2025 , Vol. 22 >Issue 01: 15 - 24
DOI: https://doi.org/10.3877/cma.j.issn.1672-6448.2025.01.003
富血供子宫肌瘤超声造影特征及其组织病理学相关性
Copy editor: 吴春凤
收稿日期: 2024-09-03
网络出版日期: 2025-04-18
基金资助
国家自然科学基金（82272004，81974470）浙江省自然科学基金（LZ22H180001）
版权
Contrast-enhanced ultrasound features of highly vascularized uterine leiomyoma and their correlation with pathology
Received date: 2024-09-03
Online published: 2025-04-18
Copyright
目的
探讨不同病理类型富血供子宫肌瘤超声造影特征及其与组织病理学的相关性，为临床治疗方案的选择提供影像学依据。
方法
收集2021 年6 月至2023 年10 月在浙江大学医学院附属妇产科医院因子宫肌瘤住院并进行手术治疗的病例78 例，共计97 枚病灶，均经彩色/能量多普勒超声检查诊断为富血供的子宫肌瘤，术前均行超声造影检查。根据组织病理学结果将病灶分为普通子宫肌瘤组、普通子宫肌瘤变性组、特殊类型子宫肌瘤组及子宫肉瘤组4 组进行比较；再将普通子宫肌瘤变性组中水肿变性子宫肌瘤、透明变性子宫肌瘤和特殊类型子宫肌瘤组中富细胞性平滑肌瘤与普通子宫肌瘤组进行比较。使用Fisher 确切概率法比较组间超声造影特征整体差异，采用Bonferroni 检验进行两两比较，分析比较各组病灶造影剂到达时间、达峰时间及增强晚期病灶内造影剂消退快慢及强化程度的超声造影模式之间的差异。
结果
97 枚彩色/能量多普勒超声检查诊断为富血供子宫肌瘤中93 枚（95.9%）最终经组织病理学诊断为良性子宫肌瘤，4 枚（4.1%）诊断为恶性子宫肉瘤。普通子宫肌瘤组（51 枚）、普通子宫肌瘤变性组（23 枚）、特殊类型子宫肌瘤组（19 枚）与子宫肉瘤组（4 枚）4 组比较造影剂到达时间（P=0.004），达峰时病灶强化程度（P=0.013）、内部造影剂分布均匀性（P＜0.001），增强晚期病灶内造影剂消退快慢（P＜0.001）、病灶强化程度（P=0.005）差异均具有统计学意义；普通子宫肌瘤组（51 枚）与普通子宫肌瘤水肿变性组（11 枚）、普通子宫肌瘤透明变性组（10 枚）和富细胞性平滑肌瘤组（11 枚）4 组比较：造影剂到达时间（P=0.001），达峰时病灶强化程度（P=0.014）、内部造影剂分布均匀性（P＜0.001），增强晚期病灶内造影剂消退快慢（P＜0.001）差异均具有统计学意义，增强晚期病灶强化程度差异无统计学意义（P=0.329）。不同病理类型富血供子宫肌瘤超声造影增强模式表现为：（1）普通子宫肌瘤组以同步均匀性等增强模式为主；（2）普通子宫肌瘤变性组达峰时不均匀性增强比例较高，其中水肿变性以快进高增强模式为主，内见“筛孔状”低灌注区；透明变性以同步等增强或低增强模式为主；（3）子宫肉瘤组快进快出不均匀性高增强比例最高，其中3 枚（75.0%）病灶可见“地图样”不规则无灌注区域；（4）特殊类型子宫肌瘤组中富细胞性平滑肌瘤快进高增强比例较高，但低于子宫肉瘤组，达峰时病灶内部造影剂分布较均匀。
结论
不同病理类型的富血供子宫肌瘤超声造影模式之间存在差异，这些差异特征有助于术前推断其组织病理学类型，为临床决策提供影像学依据。
于爽 , 王茜 , 方昀 , 陈敏 , 王立臣 , 朱江 . 富血供子宫肌瘤超声造影特征及其组织病理学相关性[J]. 中华医学超声杂志（电子版）, 2025 , 22(01) : 15 -24 . DOI: 10.3877/cma.j.issn.1672-6448.2025.01.003
Objective
To explore the correlation between contrast-enhanced ultrasound (CEUS)characteristics and pathology of highly vascularized uterine leiomyoma, in order to provide a reliable imaging basis for the selection of clinical treatment.
Methods
A total of 78 patients who were hospitalized and underwent surgical treatment for uterine leiomyoma in the Women’s Hospital School of Medicine Zhejiang University from June 2021 to October 2023 were collected.Finally, 97 lesions were diagnosed as highly vascularized uterine leiomyoma by color/energy Doppler ultrasonography, all of which underwent contrastenhanced ultrasound before surgery.According to pathology, the 97 lesions were divided into common uterine leiomyomas, common uterine leiomyomas with degeneration, special types of uterine leiomyomas,and uterine sarcoma for comparison.The edematous uterine leiomyomas and uterine leiomyomas with hyaline degeneration in the common leiomyomas with degeneration group, and the cellular leiomyomas in the special leiomyoma group were also compared with the common uterine leiomyomas group.Fisher exact probability method was used to compare the overall difference between groups, and Bonferroni test was used for pairwise comparisons.The contrast-enhanced ultrasound mode features, arrival time, time to peak,and late enhancement features were also compared among the groups.
Results
Ninety-three (95.9%) of 97 highly vascularized uterine leiomyomas diagnosed by color/energy Doppler ultrasonography were eventually diagnosed as benign leiomyoma by histopathology, and four (4.1%) were diagnosed as uterine sarcomas.The arrival time (P=0.004), the degree of enhancement at the peak (P=0.013), the uniformity of internal contrast distribution (P＜0.001), the speed of wash-out (P＜0.001), and the degree of lesion enhancement (P=0.005)differed significantly among the common uterine leiomyomas group (51 lesions), the uterine leiomyomas with degeneration group (23 lesions), the special type of uterine leiomyomas group (19 lesions), and the uterine sarcomas group (4 lesions).There were significant differences in the arrival time (P=0.001), the degree of enhancement (P=0.014), the uniformity of internal contrast distribution (P＜0.001), and the speed of washout (P＜0.001) among common leiomyoma (51 lesions), edematous uterine leiomyomas (11 lesions) and uterine leiomyomas with hyaline degeneration (11 lesions) in the common leiomyomas with degeneration group, and cellular leiomyomas (11 lesions) in the special type of leiomyomas group, though there was no significant difference in the degree of enhancement in the late stage of enhancement (P=0.329).The contrastenhanced ultrasound patterns of different pathology classifications of highly vascularized uterine leiomyoma were as follows: (1) The enhanced mode such as synchronous uniformity and equal enhanced ratio was higher in the common leiomyomas group; (2) The time to peak and inhomogeneity enhancement ratio was higher in the common leiomyomas with degeneration group.The fast-in hyperenhancement pattern was the main pattern of edematous degeneration, “honeycomb-like” hypoperfusion areas were seen internally,and hyaline degeneration was dominated by synchronous equal enhancement or low enhancement patterns;(3) The uterine sarcomas group had the highest proportion fast wash-out and inhomogeneity enhancement,and 3 lesions (75.0%) showed non-perfusion areas of “map pattern”; and (4) The proportion of cellular leiomyomas in the special type of leiomyomas group with fast-in and high enhancement was high, but lower than that of the uterine sarcoma group.
Conclusion
There are differences in contrast-enhanced ultrasound patterns between different pathologic types of highly vascularized uterine leiomyomas and uterine sarcomas.These differences can help to infer the pathology classification before surgery and provide an imaging basis for clinical decision-making.
Key words： Uterine leiomyoma; Ultrasound; Contrast-enhanced ultrasound; Pathology
±s 表示，CEUS 检查时间与手术时间间隔为服从偏态分布的计量资料，采用M（QR）表示；患者临床症状、病理结果及CEUS 特征为计数资料，使用例数与构成比描述，使用Fisher 确切概率法比较组间整体差异性，再利用Bonferroni 方法进行组间多重比较。P＜0.05 表示差异有统计学意义。表1 不同病理类型子宫肌瘤患者超声造影特征比较[枚（%）] |
| 项目 | 普通子宫肌瘤组（n=51） | 普通子宫肌瘤变性组（n=23） | 特殊类型子宫肌瘤组（n=19） | 子宫肉瘤组（n=4） | P 值 |
|---|---|---|---|---|---|
| 增强早期 | |||||
| 造影剂到达时间 | 0.004 | ||||
| 早 | 9（17.6） | 8（34.8） | 8（42.1） | 4（100）a | |
| 同步 | 34（66.7） | 11（47.8） | 5（26.3）a | 0（0）a | |
| 晚 | 8（15.7） | 4（17.4） | 6（31.6） | 0（0） | |
| 达峰时 | |||||
| 强化程度 | 0.013 | ||||
| 高增强 | 10（19.6） | 8（34.8） | 7（36.8） | 4（100）a | |
| 等增强 | 29（56.9） | 12（52.2） | 5（26.3） | 0（0） | |
| 低增强 | 12（23.5） | 3（13.0） | 7（36.8） | 0（0） | |
| 分布 | ＜ 0.001 | ||||
| 均匀 | 49（96.1） | 7（30.4） | 14（73.7）ab | 1（25.0）a | |
| 不均匀 | 2（3.9） | 16（69.6） | 5（26.3）ab | 3（75.0）a | |
| 增强晚期 | |||||
| 造影剂消退 | ＜ 0.001 | ||||
| 早 | 3（5.9） | 2（8.7） | 4（21.1） | 4（100）abc | |
| 同步 | 43（84.3） | 14（60.9） | 7（36.8）a | 0（0）a | |
| 晚 | 5（9.8） | 7（30.4） | 8（42.1）a | 0（0） | |
| 强化程度 | 0.005 | ||||
| 高增强 | 9（17.6） | 0（0） | 5（26.3） | 3（75.0）ab | |
| 等增强 | 27（52.9） | 17（73.9） | 7（36.8） | 0（0）b | |
| 低增强 | 15（29.4） | 6（26.1） | 7（36.8） | 1（25.0） |
注：a 与普通子宫肌瘤组比较，b 与普通子宫肌瘤变性组比较，c 与特殊类型子宫肌瘤组比较，差异具有统计学意义（P＜0.05） |
表2 不同病理类型亚型子宫肌瘤患者超声造影特征比较[枚（%）] |
| 项目 | 普通子宫肌瘤组（n=51） | 普通子宫肌瘤水肿变性组（n=11） | 普通子宫肌瘤透明变性组（n=10） | 富细胞性平滑肌瘤组（n=11） | P 值 |
|---|---|---|---|---|---|
| 增强早期 | |||||
| 造影剂到达时间 | 0.001 | ||||
| 早 | 9（17.6） | 7（63.6）a | 1（10.0） | 8（72.7）ab | |
| 同步 | 34（66.7） | 3（27.3） | 6（60.0） | 2（18.2）a | |
| 晚 | 8（15.7） | 1（9.1） | 3（30.0） | 1（9.1） | |
| 达峰时 | 0.014 | ||||
| 强化程度 | |||||
| 高增强 | 10（19.6） | 6（54.5） | 1（10.0） | 7（63.6）a | |
| 等增强 | 29（56.9） | 4（36.4） | 5（50.0） | 4（36.4） | |
| 低增强 | 12（23.5） | 1（9.1） | 4（40.0） | 0（0） | |
| 分布 | ＜ 0.001 | ||||
| 均匀 | 49（96.1） | 5（45.5）a | 2（20.0）a | 9（81.8）b | |
| 不均匀 | 2（3.9） | 6（54.5）a | 8（80.0）a | 2（18.2）b | |
| 增强晚期 | |||||
| 造影剂消退 | ＜ 0.001 | ||||
| 早 | 3（5.9） | 2（18.2） | 0（0） | 7（63.6）ab | |
| 同步 | 43（84.3） | 5（45.5）a | 5（50.0） | 3（27.3）a | |
| 晚 | 5（9.8） | 4（36.4） | 5（50.0）a | 1（9.1） | |
| 强化程度 | 0.329 | ||||
| 高增强 | 9（17.6） | 0（0） | 0（0） | 3（27.3） | |
| 等增强 | 27（52.9） | 8（72.7） | 5（50.0） | 4（36.4） | |
| 低增强 | 15（29.4） | 3（27.3） | 5（50.0） | 4（36.4） |
注：a 与普通子宫肌瘤组比较，b 与普通子宫肌瘤透明变性组比较，差异具有统计学意义（P＜0.05） |
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