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岭南现代临床外科 ›› 2019, Vol. 19 ›› Issue (06): 679-681.DOI: 10.3969/j.issn.1009-976X.2019.06.006

• 论著与临床研究 • 上一篇    下一篇

MRI-DWI鉴别诊断肿块型自身免疫性胰腺炎与胰腺导管腺癌

易志龙, 李永*, 王智慧, 潘恒   

  1. 中山大学孙逸仙纪念医院放射科,广州510120
  • 通讯作者: 李永

MRI-DWI differential diagnosis of focal autoimmune pancreatitis and Pancreatic ductal adenocarcinoma

YI Zhilong, LI Yong*, WANG Zhihui, PAN Heng   

  1. Department of Radiology, Sun Yat?sen Memorial Hospital of Sun Yat?sen University, Guangzhou 510120, China
  • Online:2019-12-20 Published:2019-12-20
  • Contact: Yong Li

摘要:

 

MRI-DWI鉴别诊断肿块型自身免疫性胰腺炎与胰腺导管腺癌

易志龙, 李永*, 王智慧, 潘恒

[摘要] 目的 分析肿块型自身免疫性胰腺炎(AIP)和胰腺导管腺癌(PC)的影像学表现,探讨MRI-DWI在鉴别诊断二者方面的价值。方法 收集2016年3月至2019年6月中山大学孙逸仙纪念医院经病理诊断的胰腺导管腺癌30例,达到临床诊断标准的肿块型自身免疫性胰腺炎15例,回顾性分析上述患者的影像学特征,在DWI上的表现及ADC值的区别。结果 肿块型胰腺炎患者中,大部分病灶T2WI呈不均匀的高信号,T1WI表现为等信号和低信号,DWI为等或高信号,不均匀较明显强化。胰腺导管腺癌患者中,大多数病灶T2WI病灶呈稍高信号,T1WI呈低信号,少部分的病灶呈现混杂信号或者等信号,DWI为低信号为主,不均匀低强化为主。二者均可伴有主胰管的扩张,胰腺导管腺癌同时可伴有主胰管的中断。当b值=800 s/mm2时,肿块型AIP的ADC平均值为(1.38±0.11)×10-3 mm2/s(平均值±标准差),胰腺导管腺癌的ADC平均值为(1.03±0.15)×10-3 mm2/s(平均值±标准差),P<0.05,二者间差异有统计学意义。结论 肿块型自身免疫性胰腺炎(AIP)和胰腺导管腺癌(PC)的影像学表现有差异,DWI序列及ADC值有助于鉴别诊断二者。

[关键词] 自身免疫性胰腺炎;胰腺导管腺癌;磁共振成像;诊断

肿块型自身免疫性胰腺炎(autoimmune pancreatitis,AIP)是慢性胰腺炎的一种独特类型,据报道发生率为7%[1]。组织病理学上,AIP的特征是混合的炎性细胞浸润-主要是CD4阳性的T淋巴结细胞和免疫球蛋白G4浆细胞-围绕胰管,并与肿瘤样的纤维化区域和闭塞性静脉炎相关,导致器官功能障碍[2]。当AIP的纤维化成分占据胰腺实质,就会形成类似于肿块的占位效应,加上AIP和胰腺癌具有类似的症状,如无痛性黄疸,腹痛或糖尿病等,因此给正确诊断带来了挑战,MRI被证明有助于区分胰腺癌和慢性胰腺炎[3]。本研究目的是评估常规DWI在鉴别AIP和胰腺癌中的价值。

通过进行产前超声检查能够发现胎儿的肺内部异常病灶,特别是运用彩色多普勒超声检查能够对胎儿的肺囊腺瘤以及隔离肺两类比较多见的肺内异常病灶进行明确提示和诊断。由于隔离肺和肺囊腺瘤均具有比较显著的超声特点,因此通过进行产前超声检查有利于发现胎儿的肺内异常,并结合隔离肺和肺囊腺瘤的超声特点进行具体判断予以明确[2]。

1 资料与方法

1.1 研究对象

2016年3月至2019年6月中山大学孙逸仙纪念医院经病理诊断的胰腺导管腺癌30例;达到临床诊断标准的肿块型自身免疫性胰腺炎15例,即对类固醇治疗的反应,临床症状得到缓解,胰腺病灶减少或消失和/或信号改变[4,5]

据悉,本次培训交流由交通运输部海事局主办,广东海事局承办,旨在增进和帮助东盟、南亚相关国家熟悉我国非公约船舶技术标准和监督管理规范,为东盟和南亚国家建立符合自身现实的需要的非公约船舶技术标准和管理规则提供可复制的经验,珠海是此次区域非公约船舶安全管理培训的第二站。(钟铮 米佳强)

1.2 成像方法

MRI检查:采用Philips 3.0 T超导型磁共振扫描 仪 。 轴 位 SPIR T2WI,TR/TE 1957 ms/80 ms,FOV 38 cm×38 cm;mDIXON序列扫描,FOV 39 cm×39 cm;DWIb=0/800 s/mm2,TR/TE 3 000 ms/50 ms,FOV 42 cm×42 cm;冠状位e-THRIVE TR/TE 3.04 ms/1.43 ms,FOV 40 cm×40 cm;轴位/冠状位T1WI增强扫描(e-THRIVE,轴位 TR/TE 2.86 ms/1.37 ms,FOV 37 cm ×37 cm;冠状位 TR/TE 3.04 ms/1.43 ms,FOV 40 cm×40 cm)。对比剂经肘静脉注射钆喷酸葡胺注射液(GE药业),剂量0.1 mmol/kg,速率为3 mL/s。

1.3 图像分析

胰腺导管腺癌是恶性程度较高的肿瘤,需要进行必要的手术及术后化疗,而肿块型胰腺炎属于慢性炎症一种,只需要激素及相关抗炎治疗即可,二者治疗方法上差别很大[12]。因此治疗前精确诊断二者意义重大。常规MRI可以进行多参数、多方位扫描,且高组织分辨率,对于胰腺及病变的显示具有较大的优势,随着DWI序列在高场强MRI中的进一步应用,诊断准确性与特异性有了进一步的提高。本研究中,肿块型自身免疫性胰腺炎与胰腺导管腺癌影像学特征各不相同。平扫时虽然二者均表现为肿块的占位效应,但肿块型AIP病灶是慢性炎症纤维化后的形成的肿块,纤维化组织丰富,因此信号偏均匀。而胰腺癌肿块内多见坏死、囊变及出血等,因此表现为片状、斑片状混杂信号。增强扫描时,胰腺癌因为血管密度降低,因此各期强化程度均低于正常胰腺组织。运用DWI序列得到的ADC图,能够区分肿块型胰腺炎与胰腺癌,二者的ADC值分别为(1.38±0.11)×10-3 mm2/s(平均值±标准差),(1.03±0.15)×10-3 mm2/s(平均值±标准差)。

①严重肝肾疾病、糖尿病、痛风、继发性高血脂症者。②3个月内发生急性心肌梗死、脑血管意外和重大手术的患者。③妊娠及哺乳期妇女。

1.4 统计学处理

AIP在形态在有弥漫型和局限型,影像上的表现不同[5],胰头的炎症和纤维化改变可能会类似于胰腺癌的特征。如CA 19-9或IgG4的血清标志物具有有限的敏感性和特异性[7]。Dong等研究中,PET/CT检查中,急、慢性胰腺炎高摄取的局限性病灶是误诊为胰腺癌的主要因素[6]

肿块型自身免疫性胰腺炎与胰腺导管腺癌一般资料与影像学特征结果如表1所示。肿块型胰腺炎患者中,大部分病灶T2WI呈不均匀的高信号,T1WI表现为等信号和低信号,DWI为等或高信号,不均匀较明显强化(图1)。胰腺导管腺癌患者中,大多数病灶T2WI病灶呈稍高信号,T1WI呈低信号,少部分的病灶呈现混杂信号或者等信号,DWI为低信号为主,不均匀低强化为主(图2)。二者均可伴有主胰管的扩张,胰腺癌可侵犯主胰管,造成主胰管的中断。当b值=800 s/mm2时,肿块型AIP的ADC平均值为(1.38±0.11)×10-3 mm2/s(平均值±标准差),胰腺癌的ADC平均值为(1.03±0.15)×10-3 mm2/s(平均值±标准差),P<0.05。肿块型胰腺炎病灶ADC值明显低于胰腺癌病灶,差异有统计学意义。

2 结 果

该研究得到当地伦理委员会的批准,所有患者均签署了知情同意书。

表1 肿块型AIP组和胰腺导管腺癌组一般资料和影像特征比较

 

图1 a-d分别为肿块型自身免疫性胰腺炎患者T2W、T1W+C、DWI、ADC图像,白色箭头所指为胰头局灶性炎性病灶,信号不均匀,弥散受限不明显,ADC值稍减低

图2 a-d分别为胰腺导管腺癌患者T2W、T1W+C、DWI、ADC图像,白色箭头所指为胰头癌病灶,信号较均匀,弥散受限明显,ADC值明显减低

3 讨论

观察内容包括病灶边界、信号特点、MRI增强扫描的强化特征,DWI信号高低、有无主胰管扩张、中断等。在DWI序列生成的ADC图像上测量ADC值。

采用SPSS 20.0软件进行数据处理,对AIP、胰腺癌患者的ADC值进行独立因素t检验,P<0.05为差异统计学意义。

日本监管体系的独特性十分明显,相关的监管机构需要对一些进口食品的安全性进行监管,而其他的安全监管工作需要地方性的监管机构负责,这和日本食品的产业结构存在很大联系。日本农产品的自给率非常低,食品监管成为重点,所以中国在进行食品监管时,可以将日本的工作经验作为参考。对中日两国的企业进行比对分析发现,日本企业更重视自身职责,很多企业在生产与加工中都能达到严格规范,特别是在原料加工和出厂方面,整个过程都更严格。

Klauβ等的研究表明AIP的ADC值大于胰腺癌,且AIP患者使用激素治疗后,ADC值逐步增高[9]。胰腺癌组织中细胞密度较胰腺炎症明显增高,生物膜结构及细胞外间隙减少,因此水分子的弥散明显受限,ADC值较小[10-12]

本研究主要不足之处在于肿块型AIP病例数目较少,只有15例,对于影像学特征的分析很难做到全面,如对与周围组织的关系等的分析。

总之,MRI鉴别诊断肿块型AIP、胰腺导管腺癌具有一定的优势,尤其MRI-DWI能很好鉴别诊断肿块型自身免疫性胰腺炎和胰腺导管腺癌。

参考文献

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[2] Zamboni G,Lüttges J,Capelli P,et al.His-topathological features of diagnostic and clinical relevance in autoimmune pancreatitis:a study on 53 resection specimens and 9 biopsy specimens[J].Virchows Arch,2004,445(6):552-563.

[3] Kamisawa T,Takuma K,Anjiki H,et al.Differentiation of autoimmune pancreatitis from pancreatic cancer by diffusion-weighted MRI[J].Am JGastroenterol,2010,105(8):1870-1875.

[4] Manfredi R,Graziani R,Cicero C,et al.Autoimmune pancreatitis:CT patterns and their changes after steroid treatment[J].Radiology,2008,247(2):435-443

[5] 张燕绒,黄晓辉,邱乾德.Ⅰ型自身免疫性胰腺炎的MRI表现特征[J].医学影像学杂志,2019,29(5):803-807.

[6] Dong A,Dong H,Zhang L,et al.Hypermetabolic lesions of the pancreas on FDG PET/CT[J].Clin Nucl Med,2013,38(9):e354-366.

[7] Esposito I,Bergmann F,Penzel R.et al.Oligoclonal T-cell populations in an inflammatory pseudotumor of the pancreas possibly related to autoimmune pancreatitis:an immunohistochemical and molecular analysis[J].Virchows Arch,2004,444(2):119-126.

[8] Lee NK,Kim S,Kim TU,et al.Diffusion-weighted MRI for differentiation of benign from malignant lesions in the gallbladder[J].Clin Radiol,2014,69(2):e78-85.

[9] Klauβ M,Maier-Hein K,Tjaden C,et al.IVIM DW-MRIof autoimmune pancreatitis:therapy monitoring and differentiation from pancreatic cancer[J].Eur Radiol,2016,26(7):2099-106.

[10]Hur BY,Lee JM,Lee JE et al.Magnetic resonance imaging findings of the mass-forming type of autoimmune pancreatitis:comparison with pancreatic adenocarcinoma[J].J MagnReson Imaging,2012,36(1):188-197.

[11]Frulloni L,Scattolini C,Falconi M.et al.Autoimmune pancreatitis:differences between the focal and diffuse forms in 87 patients[J].Am JGastroenterol.2009,104(9):2288-2294.

[12]赵过超,吴文川.自身免疫性胰腺炎的诊断与治疗[J].中华肝脏外科手术学电子杂志,2019,8(3):196-201.

MRI-DWI differential diagnosis of focal autoimmune pancreatitis and Pancreatic ductal adenocarcinoma

YI Zhilong,LI Yong*,WANGZhihui,PAN Heng
Department of Radiology,Sun Yat-sen Memorial Hospital of Sun Yat-sen University

[Abstract] Objective To analyze the imaging findings of focal autoimmune pancreatitis(AIP)and pancreatic cancer(PC),and to explore the value of MRI-DWI in differential diagnosis.Methods Thirty patients which were pathologically diagnosed as pancreatic cancer and 15 patients with mass-type autoimmune pancreatitis with clinical diagnostic criteria were enrolled from Sun Yat-sen Memorial Hospital of Sun Yat-sen University in March 2013 to June 2019.The imaging characteristics of the above patients were retrospectively analyzed.The ADC values on DWI between focal autoimmune pancreatitis and pancreatic cancer werec ompared.Results In patients with focal pancreatitis,most of the lesions showed equal and low signals on T1WI,uneven signals and high signalson T2WI,and was equal or high signalon DWI,with high Inhomogeneity enhancement.Most of the lesions in patients with pancreatic cancer showed low signal,and a small number of lesions showed mixed signals or signalson T1WI,while most lesions showed high signalon T2WI and low signalon DWI,with low enhancement.The both can be accompanied by the expansion of the main pancreatic duct.The interruption of the main pancreatic duct only can be observed in pancreatic ductal adenocarcinoma.When b value=800 s/mm2,the average ADC value of the focal AIP was(1.38±0.11)×10-3 mm2/s(mean ± standard deviation),and the mean ADC value of pancreatic cancer was(1.03±0.15)×10-3 mm2/s(mean ± standard deviation),P<0.05,the difference was statistically significant.Conclusion The imaging findings of focal autoimmune pan-creatitis(AIP)and pancreaticductal adenocarcinoma(PC)are different.DWI sequence and ADC value are helpful for differential diagnosis.

[Key words] Autoimmune pancreatitis;pancreatic ductal adenocarcinoma;magnetic resonance imaging;diagnosis

doi:10.3969/j.issn.1009-976X.2019.06.006

中图分类号:R445.2

文献标识码:A

作者单位:中山大学孙逸仙纪念医院放射科,广州510120

*通讯作者:李永,Email:liyong0112@126.com

Corresponding author:LI Yong,liyong0112@126.com

(收稿日期:2019-09-30)

 

关键词: 自身免疫性胰腺炎, 磁共振成像, 胰腺导管腺癌, 诊断

Abstract: Objective To analyze the imaging findings of focal autoimmune pancreatitis (AIP) and pancreatic cancer (PC), and to explore the value of MRI?DWI in differential diagnosis. Methods Thirty patients which were pathologically diagnosed as pancreatic cancer and 15 patients with mass?type autoimmune pancreatitis with clinical diagnostic criteria were enrolled from Sun Yat?sen Memorial Hospital of Sun Yat?sen University in March 2013 to June 2019. The imaging characteristics of the above patients were retrospectively analyzed. The ADC values on DWI between focal autoimmune pancreatitis and pancreatic cancer werec ompared. Results In patients with focal pancreatitis, most of the lesions showed equal and low signals on T1WI, uneven signals and high signalson T2WI, and was equal or high signalon DWI,with high Inhomogeneity enhancement. Most of the lesions in patients with pancreatic cancer showed low signal, and a small number of lesions showed mixed signals or signalson T1WI, while most lesions showed high signalon T2WI and low signalon DWI,with low enhancement. The both can be accompanied by the expansion of the main pancreatic duct. The interruption of the main pancreatic duct only can be observed in pancreatic ductal adenocarcinoma. When b value=800 s/mm2, the average ADC value of the focal AIP was (1.38±0.11)×10-3 mm2/s (mean ± standard deviation), and the mean ADC value of pancreatic cancer was (1.03±0.15)×10-3 mm2/s (mean ± standard deviation), P<0.05, the difference was statistically significant. Conclusion The imaging findings of focal autoimmune pancreatitis (AIP) and pancreaticductal adenocarcinoma (PC) are different. DWI sequence and ADC value are helpful for differential diagnosis.

Key words: pancreatic ductal adenocarcinoma, Autoimmune pancreatitis, magnetic resonance imaging, diagnosis

中图分类号: