1、； 循證醫學實踐教學案例分析 2014年2月18日修訂科別:口腔頜面外科住院號:38871入院日期:2014.3.6報告者姓名:職務: 住院醫師 基地醫師 þ實習醫師 完成時間:2014.4.11病例摘要患者，女，31歲。因“右上腭腫塊2年余，伴脹痛3個月”之主訴于2014年3月16日收住我科。查體：患者一般情況良好，右眶下隆起，鼻道無異常分泌物，開口度：30cm，牙列完整無叩痛，右上腭部明顯隆起，內界接近中線，后界達軟腭前部，黏膜光滑無潰瘍，觸之中等硬度，無明顯壓痛，上頜瓦氏位片示，右上頜竇內有一半球形軟組織陰影。MRI與CT掃描見右上頜竇內有一半球形軟組織陰影，上頜竇底骨質無規則

2、破壞。腫塊穿刺液涂片發現異形細胞，血尿常規、生化檢驗無異常。初步診斷右上頜骨惡性腫瘤，侵犯上頜竇。于2014年3月13日在經鼻氣管插管全麻下。行右上頜骨次全切除術。手術進行順利，術后恢復良好。術后病理報告：腺樣囊性癌。由修復科行上頜贗復體修復，恢復上頜形態及咀嚼功能，于2014年4月7日出院。提出可回答的臨床問題(Asking)P:唾液腺腺樣囊性癌患者I:CT或者MRI診斷C:病理診斷O:診斷正確率的評價檢索最有用的證據(Acquire)關鍵詞( Key word )：oral adenoid cystic carcinoma，CT or MRI數據庫來源 ( Database )：PubMe

3、d Clinical Queries主要內容：Perineural spread of adenoid cystic carcinoma in the oral and maxillofacial regions: evaluation with contrast-enhanced CT and MRIObjectives: The objective of this study was to compare the accuracy of contrast-enhanced CT (CECT) and contrast-enhanced MRI (CEMRI) in the detectio

4、n of perineural spread (PNS) of adenoid cystic carcinoma (ACC) in the oral and maxillofacial regions.Methods: This study consisted of 13 ACCs from 13 patients, all of which were histopathologically diagnosed. Both CECT and CEMRI were performed in all patients before the treatment. The images of each

5、 patient were retrospectively evaluated for the detection of PNS. The definitions of PNS included abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal, and enlargement or excessive

6、contrast enhancement of a nerve.Results: 11 out of 13 cases were proven to exhibit PNS histopathologically. 8 of the 11 cases for which PNS was histopathologically proven exhibited PNS on MR images. Six of the eight cases for which PNS was exhibited on MR images also exhibited PNS on CT images. The

7、sensitivity, specificity and accuracy for the detection of PNS were 55%, 100% and 62% on CT images and 73%, 100% and 77% on MR images, respectively. Although the accuracy of PNS on MR images was slightly superior to that on CT images, there were no statistically significant differences between the d

8、etection of PNS on CT images and on MR images.Conclusions: CT and MR images are equally useful for the detection of PNS of ACC in the oral and maxillofacial regions.證據評價 (Appraisal )證據等級：DWorksheet：一、標準診斷方法的確定：組織病理學檢查的神經侵犯（the presence of PNS by the histopathological diagnosis）二、診斷對象的選擇：The study sa

9、mple was derived from the population of patients who presented to Osaka University Dental Hospital, and were histopathologically diagnosed with ACC between June 2000 and December 2007.此研究中病例組指的是患有腺樣囊性癌有神經侵犯的病例。病例組和對照組的確定是根據標準診斷方法，即組織病理學檢查的神經侵犯（the presence of PNS by the histopathological diagnosis）的

10、陰陽性來決定的。陽性為病例組，陰性為非病例組。1. 病例組包括該病的各種類型：神經侵犯（PNS）有一個標準（the basis of Ginsbergs criteria of PNS）,包括不正常牙的密度，翼腭窩的增強，腭孔、切牙管上頜管和孔神經侵犯性（abnormal density/signal intensity, contrast enhancement or widening of the pterygopalatine fossa, palatine foramen, incisive canal, mandibular foramen and mandibular canal,

11、 and enlargement or excessive contrast enhancement of a nerve），其多樣性體現了病例組的多樣性。2. 對照組是未表現為神經侵犯的病例，由于此研究重點對CT和MRI的診斷比較，沒有包括易與該病混淆的其他病例。CT和MRI相互對比。三、列出評價診斷試驗的四格表：標準診斷病例組非病例組病例組非病例組診斷試驗CT+606診斷試驗MRI+8085273251121311213四、計算各項診斷試驗的評價指標：1. CT靈敏度（真陽性率）55%，漏診率（假陰性率）45%特異性（真陰性率）100%，誤診率（假陽性率）0%預測值，陽性100%，陰性29

12、%似然比LR，試驗陽性無窮大，實驗陰性45%神經侵犯疾病概率85%神經侵犯疾病比率550%驗前比550%驗后比，陽性無窮大，陰性278%驗后概率，陽性27%，陰性74%2. MRI靈敏度（真陽性率）73%，漏診率（假陰性率）27%特異性（真陰性率）100%，誤診率（假陽性率）0%預測值，陽性100%，陰性40%似然比LR，試驗陽性無窮大，實驗陰性72%神經侵犯疾病概率85%神經侵犯疾病比率550%驗前比550%驗后比，陽性無窮大，陰性396%驗后概率，陽性20%，陰性80%3. 處理綜合實驗結果陰性驗后比=178%五、診斷試驗的評估：1. 真實性：采用盲法：Thesefindings were

13、 independently evaluated on the CT and MR images by two radiologists who did not know the results of the histopathological examination and then consensus readings for interpretation discrepancies was performed.診斷試驗包含適當的病譜診斷試驗的檢測結果不會影響參考標準的運用存在相同真實性由于樣本量不夠大，對于其數值的真實性存在質疑2. 重要性：特異性較強，能夠診斷疾病，但是敏感性不夠沒有進

14、行分層似然比3. 實用性由于樣本量不夠大，對于其數值的可能存在偏倚但是實用性必須得到重視。由于腺樣囊性癌具有極強的神經侵犯性，其相較于其他唾液腺腫瘤比較保守的方法，手術范圍必須擴大，并且果斷犧牲各種神經。所以術前診斷室非常重要的，有利于手術方案的確定。可以在本單位開展，因為CT和MRI的運用。驗前概率估計該病發生神經侵犯的概率，可以作為估算驗后概率得到相對可靠的神經侵犯的概率，為手術方案的確定作指導。證據解讀及證據應用( Apply )由于腺樣囊性癌具有極強的神經侵犯性，其相較于其他唾液腺腫瘤比較保守的方法，手術范圍必須擴大，并且果斷犧牲各種神經。所以術前診斷室非常重要的，有利于手術方案的確定。病人在追求治愈疾病的同時，也注重術后的生活質量。基于可能犧牲神經，導致病人許多感覺運動功能喪失，例如面癱等嚴重影響其生存治療。病人的志愿更