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Value of Preoperative Ultrasound in the Diagnosis and Localization of Soft-tissueTumor-associated Hypophosphatemic Osteomalacia
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摘要:
目的 探讨术前超声诊断对软组织肿瘤相关性低磷骨软化症病变手术定位切除的指导价值及良恶性病灶成像特征。 方法 回顾分析北京协和医院2005年1月至2016年6月收治的63例软组织肿瘤相关性低磷骨软化病患者的临床资料及术前超声图像资料，对照手术及病理结果，分析超声图像特征，比较良恶性超声特征差异。 结果 63例患者的65个病变全部在术前超声定位下完整切除，病理结果均为磷酸盐尿性间叶组织肿瘤，其中良性病灶56个，中位最大径2.3 cm(1.6~3.3 cm)，恶性病灶9个，中位最大径3.0 cm(2.5~5.5 cm)，两者差异无统计学意义(P＞0.05)。恶性结节钙化和血流信号丰富的比例高于良性结节, 差异有统计学意义(100%/62.5%和66.7%/28.57%，P均＜0.05)。其他征象如形态、边界、边缘特征、内部回声、回声水平、均匀性差异均无统计学意义(P均＞0.05)。良恶性结节的成像模式具有差异(P=0.009)，恶性病变66.7%为Ⅰ类，33.3%为Ⅱ类；良性病变80.3%为Ⅱ类和Ⅲ类。 结论 术前超声定位可以帮助手术完整切除软组织肿瘤相关性低磷骨软化病变，部分超声特征及成像模式对于鉴别良恶性病灶有帮助。 -
关键词:
- 软组织肿瘤相关性低磷骨软化症 /
- 超声 /
- 定位
Abstract:Objective To study the role of preoperative ultrasound in the targeted removal of soft-tissue tumor-associated hypophosphatemic osteomalacia, and to explore ultrasound features of benign and malignant lesions. Methods We reviewed the sonographic and clinical records of 63 patients with soft-tissue tumor-induced hypophosphatemic osteomalacia who were treated at Peking Union Medical College Hospital between January 2005 and June 2016. Compared with surgical and pathological results, we retrospectively analyzed the ultrasonic features of benign and malignant lesions. Results All 65 lesions in the 63 patients were removed completely and successfully as guided by preoperative localization with ultrasound.Pathology identified them all as phosphaturic mesenchymal tumors, including 56 benign lesions and 9 malignant lesions.The median maximum diameter of the benign group was 2.3(1.6-3.3)cm, and that of the malignant group was 3.0 (2.5-5.5)cm, there was no statistically significant difference between the two groups(P > 0.05). The malignant lesions were more likely to be of calcificacion and rich blood flow signals than benign lesions (100%/62.5%, 66.7%/28.57%, both P < 0.05). Other features such as shape, margin, border, structure, echogenicity and echo uniformity were found with no statistically significant difference(all P > 0.05). The ultrasound pattern was different between benign and malignant lesions (P=0.009), and 66.7% of the malignant lesions were in class Ⅰ, 33.3% were in class Ⅱ, while 80.3% of the benign lesions were in classes Ⅱ and Ⅲ. Conclusions Ultrasonic preoperative localization could help guide complete resection of soft-tissue tumor-associated hypophosphatemic osteomalacia.Some specific ultrasound features and imaging patterns may be useful to differentiate malignant and benign lesions. -
图 1 左膝关节内侧皮下脂肪层磷酸盐尿性间叶肿瘤超声图
女，45岁，因“腰腿痛近2年，胸痛1年”就诊。术前超声检查发现左膝关节内侧皮下脂肪层内低回声，大小1.1 cm×1.0 cm，形态不规则，边界清，内部回声不均匀，内可见点状及短条状强回声(A)。彩色多普勒超声显示结节周边及内部见丰富血流(B)，超声分类为Ⅰ类。术前定位后完整切除，病理为低度恶性潜能磷酸盐尿性间叶肿瘤。
图 2 左前臂磷酸盐尿性间叶肿瘤超声图
男，42岁，因“全身骨痛、活动障碍3年”就诊。术前超声检查发现左前臂背侧近尺侧低回声，范围4.2 cm×0.7 cm×0.9 cm，距离体表 0.25 cm，形态不规则，回声不均，内见条状强回声，其外侧缘包绕肌腱(A，C)；彩色多普勒超声显示结节内部血流丰富(B，D)，超声分类为Ⅰ类。术前定位后完整切除，病理为左前臂良性磷酸盐尿性间叶性肿瘤。
表 1 63例(65个病灶)软组织肿瘤相关性低磷骨软化症患者基本临床资料
临床特征 恶性 良性 χ2/t值 P值 性别[n(%)] 1.386 0.239 男 3(8.1) 34(91.9) 女 6(21.4) 22(78.6) 入院年龄[n(%)] 0.002 ＜30岁 1(11.1) 11(19.7) 30~50岁 8(88.9) 25(44.6) ＞50岁 0 20(33.7) 平均入院年龄(x±s, 岁) 38±6 45±13 3.473 0.002 发病年龄[n(%)] 0.090 ＜30岁 6(66.67) 13(23.22) 30~50岁 3(33.33) 35(62.50) ＞50岁 0(0) 8(14.28) 平均发病年龄(x±s, 岁) 26±9 40±13 3.019 0.004 发病时长[n(%)] 0.010 ≤10年 5(55.56) 52(92.86) ＞10年 4(44.44) 4(7.14) 平均发病时长(x±s, 年) 9.22±7.01 5.23±4.39 1.629 0.103 数目[n(%)] 1.000 单发 9(100) 52(92.9) 多发 0(0) 4(7.1) 复发情况[n(%)] 1.185 0.276 复发 2(22.2) 3(5.4) 未复发 7(77.8) 53(94.6) 首次发现病灶[n(%)] CT 2(22.2) 12(21.4) 0.000 1.000 MRI 3(33.3) 25(44.6) 0.075 0.785 PET/CT 2(22.2) 15(26.8) 0.000 1.000 MRI:磁共振成像；PET/CT:正电子发射断层显像/计算机体层成像 
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表 2 术前超声对65个软组织肿瘤相关性低磷骨软化症病灶的检测结果
病灶部位 数量[n(%, 良性/恶性] 最大径(cm) 良性病灶[cm, 中位数(四分位数间距)] 恶性病灶[cm, 中位数(四分位数间距)] 范围 中位数(四分位数间距) 颈部 1(1.5, 1/0) 3.20 3.2 3.2 - 胸部 1(1.5, 1/0) 3.00 3.0 3 - 腹股沟 1(1.5, 1/0) 1.30 1.3 1.3 - 直肠左后壁左外侧 1(1.6, 1/0) 2.90 2.9 2.9 - 臀部 2(3.1, 2/0) 1.50~3.30 2.4(1.5~3.3) 2.4(1.5~3.3) - 四肢 59(90.8, 50/9) 上臂 4(6.2, 4/0) 2.30~4.6 3.3(2.6~4.3) 3.3(2.6~4.3) - 手 2(3.1, 2/0) 1.60~3.90 2.8(1.6~3.9) 2.8(1.6~3.9) - 腕关节 1(1.5, 1/0) 3.90 3.9 3.9 - 前臂 2(3.1, 2/0) 3.10~4.20 3.7(3.1~4.2) 3.7(3.1~4.2) - 大腿 16(24.6, 13/3) 0.60~7.30 2.4(1.5~4.1) 2.6(1.3~7.3) 2.3(1.8~2.7) 膝关节 7(10.8, 5/2) 1.10~21.30 2.2(1.5~2.8) 2.2(2.0~2.8) 11.2(1.1~21.3) 腘窝 3(4.6, 3/0) 1.60~1.90 1.9(1.6~1.9) 1.9(1.6~1.9) - 小腿 11(16.9, 9/2) 0.70~11.10 2.7(1.4~3.3) 2.4(1.2~4.0) 3.0(2.5~11.1) 踝关节 3(4.6, 2/1) 0.60~5.00 2.9(0.6~5.0) 1.8(0.6~2.9) 5.0 足底 10(15.4, 9/1) 1.40~4.00 2.2(1.9~3.0) 2.1(1.9~3.5) 4.0
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表 3 63例(65个病灶)软组织肿瘤相关性低磷骨软化症良恶性结节的超声特征比较[n(%)]
超声特征 良性(n=56) 恶性(n=9) χ2值 P值 钙化 4.986 0.026 无钙化 21(37.5) 0(0) 钙化 35(62.5) 9(100) 血流 4.860 0.027 0级 10(17.8) 0(0) 1级 8(14.3) 0(0) 2级 22(39.3) 3(33.3) 3级 16(28.6) 6(66.7) 形态 0.254 0.614 规则 36(64.3) 5(55.6) 不规则 20(35.7) 4(44.4) 边界 2.585 0.108 清晰 49(87.5) 6(66.7) 不清晰 7(12.5) 3(33.3) 边缘特征 0.428 0.513 平滑 43(76.8) 6(66.7) 不平滑 13(23.2) 3(33.3) 内部回声 - ＞0.999 囊实性 3(5.4) 0(0) 实性 53(94.6) 9(100) 回声水平 1.062 0.303 低回声 50(89.3) 9(100) 等回声 6(10.7) 0(0) 均匀性 3.633 0.057 均匀 25(44.6) 1(11.1) 不均匀 31(55.4) 8(88.9)
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表 4 63例(65个病灶)软组织肿瘤相关性低磷骨软化症良恶性结节的超声成像模式比较[n(%)]
分组 Ⅰ类 Ⅱ类 Ⅲ类 P值 良性 11(19.6) 29(51.8) 16(28.6) 0.009 恶性 6(66.7) 3(33.3) 0(0)
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