作者投稿
专家审稿
编辑办公
邮件订阅
RSS
Ultrasound Diagnosis and Misdiagnosis Analysis of Accessory Cavitated Uterine Malformation
-
摘要:目的
探讨子宫附腔畸形(accessory cavitated uterine malformation, ACUM)的超声声像图特征, 并分析误诊原因, 以加强对本病的认识, 提高超声医师的诊断能力。
方法收集2013年12月—2023年12月于北京协和医院就诊, 并经手术病理确诊为ACUM的患者临床、病理及影像学资料, 分析其超声特征、首诊误诊原因。
结果共11例患者纳入本研究, 平均确诊年龄(27.1±7.4)岁, 平均初潮(6.1±5.5)年后出现痛经。术前超声显示ACUM均为单一病灶, 位于圆韧带附着处下方子宫肌层内, 平均最大直径(3.0±1.0)cm。病灶整体呈形态规则的厚壁囊实性结构, 多数呈圆形或椭圆形(90.9%, 10/11), 边界清晰(72.7%, 8/11), 且与宫腔不相通(100%, 11/11)。所有病灶内部均为囊性空腔, 多呈磨玻璃样改变(90.9%, 10/11), 囊腔内衬呈内膜样线状高回声(90.9%, 10/11)。病灶周边均由肌层样低回声或中等回声包绕, 彩色多普勒超声示周边环状或半环状血流信号。所有患者均未合并腺肌症等其他子宫病变。误诊分析: 11例患者中, 首次超声正确诊断6例, 首次MRI正确诊断5例, 其中2例MRI误诊为残角子宫而超声检查均提示ACUM且双侧宫角可见。
结论ACUM具有特征性的超声声像图表现, 当年轻女性出现进行性痛经, 超声于一侧圆韧带下方子宫肌层内探及形态规则的厚壁囊实性包块时, 需考虑ACUM可能。
Abstract:ObjectiveTo explore the ultrasound characteristics of accessory cavitated uterine malformation (ACUM) and the causes of misdiagnosis, in order to better understand the disease and improve the diagnostic ability of radiologists.
MethodsWe retrospectively collected clinical, pathological and imaging data of ACUM patients who were diagnosed after surgery at Peking Union Medical College Hospital from December2013 to December 2023. Besides, we analyzed ultrasound features of ACUM and the cause of misdiagnosis.
ResultsA total of 11 patients were included, with a mean age of diagnosis of (27.1±7.4)years. There was a mean interval of (6.1±5.5)years between menarche and onset of dysmenorrhea. Preoperative ultrasound showed that ACUM appeared as solitary lesions located under the insertion of the round ligament, with a mean maximum diameter of (3.0±1.0)cm. Lesions were round or oval (90.9%, 10/11) and not connected to the uterine cavity (100%, 11/11) with clear boundaries (72.7%, 8/11), presenting as regular thick-walled cystic-solid structures. Cystic areas were observed within the mass (100%, 11/11) with a ground-glass-like appearance (90.9%, 10/11) and hyperechoic endometrial lining (90.9%, 10/11). The surrounding of the mass showed hypoechoic or isoechoic areas resembling the muscular layer and circular or semi-circular vascularity was detected around the mass. No adenomyosis or other uterine lesions were found. Analysis of misdiagnosis: Among the 11 ACUM cases, 6 were correctly diagnosed by the initial ultrasound examination, and 5 cases by MRI. Two patients were misdiagnosed as residual horn uterus by MRI, despite ultrasound suggesting ACUM with visible bilateral uterine horns.
ConclusionsACUM exhibits distinct ultrasound characteristics. When young women present with progressive dysmenorrhea and ultrasound reveals a regular cystic-solid mass with thick wall located under the round ligament insertion, ACUM should be considered.
-
经过一天烈日的炙烤，住院部外面的地表温度已经高达40 ℃，进进出出需要加强监护的患者还在不断增加，面对监护室内堆积如山的病患，大家的心情已经烦躁不安。高速周转的病房似乎又经历了一波“大洗牌”，病床上躺着不同的面孔，交班正仔细且有序地进行着。“号外……又有新病人要从急诊科转入，目前鼻导管10 L/min吸氧中，呼吸困难，需要重新评估插管指征......”值班护士小罗一边接听着电话，一边冲大家喊道。此刻空气仿佛凝住了一般，最尴尬的事情莫过如此——在交班时要来病人。“大家先交班，速战速决，准备收病人......”作为今天当值的高年资主治医师，我立刻说道。
伴随着转运车的声音，病人送来了，大家立刻围了上去，按照平时标准动作过床、吸氧、完成心电监护连接。我走到病床边，那是一位白发苍苍、胸前皮下还隐约有一枚“勋章”的爷爷，一看心电监护，我本能地反应那枚东西应该是心脏永久起搏器。为了判断病人意识及症状，我拍了拍老人肩膀，问道：“爷爷，您知道这是在哪儿吗？”老人没有回答，但是眼睛在不停地转动，嘴巴似乎要表达什么，带着一点儿北方口音，但听得不太清楚。我瞬时像明白了什么，于是俯下身去对着他的耳朵大声喊道：“爷爷，您知道这是在哪儿吗？您是不是听得不太清楚？”老人摇了摇头，又点了点头。
此时，我身旁一位经验丰富的“老医生”冲我扬了扬手中的听诊器听筒，我第一反应是她要听诊，于是连忙说道：“我来吧。”但她却直接把听头给爷爷戴上了，并对着听筒大声说道：“老爷子，这样能听清吗？”老人喃喃地回答：“听清了，听清了……”慢慢地，他紧崩的神情似乎也逐渐舒展开来。经过一系列问诊和针对性的处理后，爷爷慢慢睡着了。
病人急性呼吸窘迫的病因尚未完全明确，依然有病情随时加重的危险，依照惯例，我们立即联系家属了解老人的病史并进行谈话签字。通过与家属充分沟通，我们了解到了爷爷的慢性病史以及本次发病的诱因，还得知爷爷听力不好，这几天辗转各大医院，一直没休息好，病情也越来越重了。好在经过我们悉心的治疗和照顾，两周后爷爷终于出院了！
门诊复诊时，我看到爷爷耳朵上多了一副助听器，便打趣道：“爷爷，现在声音清楚多了吧？”爷爷笑着回答：“这玩意儿还是没有你们给我戴的东西听得清楚。”我和家属听完都哈哈大笑起来……
后记
听诊器的发明已有近200年的历史，其除了可以帮助医生完成重要的听诊检查外，在某些情况下还可以成为与病人沟通的桥梁。从法国医生雷奈克为了诊治患者，第一次提出“听诊器”的概念，到吴孟超院士在冬天查房时先用双手捂热听诊器再为患者听诊，再到为了能让患者听清楚，发现听诊器的新用途……不同听诊器的故事中，有不同的主人公以及不同的场景，但伴随的都是那份来自医生的爱，那份给予患者温暖的爱。病人与医生之间的第一步，是沟通，是了解，但病人在任何时候和任何状态下，都一定是需要帮助的那个人。任何人在面对身体的病痛时，或是因为没有足够专业的知识，或是因为疾病带来的切肤之痛，无论是酸胀、麻木、疼痛、无力，还是其他任何一种异样的感觉，都会让其内心产生对于异常表现的无限猜测以及随之而来的焦虑、恐慌。初入医学院时的我，心里想的只是如何掌握高精尖的各种医学技术，如何把病看好。进入医院工作多年以后，特别是在经历新型冠状病毒感染疫情后，我深切地体会到，不管医生的技术有多精湛，医疗水平有多高超，医生的关怀和援助永远都是病人最坚实的情感堡垒。治病一定是依靠科学，但让病人感觉到舒服却更需要医生对于患者那颗帮助的心。从医和患这层关系构建起来的那一刻起，他们就不该是对立的，而是共生的，更是共情的，感同身受、同气连枝才是医治疾病的起点，更是每一个合格医生毕生追求的终点。
临床医生正如其名字一样，需要站在床边仔细观察病人。观察的目的除正确诊断病情外，更重要的是察觉病人最需要的帮助是什么。故事中的老人一直处于听不清周围声音的状态，这时候病人可能会感到恐惧与烦躁，甚至会导致病情恶化，而一次仔细的观察就能够使问题迎刃而解。一个小小的听诊器，以及听诊器带来的这份“逆向思维”，彰显的不仅是一种临床采集病史的技巧，更是医生把心打开，试图去侧耳倾听病人诉说的耐心，以及尽其所能去关爱病人的慈悲。
因此，听诊器的故事，讲述的不是一种疾病的诊断，更不是一个病例的转归，听诊器联通的亦非症状与诊断，心跳与鼓膜，而是受伤的心和呵护的手，告诉我你哪里不舒服，我一定会想办法听到你的诉说，也一定会陪着你直到疾病消散。把痛苦告诉我，把希望传给你，这才是听诊器的真正意义所在，才是医生和病人最正确的相处方式。一如美国医生特鲁多对医生这个职业的经典描述——有时是治愈，常常是帮助，总是去安慰！
作者贡献：纪菲负责研究设计、病历资料收集、结果分析及论文初稿撰写；杨萌、苏娜指导论文撰写及修订；刘华祯、付子婧参与数据收集；齐振红提供影像学资料支持。利益冲突：所有作者均声明不存在利益冲突 -
![]()
图 1 ACUM患者腹腔镜下手术术中影像及大体标本
A.子宫左侧圆韧带下方轻度隆起；B.固有韧带处见蓝紫色内异灶结节；C、D.病灶切开后可见巧克力样液体流出；E.附腔包块内见褐色内膜样组织；F.大体标本示厚壁空腔包块
Figure 1. Laparoscopic and macroscopic images of patients with ACUM
A.laparoscopic view shows a mass bulging on the surface of the left-sided myometrium; B.a blue-purple endometriosis around the ligaments; C/D.the drainage of chocolate-colored fluid from the cavity during the excision of ACUM; E.brown endometrial-like tissue inside the inner part of the lesion; F.macroscopic image shows a cavitated mass with a thick muscular wall
ACUM: 同表 1![]()
图 2 ACUM患者典型超声声像图特征(箭头)
A.子宫左侧宫角下方肌层内厚壁囊实性包块；B.囊腔内局部呈中高回声；C.囊壁内衬线样高回声; D.病灶周边由低回声肌层包绕，周边探及半环状血流信号；E.双侧宫角形态正常；F.右侧卵巢形态大小正常
A、B、C为经阴道超声，D、E、F为经腹超声；ACUM：同表 1Figure 2. Representative pictures of patients with ACUM on ultrasound(arrow)
A.a cystic-solid mass with thick wall located under the left uterine horn; B.hyperechoic component within central cavity; C.the cavity lined by hyperechoic endometrium; D.the mass surrounded by hypoechoic muscular layer with semi-circular vascularity; E.bilateral cornua with normal shape; F.the right ovary with normal appearance
A/B/C: transvaginal ultrasound image, D/E/F: transabdominal ultrasound image![]()
图 3 ACUM患者典型盆腔MRI图像特征(箭头)
A.T2WI冠状面示子宫左侧肌层内圆形病灶；B.T2WI横断面示双侧宫角形态正常；C.T1WI横断面示病灶中央呈短TI信号
Figure 3. Typical pelvic MRI pictures of patients with ACUM(arrow)
A.coronal T2WI MRI image demonstrates an oval left-sided mass in the outer myometrium of the uterus; B.axial T2WI image displays bilateral normal horns; C.central cavity shows high T1 signal on axial T1WI image
ACUM、MRI: 同表 1表 1 11例ACUM病例首诊超声及MRI诊断结果
Table 1 Initial diagnosis of ultrasound and MRI examination of 11 patients with ACUM
病例编号 超声 MRI诊断 方式 诊断 1 经阴道 ACUM ACUM 2 经腹 性质待定 ACUM 3 经阴道 残角子宫 残角子宫 4 经阴道 ACUM/腺肌瘤 ACUM 5 经阴道 输卵管积水 ACUM 6 经阴道 ACUM 残角子宫 7 经腹 ACUM 残角子宫 8 经直肠 ACUM ACUM/残角子宫 9 经腹 ACUM ACUM/肌瘤变性 10 经阴道 ACUM/腺肌瘤 卵巢子宫内膜异位症 11 经阴道 ACUM ACUM ACUM(accessory cavitated uterine malformation)：子宫附腔畸形；MRI(magnetic resonance imaging)：磁共振成像 
下载: 导出CSV
-
[1] 戴晴. 浅谈子宫附腔畸形的临床特征及超声影像学应用进展[J]. 中华医学超声杂志(电子版), 2022, 19(10): 1036-1041. Dai Q. Accessory cavitated uterine malformation: clinical characteristics and application of ultrasound in diagnosis[J]. Chin J Med Ultrasound (Electron Ed), 2022, 19(10): 1036-1041.
[2] Cozzutto C. Uterus-like mass replacing ovary: report of a new entity[J]. Arch Pathol Lab Med, 1981, 105(10): 508-511. http://doc.paperpass.com/foreign/rgArti1981143972712.html
[3] Timmerman S, Stubbe L, Van Den Bosch T, et al. Accessory cavitated uterine malformation (ACUM): a scoping review[J]. Acta Obstet Gynecol Scand, 2024, 103(6): 1036-1045. DOI: 10.1111/aogs.14801
[4] 黄乐文, 黄安茜, 包凌云, 等. 子宫不典型附腔畸形1例及文献复习[J]. 中国医学影像技术, 2023, 39(8): 1268-1270. Huang L W, Huang A Q, Bao L Y, et al. Atypical uterine accessory cavitated uterine mass: case report and literature review[J]. Chin J Med Imaging Technol, 2023, 39(8): 1268-1270.
[5] 李海燕, 刘敏茵, 欧阳振波, 等. 罕见的子宫附腔1例及文献复习[J]. 妇产与遗传(电子版), 2023, 13(2): 55-57. Li H Y, Liu M Y, Ouyang Z B, et al. Rare case of uterine adnexa and literature review[J]. Obstet Gynecol Genet (Electron Ed), 2023, 13(2): 55-57.
[6] 王铭, 苏娜, 刘真真, 等. 超声对子宫附腔畸形的诊断价值探讨: 附2例报告[J]. 中华超声影像学杂志, 2022, 31(11): 997-999. Wang M, Su N, Liu Z Z, et al. Value of ultrasound in diagnosis of accessory cavity uterine malformation: report of two cases[J]. Chin J Ultrasonogr, 2022, 31(11): 997-999.
[7] Acién P, Acién M, Fernández F, et al. The cavitated accessory uterine mass: a Müllerian anomaly in women with an otherwise normal uterus[J]. Obstet Gynecol, 2010, 116(5): 1101-1109. DOI: 10.1097/AOG.0b013e3181f7e735
[8] Na K Y, Kim G Y, Won K Y, et al. Extrapelvic uterus-like masses presenting as colonic submucosal tumor: a case study and review of literature[J]. Korean J Pathol, 2013, 47(2): 177-181. DOI: 10.4132/KoreanJPathol.2013.47.2.177
[9] Acién P, Sánchez Del Campo F, Mayol M J, et al. The female gubernaculum: role in the embryology and development of the genital tract and in the possible genesis of malformations[J]. Eur J Obstet Gynecol Reprod Biol, 2011, 159(2): 426-432. DOI: 10.1016/j.ejogrb.2011.07.040
[10] Pfeifer S M, Attaran M, Goldstein J, et al. ASRM Müllerian anomalies classification 2021[J]. Fertil Steril, 2021, 116(5): 1238-1252. DOI: 10.1016/j.fertnstert.2021.09.025
[11] Acién P, Bataller A, Fernández F, et al. New cases of accessory and cavitated uterine masses (ACUM): a significant cause of severe dysmenorrhea and recurrent pelvic pain in young women[J]. Hum Reprod, 2012, 27(3): 683-694. DOI: 10.1093/humrep/der471
[12] Boitor-Borza D, Rotar C, Muresan D. Accessory cavitated uterine mass in a multiparous patient with progressive dysmenorrhea[J]. Am J Obstet Gynecol, 2024, 230(4): 458-461. DOI: 10.1016/j.ajog.2023.11.1236
[13] 林琪, 王慧芳, 卢峻, 等. 单角子宫和残角子宫的超声诊断及漏误诊分析[J]. 中国超声医学杂志, 2010, 26(7): 648-650. Lin Q, Wang H F, Lu J, et al. Ultrasound diagnosis and misdiagnosis of unicornuate uterus and rudimentary uterus horn[J]. Chin J Ultrasound Med, 2010, 26(7): 648-650.
[14] Ludwin A, Ludwin I, Martins W P. Robert's uterus: modern imaging techniques and ultrasound-guided hysteroscopic treatment without laparoscopy or laparotomy[J]. Ultrasound Obstet Gynecol, 2016, 48(4): 526-529. DOI: 10.1002/uog.15976
[15] 中华医学会妇产科学分会, 中国医师协会妇产科医师分会女性生殖道畸形学组. 女性生殖器官畸形命名及定义修订的中国专家共识(2022版)[J]. 中华妇产科杂志, 2022, 57(8): 575-580. Chinese Society of Obstetrics and Gynecology, Chinese Medical Association Female Genital Anomalies Study Group, Chinese Obstetricians and Gynecologists Association. Chinese experts' consensus on the nomenclature and definition revision of female genital malformations (2022)[J]. Chin J Obstet Gynecol, 2022, 57(8): 575-580.
[16] Bazot M, Daraï E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis[J]. Fertil Steril, 2018, 109(3): 389-397. DOI: 10.1016/j.fertnstert.2018.01.024
[17] Van Den Bosch T, De Bruijn A M, De Leeuw R A, et al. Sonographic classification and reporting system for diagnosing adenomyosis[J]. Ultrasound Obstet Gynecol, 2019, 53(5): 576-582. DOI: 10.1002/uog.19096
[18] Peyron N, Jacquemier E, Charlot M, et al. Accessory cavitated uterine mass: MRI features and surgical correlations of a rare but under-recognised entity[J]. Eur Radiol, 2019, 29(3): 1144-1152. DOI: 10.1007/s00330-018-5686-6
[19] 赵威武, 孙厚坦, 李璐璐, 等. 输卵管积水的超声诊断及漏诊、误诊原因分析[J]. 中国医学影像技术, 2010, 26(8): 1594-1595. Zhao W W, Sun H T, Li L L, et al. Ultrasonic diagnosis of hydrosalpinx and the causes of missed diagnosis and misdiagnosis[J]. Chin J Med Imaging Technol, 2010, 26(8): 1594-1595.
-
期刊类型引用(2)
1. 殷晓玉，蒋诗萌，王军. 辅助技术在智能可穿戴设备中的研究进展. 毛纺科技. 2024(05): 127-133 . 
百度学术
2. 冯郑文，胡永强，朱宸立，李海瑾，李卉，杜娟. 国外基层老年人辅助技术服务开展现状及对我国的启示. 中华全科医师杂志. 2024(07): 752-757 . 百度学术
其他类型引用(1)
计量
- 文章访问数: 584
- HTML全文浏览量: 66
- PDF下载量: 31
- 被引次数: 3
