早期诊断输卵管外异位妊娠的临床初探

目的探讨临床上提高输卵管外异位妊娠早期诊断准确率的途径。方法回顾分析近年经手术后病理证实的输卵管以外部位的异位妊娠的术前超声诊断情况。结果 33例患者22例在术前确诊,9例误诊,2例漏诊。结论经阴道超声结合彩色多普勒超声可提高异位妊娠的诊断准确率。     

Bcl-2 expression as a novel immunohistochemical marker for ruptured tubal ectopic pregnancy

Programmed cell death by apoptosis occurs in fetal and maternal tissues during early pregnancy and plays an important role during implantation, decidualization, and in fetal development. In the regulation of apoptosis, bcl-2 is one of the central controlling genes, and acts by protecting the cell against apoptosis. It is postulated that invasiveness of ectopic trophoblast towards and through the muscularis zone of the tubal wall consequently leading to tubal rupture might be due to disturbed regulation of apoptosis. By means of immunohistochemistry and a computerized image analysis, bcl-2 immunostaining was localized and quantified in 36 randomly selected paraffin-embedded ectopic trophoblast tissue specimens collected from women undergoing surgery for ruptured (n = 18) and non-ruptured (n = 18) tubal ectopic pregnancies. Immunostaining was found in the villi syncytiotrophoblast in all patients, while the percentage of positive bcl-2 immunostained area (%PA) (P = 0.0009) and staining intensity (P = 0.0042) were consistently greater in the group of ruptured ectopic pregnancies. Including the variables %PA and saturation into a logistic regression model for a probability threshold of 0.5 (<0.5 = non-ruptured ectopic pregnancy, >0.5 = ruptured ectopic pregnancy) to identify tubal rupture, a sensitivity and specificity of 94.4% were found. It is suggested that elevated bcl-2 immunostaining in the syncytiotrophoblast layer reflects unlimited cell survival of ectopic trophoblast and could lead to the establishment of a circulating marker for tubal rupture.     

Rare ectopic pregnancies after in-vitro fertilization: one unilateral twin and four bilateral tubal pregnancies

Between 1985 and 1989, one unilateral twin and four bilateral tubal pregnancies were encountered among 124 extrauterine pregnancies and 1648 intrauterine pregnancies following in-vitro fertilization and embryo transfer. The two factors associated with this high incidence of single and multiple extrauterine pregnancies were tubal damage and multiple embryo transfer. Embryos at different stages of development appear to have the capacity to implant ectopically. Despite advances in diagnostic capabilities, ectopic pregnancy remains a major cause of maternal mortality. Early diagnosis prior to rupture must be made if mortality and morbidity are to be abolished. The use of transvaginal sonography has improved the diagnosis of ectopic pregnancy and should be routinely used in all pregnancies following assisted conception. The identification of an intrauterine pregnancy should not be sufficient to rule out the possibility of an extrauterine pregnancy or even bilateral tubal pregnancies.     

颅内生殖细胞瘤的MRI影像表现及诊断

目的 探讨颅内生殖细胞瘤的MRI表现,旨在提高对本病的影像诊断准确率。方法 回顾性分析2014年12月~2019年5月我院经手术病理或临床诊断性放射治疗确诊的13例颅内生殖细胞瘤患者的MRI影像资料,分析其临床表现、影像表现及诊断。结果 病变位于松果体区患者9例,MRI检查肿瘤实质部分T1WI呈稍低信号,T2WI和FLAIR 呈高或稍高信号,DWI呈等或稍高信号,增强扫描呈明显强化;肿瘤伴有囊变者1例,伴有钙化者3例,4例患者伴脑积水;3例患者出现转移灶,累及三脑室、侧脑室等,其MRI信号及强化方式与原发灶相似。病变位于鞍区患者3例,肿瘤形态、大小不一,T1WI 呈稍低信号,T2WI和FLAIR 呈稍高信号,增强扫描呈明显强化。1例患者的病变位于右侧基底节区,形态不规则,T1WI呈等信号,T2WI、FLAIR及DWI均呈稍高信号,增强扫描无强化,同侧大脑脚较对侧萎缩。结论 MRI对颅内生殖细胞瘤的影像诊断与鉴别诊断具有重要价值。     

Simultaneous bilateral tubal pregnancy after intracytoplasmic sperm injection

Since the advent of assisted reproductive technology, the concernabout ectopic implantation of embryos has increased dramatically.Simultaneous bilateral tubal pregnancy is the least common typeof ectopic implantation of two embryos. In this report we presentthe first case of simultaneous bilateral tubal pregnancy afterintracytoplasmic sperm injection (ICSI) and embryo transfertreatment. The present case had no risk factor for ectopic pregnancy.Therefore, for early diagnosis and management of such cases,close clinical follow-up and routine ultrasonography followingICSI are necessary.     

Implementation of probabilistic decision rules improves the predictive values of algorithms in the diagnostic management of ectopic pregnancy.

Current algorithms for the diagnosis of ectopic pregnancy do not take into account the heterogeneity in patient profiles. Such heterogeneity can lead to differences in the pre-test probability of ectopic pregnancy. In patients with clinical symptoms, for example, the probability of presence of an ectopic pregnancy is higher than in symptom-free patients. Any additional tests should then be interpreted differently, depending on the pre-test probability. We present a diagnostic algorithm that uses probabilistic decision rules for the evaluation of women with suspected ectopic pregnancy with flexible cut-off levels for test positivity We compare it with a general algorithm that uses fixed cut-off levels. Fictitious cohorts, varying in prevalence of ectopic pregnancy were put together, using data obtained from a cohort of >800 women with suspected ectopic pregnancy. In the inflexible algorithm, ectopic pregnancy was diagnosed whenever it could be visualized at transvaginal sonography, or where serum human chorionic gonadotrophin (HCG) exceeded a rigid cut-off level; ectopic pregnancy was rejected if an intrauterine pregnancy was seen or when serum HCG decreased. In the flexible algorithm, a post-test probability was obtained after each test, using pre-test probabilities and test-based likelihood ratios. Ectopic pregnancy was diagnosed whenever the post-test probability for ectopic pregnancy exceeded 95%, whereas this diagnosis was rejected if the calculated post-test probability fell below 1%. For both algorithms, sensitivity and specificity as well as predictive values were calculated. At each prevalence, the inflexible algorithm was associated with a sensitivity of 93% and a specificity of 97%. In contrast, the sensitivity and specificity of the flexible, individualized algorithm depended on the prevalence of ectopic pregnancy. Consequently, predictive values varied strongly when the inflexible algorithm was used, whereas they were much more stable after using the flexible algorithm. For five possible valuations of false positive and false negative diagnoses, the flexible algorithm reduced the expected disutility, compared with the inflexible algorithm. It is concluded that clinicians should incorporate probabilistic decision rules in algorithms used for the diagnosis of ectopic pregnancy.     

A review of 254 ectopic pregnancies in a teaching hospital in the Trent Region, 1977-1990.

A total of 254 cases of ectopic pregnancy were reviewed in a teaching hospital in Sheffield, in three defined periods: I, 1977-9; II, 1985-7 and III, 1988-90. A previous history of infertility was noted in 37% of cases. Overall, the presenting symptoms, clinical, laboratory, operative as well as histological findings, are in broad agreement with other series. The incidence increased steadily from 8.6 per 1000 total births in period I to 16.5 per 1000 total births in period III. A number of changes noted in recent years include: (1) the diagnosis of ectopic pregnancy was made significantly (P less than 0.05) earlier; (2) a significantly (P less than 0.05) greater proportion of ectopic pregnancies had an association with the following factors: previous tubal surgery, the diagnosis established with ultrasonography, laparotomy preceded by laparoscopy and treatment by conservative surgery; and (3) a significantly (P less than 0.05) smaller proportion of ectopic pregnancies had the diagnosis based on pelvic tenderness or pelvic mass. During the period 1988-90 a total of 126 laparoscopies were performed for suspected ectopic pregnancy, of which 82 (65%) were confirmed to have ectopic pregnancy and 44 (35%) were thought to have no evidence of ectopic pregnancy on laparoscopy. However, two of the latter cases were subsequently found to have an ectopic pregnancy within 2 weeks. The clinical implications of these findings are discussed.     

Endovaginal sonography for the early diagnosis of intrauterine and ectopic pregnancies.

Endovaginal sonography, together with beta-HCG titre, was used to diagnose ectopic pregnancy in 58 patients. Transabdominal ultrasound failed to conclude this diagnosis. The data from endovaginal sonography revealed the presence of a gestational sac in all 15 patients with normal pregnancies at a beta-HCG level of 1042 mIU/ml. Of the 23 patients with pathological pregnancies only 61% had an intrauterine gestational sac. Only 15% of the 20 patients with ectopic pregnancies showed an increase in beta-HCG greater than 66% in 48 h, while in normal pregnancy, this increase was found in 71% of the patients. The endovaginal findings of the ectopic gestation revealed a complex adnexal mass in 55%, a cystic mass in 30% and fluid in the cul-de-sac in 20%. The diagnostic indices of adnexal and cul-de-sac sonographic findings in the ectopic group further improved specificity and positive predictive accuracy. The detection of ectopic versus intrauterine gestation showed a high sensitivity of 95%, a specificity of 100%, a positive predictability of 100% and a negative predictability of 97%. The data confirm the value and reliability of endovaginal and cul-de-sac sonography, combined with measurement of the beta-HCG level in the early diagnosis of ectopic pregnancy. This combined approach not only makes the differentiation between normal and extrauterine gestation more accurate but also helps to avoid unnecessary diagnostic laparoscopy and hospitalization.     

Primary omental pregnancy: case report

Omental pregnancy is a very rare form of ectopic pregnancy. Here we presented a case of primary omental pregnancy diagnosed at surgical exploration. A 28 year old woman submitted with severe abdominal pain, without any delay of menstruation. History of the patient revealed no use of contraceptive method. There was no gestational sac in the endometrial cavity and no tubal ring in the adnexa, but free peritoneal fluid in the pouch of Douglas was detected at ultrasonography. Laparotomy was done according to pre-operative diagnosis of ruptured tubal pregnancy. Bilateral tubes and ovaries were intact; omental pregnancy was detected and partial omentectomy was performed. Although 16 cases of omental pregnancy (mostly secondary) were reported in the literature, herein we describe a primary omental pregnancy without adnexial involvement.     

Pregnancy: Heterotopic pregnancy obtained after in-vitro fertilization and embryo transfer following bilateral total salpingectomy: case report

Heterotopic (coexistent ectopic and intra-uterine) pregnancyis common following in-vitro fertilization and multiple embryotransfer. Total bilateral salpingectomy is generally consideredto eliminate the risk of ectopic, and hence heterotopic pregnancy.This is, however, not strictly correct as it does not eliminatethe risk of interstitial tubal pregnancy. This is the firstreported case of a heterotopic pregnancy following total bilateralsalpingectomy. The diagnostic pitfalls and a suggested methodof avoiding them are discussed.     

Pregnancy: Intramural pregnancy following difficult embryo transfer

We report an intramural pregnancy following a difficult embryotransfer in a 31 year-old woman, having in-vitro fertilizationand embryo transfer for tubal factor infertility. The creationof a ‘false passage’ at a previous instrumentationof the cervix may be implicated in the ectopic placement ofembryos     

SPIO标记猪脂肪干细胞的生物学特性与多向分化潜能及体外3.0T MR成像

背景：不同种类细胞的最佳化标记方案需要大量实验证明,而每种细胞对应标记策略的安全性检测至关重要。 目的：应用超顺磁性氧化铁联合多聚左旋赖氨酸标记猪脂肪干细胞,探讨磁标记对细胞生物学特性和多向分化潜能的影响以及标记细胞体外3.0T MR成像特性。 方法：五指山小型猪皮下脂肪分离培养脂肪干细胞;超顺磁性氧化铁-多聚左旋赖氨酸复合物标记液标记脂肪干细胞;应用3.0T MR对不同浓度标记细胞进行T1WI、T2WI及T2*WI序列体外成像。 结果与结论：普鲁士蓝染色显示标记细胞胞质内含有多少不等的蓝染铁颗粒,细胞标记率近100%;标记细胞向心肌、骨、脂肪方向诱导分化成功;不同浓度标记细胞MR扫描显示,随细胞浓度升高,3种序列信号变化率均增加;相同浓度细胞T2*WI信号变化率最大,T1WI最小,同一浓度3种MR序列间信号变化率差异均有显著性意义(P < 0.01);3.0T MR成像能检测到至少1×10⁶ L^-1标记细胞。结果显示应用超顺磁性氧化铁联合多聚左旋赖氨酸标记方案可有效标记脂肪干细胞,不影响细胞活力、增殖及多向分化能力;T2*WI序列检测标记细胞最敏感。     

应用MRI技术对肝脏局灶结节性增生的诊断

目的 评估磁共振成像（magnetic resonance imaging,MRI）技术对肝脏局灶结节性增生（focal nodular hyperplasia,FNH）的诊断价值.方法 回顾性分析齐齐哈尔市第一医院2008年1月至2010年4月经手术切除或穿刺活检病理证实的10例26灶FNH 磁共振平扫、动态增强表现,由3名有经验的医师做MR表现诊断.结果 对于10例中的26个病灶,平扫T1WI上23个病灶为稍低或等信号、3个病灶为稍高信号;T2WI上23个病灶呈稍高信号、1个病灶等信号,2个病灶呈稍低信号.在动脉期5个病灶明显不均匀增强、19个病灶显著均匀增强,门静脉期和延迟期13个病灶呈稍高信号,11个病灶呈等/稍低信号,2个病灶无强化.11个病灶检出瘢痕,T1WI呈低信号,T2WI呈低或高信号,动脉期无增强、门静脉期或延迟期增强.8例诊断正确,1例诊断为良性病变（定性困难）,1例误诊为恶性肿瘤.结论 MRI能显示单发或多发FNH的特征性改变,并在术前正确诊断大部分FNH.     

Diffusion weighted MR imaging in acute vertebral compression fractures: differentiation between malignant and benign causes

Aim

The primary objective of this study was to evaluate the specificity and sensitivity of diffusion weighted MR imaging (DWI) in the differentiation and characterisation between benign and malignant vertebral compression fractures compared with conventional T1 WI, T2 WI and fat suppressed contrast enhanced T1 WI in the Malaysian population.

Materials and Methods

Thirty five patients with 68 vertebral compression fractures were imaged using the conventional T1 WI, T2 WI, fat suppressed contrast enhanced T1-weighted, and steady state free precession diffusion-weighted (SSFP DWI) sequences on a 1.5 T MR scanner. Signal intensities were analysed qualitatively for all the sequences by comparison to adjacent normal marrow. A quantitative assessment of the signal intensity in the SSFP DWI was also performed.

Results

T1 WI and T2 WI images are of limited diagnostic value because of the variability in signal intensities. Contrast enhanced images had sensitivity and specificity of 93% and 71%, respectively with a negative predictive value (NPV) of 93%. On diffusion-weighted MR imaging, sensitivity was 87% with specificity of 92%. The positive predicative value (PPV) and NPV were both 90%. The quantitative assessment of ratio revealed a statistical significant difference between the benign (0.96) and the malignant (1.73) group of lesion (Mann-Whitney U-test, p=0.0001).

Conclusions

We found that absence of contrast enhancement has a high NPV (90%) while SSFP DWI has both a high PPV (90%) and high NPV (90%) in detecting malignant vertebral compression fractures. Furthermore, in our study the ratio of lesion intensity technique offers an excellent criterion to differentiate between the benign and malignant lesions, and the presence of iso- or hypointensity of the collapsed vertebral bodies is suggestive of a benign lesion while hyperintensity is highly suggestive of malignancy. We also found that using the NLMR showed a statistical significant difference between the malignant and benign groups (p<0.0001) with osteoporotic and malignant lesions have mean values of 0.96 (SD 0.25) and 1.73 (SD 0.4) respectively.     

Heterotopic pregnancy after IVF-ET: report of a case and a review of the literature

A case of heterotopic, intrauterine and tubal ectopic pregnancy is reported, following in-vitro fertilization and transfer of four 4-cell embryos. The literature on the subject is reviewed and the possible aetiological factors, as well as the clinical essentials for early pre-operative diagnosis are discussed.     

钆塞酸二钠增强磁共振和弥散加权成像诊断肝细胞癌TACE术后 存活或复发病灶的价值

目的:探究钆塞酸二钠（Gd-EOB-DTPA）增强磁共振（MRI）和弥散加权成像（DWI）诊断肝细胞癌（HCC）经导管肝 动脉化疗栓塞（TACE）术后存活或复发病灶的价值。方法:前瞻性连续纳入初次接受TACE治疗的96 例患者的129 个 HCC病灶。以CT 和/或MRI 随访，手术病理为诊断金标准，探究Gd-EOB-DTPA增强MRI 和DWI 对TACE术后1~2 月 HCC病灶存活或复发的诊断准确性，并采用ROC曲线分析ADC值对存活或复发病灶的鉴别诊断价值。运用卡方检验分 析T1WI信号、T2WI信号、形态、包膜、DWI信号、动脉期增强表现及肝特异期信号判断TACE术后存活或复发的价值。结 果:（1）金标准证实TACE术后存活病灶29个，肝内复发病灶18个，完全坏死病灶82个；（2）TACE术后HCC存活或复发病 灶多呈现出T1WI 低信号、T2WI 高信号、DWI 高信号的表现，89.36%（42/47）病灶动脉期强化，91.49%（43/47）肝细胞期未 见造影剂摄取呈低信号；（3）Gd-EOB-DTPA增强MRI 和DWI 诊断TACE术后存活或复发病灶的敏感度、特异度分别为 93.62%和91.49%、96.34%和95.12%，两者联合诊断的敏感度和特异度为95.74%、100.00%；（4）病灶无包膜、DWI高信号、 动脉期增强是判断TACE术后存活或复发的独立重要因素（P<0.05）。结论:Gd-EOB-DTPA增强MRI和DWI对TACE术 后HCC存活或复发病灶具有较高的诊断价值，可应用于TACE术后临床随访。     

恶性蝾螈瘤MR影像分析（附1例报道）

目的：探讨恶性蝾螈瘤（MTT）的MRI表现和临床病理特点,提高临床对MTT的认识.方法：手术切除辅以放疗治疗右前臂MTT 1例.结合文献复习,分析MTT的MRI表现及病理特征.结果：MTT的MRI表现为T1WI稍低信号、T2WI高信号的软组织肿块,肿瘤信号不均、T2WI上高信号肿块影内环形或线样低信号分隔影或许是MTT的特征性MRI表现之一.MTT的恶性度高,其治疗以手术切除为主,疗效及预后不佳,易在短期内复发及转移.结论：深入了解MTT的MRI表现,对MTT的早期诊断、早期治疗具有重要价值.     

视神经磁共振成像方法研究

目的　探讨视神经磁共振 (MRI)成像最佳方法及正常视神经MRI征象 .方法　随机选择 4 0例进行头部检查 ,无眼部疾患或视力障碍患者作为正常视神经研究对象 .使用PhilipsACS -NT15 1.5T超导型磁共振成像仪及正交头线圈 .成像序列包括自旋回波T1加权成像 (SET1WI)及超快速自旋回波加或不加脂肪频谱饱和技术成像 (TSE±SPIRT2WI) .扫描方位包括与视神经平行轴位、斜矢状位及与视神经长轴垂直冠状位和标准冠状位 .结果　视神经眶内段、管内段及视束粗细均匀 .SET1WI显示视神经较周围的蛛网膜下腔信号强度稍高 ,T2WI显示视神经呈相对低信号 ,与脑髓质信号相等 ,周围包绕高信号脑脊液 .与视神经长轴平行的轴位及斜矢状位T1WI及T2WI均可显示视神经全貌 ,与视神经长轴垂直冠状位TSE +SPIRT2WI技术显示视神经信号均匀 .结论　MRI可以较好地显示视神经解剖 ,与视神经长轴垂直冠状位TSE +SPIRT2WI可以较好地显示信号特征 .     

Tubal ectopic pregnancy: a patho-physiological explanation involving endometriosis

The condition of tubal ectopic pregnancy is presented from diverse points of view, bringing out physiological explanations for its occurrence in primates and striking absence in other mammals. Part of the flexibility underlying ectopic pregnancy in humans stems from the absence of a uterine luteolytic mechanism, enabling early embryonic development in the Fallopian tube without compromising function of the corpus luteum. Attention is devoted to a potential overlap between the composition of tubal and uterine fluids, and to specific mixing between the two fluid compartments, expressed in an ability of the human oocyte or zygote to tolerate transplantation to the uterus. Perturbed tubal oocyte transport is seen as a contributory factor, not least as a sequel to episodes of infection and a modified endosalpinx, but the essay then reasons strongly for an involvement of endometriosis in the aetiology of tubal ectopic pregnancy. Proliferation of refluxed endometrial tissue arrested within the Fallopian tube could provide the epithelial characteristics of a uterine environment. Accordingly, an experimental model is proposed for tubal ectopic pregnancy in animals based upon transplants of endometrial tissue and the subsequent introduction of embryos into both the Fallopian tubes and uterus; the latter would suppress the luteolytic mechanism. Finally, advances are suggested based upon molecular scanning of human ectopic tissues and those derived from animal models. If molecular probes could be developed to detect either early tubal pregnancy or a propensity to this pathology, such advances would clearly have clinical relevance-not least in view of an enhanced incidence of tubal pregnancy arising after assisted reproduction technology.     

Equivocal diagnoses in breast aspiration biopsy cytology: sources of uncertainty and the role of "atypical/indeterminate" terminology.

In 1996, a National Cancer Institute committee recommended four categories as uniform terminology for breast fine-needle aspirations (FNAs): benign, malignant, suspicious/probably malignant, and atypical/indeterminate. The latter is a controversial category. This study evaluates the usefulness of the atypical/indeterminate term, and examines sources of diagnostic equivocation in breast FNA. Eight hundred and twenty-two consecutive breast FNAs were previously classified as benign, malignant, suspicious, or unsatisfactory. Two hundred and thirteen (25.9%) cases had surgical follow-up and were classified as true positive (TP), false positive (FP), true negative (TN), false negative (FN), true suspicious (TS), or false suspicious (FS). Slides from FN, FP, TS, and FS were reviewed for interpretative error, poor clarity or preservation, obscuring material, sampling error, or insufficient malignant criteria. Cases were also evaluated as to whether classification as "atypical/indeterminate" would have improved patient care. There were 21/822 (2.6%) FN, 37/822 (4.5%) TS + FS, and 0 FP diagnoses. Seventy percent of suspicious diagnoses showed cancer on follow-up. The majority of FN and suspicious cases were due to sampling problems and insufficient criteria of malignancy. None were deemed more appropriately classified as "atypical/indeterminate" All required surgical confirmation for treatment. All equivocal breast diagnoses are due to similar problems. Splitting them into "suspicious/probably malignant" and "atypical/indeterminate" would not lower the biopsy rate. A simpler three-part terminology of benign, malignant, and suspicious/equivocal, without qualification of the latter favoring benign or malignant, would provide more effective communication and appropriate follow-up. Diagn. Cytopathol. 1999;21:217-222.