子宫颈癌a期期 34岁岁-Stage a cervical carcinoma in a 34-ye
45、ar-old womanT2WIT2WIT2WIT1WI癌肿累及阴道上部癌肿累及阴道上部2/3involved in upper 2/3 ofvagina565 6子宫颈癌a 期 3 4 岁T 2 WI T 2 WI T 2 WI T 1 WI57子宫颈癌子宫颈癌b期期 47岁岁-Stage b cervical carcinoma in a 47-year-old woman宫颈旁组织浸润宫颈旁组织浸润parametrial invasionT2WIT2WISala,E.et al.Am.J.Roentgenol.2007;188:1577-1587575 7子宫颈癌b 期 4 7 岁宫颈旁
46、组织浸润T 2 WIT 2 WI58子宫颈癌子宫颈癌b期期-Stage b cervical carcinoma宫颈旁组织浸润宫颈旁组织浸润parametrial invasionT2WIT2WIT2WIT2WI585 8子宫颈癌b 期宫颈旁组织浸润p a r a m e t r i a l i59Copyright 2007 by the American Roentgen Ray Society子宫颈癌子宫颈癌IIb期期 42岁岁-Stage IIb cervical cancer in 42-year-old womanT2WI宫颈旁组织浸润宫颈旁组织浸润parametrial inva
47、sionT2WISala,E.et al.Am.J.Roentgenol.2007;188:1577-1587595 9子宫颈癌I I b 期 4 2 岁T 2 WIT 2 WI 5 960子宫颈癌子宫颈癌IIIa期期 45岁岁-Stage a cervical cancer in 45-year-old womanT2WI累及阴道下累及阴道下1/3extends to the lower 1/3 of vaginaT2WI606 0子宫颈癌I I I a 期 4 5 岁6 061子宫颈癌子宫颈癌IVa期期 39岁岁-Stage a cervical cancer in 39-year-old
48、 womanT2WI累及直肠累及直肠extends to rectumT2WISala,E.et al.Am.J.Roentgenol.2007;188:1577-1587616 1子宫颈癌I V a 期 3 9 岁T 2 WIT 2 WI 6 162Copyright 2007 by the American Roentgen Ray Society子宫颈癌子宫颈癌IVa期期-Stage a cervical cancer累及膀胱累及膀胱extends to rectum and bladderT2WISala,E.et al.Am.J.Roentgenol.2007;188:1577-15
49、87626 2子宫颈癌I V a 期累及膀胱T 2 WI 6 263（三）子宫肉瘤（三）子宫肉瘤Uterine Sarcoma636 3（三）子宫肉瘤6 364nnn病因：尚不清Etiology:unclear肿瘤来源:子宫平滑肌、子宫内膜间质、血管、纤维组织Oncology Source:uterine smooth muscle,endometrial stromal,vascular,fibrous tissues病理分类：子宫平滑肌肉瘤、子宫内膜间质肉瘤、混合型同源mullerian肉瘤、混合型异源mullerian肉瘤Pathological classification:uteri
50、ne leiomyosarcoma,endometrial stromalsarcoma,homologous mixed mullerian sarcoma,mixed mullerianheterologous sarcoma子宫肉瘤的临床特征子宫肉瘤的临床特征Clinical Characters of Uterine Sarcoma646 4 n 病因：尚不清子宫肉瘤的临床特征6 465临床表现Clinical manifestationsnnnn最常见症状不规则阴道出血Common symptoms-irregular vaginal bleeding肿瘤生长过快、过度膨胀或瘤内出血
