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中华医学超声杂志(电子版) ›› 2024, Vol. 21 ›› Issue (07) : 749 -751. doi: 10.3877/cma.j.issn.1672-6448.2024.07.019

病例报告

稽留流产合并子宫上皮样平滑肌瘤水肿变性超声造影误诊一例并文献复习
方昀1, 朱江2,()   
  1. 1. 324000 浙江衢州,温州医科大学附属衢州医院(衢州市人民医院)超声科;310016 杭州,浙江大学附属妇产科医院超声科
    2. 310016 杭州,浙江大学附属妇产科医院超声科
  • 收稿日期:2023-12-03 出版日期:2024-07-01
  • 通信作者: 朱江
  • 基金资助:
    浙江省自然科学基金(LZ22H180001); 衢州市科技局指导性科技攻关项目(2022005)

Misdiagnosis of missed miscarriage complicated with uterine epithelioid leiomyoma with edema and degeneration by contrast-enhanced ultrasound: a case report and literature review

Yun Fang, Jiang Zhu()   

  • Received:2023-12-03 Published:2024-07-01
  • Corresponding author: Jiang Zhu
引用本文:

方昀, 朱江. 稽留流产合并子宫上皮样平滑肌瘤水肿变性超声造影误诊一例并文献复习[J]. 中华医学超声杂志(电子版), 2024, 21(07): 749-751.

Yun Fang, Jiang Zhu. Misdiagnosis of missed miscarriage complicated with uterine epithelioid leiomyoma with edema and degeneration by contrast-enhanced ultrasound: a case report and literature review[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(07): 749-751.

患者女性,36岁,停经60余天,来院产检,经阴道彩色多普勒超声发现子宫体如孕50余天,胚囊大小3.7 cm×1.8 cm,胚芽长1.5 cm,未及心管搏动。子宫肌层右后壁见等回声团,大小4.1 cm×1.1 cm×3.3 cm,边界清楚,形态尚规则,内部回声欠均匀,由肌壁间向浆膜外突起,彩色多普勒血流成像(color Doppler flow imaging,CDFI)见丰富的绕边及内部血流信号(图1)。频谱多普勒测得峰值血流速度0.87 m/s,阻力指数0.4,弹性成像显示包块质软,双侧卵巢未见明显异常回声。超声提示:(1)宫内早孕,胚胎停育;(2)子宫右后壁等回声区,首先考虑子宫肌瘤(肉瘤变不完全除外),建议行静脉妇科超声造影(contrast-enhanced ultrasound,CEUS)。盆腔增强磁共振检查:(1)胚芽显示不清;(2)子宫右后壁肿块T1加权成像等低信号,T2加权成像稍高信号,弥散加权成像稍高信号,增强后明显强化,诊断:子宫富血管性肿块,考虑肌瘤(图2)。CEUS:经肘静脉团注造影剂1.5 ml(SonoVue,Bracco公司),14 s时,病灶早于肌层显示周边及中心的同步灌注,而后实质快速增强;20 s达峰,实质内显现较弥漫、大小均匀的筛孔状低灌注点;于增强晚期30 s出现晚于肌层的缓慢消退,以低灌注点尤为显著,而后病灶周边"血管环"开始出现并持续,造影总时长达3 min多,整体呈"快进-慢出不均匀高增强"模式。造影提示:子宫肌瘤伴水肿变性可能性大(图3a~3f)。遂行腹腔镜下子宫肿块剔除术,术中见肿块表面多根血管爬行,质软,切面黄色(图3g)。常规病理(图3h):考虑上皮样平滑肌瘤伴水肿变性,核分裂(0~1)/10HPF。免疫组织化学染色:CD10(+)、ALK(-)、P-Trk(-)、CK(-)、P53(野生型)、ER(+)、Desmin(+)、Ki-67(15%+)、P16(部分+)、SMA(部分+)、HMB45(-)、S-100(-)、Melan-A(+)。患者术后1年复查未见明显复发征象。

图1 患者子宫彩色多普勒超声声像图。图a示胚芽无心管搏动,图b示病灶等回声,边界清楚,内部回声欠均匀,图c示病灶周边及内部血流丰富
图2 患者盆腔磁共振成像图。图a:病灶T1加权成像呈等低信号;图b:病灶T2加权成像稍高信号;图c:病灶增强后明显强化
图3 患者子宫超声造影及手术病理图像。图a:增强早期14 s示周边及内部同步显影;图b、c:造影参量模式示4 s内整体快速高增强(灌注顺序为红色-亮黄-绿色-蓝色-紫色);图d:增强达峰期实质内较弥漫、均匀的筛孔状低灌注点(白箭头);图e:增强晚期低灌注点廓清较显著(白箭头);图f:增强晚期周边"血管环"清晰(白箭头);图g:术中病灶;图h:常规病理(HE×40)图示上皮样肌瘤水肿变性
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