悪性腫瘍３０

【臨床症状】50代　ある疾患と診断されている　病期診断目的

【問題】画像所見と診断名は？

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➡ 造影画像
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    ▶答えはこちら
    • すでに子宮体癌と診断されている症例
    • 子宮体部に7×6cm程度の腫瘤影を認める
    • T2WIでやや高信号、T1WIで低信号、拡散強調で高信号、ADCで信号低下、濃染効果ありのため子宮体癌に矛盾しない所見
    • Junctional zoneの不明瞭化もあり、広範な筋層浸潤が疑われる
    • また下部で膀胱壁浸潤も疑われる
    • 傍大動脈リンパ節の腫大あり、転移疑い
    • 上記より子宮体癌、StageⅣB（もしくはⅣA）と診断される
    • 後日、FDG-PETを実施し上記診断に矛盾しない所見だった

    【子宮体癌】

    ・子宮体癌は子宮内膜癌と子宮体部肉腫を包括する用語

    ・子宮内膜癌は近年増加傾向であり、食生活の欧米化、晩婚化、未婚化などのライフスタイルの変化が背景にあるとされている

    ・40代から増加し50代がピーク

    ・初期は自覚症状はなく、不正出血で発見される事が多い

    ・プロゲステロンによる拮抗を受けないエストロゲン暴露、肥満、糖尿病などがリスクファクターとして知られており、早発月経や未産などのエストロゲン暴露期間の延長によりリスクが増加する

    ・子宮内膜癌は発生機序によってTypeⅠとTypeⅡに分類される

    • TypeⅠ：発癌機序はエストロゲン依存性、好発年齢は周閉経期、組織型は類内膜癌、予後は良い
    • TypeⅡ：八隻機序はde novo発生、好発年齢は高齢者、組織型は漿液性癌、明細胞癌、予後は不良

    ・画像診断の役割は筋層浸潤の有無

    1. T2WIによるjunctional zone、Dynamic早期相におけるSEE：subendometrial enhancementの途絶があると筋層浸潤の可能性が高い
    2. 拡散強調画像における腫瘍の輪郭が不整であれば筋層浸潤の可能性がある
    3. 筋層浸潤が1/2未満であればⅠA期、1/2以上であればⅠB期となる
    4. 子宮内膜癌により内膜の肥厚が起こり、閉経後の子宮内膜のカットオフ値は5mmが有所見とされている
    5. Dymamic早期相では内膜癌は乏血性でわずかに造影される程度で、後期相では筋層の造影効果により明瞭なコントラストが認められる
    6. 頚部間質浸潤の評価は、T2WI、Dynamic早期相、拡散強調で行い、間質の断裂や菲薄化、造影画像での頚管上皮の断裂、拡散強調での高信号化などがある
    参考書籍：婦人科MRIアトラス 改定第2版