眼眶肿瘤的影像学及眼部肿瘤的彩色多普勒血流成像研究
摘要
第一部分 常见眼眶原发性肿瘤的影像学诊断与临床病例分析 目的 探讨超声、CT及MRI三种影像学诊断方法对眼眶肿瘤定位、定性诊断的差异；分析各种眼眶原发性肿瘤的临床、影像学特点。方法 对长征医院眼科1992年1月～2001年11月收治的眼眶病人中的310例320眼原发性眼眶肿瘤患者超声、CT及MRI表现进行回顾性分析。用Access进行数据整理，SPSS软件进行统计分析。结果 310例病例中血管瘤98例，粘液囊肿45例，神经源性肿瘤44例，泪器肿瘤34例，淋巴瘤32例，炎性假瘤24例，皮样囊肿14例，骨、软骨肿瘤12例，其它7例。肿瘤部位：肌锥内间隙132眼，肌锥外间隙52眼，骨膜下间隙26眼。超声检查320眼，CT检查255眼，MRI检查148眼。279眼行手术摘除肿块，并进行病理检查。不同种类的肿瘤三种影像学检查方法定性、定位诊断率不同。海绵状血管瘤三种检查方法定性符合率有显著差别，B型超声定性符合率最高，结合CT或MRI可明显降低定性误诊率；淋巴瘤三种影像学检查误诊率高，结合病理、免疫表型可明显提高确诊率；神经源性肿瘤、泪器肿瘤及粘液囊肿，CT结合临床表现发现率高。MRI对视神经管部位肿瘤显示优于其他两种检查。结论 超声作为眼眶肿瘤诊断的最方便手段，可作为常规检查；当肿瘤部位较深，有骨质侵蚀或破坏时，或怀疑邻近部位肿瘤侵犯眼眶应选CT进一步确诊；当怀疑脂肪瘤、皮样囊肿、视神经肿瘤管内或颅内蔓延等软组织肿瘤行MRI检查。各种影像学检查方法在不
同肿瘤侧重点不同。
根据良、恶性肿瘤血流供应的差异及彩色多普勒血流成像（CDFI）的原理，本文设计第二部分眼部肿瘤的彩色多普勒血流成像临床研究。目的 进一步探讨眼部肿瘤血液供应特点，为肿瘤诊断提供最佳方法。方法 测量肿块的血流及眼动脉、视网膜中央动静脉、睫状后动脉的血流并与对侧正常眼相应动脉血流作对照，以SPSS软件进行统计分析。结果 恶性肿瘤血流供应明显高于对照组（P<0.001），而眼动脉，视网膜中央动静脉及睫状后动脉与对照组情况不一。结论 CDFI作为一种检查血流的方法在眼部肿瘤良、恶性诊断方面有其重要价值。
Analysis of imageology on primary orbital tumor and study of Color Doppler Flowing Imaging on ocular tumor
Abstract
Purpose The fist part of this paper is to determine characteristic of primary orbital tumor(POT) on ultrasonography,computer tomography and magnetic resonance imaging and to analyze the difference of surgical.Methods Three hundred and twenty eyes of 310 patients(during the period from 1992 to 2001 at the Changzheng hospital)suffering from POT are retrospectively analyzed.Clinical manifestitions, medical imagelogical features and operation methods are measured. All data are collected with Microsoft Access and analyzed by SPSS software.Result Among 310 cases hemangioma accounts for 98 cases,neurogenic tumor 44 cases,lacrimal duct tumor 34 cases, lymphoma 32 cases,inflammatory psedotumor 24 cases, dermoid cyst 14 cases,mucocele 45 cases and bone tumor 12 cases.Location:intracone 132 cases,extracone 52 cases,subperiosteum interspace 20 cases,lacrimal gland and lacrimal sac 34 cases and nasal sinus 45 cases.All suffered eyes were examed with ultrasonography,255 eyes with CT and 148 eyes with MRI. Tumors of 279 eyes were extirpated.Conclusion (1)MRI,CT and US have distinguished difference in diagnosis of cavernous hemangioma,and US has the highest detective rate.If combined with three methods,misdiagnosis rate may be significantly decreased;there is no relation between tension and protuberence of the concerned eye.(2)On lymphoma three methods have a low diagnosis rate;in order to acquire higher diagnosis rate,pathological and immunological examinations should be considered.(3)On neurogenic tumor,lacrimal duct and nasal sinus tumor,CT has a higher diagnosis rate.On neurotubules tumor,MRI takes advantage over CT and US.Ultrasonography as the most convenient method in diagnosising POT is considered as regular tool. When the lesion extends deep and destroy orbital bone or adjacent tumor invades orbital cavity,CT should be further considered.If liposarcoma,dermoid cyst,neurotubule tumor or intracranial invasion is suspected,MRI should be highly considered. Further investigation shows that there is a distinguish difference between lateral orbitotomy
and medial orbitotomy in excision of POT,especially locating at deep orbital cavity.
Purpose The second part of this paper to analyze the usefulness of color Doppler flow imaging in the differentiation of benign and malignant ocular tumors；to study the CDFI characteristic of ocular and orbital tumors and to seek out some further practical diagnostic criteria. Methods Blood flow in tumor and the central retinal artery, the posterior cliliary arteries, the ophthalmic artery and the central retinal vein was assessed by CDFI in 55 patients. Blood velocity measurements in orbital vessels in these patients were compared with the same measurements on contralateral eyes.Diagnosis was confirmed during surgery or by biopsy. Result Different tumors have different echograms and characteristic bloods.(1) There are significant difference between malignant and benign lesions in peak systolic velocity（P=0.00003）,peak diastolic velocity（P=0.0002）resistent index (P=0.035),PSVOA（P=0.005） and OARI（P=0.005）The Resistent index（RI）of malignant tumor is high (RI>0.70),but benign is low (mean RI<0.70).(2)The highest blood supply in malignant tumor is MALT lymphoma and melanoma of choroids;lipoasrcoma has low blood supply. The highest blood supply in benign tumor is meningioma and neurofibroma; mucocele, OCH and dermoid cyst have the lowest blood supply. Conclusion Comparison of blood flow in all patients has shown that there is statistically significant difference between blood supply of malignant lesion and that of benign lesion. Blood supply of the troubled eye and controlled eye has sorts of states.CDFI may help to provide a more precise preoperative histological diagnosis noninvasively.
同肿瘤侧重点不同。
根据良、恶性肿瘤血流供应的差异及彩色多普勒血流成像（CDFI）的原理，本文设计第二部分眼部肿瘤的彩色多普勒血流成像临床研究。目的 进一步探讨眼部肿瘤血液供应特点，为肿瘤诊断提供最佳方法。方法 测量肿块的血流及眼动脉、视网膜中央动静脉、睫状后动脉的血流并与对侧正常眼相应动脉血流作对照，以SPSS软件进行统计分析。结果 恶性肿瘤血流供应明显高于对照组（P<0.001），而眼动脉，视网膜中央动静脉及睫状后动脉与对照组情况不一。结论 CDFI作为一种检查血流的方法在眼部肿瘤良、恶性诊断方面有其重要价值。
Analysis of imageology on primary orbital tumor and study of Color Doppler Flowing Imaging on ocular tumor
Abstract
Purpose The fist part of this paper is to determine characteristic of primary orbital tumor(POT) on ultrasonography,computer tomography and magnetic resonance imaging and to analyze the difference of surgical.Methods Three hundred and twenty eyes of 310 patients(during the period from 1992 to 2001 at the Changzheng hospital)suffering from POT are retrospectively analyzed.Clinical manifestitions, medical imagelogical features and operation methods are measured. All data are collected with Microsoft Access and analyzed by SPSS software.Result Among 310 cases hemangioma accounts for 98 cases,neurogenic tumor 44 cases,lacrimal duct tumor 34 cases, lymphoma 32 cases,inflammatory psedotumor 24 cases, dermoid cyst 14 cases,mucocele 45 cases and bone tumor 12 cases.Location:intracone 132 cases,extracone 52 cases,subperiosteum interspace 20 cases,lacrimal gland and lacrimal sac 34 cases and nasal sinus 45 cases.All suffered eyes were examed with ultrasonography,255 eyes with CT and 148 eyes with MRI. Tumors of 279 eyes were extirpated.Conclusion (1)MRI,CT and US have distinguished difference in diagnosis of cavernous hemangioma,and US has the highest detective rate.If combined with three methods,misdiagnosis rate may be significantly decreased;there is no relation between tension and protuberence of the concerned eye.(2)On lymphoma three methods have a low diagnosis rate;in order to acquire higher diagnosis rate,pathological and immunological examinations should be considered.(3)On neurogenic tumor,lacrimal duct and nasal sinus tumor,CT has a higher diagnosis rate.On neurotubules tumor,MRI takes advantage over CT and US.Ultrasonography as the most convenient method in diagnosising POT is considered as regular tool. When the lesion extends deep and destroy orbital bone or adjacent tumor invades orbital cavity,CT should be further considered.If liposarcoma,dermoid cyst,neurotubule tumor or intracranial invasion is suspected,MRI should be highly considered. Further investigation shows that there is a distinguish difference between lateral orbitotomy
and medial orbitotomy in excision of POT,especially locating at deep orbital cavity.
Purpose The second part of this paper to analyze the usefulness of color Doppler flow imaging in the differentiation of benign and malignant ocular tumors；to study the CDFI characteristic of ocular and orbital tumors and to seek out some further practical diagnostic criteria. Methods Blood flow in tumor and the central retinal artery, the posterior cliliary arteries, the ophthalmic artery and the central retinal vein was assessed by CDFI in 55 patients. Blood velocity measurements in orbital vessels in these patients were compared with the same measurements on contralateral eyes.Diagnosis was confirmed during surgery or by biopsy. Result Different tumors have different echograms and characteristic bloods.(1) There are significant difference between malignant and benign lesions in peak systolic velocity（P=0.00003）,peak diastolic velocity（P=0.0002）resistent index (P=0.035),PSVOA（P=0.005） and OARI（P=0.005）The Resistent index（RI）of malignant tumor is high (RI>0.70),but benign is low (mean RI<0.70).(2)The highest blood supply in malignant tumor is MALT lymphoma and melanoma of choroids;lipoasrcoma has low blood supply. The highest blood supply in benign tumor is meningioma and neurofibroma; mucocele, OCH and dermoid cyst have the lowest blood supply. Conclusion Comparison of blood flow in all patients has shown that there is statistically significant difference between blood supply of malignant lesion and that of benign lesion. Blood supply of the troubled eye and controlled eye has sorts of states.CDFI may help to provide a more precise preoperative histological diagnosis noninvasively.
引文
[1]宋国祥，吴中耀.眼眶病学.北京：人民卫生出版社,第一版.1999:135-142.
[2]周永昌，郭万学.超声医学.北京：科学技术文献出版社，第三版.1988:75-92.
[3]陈星荣，沈天真，段承祥等.全身CT及MRI.上海：上海大学出版社，第一版.1997:6-32.
[4]高元桂，蔡幼铨，蔡祖龙.磁共振成像诊断学.北京：人民军医出版社，第一版.1993:3-19.
[5]Erickson SJ,Hendrix LE,Massaro BM,et al.Color Doppler flowing imaging of the normal and abnormal orbit.Radiology,1989,173:511.
[6]Selva D, Strianese D, Bonavolonta G,et al. Orbital venous-lymphatic malformations (lymphangiomas) mimicking cavernoushemangiomas. Am J Ophthalmol,2001,131:364-370.
[7]安裕志，李彬，鲜军舫等.常易混淆的眶尖部肿瘤的MRI特点.中华眼科杂志,2000,36:270-271.
[8]Sood S,Vashisht S,Betharia SM,et al.CT evaluation of orbital osseous hemangioma. Australas Radiol,1992,36:124-126.
[9]Fries PD,Char DH.Bilateral orbital cavernous haemangiomas. Br J Ophthalmol, 1988,72:871 -873.
[10]Sullivan TJ,Aylward GW,Wright JE,et al.Bilateral multiple cavernous haemangiomas of the orbit. Br J Ophthalmol,1992,76: 627-629.
[11]Shields JA,Hogan RN. Bilateral cavernous haemangiomas of the orbit.Br J Ophthalmol, 2000, 84:928 -935.
[12]Johnson TE,Nasr AM,Nalbandian RM,et al.Enchondromatosis and hemangioma (Maffucci's syndrome) with orbital involvement. Am J Ophthalmol,1990,110:153- 159.
[13]Mendivil A, Cuartero V.Color Doppler image of central retinal artery of eyes with an intraconal mass.Curr Eye Res,1999,18: 104-109.
[14]Sir Stewart Duke-elder.System of Ophthalmology:the ocular adnexa. London: Henry kimpton, 1974:1091-1095.
[15]Leinung S,Lots I,Wurl P,et al.Monstroses venous hemangiom of the retroperitoneum. Problems in diagnosis.Zentralbl-Chir,1999,124:843-847.
[16]Katz SE, Rootman J, Vangveeravong S,et al.Combined venous lymphatic malformations of the orbit (so-called lymphangiomas). Association with noncontiguous intracranial vascular anomalies. Ophthalmology,1998,105: 176-184.
[17]Parentin F，Borzaaghini L,Perissutti P.The role of ultrasonography in the diagnosis of orbital lymphangiomas. Ophthalmologica,2001,215: 238-240
[18]鲜军舫，王振常，田其昌，等.眼眶神经鞘瘤的CT和MRI研究.中华放射学杂志,2000,34: 258-260.
[19]Song,GX.CT findings in 49 cases of primary orbital meningioma. Chung Hua Yen Ko Tsa Chih,1990,26:304-306.
[20]Hashimoto, M,Tomura,N,Watarai,J.Retrobulbar orbital metastasis mimicking meningioma. Radiat Med,1995,13:77-79.
[21]宋国祥，吴中耀.眼眶病学.北京：人民卫生出版社,第一版.1999:195-196.
[22]何球藻，吴厚生，曹雪涛.细胞与分子免疫学.上海：上海科学技术文献出版社,2000,155 -172.
[23]Moriyama H, Nakajima T, Honda Y.Studies on mucocoeles of the ethmoid and sphenoid sinuses: analysis of 47 cases.J Laryngol Otol,1992,106: 23-27.
[24]Curtin HD, Rabinov JD .Extension to the orbit from paraorbital disease. The sinuses. Radiol Clin North Am, 1998,36:1201-1213.
[25]James VF,Janice GA.Ophthalmology secrets.Pennsylvania:HANLEY & BELFUS,Inc, 1998,506.
[26]Knowles DM,Jakobiec FA.Orbital Lymphoid Neoplasmas.A clinico- pathologic study of 60 patients.Cancer,1980,46: 576-579.
[27]Harris NL,Jaffe ES,Stein H,et al.A revised European-American classification of lymphoid neoplasmas: a propasal from the International Lymphoma Study Group. Blood,1994,84:1361-1392.
[28]Hoang Xuan Tm,Bodaghi B,Toublanc M.Scleritis and mucosal-associated lymphoid tissue lymphoma: a new masquerade syndrome.Ophthalmology,1996, 103:631-635.
[29]Mark Cahill,Colma Barnes,Paul Moriarty,et al.Ocular adnexal lymphoma-comparison of MALT lymphoma with other histological types.Br J Ophthalmol,1999,83:742-747.
[30]White WL,Ferry JA,Harris NL,et al.Ocular adnexal lymphoma-a clinico- pathologic study with identification of lymphomas of mucosa associated lymphoid tissue type. Ophthalmology, 1995,102:1994-2006.
[31]Akpek EK,Polcharoen W,Ferry JA,et al.Conjunctival lymphoma masquerading as chronic conjunctivitis.Ophthalmology,1999,106:757 -760.
[32]Voegtle R,Choudat L, Agbaguede I, et al.Lymphomes lacrymaux de type MALT J Fr Ophtalmol,1999,22:884-887.
[33]Auer IA, Gascoyne RD, Connors JM, et al. t(11;18)(q21;q21) is the most common translocation in MALT lymphomas. Ann-Oncol,1997,8:979-985.
[34]Ferry JA, Yang WI,Zukerberg LR,et al.CD5+ extranodal marginal zone B-cell (MALT) lymphoma. A low grade neoplasm with a propensity for bone marrow involvement and relapse. Am J Clin Pathol,1996,105:31-37.
[35]Wotherspoon AC,Finn TM,Isaacson PG.Trisomy 3 in low-grade B-cell lymphomas of mucosa-associated lymphoid tissue.Blood,1995,85:2000- 2004.
[2]周永昌，郭万学.超声医学.北京：科学技术文献出版社，第三版.1988:75-92.
[3]陈星荣，沈天真，段承祥等.全身CT及MRI.上海：上海大学出版社，第一版.1997:6-32.
[4]高元桂，蔡幼铨，蔡祖龙.磁共振成像诊断学.北京：人民军医出版社，第一版.1993:3-19.
[5]Erickson SJ,Hendrix LE,Massaro BM,et al.Color Doppler flowing imaging of the normal and abnormal orbit.Radiology,1989,173:511.
[6]Selva D, Strianese D, Bonavolonta G,et al. Orbital venous-lymphatic malformations (lymphangiomas) mimicking cavernoushemangiomas. Am J Ophthalmol,2001,131:364-370.
[7]安裕志，李彬，鲜军舫等.常易混淆的眶尖部肿瘤的MRI特点.中华眼科杂志,2000,36:270-271.
[8]Sood S,Vashisht S,Betharia SM,et al.CT evaluation of orbital osseous hemangioma. Australas Radiol,1992,36:124-126.
[9]Fries PD,Char DH.Bilateral orbital cavernous haemangiomas. Br J Ophthalmol, 1988,72:871 -873.
[10]Sullivan TJ,Aylward GW,Wright JE,et al.Bilateral multiple cavernous haemangiomas of the orbit. Br J Ophthalmol,1992,76: 627-629.
[11]Shields JA,Hogan RN. Bilateral cavernous haemangiomas of the orbit.Br J Ophthalmol, 2000, 84:928 -935.
[12]Johnson TE,Nasr AM,Nalbandian RM,et al.Enchondromatosis and hemangioma (Maffucci's syndrome) with orbital involvement. Am J Ophthalmol,1990,110:153- 159.
[13]Mendivil A, Cuartero V.Color Doppler image of central retinal artery of eyes with an intraconal mass.Curr Eye Res,1999,18: 104-109.
[14]Sir Stewart Duke-elder.System of Ophthalmology:the ocular adnexa. London: Henry kimpton, 1974:1091-1095.
[15]Leinung S,Lots I,Wurl P,et al.Monstroses venous hemangiom of the retroperitoneum. Problems in diagnosis.Zentralbl-Chir,1999,124:843-847.
[16]Katz SE, Rootman J, Vangveeravong S,et al.Combined venous lymphatic malformations of the orbit (so-called lymphangiomas). Association with noncontiguous intracranial vascular anomalies. Ophthalmology,1998,105: 176-184.
[17]Parentin F，Borzaaghini L,Perissutti P.The role of ultrasonography in the diagnosis of orbital lymphangiomas. Ophthalmologica,2001,215: 238-240
[18]鲜军舫，王振常，田其昌，等.眼眶神经鞘瘤的CT和MRI研究.中华放射学杂志,2000,34: 258-260.
[19]Song,GX.CT findings in 49 cases of primary orbital meningioma. Chung Hua Yen Ko Tsa Chih,1990,26:304-306.
[20]Hashimoto, M,Tomura,N,Watarai,J.Retrobulbar orbital metastasis mimicking meningioma. Radiat Med,1995,13:77-79.
[21]宋国祥，吴中耀.眼眶病学.北京：人民卫生出版社,第一版.1999:195-196.
[22]何球藻，吴厚生，曹雪涛.细胞与分子免疫学.上海：上海科学技术文献出版社,2000,155 -172.
[23]Moriyama H, Nakajima T, Honda Y.Studies on mucocoeles of the ethmoid and sphenoid sinuses: analysis of 47 cases.J Laryngol Otol,1992,106: 23-27.
[24]Curtin HD, Rabinov JD .Extension to the orbit from paraorbital disease. The sinuses. Radiol Clin North Am, 1998,36:1201-1213.
[25]James VF,Janice GA.Ophthalmology secrets.Pennsylvania:HANLEY & BELFUS,Inc, 1998,506.
[26]Knowles DM,Jakobiec FA.Orbital Lymphoid Neoplasmas.A clinico- pathologic study of 60 patients.Cancer,1980,46: 576-579.
[27]Harris NL,Jaffe ES,Stein H,et al.A revised European-American classification of lymphoid neoplasmas: a propasal from the International Lymphoma Study Group. Blood,1994,84:1361-1392.
[28]Hoang Xuan Tm,Bodaghi B,Toublanc M.Scleritis and mucosal-associated lymphoid tissue lymphoma: a new masquerade syndrome.Ophthalmology,1996, 103:631-635.
[29]Mark Cahill,Colma Barnes,Paul Moriarty,et al.Ocular adnexal lymphoma-comparison of MALT lymphoma with other histological types.Br J Ophthalmol,1999,83:742-747.
[30]White WL,Ferry JA,Harris NL,et al.Ocular adnexal lymphoma-a clinico- pathologic study with identification of lymphomas of mucosa associated lymphoid tissue type. Ophthalmology, 1995,102:1994-2006.
[31]Akpek EK,Polcharoen W,Ferry JA,et al.Conjunctival lymphoma masquerading as chronic conjunctivitis.Ophthalmology,1999,106:757 -760.
[32]Voegtle R,Choudat L, Agbaguede I, et al.Lymphomes lacrymaux de type MALT J Fr Ophtalmol,1999,22:884-887.
[33]Auer IA, Gascoyne RD, Connors JM, et al. t(11;18)(q21;q21) is the most common translocation in MALT lymphomas. Ann-Oncol,1997,8:979-985.
[34]Ferry JA, Yang WI,Zukerberg LR,et al.CD5+ extranodal marginal zone B-cell (MALT) lymphoma. A low grade neoplasm with a propensity for bone marrow involvement and relapse. Am J Clin Pathol,1996,105:31-37.
[35]Wotherspoon AC,Finn TM,Isaacson PG.Trisomy 3 in low-grade B-cell lymphomas of mucosa-associated lymphoid tissue.Blood,1995,85:2000- 2004.