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聚丙烯酰胺水凝胶(polyacrylamide hydrogel,PAHG)是一种用于注射填充、不被人体吸收的水凝胶,自1997年后被广泛应用于注射隆乳术。但由于并发症较多,2006年以后我国禁止在美容行业临床应用PAHG[1]。随着对PAHG注射隆乳术后并发症的深入认识,以及动物模型研究表明,PAHG具有明显的致畸、致癌等特性。MRI对PAHG术后并发症的诊断、填充物清除术前评估和疗效评价已有较多研究[1-2]。王蓼等[1]认为,MRI可作为PAHG注射隆乳术后并发症的首选影像学检查方法。而对于PAHG注射隆乳术后乳腺病变的MR诊断[3-5]和成像技术研究尚不充分[6]。本文拟回顾性分析PAHG注射隆乳患者的多序列MRI扫描结果,比较各序列成像对乳腺病变的检出效能,以期优选扫描序列,提高PAHG注射隆乳后乳腺病变的MRI检出率和诊断准确率。
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80例160个乳腺中共检出86个病灶,全部经手术病理确诊,结果见表 1。其中,单侧乳腺1个病灶74例;单侧乳腺2个病灶1例;双侧乳腺各1个病灶5例。乳腺病灶性质:乳腺癌30个(图 1)、纤维腺瘤21个、导管内乳头状瘤14个、囊肿10个、脓肿6个(图 2)、乳腺腺病5个。
扫描序列 乳腺癌 纤维腺瘤 导管内乳头状瘤 囊肿 脓肿 乳腺腺病 合计 检出率/% 乳腺癌诊断准确率/% T1加权成像 10 5 3 7 1 2 28 32.56 33.33 T2加权成像 20 10 4 10 6 3 53 61.11 66.67 STIR 20 11 5 10 6 3 55 63.88 66.67 MRH 14 7 2 8 4 1 36 41.66 46.67 DWI 30 16 12 10 6 3 77 89.53 100 LAVA 30 21 14 10 6 5 86 100 100 注:表中,PAHG:聚丙烯酰胺水凝胶;STIR:短时间反转恢复;MRH:MR水成像;DWI:弥散加权成像;LAVA:肝脏容积超快速多期动态增强成像。 表 1 不同MRI序列对PAHG注射隆乳后乳腺病灶(86个)的总检出情况
Table 1. Total detection lesions(86) of different sequences of MR with PAHG injection for augmentation mammoplasty
图 1 患者女性,45岁,聚丙烯酰胺水凝胶注射隆乳术后10年,右侧乳腺外象限扪及肿块,经病理证实为浸润性导管癌Ⅱ级。图中,A:T1加权像呈稍低信号;B:T2加权像呈等信号;C:短时间反转恢复呈等信号;D:弥散加权成像b=800 mm2/s呈稍高信号,病灶边缘模糊;E:肝脏容积超快速多期动态增强3 min图像,显示病灶明显均匀强化;F:肝脏容积超快速多期动态增强时间-信号曲线,呈速升速降型(红色曲线)。右乳腺皮肤表面见鱼肝油胶囊标记(短箭头),对应部位乳腺外上象限见小结节灶(长箭头),大小约2.5 cm×1.1 cm×1.0 cm。
Figure 1. Female patient, 45 years old. 10 years later with polyacrylamide hydrogel injection for augmentation mammoplasty. A mass was touched(with two Cod Liver Oil capsules marker, Short arrow) on the right upper quadrant of the right breast, and was confirmed invasive ductal carcinoma grade Ⅱ by the pathology(long arrow, 2.5 cm×1.1 cm×1.0 cm).
图 2 患者女性,40岁,聚丙烯酰胺水凝胶注射隆乳术后3年,双侧乳腺外象限扪及包块,经手术病理证实为脓肿。图中,A:T1加权像呈稍低信号;B:T2加权像呈高信号;C:短时间反转恢复呈高信号;D:弥散加权成像b=800 mm2/s呈高信号;E:肝脏容积超快速多期动态增强9 min图像,显示病灶环形强化,边缘清晰;F:MR水成像容积再现图,明确显示了结节灶与聚丙烯酰胺水凝胶注射物的立体关系。双侧乳腺见完整PAHG注射填充物。右侧乳腺外上象限见结节灶(箭头),大小约1.9 cm×2.0 cm×2.4 cm。
Figure 2. Female patient, 40 years old. 3 years later with polyacrylamide hydrogel injection for augmentation mammoplasty. Masses were touched in bilateral outer quadrant of the breasts and were diagnosed as abscess by pathology.
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各序列对乳腺病变的总检出率有显著性差异,R×C交叉表卡方检验显示:χ2=129.428,P<0.05,差异有统计学意义;各序列图像对乳腺癌的诊断准确率也有显著性差异,R×C交叉表分析显示:χ2=51.843,P<0.05,差异有统计学意义(表 1)。
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乳腺病变总检出率中,除T1加权与MRH、T2加权与STIR的差异无统计学意义外,其他序列之间的差异均有统计学意义。而乳腺癌诊断准确率中,MRH与T1加权、MRH与T2加权、MRH与STIR、T2加权与STIR,以及DWI与LAVA增强序列之间的差异均无统计学意义,其他序列之间的差异有统计学意义(表 2)。
组别 乳腺病变检出率 乳腺癌诊断准确率 χ2值 P值 χ2值 P值 ①与② 14.584 0.000 6.667 0.010 ①与③ 16.974 0.000 6.667 0.010 ①与④ 1.593 0.207 1.111 0.292 ①与⑤ 58.702 0.000 30.000 0.000 ①与⑥ 87.509 0.000 30.000 0.000 ②与③ 0.100 0.752 0.000 1.000 ②与④ 6.729 0.009 2.443 0.118 ②与⑤ 18.145 0.000 12.000 0.001 ②与⑥ 40.835 0.000 12.000 0.001 ③与④ 8.424 0.004 2.443 0.118 ③与⑤ 15.767 0.000 12.000 0.001 ③与⑥ 37.816 0.000 12.000 0.001 ④与⑤ 43.368 0.000 21.818 0.000 ④与⑥ 70.492 0.000 21.818 0.000 ⑤与⑥ 9.497 0.003 0.000 1.000* 注:表中,PAHG:聚丙烯酰胺水凝胶;①:T1加权像;②:T2加权像;③:STIR(短时间反转恢复);④:MRH(MR水成像);⑤:DWI(弥散加权成像);⑥:LAVA(肝脏容积超快速)多期动态增强成像;*:Fisher精确概率法。 表 2 不同MRI序列对PAHG注射隆乳后乳腺病变总检出率和乳腺癌诊断准确率的组内两两比较情况
Table 2. Pairwise comparison within groups for total detection rate of breast lesions and diagnosis accuracy of breast cancer by different MR sequences with PAHG injection for augmentation mammoplasty
不同MRI序列检出聚丙烯酰胺水凝胶注射隆乳患者乳腺病变效能的比较研究
The different MRI sequences to detect breast lesions in polyacrylamide hydrogel injection for augmentation patients:a comparative study
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摘要:
目的 探讨不同MRI序列对聚丙烯酰胺水凝胶(PAHG)注射隆乳后乳腺病变的检出效能。 方法 回顾性分析80例临床怀疑合并乳腺病变的注射隆乳患者的MRI影像资料,扫描序列包括T1加权像、T2加权像、短时间反转恢复(STIR)、弥散加权成像(DWI)、MR水成像(MRH)及肝脏容积超快速(LAVA)三维多期动态增强序列,分析各序列图像中病灶的信号特点、位置、形态、大小和数量,以及时间-信号强度曲线,分别计算不同序列对乳腺病变的总检出率和对乳腺癌的诊断准确率。各序列病灶的总检出率差异采用R×C交叉表卡方检验,组内两两比较采用卡方检验分析。 结果 160个乳腺中共检出86个病灶,其中乳腺癌病灶30个。T1加权像、T2加权像、STIR、DWI、MRH及LAVA增强序列对乳腺病灶的总检出率分别为32.56%(28/86)、61.11%(53/86)、63.88%(55/86)、41.66%(36/86)、89.53%(77/86)、100%(86/86),其中乳腺癌病灶诊断准确率分别为33.33%(10/30)、66.67%(20/30)、66.67%(20/30)、46.67%(14/30)、100%(30/30)、100%(30/30)。对各序列乳腺病变的总检出率行R×C交叉表卡方检验:χ2=129.428,P < 0.05,差异有统计学意义;对各序列乳腺癌病灶诊断准确率行R×C交叉表卡方检验:χ2=51.843,P < 0.05,差异有统计学意义。对各序列乳腺病变总检出率和乳腺癌病灶诊断准确率行组内两两比较分析,除T1加权像与MRH、T2加权像与STIR对乳腺病变总检出率的差异无统计学意义外(χ2=1.593、0.100,P均>0.05),其他均有统计学意义(χ2=6.729~87.509,P均 < 0.05);而MRH与T1加权像、MRH与T2加权像、MRH与STIR、T2加权像与STIR,以及DWI与LAVA增强序列对乳腺癌诊断准确率的差异均无统计学意义(χ2=1.111、2.443、2.443、0.000、0.000,P均>0.05),其他序列的差异有统计学意义(χ2=12.000~30.000,P均 < 0.05)。 结论 DWI和LAVA增强序列对PAHG注射隆乳后乳腺病变的总检出率最高;合理应用MRI序列,有利于提高乳腺癌病灶的诊断准确率。 Abstract:Objective To explore the detective values of various MRI sequences in breast polyacrylamide hydrogel(PAHG) injection for augmentation patients. Methods A total of 80 patients who have been injected for augmentation and who have suspected breast lesions were subjected to MRI scanning. The MRI scan sequence included T1 weighted imaging(T1WI), T2 weighted imaging(T2WI), short time inversion recovery(STIR), diffusion weighted imaging(DWI) and MR hydrography(MRH), as well as liver acquisition with valume acceleration(LAVA) dynamic contrast-enhanced sequence. The main sequence analysis indicators included the detection rate of breast disease and breast cancer, and to analyze statistically. Results A total of 86 lesions were observed in 160 breasts. The breast-lesion detection rates of the T1WI, T2WI, STIR, DWI and MRH, as well as LAVA dynamic contrast-enhanced sequence were 32.56%(28/86), 61.11%(53/86), 63.88%(55/86), 41.66%(36/86), 89.53%(77/86), and 100%(86/86), respectively; the breast-cancer detection rates of these sequences were 33.33%(10/30), 66.67%(20/30), 66.67%(20/30), 46.67%(14/30), 100%(30/30), and 100%(30/30), respectively. Each MRI scanning sequence of breast-lesion detection rate of R×C cross-table analysis, χ2=129.428, P < 0.05; the difference was statistically significant. Each MRI scanning sequence of breast-cancer detection rate of R×C cross-table analysis, χ2=51.843, P < 0.05; the difference was statistically significant. Each MRI scanning sequence detection rate of breast disease and breast cancer in the group were compared pairwise. The detection rates of breast lesions were not statistically significant in T1WI and MRH, T2WI and STIR(χ2=1.593, 0.100, both P>0.05), whereas those in the other scanning sequences were statistically significant(χ2=6.729~87.509, all P < 0.05). The differences in breast-cancer detection rates in MRH and T1WI, MRH and T2WI, MRH and STIR, T2WI and STIR, and DWI and LAVA were not statistically significant(χ2=1.111, 2.443, 2.443, 0.000, 0.000, all P>0.05), whereas those of the other sequences were statistically significant(χ2=12.000~30.000, all P < 0.05). Conclusions The total detection rate of breast lesions with PAHG injection for augmentation mammoplasty by DWI and LAVA-enhanced sequence wasthe highest. Rational use of MRI sequence will help improve the lesion detection rate of patients' breast augmentation PAHG injection and has important clinical value. -
图 1 患者女性,45岁,聚丙烯酰胺水凝胶注射隆乳术后10年,右侧乳腺外象限扪及肿块,经病理证实为浸润性导管癌Ⅱ级。图中,A:T1加权像呈稍低信号;B:T2加权像呈等信号;C:短时间反转恢复呈等信号;D:弥散加权成像b=800 mm2/s呈稍高信号,病灶边缘模糊;E:肝脏容积超快速多期动态增强3 min图像,显示病灶明显均匀强化;F:肝脏容积超快速多期动态增强时间-信号曲线,呈速升速降型(红色曲线)。右乳腺皮肤表面见鱼肝油胶囊标记(短箭头),对应部位乳腺外上象限见小结节灶(长箭头),大小约2.5 cm×1.1 cm×1.0 cm。
Figure 1. Female patient, 45 years old. 10 years later with polyacrylamide hydrogel injection for augmentation mammoplasty. A mass was touched(with two Cod Liver Oil capsules marker, Short arrow) on the right upper quadrant of the right breast, and was confirmed invasive ductal carcinoma grade Ⅱ by the pathology(long arrow, 2.5 cm×1.1 cm×1.0 cm).
图 2 患者女性,40岁,聚丙烯酰胺水凝胶注射隆乳术后3年,双侧乳腺外象限扪及包块,经手术病理证实为脓肿。图中,A:T1加权像呈稍低信号;B:T2加权像呈高信号;C:短时间反转恢复呈高信号;D:弥散加权成像b=800 mm2/s呈高信号;E:肝脏容积超快速多期动态增强9 min图像,显示病灶环形强化,边缘清晰;F:MR水成像容积再现图,明确显示了结节灶与聚丙烯酰胺水凝胶注射物的立体关系。双侧乳腺见完整PAHG注射填充物。右侧乳腺外上象限见结节灶(箭头),大小约1.9 cm×2.0 cm×2.4 cm。
Figure 2. Female patient, 40 years old. 3 years later with polyacrylamide hydrogel injection for augmentation mammoplasty. Masses were touched in bilateral outer quadrant of the breasts and were diagnosed as abscess by pathology.
表 1 不同MRI序列对PAHG注射隆乳后乳腺病灶(86个)的总检出情况
Table 1. Total detection lesions(86) of different sequences of MR with PAHG injection for augmentation mammoplasty
扫描序列 乳腺癌 纤维腺瘤 导管内乳头状瘤 囊肿 脓肿 乳腺腺病 合计 检出率/% 乳腺癌诊断准确率/% T1加权成像 10 5 3 7 1 2 28 32.56 33.33 T2加权成像 20 10 4 10 6 3 53 61.11 66.67 STIR 20 11 5 10 6 3 55 63.88 66.67 MRH 14 7 2 8 4 1 36 41.66 46.67 DWI 30 16 12 10 6 3 77 89.53 100 LAVA 30 21 14 10 6 5 86 100 100 注:表中,PAHG:聚丙烯酰胺水凝胶;STIR:短时间反转恢复;MRH:MR水成像;DWI:弥散加权成像;LAVA:肝脏容积超快速多期动态增强成像。 表 2 不同MRI序列对PAHG注射隆乳后乳腺病变总检出率和乳腺癌诊断准确率的组内两两比较情况
Table 2. Pairwise comparison within groups for total detection rate of breast lesions and diagnosis accuracy of breast cancer by different MR sequences with PAHG injection for augmentation mammoplasty
组别 乳腺病变检出率 乳腺癌诊断准确率 χ2值 P值 χ2值 P值 ①与② 14.584 0.000 6.667 0.010 ①与③ 16.974 0.000 6.667 0.010 ①与④ 1.593 0.207 1.111 0.292 ①与⑤ 58.702 0.000 30.000 0.000 ①与⑥ 87.509 0.000 30.000 0.000 ②与③ 0.100 0.752 0.000 1.000 ②与④ 6.729 0.009 2.443 0.118 ②与⑤ 18.145 0.000 12.000 0.001 ②与⑥ 40.835 0.000 12.000 0.001 ③与④ 8.424 0.004 2.443 0.118 ③与⑤ 15.767 0.000 12.000 0.001 ③与⑥ 37.816 0.000 12.000 0.001 ④与⑤ 43.368 0.000 21.818 0.000 ④与⑥ 70.492 0.000 21.818 0.000 ⑤与⑥ 9.497 0.003 0.000 1.000* 注:表中,PAHG:聚丙烯酰胺水凝胶;①:T1加权像;②:T2加权像;③:STIR(短时间反转恢复);④:MRH(MR水成像);⑤:DWI(弥散加权成像);⑥:LAVA(肝脏容积超快速)多期动态增强成像;*:Fisher精确概率法。 -
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