Soft-tissue Hemangiomas in Infants and Children: Diagnosis Using Doppler Sonography 嬰兒和兒童的軟組織血管瘤：使用多普勒超聲診斷
Josée Dubois 若澤·杜布瓦
Heidi B. Patriquin 海蒂·B·帕特里金
Laurent Garel' 勞倫特·加雷爾
Julie Powell 朱莉·鮑威爾
Denis Filiatrault 丹尼斯·菲利婭特洛
Michèle David 米雪兒·大衛
Andrée Grignon 安德烈·葛林尼恩
Received October 27, 1997; accepted after revision February 5,1998 收到 1997 年 10 月 27 日; 經修改後於 1998 年 2 月 5 日接受
Department of Medical Imaging, Hôpital Sainte-Justine, 3175 Côte-Sainte-Catherine, Montréal, Québec, Canada H3T IC5. Address correspondence to J. Dubois. 醫療影像部, Hôpital Sainte-Justine, 3175 Côte-Sainte-Catherine, 蒙特婁, 魁北克, 加拿大 H3T 1C5。請致函 J. Dubois。
Department of Dermatology, Hôpital Sainte-Justine, Montréal, Québec, Canada H3T IC5. 皮膚科, 聖儒斯汀醫院, 蒙特婁, 魁北克, 加拿大 H3T 1C5。
Department of Hematology, Hôpital Sainte-Justine, Montréal, Québec, Canada H3T IC5. 血液內科，聖·朱斯汀醫院，蒙特利爾，魁北克，加拿大 H3T IC5。
AJR 1998;171:247-252 美國放射學雜誌 1998;171:247-252
0361-803X/98/1711-247
(C) American Roentgen Ray Society (C) 美國 X 光線學會
OBJECTIVE. We describe the sonographic appearance and vascularization of hemangiomas and determine if vessel density and peak systolic Doppler shifts distinguish hemangiomas from other superficial soft-tissue masses. 目的。我們描述血管瘤的超聲波影像和血管化,並確定血管密度和峰值收縮期杜卜勒移位是否可以區分血管瘤與其他淺部軟組織腫塊。
SUBJECTS AND METHODS. Our pilot study included 20 infants and children with hemangiomas who were to undergo biopsy before treatment with interferon alpha-2b. 主題與方法。我們的試驗性研究包括 20 位需要在使用干擾素α-2b 治療前進行活檢的血管瘤患兒。 We used Doppler sonography to determine the number of vessels per square centimeter, peak arterial Doppler shift, resistive index, and signs of arteriovenous shunting. 我們使用多普勒超聲波檢查來確定每平方厘米血管數量、動脈多普勒移位峰值、阻力指數和動靜脈分流的跡象。 All hemangiomas showed high vessel density (more than five per square centimeter) and high Doppler shifts (more than ), and these two factors became our diagnostic criteria. A prospective study of tients was then carried out. One hundred sixteen consecutive pediatric patients with superficial soft-tissue masses were examined using Doppler sonography; sonographic findings were compared with the final diagnoses that were established by biopsy, CT, or clinical follow-up. 所有血管瘤都表現出高血管密度(每平方厘米超過五個)和高多普勒頻移(超過 ),這兩個因素成為了我們的診斷標準。然後進行了一項 例患者的前瞻性研究。一百一十六例連續的小兒表淺軟組織質量患者接受了多普勒超聲波檢查;超聲波檢查結果與通過活檢、CT 或臨床隨訪建立的最終診斷進行了比較。
RESULTS. The final diagnoses included 70 hemangiomas, 20 venous malformations, three arteriovenous malformations, three arteriolocapillary malformations, and 20 other masses. 結果。最終診斷包括 70 例血管瘤、20 例靜脈畸形、3 例動靜脈畸形、3 例動脈-毛細血管畸形和 20 例其他腫塊。 Fifty-nine lesions showing high vessel density (more than five per square centimeter) and a peak arterial Doppler shift exceeding were correctly diagnosed as hemangiomas (sensitivity, ; specificity, ). One arteriovenous malformation showed high vessel density and high Doppler shifts, but none of the other masses that were not hemangiomas did. 五十九個病變顯示高血管密度(每平方厘米超過五個)和峰值動脈多普勒移位超過 的,被正確診斷為血管瘤(敏感性, ; 特異性, )。一個動靜脈畸形顯示高血管密度和高多普勒移位,但其他非血管瘤的腫塊均未出現此現象。 Eleven patients with hemangiomas who were being treated with interferon at the time of the study fulfilled only one of the two diagnostic criteria. 在研究期間正在接受干擾素治療的 11 名血管瘤患者,僅符合診斷標準中的一項。
CONCLUSION. High vessel density and high peak arterial Doppler shift can be used to distinguish hemangiomas from other soft-tissue masses. 結論。高血管密度和高峰動脈多普勒位移可用於將血管瘤與其他軟組織腫塊區分開來。
Hemangiomas, which are among the most common soft-tissue tumors in infants [1-3], typically appear as slightly raised, bluish red subcutaneous masses that resemble the surface of a strawberry and regress as the child grows older. 血管瘤是嬰兒最常見的軟組織腫瘤之一[1-3]，通常表現為略微隆起的藍紅色皮下腫塊，外觀像草莓表面，隨著孩子成長而逐漸消退。 Some hemangiomas do not have this typical appearance because part or all of the lesion is deep in the soft tissue and the overlying skin appears normal. 有些血管瘤並沒有這種典型外觀,因為部分或全部病變位於軟組織深處,而上覆皮膚外觀正常。 These lesions are difficult to distinguish clinically from more suspicious soft-tissue masses, such as vascular malformations, soft-tissue tumors (e.g., metastases from neuroblastoma or rhabdomyosarcoma), and infantile myofibromatosis. 這些病變臨床上很難與更可疑的軟組織腫塊區分,例如血管畸形、軟組織腫瘤(如神經母細胞瘤或橫紋肌肉瘤的轉移)和小兒肌纖維瘤。 Children with such lesions are usually referred for imaging studies or biopsy. 有這種病變的兒童通常會被轉介做成像研究或活檢。
Blood flow in superficial vessels is readily discernible using Doppler sonography. 使用多普勒超聲波可以很容易地觀察到表淺血管中的血液流動。 We sought to ascertain whether hemangiomas have characteristic features that can be seen using high-frequency gray-scale and Doppler sonography and whether they can be distinguished from other superficial soft-tissue masses in infants and children. 我們致力於確定血管瘤是否具有可透過高頻灰階和多普勒超聲波成像觀察到的特徵,以及是否可將其與嬰幼兒的其他淺層軟組織腫塊區分開來。
Subjects and Methods 研究對象與方法
Pilot Study 試驗性研究
To determine the general appearance and vascularization characteristics of soft-tissue hemangiomas in infants, we performed high-resolution gray-scale and Doppler sonography and CT with IV contrast material on 20 infants and children with hemangiomas who were about to undergo biopsy before commencing therapy with interferon alpha- (Intron , Schering, Canada). We used a Mark 9 HDI scanner (ATL, Seattle, WA) with a linear array transducer. Color Doppler sonograms were obtained with low-pulse repetition frequency and a wall filter. Pulse-repetition frequency was increased only if aliasing occurred. The area of greatest vasculariza- 為了確定嬰幼兒軟組織血管瘤的整體外觀和血管化特徵,我們在 20 名即將接受活檢治療前使用干擾素 alpha- （Intron ，Schering，加拿大）的嬰幼兒和兒童中執行了高分辨率灰度和多普勒超聲和 CT 造影。我們使用 Mark 9 HDI 掃描儀（ATL，西雅圖，WA）和 線性陣列探頭。彩色多普勒超聲圖像是以低脈沖重複頻率和牆過濾器獲取的。如果出現混疊,則只增加脈沖重複頻率。最大血管化區域是……
Dubois et al. 杜布瓦等人。
Fig. 1.-Hemangioma of right cheek in 2-month-old girl (normal overly ing skin). 圖 1. - 2 個月大女嬰右臉頰上的血管瘤 (表皮肌膚正常)。
A, Gray-scale sonogram reveals heterogeneous mass (arrows). 灰階超聲波顯示異質性腫塊(箭頭)。
B, Color Doppler sonogram shows high vessel density (more than five visible vessels per square centimeter). B, 彩色多普勒超聲圖顯示高血管密度(每平方厘米可見五個以上血管)。
tion was selected, and the number of vessels per square centimeter outlined on color Doppler imaging was counted. Peak arterial Doppler shifts and the resistive index (RI) were ascertained with pulsed Doppler sonography. 選擇的動脈部位，並使用彩色多普勒成像計算每平方厘米內的血管數量。利用脈衝多普勒超聲檢測獲得動脈峰值多普勒頻移和阻力指數(RI)。 All of these lesions were verified as hemangiomas by biopsy. They had variable appearance on gray-scale sonography but were highly vascular, containing at least five vessels per square centimeter; the peak velocity was higher than . On CT, the hemangiomas showed rapid uptake and intense, persistent retention of contrast material. These findings were used as the criteria for the diagnoses of hemangiomas in the subsequent prospective study. 所有這些病變通過活組織檢查被證實為血管瘤。它們在灰階超聲顯示各不相同,但都高度血管化,每平方厘米至少有 5 條血管；峰值速度高於 。在 CT 上,血管瘤表現為快速攝取和對比劑的強烈持續滯留。這些結果被用作後續前瞻性研究中對血管瘤的診斷依據。
Prospective Clinical Study 預期臨床研究
All infants and children referred to our dermatology-vascular malformations clinic with clinically diagnosed hemangiomas or other superficial soft-tissue masses were screened by the attending dermatologist. Patients were referred for sonographic and CT examination if the lesion did not have the typical physical appearance of a hemangioma or appeared to have a subcutaneous extension that was difficult to assess clinically. 所有被轉介至我們皮膚科-血管畸形診所,被臨床診斷為血管瘤或其他淺表性軟組織腫塊的嬰兒和兒童,均由主治皮膚科醫生進行篩查。如果病灶沒有血管瘤典型的物理外觀,或似乎有難以臨床評估的皮下延伸,則將患者轉介進行超聲和 CT 檢查。 Between June 1991 and January 1996. all such children were examined by sonography, and the sonographic diagnoses were compared with the final diagnoses. 在 1991 年 6 月至 1996 年 1 月期間,所有此類兒童均進行了超音波檢查,並將超音波診斷與最終診斷進行了比較。
Sonograms were obtained by one of four pediatric radiologists trained in Doppler sonography to whom the details of the sonographic technique for the study had been carefully explained. Either a Quantum II (Siemens, Issaquah, WA) with a 7.5 linear gray-scale and Doppler transducer or a Mark 9 HDI (ATL) with a or transducer was used. A 1 -cm-thick standoff pad was used when necessary. The length, width, and depth of the lesions were measured using electronic calipers. Echogenicity was assessed as hypoechoic or hyperechoic. 影像圖像由四位接受過多普勒超音波培訓的兒科放射科醫生獲得,他們已經仔細解釋了此研究的超音波技術細節。使用了 Quantum II (Siemens, Issaquah, WA) 配備 7.5 MHz 線性灰階和多普勒探頭,或 Mark 9 HDI (ATL) 配備 5 MHz 或 7.5 MHz 探頭。必要時使用 1 公分厚的墊塊。使用電子卡尺測量病變的長、寬和深度。回聲性被評估為低回聲或高回聲。 Gray-scale sonography was used to look for visible vessels around or within the lesion. Internal architecture was classified as homogeneous or heterogeneous. 灰階超音波被用於尋找病變周圍或內部可見的血管。內部結構被分類為均質或非均質。 Doppler sonography was performed using the lowest pulse-repetition frequency and Doppler gain settings that did not cause aliasing (pulse-repetition frequency, ; wall filter, ). Color Doppler sonography was used to scan the entire lesion with a restricted field of view. The area of greatest vascularity was retained for analysis. The field of interest was reduced to . Vessels were identified by color-flow signals, and vessel density was defined semiquantitatively as sparse or low density (fewer than two vessels per square centimeter), moderate or medium (two to four vessels per square centimeter), and numerous or high (more than five vessels 多普勒超音波檢查是使用最低脈衝重複頻率和多普勒增益設定,避免產生混疊(脈衝重複頻率, ; 壁濾波器, )。使用彩色多普勒超音波掃描整個病變,採用縮小視野。保留最大血管分布區域進行分析。將觀察範圍縮小至 。通過色流信號識別血管,並以半定量方式定義血管密度為稀疏或低密度(每平方厘米少於兩條血管)、中度或中等(每平方厘米兩至四條血管)以及眾多或高密度(每平方厘米超過五條血管)。
Diagnosing Childhood Hemangiomas with Doppler Sonography 用多普勒超聲診斷兒童血管瘤
A
Fig. 2.-Hemangioma of orbital region in 2-month-old girl. A, Color Doppler sonogram shows high vessel density. 圖 2.-2 個月大女嬰眶部血管瘤。A, 彩色多普勒超音波顯示高血管密度。
B, Spectroscopy shows high systolic flow with peak of . 榴彈波譜顯示高收縮血流波峰低於 。
per square centimeter). A pulsed Doppler examination was then performed. placing the Doppler sample into arteries and veins. Peak arterial systolic Doppler shifts were noted and classified as low ( ). moderate ( ). or high ( ). The RI was calculated (systolic - diastolic / systolic Doppler shifts). Evidence of arteriovenous shunting was sought. including high diastolic flow. RI less than 0.5 , and pulsatile venous flow. 每平方厘米)。然後進行脈衝多普勒檢查,將多普勒樣本置於動脈和靜脈中。記錄了動脈收縮期峰值多普勒頻移,並將其分類為低( )、中度( )或高( )。計算了 RI(收縮期 - 舒張期 / 收縮期多普勒頻移)。尋找動靜脈分流的證據,包括高舒張期流量、RI 小於 0.5 和脈動性靜脈流。
Eighty-five percent of these examinations were performed without sedation of the patient. The remainder were performed immediately after CT, taking advantage of the sedation necessary for that examination. Informed consent was obtained from patients" parents. 八十五％的檢查在未使用鎮靜劑的情況下進行。其餘的檢查是在進行 CT 檢查後立即進行的,利用了該檢查所需的鎮靜。已經從患者的父母那裡獲得了知情同意。 The study was approved by the hospital committee on human experimentation. After Doppler sonograms were obtained, the examining radiologist reported the diagnostic impression to the clinician. 該研究已獲得醫院倫理委員會批准。在取得多普勒超聲波圖像後,檢查放射科醫生向臨床醫生報告了診斷結果。 At the end of the study period, all sonograms were reviewed by the principal investigator. 在研究期結束時,所有超音波檢查結果都由主要研究人員進行審查。
The diagnosis of hemangioma was made if the Doppler examination showed high vessel density (more than five vessels per centimeter) and a high Doppler shift ( ). 如果多普勒檢查顯示高血管密度(每厘米超過五條血管)和高多普勒位移( ),則診斷為血管瘤。 All masses that did not fulfill these criteria were called "other massesnonhemangioma." Lesions with several sites of arteriovenous shunting were called "nonhemangioma-likely arteriovenous malformation." Biopsy was performed if a lesion did not fulfill the criteria for hemangioma on clinical follow-up or on CT. 不符合這些標準的所有腫塊被稱為「其他腫塊 - 非血管瘤」。具有多個動靜脈分流位點的病變被稱為「非血管瘤 - 可能為動靜脈畸形」。如果病變在臨床追蹤或 CT 檢查中不符合血管瘤標準,則會進行活檢。 The final diagnosis was established by clinical follow-up (regression or stability of the mass after age 2 years) in 49 patients: angiography or phlebography in 23 patients: and CT and biopsy in 44 patients. The sonographic findings were compared with the final diagnoses. 最終診斷是透過臨床隨訪（大於 2 歲時腫塊的退縮或穩定）確立的，共有 49 名患者；血管造影或靜脈造影則有 23 名患者；以及電腦斷層掃描和活組織檢查共有 44 名患者。超音波檢查的結果與最終診斷進行了比較。 Sensitivity, specificity, positive predictive value, negative predictive value. and diagnostic accuracy of the sonographic examinations were calculated. 超音波檢查的敏感度、特異度、陽性預測值、陰性預測值和診斷準確度均已計算。
Results 結果
One hundred sixteen infants and children who were 2 days to 7 years old (mean age, 18 months old) were examined. The final diagnoses included 70 hemangiomas, 20 venous malformations, three arteriovenous malformations, three arteriolocapillary malformations, and 20 other masses. 有 116 名年齡介於 2 天至 7 歲(平均 18 個月)的嬰兒和兒童接受了檢查。最終診斷包括 70 例血管瘤、20 例靜脈畸形、3 例動靜脈畸形、3 例動脈毛細血管畸形和 20 例其他腫塊。
The size of the hemangiomas ranged from 2 to . The gray-scale sonographic appearance was nonspecific. One lesion showed a small calcification. In four lesions, one or two vessels were visible on gray-scale sonography. In the remainder of patients, no vessels were seen on gray-scale sonography. 血管瘤的大小範圍從 2 到 。灰階超聲波外觀沒有特異性。一個病變顯示有少許鈣化。在四個病變中,灰階超聲波可見一或兩個血管。在其餘的患者中,灰階超聲波未發現任何血管。
Doppler sonography revealed high vessel density (five vessels or more per square centimeter) in ) of 70 hemangiomas and a maximum systolic Doppler shift greater than 2 in ) of 70 (Figs. 1-3). Using these two criteria established in the pilot study, we were able to make diagnoses of hemangioma in of 70 hemangiomas. Maximum Doppler shifts ranged from 1.1 to 10 with a mean of . RI ranged from 0.25 to 0.89 with a mean of 0.59 ). Eleven hemangiomas fulfilled only one of the two diagnostic criteria and were therefore diagnosed as "mass-nonhemangioma" on sonography. These 11 masses were clinically stable, and the children were receiving interferon treatment at the time. 多普勒超聲波檢查顯示,70 個血管瘤中有 個高血管密度(每平方厘米 5 個或更多血管),而 70 個中有 個最大收縮期多普勒移位超過 2 (圖 1-3)。利用這兩項在先導研究中建立的標準,我們能夠診斷出 70 個血管瘤中的 個。最大多普勒移位範圍從 1.1 到 10 ,平均值為 。阻力指數範圍從 0.25 到 0.89,平均值為 0.59 。有 11 個血管瘤只符合其中一項診斷標準,因此在超聲波檢查中被診斷為"非血管瘤質量"。這 11 個質量在臨床上是穩定的,孩子們當時正在接受干擾素治療。
Three hemangiomas with high vessel density and peak systolic shifts greater than had one or two sites of arteriovenous shunting. No feeding vessels were seen on gray-scale sonography. We correctly diagnosed these lesions as hemangiomas. Three other small lesions had many sites of arteriovenous shunting. 三個血管瘤具有高血管密度和峰值收縮期位移大於 的,有一個或兩個動靜脈分流部位。在灰階超聲波檢查中未見供血血管。我們正確診斷這些病變為血管瘤。另外三個小病變有多個動靜脈分流部位。 Several dilated vessels were noted on grayscale sonography and identified as feeding arteries and veins on Doppler sonography. One lesion had high vessel density and peak systolic shift greater than . The other two had moderate vessel density (three per square centimeter) with a high Doppler shift ( ). We therefore made the diagnosis of "lesionnonhemangioma, probably arteriovenous malformation" (Fig. 4) in these three patients. This diagnosis was confirmed by angiography. 在灰階超聲檢查中發現了幾條擴張的血管,在多普勒超聲檢查中被確認為供血動脈和靜脈。一個病灶的血管密度很高,峰收縮期位移大於 。另外兩個病灶有中度的血管密度(每平方厘米三個),高多普勒位移( )。因此我們對這三名患者做出了「非血管瘤病灶,可能是動靜脈畸形」(圖 4)的診斷。該診斷經血管造影證實。
The 49 nonhemangioma soft-tissue masses had zero to five vessels per square centimeter and a maximum systolic Doppler shift of 0.8 to , with a mean of . The RI ranged from 0.2 to 1.00 , with a mean of 0.45 Figs. 5 and 6). None fulfilled the two criteria for the diagnosis of hemangioma. Some lesions had only venous flow. Three atypical masses that were clearly not hemangiomas were difficult to diagnose on Doppler sonography. 49 個非血管瘤軟組織腫塊每平方厘米內有零至五條血管,最大收縮期多普勒位移為 0.8 至 ，平均為 。RI 範圍為 0.2 至 1.00，平均為 0.45 (見圖 5 和 6)。沒有一個符合血管瘤診斷的兩個標準。部分病變僅有靜脈血流。三個明顯不是血管瘤的非典型腫塊在多普勒超聲診斷上難以診斷。 They did not fulfill the two sonographic criteria used for the diagnosis of hemangioma and were therefore labeled "other masses." In one mass, vessel density was moderate (three per square centimeter), with a high peak systolic Doppler shift ( ). The diagnosis of "mass-nonhemangioma" was made. The mass was very hard on palpation. Biopsy showed a rhabdomyosarcoma. Another mass, which had appeared late in childhood, had high vessel density (more than five per square centimeter) and moderate Doppler shift ( ). It 它們不符合用於血管瘤診斷的兩個超聲波標準,因此被歸類為「其他腫塊」。在一個腫塊中,血管密度適中(每平方厘米三個),高峰收縮期多普勒位移( )。診斷為「非血管瘤腫塊」。觸診時腫塊非常堅硬。活檢顯示為橫紋肌肉瘤。另一個腫塊在童年晚期出現,血管密度高(每平方厘米五個以上),多普勒位移適中( )。
Dubois et al. 杜布瓦等人。
Fig. 3.-Hemangioma with normal overlying skin on back of 6 -monthold boy. 圖 3.-六個月大男孩背部的正常覆蓋皮膚血管瘤。
A. Color Doppler sonogram shows high vessel density (more than five per square centimeter). 彩色多普勒超聲圖顯示高血管密度(每平方厘米超過五個)。
Fig. 4.-Arteriovenous malformation of face in 2 -year-old girl. 圖 4.-2 歲女童面部動靜脈畸形。
A, Gray-scale sonogram shows several vessels (arrow). 灰階超音波成像顯示多條血管(箭頭)。
B, Spectroscopy shows large feeding artery (arrow). Blood flow has low resistance and high diastolic flow, suggesting arteriovenous shunting. B、光譜分析顯示有大型餵食動脈(箭頭)。血流阻力低、舒張期血流高,表示存在動靜脈分流。
C, Spectroscopy shows large draining vein (arrow). Blood flow is pulsatile, compatible with venous flow distal to arteriovenous malformation. C，光譜學顯示大導流靜脈(箭頭)。血流呈脈動性，與動靜脈畸形遠端的靜脈血流相符。
Fig. 5.-Infantile myofibromatosis on back of 1-month-old girl. 圖 5.-1 個月大女嬰背部的嬰兒肌纖維瘤症。
A, Gray-scale sonogram reveals nonspecific mass (arrows). 灰階超音波顯示非特異性腫塊(箭頭)。
B, Color Doppler spectroscopy shows low vessel density with systolic peak of . B, 彩色多普勒光譜術顯示低血管密度,收縮峰值 。
was identified as an angiofollicular hamartoma on biopsy. A lesion in a neonate had low vessel density (fewer than two per square centimeter) with very high Doppler shifts ( ). No specific sonographic diagnosis was made. opsy showed a sarcoma. 經活組織檢查被鑑定為血管濾泡性血管瘤。一名新生嬰兒的病灶血管密度較低(每平方厘米少於兩個)且多普勒位移很高( )。未作出特定超聲診斷。 活檢顯示為肉瘤。
Using the two criteria of high vessel density (more than five per square centimeter) and peak arterial Doppler shift greater than 2 for the diagnosis of hemangioma, we found the sensitivity of the Doppler sonography to be (59/70); specificity, (45/ 46); positive predictive value, (59/61); and negative predictive value, (45/55). 使用高血管密度(每平方厘米超過五個)和動脈多普勒移位峰值大於 2 的兩個診斷血管瘤的標準,我們發現多普勒超聲波的敏感性為 (59/70);特異性為 (45/46);陽性預測值為 (59/61);陰性預測值為 (45/55)。
Discussion 討論
Infantile hemangiomas are benign vascular lesions characterized by a phase of initial growth and angiogenesis, a plateau phase of inactivity, slow resolution of angiogenesis, and regression of both the size and vascularity of the tumors [4-6]. 嬰兒血管瘤是良性血管病變,特徵包括初期生長和血管生成階段、休眠期、血管生成緩慢減退以及腫瘤大小和血管密度逐步減少的過程[4-6]。 Their severity varies; hemangiomas range from an asymptomatic, discolored spot on the skin to large, highly disfiguring masses that can be life-threatening when they occur near vital structures such as the airway. Their high vascularity can cause high output heart failure. 它們的嚴重程度有所不同;血管瘤從無症狀的皮膚色斑到大型、嚴重畸形的肫塊不等,當它們發生在如呼吸道等重要結構附近時,可能會危及生命。它們的高度血管性可能導致高輸出性心力衰竭。 Sequestration of platelets in the lesion may lead to thrombocytopenia (Kasa- 麥粒腫的血小板沖淤可能導致血小板減少症(Kasa-)
bach-Merritt syndrome). Microscopically, the hallmark of a growing hemangioma is a proliferation of endothelial cells, forming syncytial masses composed of numerous vessels or cords of endothelial cells. The vessel lumens are often compressed. 巴赫-默里特症候群。在顯微鏡下,正在增長的血管瘤的特徵是內皮細胞增殖,形成由許多血管或內皮細胞索組成的融合性細胞塊。血管腔通常被壓縮。 Occasional mitotic figures are seen. However, the nuclei have a benign appearance and are not pleomorphic. As the proliferative phase progresses, vascular channels are less compressed and capillary lumens lined by plump endothelial cells may be seen [7]. 偶爾可見有絲分裂。然而,核呈良性形態,且無多形性。隨著增殖期的進行,血管通道逐漸減少壓迫,並可見充盈內皮細胞的毛細血管腔腔[7]。 Mast cells are also abundant in proliferating hemangioma tissue [8]. Most hemangiomas have a typical "strawberry" appearance with well- 頭皮組織中也存在大量的肥大細胞[8]。大多數血管瘤都呈現典型的「草莓」外觀,具有良好的
Fig. 6.-Atypical mass on forehead of 1-week-old boy. 圖 6.-1 周大男嬰額頭的非典型腫塊。
A, Color Doppler sonogram shows low vessel density. 彩色多普勒超聲圖顯示血管密度低。
B, Spectroscopy shows peak Doppler shift of . Rhabdomyosarcoma was diagnosed by biopsy. 光譜學顯示唐布勒位移峰值為 。生物檢查診斷為橫紋肌肉瘤。
Dubois et al. 杜布瓦等人。
defined borders. This type presents little diagnostic difficulty on clinical examination. Diagnostic problems arise when lesions are atypical and when all or part of a lesion lies deep in the subcutaneous tissues and therefore cannot be clearly defined on physical examination. 界定的邊界。此類型在臨床檢查中診斷困難不大。當病變不典型且全部或部分深藏於皮下組織中而無法在身體檢查中清楚界定時,就會出現診斷問題。 This type of lesion is difficult to distinguish from vascular malformations and tumors such as infantile myofibromatosis, neuroblastomas, metastases, and sarcomas. Children with such lesions are usually referred for imaging studies. 這種病變很難從血管畸形和腫瘤中區別出來,例如嬰兒肌纖維瘤症、神經母細胞瘤、轉移和肉瘤。 患有此類病變的兒童通常會被轉介進行影像學檢查。
Because modem sonographic equipment is ideally suited to examining superficial lesions, this noninvasive method is useful in examining children with such lesions. 由於現代超音波設備非常適合檢查表淺病變,這種非侵入性方法在檢查患有此類病變的兒童時很有用。 Feeding arteries and veins are more easily identified by Doppler sonography than by CT because the lesions can be examined in many planes. 以多普勒超聲波檢查比電腦斷層掃描更容易識別餵血動脈和靜脈,因為病變部位可從多個角度進行檢查。
In our pilot study of biopsy proven hemangiomas, we found that all hemangiomas had blood flow through many vessels too small to be seen on gray-scale sonography. 在我們的活體切片證明血管瘤的先導研究中,我們發現所有血管瘤都有通過許多肉眼無法在灰度超音波成像中觀察到的微小血管的血流。 We devised a method of estimating vessel density by counting the number of vessels per square centimeter shown on color Doppler sonography in the area of greatest vascularization in each lesion. Technical factors were kept constant. 我們制定了一種通過計算每個病灶最豐富血管區域內每平方厘米血管數量來估算血管密度的方法。技術因素保持不變。 The vessel count is semiquantitative at best, considering that one tortuous vessel may yield more than one color Doppler signal. We classified vessel density as low, medium, or high. 血管計數最多只能半定量,因為一條迂曲的血管可能會產生多個彩色多普勒訊號。我們將血管密度分類為低、中或高。 Maximum systolic Doppler shift rather than velocity was measured because the vessel beam angle was rarely known. The 20 patients with hemangiomas in the pilot study had a maximum Doppler shift exceeding . During the prospective study of 116 children with various subcutaneous masses, we found that the two criteria of high vessel density and Doppler shift greater than allowed us to distinguish hemangiomas from other lesions, which had fewer vessels or lower Doppler shifts. 由於罕知血管束夾角,因此測量最大收縮期多普勒頻移而非速度。在先導研究中,20 名患有血管瘤的患者其最大多普勒頻移超過 。在對 116 名不同皮下腫塊患兒進行前瞻性研究中,我們發現高血管密度和多普勒頻移大於 兩項標準可將血管瘤從其他具較少血管或低多普勒頻移的病變中區分出來。
A number of pitfalls were encountered. Arteriovenous malformations also showed more than five vessels per square centimeter and Doppler shift exceeding . However, feeding vessels large enough to be seen on gray-scale sonography were found to be feeding arteries and draining veins on spectroscopy. Multiple sites of arteriovenous shunting were identified by very high diastolic Doppler shifts ( ) and abnormally pulsatile draining veins. Each arteriovenous malformation was associated with a small soft-tissue mass. We were unable to confirm the work of Meyer et al. 發現了一些陷阱。動靜脈畸形也顯示每平方厘米有超過五條血管，多普勒頻移超過 。然而，在灰階超聲檢查中可見的供血血管證實為供血動脈和引流靜脈。通過非常高的舒張期多普勒頻移（ ）和異常搏動的引流靜脈確定了多處動靜脈通訊。每個動靜脈畸形都與一小塊軟組織包塊相關。我們無法證實 Meyer 等人的工作。 [9], who found that arteriovenous malformations can be differentiated from hemangiomas by the absence of a soft-tissue mass. Only one of 70 hemangiomas showed one vessel large enough to be identified on gray-scale sonography, and no pulsatile draining veins were identified. [9]研究發現，動靜脈畸形可以通過缺乏軟組織質量與血管瘤進行區分。在 70 個血管瘤中,只有一個顯示出一條足夠大的血管可以在灰階超聲中識別,並且沒有發現任何搏動性引流靜脈。 Some hemangiomas had one or two sites of arteriovenous shunting that were not of the same density as arteriovenous malformations. 一些血管瘤具有一個或二個動靜脈分流的部位,其密度並非與動靜脈畸形相同。 Two sarcomas and one angiofollicular hamartoma had the high Doppler shifts characteristic of hemangiomas, but their vessels were sparse in number and at the periphery of the lesions . 兩個肉瘤和一個血管濾泡性過度形成症具有血管瘤特徵的高多普勒移位，但它們的血管數量稀少，位於病變的周圍 。
Why do hemangiomas (benign lesions) and sarcomas sometimes share similar blood flow characteristics as seen on Doppler sonography? The answer probably lies in the concept of angiogenesis . Some lesions are capable of stimulating the host to create new vessels, usually from existing endothelial cells, by secreting angiogenesis factors. The molecular structure of several angiogenesis factors has been defined . Angiogenesis factors have been isolated from many tissues including fibroblasts, wound fluids, placentas, numerous malignant tumors, hemangioendotheliomas, and infantile hemangiomas. 為什麼血管瘤(良性病變)和肉瘤有時在多普勒超聲檢查中表現出類似的血流特徵?答案可能在於血管生成的概念。某些病變能刺激宿主創造新的血管,通常是從現有的內皮細胞開始,通過分泌血管生成因子來實現。幾種血管生成因子的分子結構已被確定。血管生成因子已從多種組織分離出來,包括纖維母細胞、創傷液、胎盤、許多惡性腫瘤、血管內皮瘤和嬰兒血管瘤。 The new vessels produced through angiogenic stimulation do not have a muscularis layer, and therefore blood flow through the network of vessels feeding them has high velocity and low resistance. Flow within the individual microscopic vessels is slow. 透過血管生成刺激產生的新血管不具有肌層，因此它們所構成的血管網路內的血流速度高、阻力低。個別顯微血管內的血流速度則較為緩慢。 Thus it is likely that the blood flow in hemangiomas that is detected by Doppler sonography occurs in the vessels feeding the neovasculature stimulated by angiogenesis factors. 因此,可能是通過多普勒超聲檢測到的血管瘤中的血流是在由血管新生因子刺激產生的新生血管中發生的。 During their phase of proliferation, hemangiomas receive maximal angiogenic stimulation, as evidenced by the large number of vessels and cords of endothelial cells seen by microscopy. 在增生期,血管瘤接受最大的血管生成刺激,顯示在顯微鏡下可見大量血管和內皮細胞索。 Other benign superficial tumors of childhood do not appear to manifest the intense degree of angiogenesis noted in hemangiomas. This may explain the difference in vessel density and peak systolic Doppler shift between hemangiomas and other benign masses. 其他良性幼年淺表瘤並未顯示出與血管瘤相似的強烈血管生成度。這可能解釋了血管瘤和其他良性腫瘤之間的血管密度和峰值收縮期血流速率的差異。
Although malignant tumors may show intense angiogenesis, the network of new vessels is usually found at the periphery of the mass. Very high Doppler shifts have been detected at the periphery of numerous malignant tumors, especially in the abdomen [10, 11]. 雖然惡性腫瘤可能會展現強烈的血管生成,但新生血管網絡通常出現在腫塊的邊緣。在許多惡性腫瘤的邊緣,特別是在腹部，已檢測到非常高的多普勒頻移[10, 11]。 It is not likely that a malignant tumor would mimic the high density of vessels throughout its mass that is seen in hemangiomas. The 11 hemangiomas in our series that had fewer than five vessels per square centimeter or less than Doppler shift were clinically stable lesions in children undergoing interferon alpha- treatment. It remains to be seen whether the diminishing angiogenic stimulation in treated or spontaneously involuting hemangiomas is reflected in changing Doppler patterns. 對於惡性腫瘤模擬血管瘤整個質量中高密度血管的情況,這種可能性較低。在我們的系列中,11 例血管瘤每平方厘米血管數小於 5 條或多普勒位移小於 的，都是接受干擾素 alpha- 治療的兒童穩定病灶。尚待觀察,經治療或自發性退縮的血管瘤中,血管形成刺激的減弱是否反映在多普勒模式的變化中。
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