二维及彩色多普勒超声对Graves病与桥本氏甲状腺炎鉴别诊断的应用价值
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摘要
目的
探讨二维及彩色多普勒超声在Graves病与桥本氏甲状腺炎鉴别诊断的价值。
方法
收集2008年8月至2008年12月在山东省立医院超声诊疗科门诊检查的正常人、Graves病及桥本氏甲状腺炎患者共57例,其中Graves病患者(GD组)19例,桥本氏甲状腺炎患者(HT组)18例,正常人(N组)20例。GD组与HT组患者均为初发病例,未经任何治疗,不合并其余甲状腺疾病。N组均无甲状腺疾病病史。对所有患者及正常人进行二维及彩色多普勒超声检查,记录甲状腺体积参数(甲状腺左右叶前后径及峡部厚度)、甲状腺回声参数(甲状腺回声级别、甲状腺内低回声区分布特点、实质内是否有强回声网格样分隔)、甲状腺实质内血流模式以及双侧甲状腺上动脉参数(内径、PSV、EDV、RI)。所有患者及正常人均经实验室检查fT3、fT4、TSH、Anti-TG、Anti-TPO。根据所测PSV,计算每人的PSVmean、PSVmax、PSVmin。除外Anti-TG、Anti-TPO阳性合并甲亢症状与体征的病例,降低桥本甲亢对本研究的影响。
统计分析:数据处理应用SPSS13.0软件包,计数资料采用卡方检验,计量资料采用t检验,两两比较采用LSD法。以P＜0.05为差异具有统计学意义。采用接受者操作特征(ROC)曲线探讨PSV对鉴别GD与HT的价值。
结果
1.GD组与HT组甲状腺双侧叶前后径及峡部厚度与N组相较,均明显增大(P＜0.05)。GD组与HT组相较,各个径线无明显差异(P=0.114,0.096,0.412)。
2.GD组与HT组病人甲状腺回声均明显减低。二者经统计学检验,无明显差异(x~2=0.044 0.75＜P＜0.9)。在低回声区的分布方面,GD组以散在分布为主,而HT组则以弥漫性分布为主,二者经检验,有统计学差异(x~2=6.190.025＜P＜0.01)。HT组甲状腺实质内网格样强回声显示率明显高于GD组,经统计学检验,有明显差异(x~2=13.77 P＜0.005)。
3.正常对照组甲状腺血流局限于甲状腺周边血管,实质内几乎测不到血流信号。GD组与HT组甲状腺实质内血流信号均明显增多,大部分病例呈现火海征。部分GD与HT病人甲状腺实质内血流主要集中于甲状腺前2/3。
4.GD组和HT组患者双侧内径均明显增宽,与正常对照组相比有明显差异(P＜0.001),但GD组HT组无明显差异(P=0.145,0.123)。GD组和HT组患者双侧PSV明显增高,与正常对照组相比,均有明显差异(P＜0.001),且GD组比HT组血流峰值流速增高更明显(P＜0.001)。对GD与HT鉴别诊断意义最大的指标是PSVmean与PSVmax,其诊断界点分别为71cm/s与85cm/s,鉴别诊断的灵敏度与特异度分别为PSVmean:94.7%、83.3%,PSVmax:89.5%、88.9%。GD组和HT组患者甲状腺上动脉舒张术期血流速度与正常对照组相较均明显增高(P＜0.001),但是GD组和HT组无明显差异(P=0.042,0.020)。GD组、HT组与正常对照组三组RI无明显差异(右侧P=0.739,0.814,0.578左侧P=0.429,0.996,0.438)。
结论
1.甲状腺二维声像图中,实质内的网格样强回声分隔对GD和HT有鉴别诊断价值价值最大,但是由于网格样强回声是桥本氏甲状腺炎发展到一定阶段才会出现,所以无法鉴别早期阶段的HT与GD。
2.广泛分布低回声的模式对二者鉴别有一定意义,但是由于本次试验使用的菲利普HDI 5000采用了X—Res与Sono—CT技术,成像清晰,结构显示清楚,而其余的机器由于性能的差异,二维成像质量相差较大,鉴别诊断的价值受到了一定限制。
3.峡部明显增厚不是HT独有的特征,不能鉴别GD与HT。
4.双侧甲状腺上动脉血流动力学参数中对二者鉴别最有意义的指标时PSVmean与PSVmax,其诊断界点分别为71cm/s与85cm/s,鉴别诊断的灵敏度与特异度分别为PSVmean:94.7%、83.3%,PSVmax:89.5%、88.9%。这提示我们在日常工作中,当单侧甲状腺上动脉PSV大于或等于85cm/s时,可仅测量单侧甲状腺上动脉,减少重复测量造成的人力物力的浪费;当单侧甲状腺上动脉PSV小于85cm/s之间时,需要测量另外一侧甲状腺上动脉,减少误诊及漏诊。
Objective
To explore the diagnostic value of 2D and Color Doppler ultrasonography in the differential diagnosis of Graves' disease and Hashimoto's thyroiditis.
Methods
Fifty-seven people in Shandong provincial hospital were selected for this study, which contain nineteen patients with Graves' disease(GD group),eighteen patients with Hashimoto's thyroiditis(HT group) and twenty normal persons(N group).All of the patients visited the hospital for thyroid disease for the first time without any kind therapy including anti-thyroid drug therapy、I~(131) therapy and surgical therapy.None of the normal persons had thyroid disease history before.All of the selected persons had US examination and laboratory test to gain the parameters as follows:(1) the parameters of thyroid volume:anterioposterior diameter of bilateral lobe and the thickness of the isthmus;(2)the parameters of echo characters of the thyroid:the echogenecity of the thyroid、the pattern of the hypoechoic distribution、the intraparenchma of the thyroid had hyperechoic septia or not;(3)the pattern of intraparenchma blood flow;(4)the parameters of bilateral superior thyroid artery:the intradiameter、SPV、EDV、RI;(5) the endocrinal parameters:the value of fT3、fT4、TSH、Anti-TG、Anti-TPO.Calculate everyone's PSVmean、PSVmax、PSVmin according to PSVright、PSVleft。
Statistical analysis:Statistical data-processing applies package SPSS 13.0.χ~2-test is applied for enumeration data statistical analysis,and t-test is applied for numberic data statistical analysis.LSD method is applied for comparison between any two groups of the three groups.To P＜0.05 for the differences are statistically significant.ROC curve is applied to explore the differential diagnosis value of PSV.
Results
1.The anterioposterior diameters of bilateral lobe and the thickness of the isthmus are longer in GD group and HT group than N group(P＜0.05),but there isn't statistical difference between GD group and HT group in any parameters(for P=0.114,0.096,0.412).
2.The echogenecity of GD group and HT group is lower than N group.The low echo distribution is sporadic in most of GD patients and diffuse in most of HT patients (χ~2=6.19 0.025＜P＜0.01).Most HT patients have hyperechoic septia(χ~2= 13.77 P＜0.005).
3.The blood flow in the intraparenchma is more in GD group and HT group than N group,and there isn't statistical difference between GD group and HT group.A big part of the patients show thyroid infero.We observe that the blood flow aggregate in the anterior 2/3 parts in GD and HT groups.
4.The same results happen to the diameter and EDV of superior thyroid artery as the blood flow(P＜0.001).The sequence of the PSV is N group、GD group、HT group from low to high.The most valuable parameters of bilateral superior thyroid arteries are PSVmean and PSVmax.There cut-off points are 71cm/s and 85cm/s.There differential diagnosis sensitivity and specificity are PSVmean:94.7%、83.3%,PSVmax:89.5%、88.9%.There isn't any difference in RI in the three groups (right P=0.739,0.814,0.578,left P=0.429,0.996,0.438).
Conclusions
1.Hyperechoic septia is most valuable in all of parameters of 2D untrasonography in differential diagnosis between GD and HT,but it could not distinguish HT in early stage from GD because the hyperechoic septia is not visible when HT is just begun which correlated with the pathologic course.
2.The distributional pattern of wide spread low echo is valuable for differential diagnosis.The application is limited in many other instruments because PHLIP HDI 5000 equiped with X-Res and Sono-CT and the photographs is more distincter.
3.The obvious thicken isthmus was not unique for HT,so it could not distinguish HT from GD.
4.The most valueable parameters of bilateral superior thyroid arteries are PSVmean and PSVmax.There cut-off points are 71cm/s and 85cm/s.There differential diagnosis sensitivity and specificity are PSVmean:94.7%、83.3%, PSVmax:89.5%、88.9%.We could measure only one side superior thyroid artery to save the time and other resources when the first PSV measured was greater than or equal to 85cm/s,We should measure bilateral superior thyroid arteries when the first PSV lower than 85cm/s to decrease the rates of misdiagnosis and missed diagnosis.
探讨二维及彩色多普勒超声在Graves病与桥本氏甲状腺炎鉴别诊断的价值。
方法
收集2008年8月至2008年12月在山东省立医院超声诊疗科门诊检查的正常人、Graves病及桥本氏甲状腺炎患者共57例,其中Graves病患者(GD组)19例,桥本氏甲状腺炎患者(HT组)18例,正常人(N组)20例。GD组与HT组患者均为初发病例,未经任何治疗,不合并其余甲状腺疾病。N组均无甲状腺疾病病史。对所有患者及正常人进行二维及彩色多普勒超声检查,记录甲状腺体积参数(甲状腺左右叶前后径及峡部厚度)、甲状腺回声参数(甲状腺回声级别、甲状腺内低回声区分布特点、实质内是否有强回声网格样分隔)、甲状腺实质内血流模式以及双侧甲状腺上动脉参数(内径、PSV、EDV、RI)。所有患者及正常人均经实验室检查fT3、fT4、TSH、Anti-TG、Anti-TPO。根据所测PSV,计算每人的PSVmean、PSVmax、PSVmin。除外Anti-TG、Anti-TPO阳性合并甲亢症状与体征的病例,降低桥本甲亢对本研究的影响。
统计分析:数据处理应用SPSS13.0软件包,计数资料采用卡方检验,计量资料采用t检验,两两比较采用LSD法。以P＜0.05为差异具有统计学意义。采用接受者操作特征(ROC)曲线探讨PSV对鉴别GD与HT的价值。
结果
1.GD组与HT组甲状腺双侧叶前后径及峡部厚度与N组相较,均明显增大(P＜0.05)。GD组与HT组相较,各个径线无明显差异(P=0.114,0.096,0.412)。
2.GD组与HT组病人甲状腺回声均明显减低。二者经统计学检验,无明显差异(x~2=0.044 0.75＜P＜0.9)。在低回声区的分布方面,GD组以散在分布为主,而HT组则以弥漫性分布为主,二者经检验,有统计学差异(x~2=6.190.025＜P＜0.01)。HT组甲状腺实质内网格样强回声显示率明显高于GD组,经统计学检验,有明显差异(x~2=13.77 P＜0.005)。
3.正常对照组甲状腺血流局限于甲状腺周边血管,实质内几乎测不到血流信号。GD组与HT组甲状腺实质内血流信号均明显增多,大部分病例呈现火海征。部分GD与HT病人甲状腺实质内血流主要集中于甲状腺前2/3。
4.GD组和HT组患者双侧内径均明显增宽,与正常对照组相比有明显差异(P＜0.001),但GD组HT组无明显差异(P=0.145,0.123)。GD组和HT组患者双侧PSV明显增高,与正常对照组相比,均有明显差异(P＜0.001),且GD组比HT组血流峰值流速增高更明显(P＜0.001)。对GD与HT鉴别诊断意义最大的指标是PSVmean与PSVmax,其诊断界点分别为71cm/s与85cm/s,鉴别诊断的灵敏度与特异度分别为PSVmean:94.7%、83.3%,PSVmax:89.5%、88.9%。GD组和HT组患者甲状腺上动脉舒张术期血流速度与正常对照组相较均明显增高(P＜0.001),但是GD组和HT组无明显差异(P=0.042,0.020)。GD组、HT组与正常对照组三组RI无明显差异(右侧P=0.739,0.814,0.578左侧P=0.429,0.996,0.438)。
结论
1.甲状腺二维声像图中,实质内的网格样强回声分隔对GD和HT有鉴别诊断价值价值最大,但是由于网格样强回声是桥本氏甲状腺炎发展到一定阶段才会出现,所以无法鉴别早期阶段的HT与GD。
2.广泛分布低回声的模式对二者鉴别有一定意义,但是由于本次试验使用的菲利普HDI 5000采用了X—Res与Sono—CT技术,成像清晰,结构显示清楚,而其余的机器由于性能的差异,二维成像质量相差较大,鉴别诊断的价值受到了一定限制。
3.峡部明显增厚不是HT独有的特征,不能鉴别GD与HT。
4.双侧甲状腺上动脉血流动力学参数中对二者鉴别最有意义的指标时PSVmean与PSVmax,其诊断界点分别为71cm/s与85cm/s,鉴别诊断的灵敏度与特异度分别为PSVmean:94.7%、83.3%,PSVmax:89.5%、88.9%。这提示我们在日常工作中,当单侧甲状腺上动脉PSV大于或等于85cm/s时,可仅测量单侧甲状腺上动脉,减少重复测量造成的人力物力的浪费;当单侧甲状腺上动脉PSV小于85cm/s之间时,需要测量另外一侧甲状腺上动脉,减少误诊及漏诊。
Objective
To explore the diagnostic value of 2D and Color Doppler ultrasonography in the differential diagnosis of Graves' disease and Hashimoto's thyroiditis.
Methods
Fifty-seven people in Shandong provincial hospital were selected for this study, which contain nineteen patients with Graves' disease(GD group),eighteen patients with Hashimoto's thyroiditis(HT group) and twenty normal persons(N group).All of the patients visited the hospital for thyroid disease for the first time without any kind therapy including anti-thyroid drug therapy、I~(131) therapy and surgical therapy.None of the normal persons had thyroid disease history before.All of the selected persons had US examination and laboratory test to gain the parameters as follows:(1) the parameters of thyroid volume:anterioposterior diameter of bilateral lobe and the thickness of the isthmus;(2)the parameters of echo characters of the thyroid:the echogenecity of the thyroid、the pattern of the hypoechoic distribution、the intraparenchma of the thyroid had hyperechoic septia or not;(3)the pattern of intraparenchma blood flow;(4)the parameters of bilateral superior thyroid artery:the intradiameter、SPV、EDV、RI;(5) the endocrinal parameters:the value of fT3、fT4、TSH、Anti-TG、Anti-TPO.Calculate everyone's PSVmean、PSVmax、PSVmin according to PSVright、PSVleft。
Statistical analysis:Statistical data-processing applies package SPSS 13.0.χ~2-test is applied for enumeration data statistical analysis,and t-test is applied for numberic data statistical analysis.LSD method is applied for comparison between any two groups of the three groups.To P＜0.05 for the differences are statistically significant.ROC curve is applied to explore the differential diagnosis value of PSV.
Results
1.The anterioposterior diameters of bilateral lobe and the thickness of the isthmus are longer in GD group and HT group than N group(P＜0.05),but there isn't statistical difference between GD group and HT group in any parameters(for P=0.114,0.096,0.412).
2.The echogenecity of GD group and HT group is lower than N group.The low echo distribution is sporadic in most of GD patients and diffuse in most of HT patients (χ~2=6.19 0.025＜P＜0.01).Most HT patients have hyperechoic septia(χ~2= 13.77 P＜0.005).
3.The blood flow in the intraparenchma is more in GD group and HT group than N group,and there isn't statistical difference between GD group and HT group.A big part of the patients show thyroid infero.We observe that the blood flow aggregate in the anterior 2/3 parts in GD and HT groups.
4.The same results happen to the diameter and EDV of superior thyroid artery as the blood flow(P＜0.001).The sequence of the PSV is N group、GD group、HT group from low to high.The most valuable parameters of bilateral superior thyroid arteries are PSVmean and PSVmax.There cut-off points are 71cm/s and 85cm/s.There differential diagnosis sensitivity and specificity are PSVmean:94.7%、83.3%,PSVmax:89.5%、88.9%.There isn't any difference in RI in the three groups (right P=0.739,0.814,0.578,left P=0.429,0.996,0.438).
Conclusions
1.Hyperechoic septia is most valuable in all of parameters of 2D untrasonography in differential diagnosis between GD and HT,but it could not distinguish HT in early stage from GD because the hyperechoic septia is not visible when HT is just begun which correlated with the pathologic course.
2.The distributional pattern of wide spread low echo is valuable for differential diagnosis.The application is limited in many other instruments because PHLIP HDI 5000 equiped with X-Res and Sono-CT and the photographs is more distincter.
3.The obvious thicken isthmus was not unique for HT,so it could not distinguish HT from GD.
4.The most valueable parameters of bilateral superior thyroid arteries are PSVmean and PSVmax.There cut-off points are 71cm/s and 85cm/s.There differential diagnosis sensitivity and specificity are PSVmean:94.7%、83.3%, PSVmax:89.5%、88.9%.We could measure only one side superior thyroid artery to save the time and other resources when the first PSV measured was greater than or equal to 85cm/s,We should measure bilateral superior thyroid arteries when the first PSV lower than 85cm/s to decrease the rates of misdiagnosis and missed diagnosis.
引文
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[24]Halil Arslan,Ozkan Unal,Ekrem Algun,et al.Power Doppler sonography in the diagnosis of Graves' disease[J].European Journal of Ultrasound,2000,11:117-122.
[25]Morosini PP,Simonella G,Mancini V,et al.Color Doppler sonography patterns related to histological findings in Graves' disease.Thyroid,1998,7:577-582.
[26]T A A MACEDO,M C CHAMMAS,et al.Reference values for Doppler ultrasound parameters of the thyroid in a healthy iodine-non-deficient population[J].The British Journal of Radiology,2007,80:625-630.
[27]周方平,盛林,刘会玲,等.二维及彩色多普勒超声对Graves病与桥本氏病的鉴别诊断[J].中国地方病防治杂志,2004,19(4):248-249.
[28]刘文玉.彩色多普勒超声对Graves病与桥本氏甲状腺炎的诊断价值[J].齐齐哈 尔医学院学报2007,28(4):408-409.
[29]余松林,主编.医学统计学[M].北京:人民卫生出版社,2004:172.
[30]Giuseppe Caruso,Marco Attard,Aurelio Caronia,Roberto Lagalla.Color Doppler measurement of blood flow in the inferior thyroid artery in patients with autoinnune thyroid diseases[J].European Journal of Radiology,2000,36:5-10.
[31]Misako Ueda,Masaaki Inaba,Yasuro Kumeda,etl.The significance of thyroid blood flow at the inferior thyroid artery as predictor for early Graves' disease relapse [J].Clinical Endocrinology,2005,63:657-662.
[32]罗福成,施红.彩色多普勒超声诊断学[M].北京:人民军医出版社,2002:107-110.
[1]王吉耀,主编.内科学[M].北京:人民卫生出版社,2005:876.
[2]Rolls PW,Mayekawa DS,Lee,et al.Color flow Doppler Sonography in Graves disease:"Thyroid Inferno".A JR,1988,150:781.
[3]Susanne L.Schulz,Uwe Seeberger,Jurgen H.Hengstmann.Color Doppler sonography in hypothyroidism[J].European Journal of Ultrasound,2003,16:183-189.
[4]于慧俊,倪炜峰.彩色多普勒超声在Graves病诊断中的应用[J].中国疗养医学.2003,12(4):272-273.
[5]初银珠,刘海霞,吴长君,等.彩色多普勒超声在Graves病诊断中的作用[J].医学影像学杂志,2006,16(7):689-691.
[6]周永昌,郭万学.超声医学第4版[M].北京:科学技术文献出版社,2002:371-390
[7]Halil Arslan,Ozkan Unal,Ekrem Algun,et al.Power Doppler sonography in the diagnosis of Graves' disease[J].European Journal of Ultrasound,2000,117-122.
[8]Fausto Bogazzi,Luigi Bartalena,Sandra Brogioni,et al.Thyroid vascularity and blood flow are not dependent on serum thyroid hormone levels:studies in vivo by color flow Doppler sonography[J].European Journal of Endocrinology,1999,140:452-456.
[9]Diekman MJM,Bakker O,Wiersinga WM.Human endothelial cells in vitro contain al-T3 receptors but do not respond to T3 with endothelin-1production[J].Journal of Endocrinological Investigation,1996,19:165-169.
[10]Halil Arslan,Ozkan Unal,Ekrem Algun,et al.Power Doppler sonography in the diagnosis of Graves' disease[J].European Journal of Ultrasound,2000,11:117-122.
[11]Morosini PP,Simonella G,Mancini V,et al.Color Doppler sonography patterns related to histologicl findings in Graves' disease.Thyroid,1998,7:577-582.
[12]T A A Macedo,M C Chammas,et al.Reference values for Doppler ultrasound parameters of the thyroid in a healthy iodine-non-deficient population[J].The British Journal of Radiology,2007,80:625-630.
[13]周方平,盛林,刘会玲,等.二维及彩色多普勒超声对Graves病与桥本氏病的鉴别诊断[J].中国地方病防治杂志,2004,19(4):248-249.
[14]刘文玉.彩色多普勒超声对Graves病与桥本氏甲状腺炎的诊断价值[J].齐齐哈尔医学院学报2007,28(4):408-409.
[15]赵荣.彩色多普勒超声在甲状腺功能亢进亚临床甲状腺功能低下诊断与鉴别诊断中的应用[J].中国超声医学杂志,2001,17(3):184-186.
[16]王珍珍,田家玮,任敏.CDFI鉴别甲状腺功能亢进与亚临床甲状腺功能减退的应用价值[J].中国超声医学杂志,2008,24(6):503-505.
[17]Fausto Bogazzi,Luigi Bartalena,Sandra Brogioni,et al.Thyroid vascularity and blood flow are not dependent on serum thyroid hormone levels:studies in vivo by color flow Doppler sonography[J].European Journal of Endocrinology,1999,140:452-456.
[18]叶任高.内科学[M].第6版.北京:人民卫生出版社,2004:740-741.
[19]Giuseppe Caruso,Marco Attard,Aurelio Caronia,Roberto Lagalla.Color Doppler measurement of blood flow in the inferior thyroid artery in patients with autoinnune thyroid diseases[J].European Journal of Radiology,2000,36:5-10.
[20]Misako Ueda,Masaaki Inaba,Yasuro Kumeda,etl.The significance of thyroid blood flow at the inferior thyroid artery,as predictor for early Graves' disease relapse [J].Clinical Endocrinology,2005,63:657-662.
[21]罗福成,施红,彩色多普勒超声诊断学[M],北京:人民军医出版社,2002:107-110.