Welcome to Visited Lingnan Modern Clinics In Surgery, Today is

Lingnan Modern Clinics in Surgery ›› 2020, Vol. 20 ›› Issue (02): 176-179.DOI: 10.3969/j.issn.1009-976X.2020.02.009

Previous Articles     Next Articles

Evaluation of contrast-enhanced ultrasound in the diagnosis of focal hepatic lesions

  

  1. 1. Department of Ultrasonography; 2. Department of Hepatobiliary Surgery, Meizhou People??s Hospital, Meizhou, Guangdong 514031, China

超声造影对肝脏占位性病变的诊断价值

  

  1. 广东省梅州市人民医院 1.超声科;2.肝胆外科,广东梅州 514031
  • 通讯作者: 李雄
  • 基金资助:
    2018年度梅州市社会发展科技计划项目

Abstract: [Abstract] Objective To explore the value of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of benign and malignant liver lesions. Methods From May 2018 to October 2019, 30 patients with focal hepatic lesions were performed contrast-enhanced ultrasound (CEUS) examination in our hospital. After SonoVue (a contrast agent) was injected into the peripheral elbow vein, time-to-peak, wash-in time, wash-out time were recorded and made the differential diagnosis of benign and malignant lesions, and the data were statistically analyzed. Results Pathological results from operation or fine-needle aspiration biopsy, 21cases with malignant lesions (including 14 HCC, 1 cholangiocarcinoma and 6 metastatic HCC), 11 cases of benign lesions (9 hemangiomas, 1 focal nodular hyperplasia, 1 cirrhosis). 21 malignant lesions and 10 benign lesions were correctly diagnosed by CEUS. The wash-in time was 12.76 ± 2.68 s vs. 16.12±3.82 s, time-to-peak 23.18±3.57 s vs. 42.78±10.46 s, wash-out time 40.69±8.42 s vs. 78.35±14.63 s between malignant lesions and benign lesions, and in which most of the malignant lesions were earlier than the benign ones. Conclusion CEUS is a very reliable technique with a high sensitivity for the differential diagnosis of benign and Malignant local hepatic lesions.

Key words: focal hepatic lesion, contrast-enhanced ultrasound, differential diagnosis

摘要:

超声造影对肝脏占位性病变的诊断价值

李雄1, 蓝思荣1, 李嘉2, 许建辉1

[摘要] 目的 探讨超声造影对肝脏占位性病变良、恶性鉴别诊断的价值。方法 2018年5月至2019年10月对30例肝脏占位性病变病人经外周肘静脉注射造影剂Sono Vue行超声造影检查,依据病变的造影开始增强时间、达峰时间及开始消退时间对其进行良恶性鉴别诊断,并分析不同类型肝脏占位性病变的增强模式。结果 以手术或穿刺病理确诊病变类型:恶性病变21个(肝细胞性肝癌14个,胆管细胞性肝癌1个,转移性肝癌6个),以穿刺病理或随访MR/CT临床诊断良性病变11个(肝血管瘤9个,肝脏局灶性结节增生1个,肝硬化结节1个)。超声造影正确诊断恶性病变21个,正确诊断良性病变10个。恶性病变开始增强时间(12.76±2.68 s vs.16.12±3.82 s)、达峰时间(23.18±3.57 s vs.42.78±10.46 s)、开始消退时间(40.69±8.42 s vs.78.35±14.63 s),大部分恶性病变明显早于良性病变,但有小部分不同类型病变间有交叉。结论 超声造影对肝脏占位性病变良、恶性的鉴别诊断准确率较高,具有较高的应用价值。

[关键词] 超声造影;肝脏占位性病变;鉴别诊断

肝脏占位性病变常在腹部超声检查、原发肿瘤的筛查、慢性肝病和肝硬化的监测中偶然发现。典型的肝脏肿块可在常规的B型和彩色多普勒超声检查中显示其特征性,如均匀高回声血管瘤[1],但对于许多肝脏占位性病变靠超声检查的确诊的准确性有限。由于普通超声的敏感性和特异性有限,或因为良性和恶性病变可能在超声上显示相似的外观[2,3],不可能对病灶进行定性。超声造影(contrast-enhanced ultrasound,CEUS)能够提高肝脏局灶性病变的检测和定性准确性[4]。虽然临床上肿瘤诊断需要增强CT和增强MRI检查,然而,CT和MRI使用的造影剂具有过敏性或肾毒性[5],MRI检查需排除有幽闭恐怖症、金属异物或金属植入物患者。相比之下,超声造影具有操作简便、经济、无放射性、无肾毒性风险、实时观察病变动态灌注等优点[6],通过增强模式,CEUS在检测肿瘤血管方面优于彩色多普勒和能量多普勒超声[7]。本研究对梅州市人民医院超声科诊断的30例患者(共32个病灶)的肝脏占位性病变采用超声造影检查,以穿刺组织学、手术病理学或临床确诊作为金标准,对肝脏占位性病变的良、恶性进行鉴别。现报告如下。

1 资料与方法

1.1 研究对象

选取2018年5月至2019年10月在本院应用CEUS检查的肝脏占位性病变患者30例,男性20例,女性10例;年龄28~73岁,平均(56±12.08)岁;11例患者肝脏有肝硬化背景,16例患者乙肝表面抗原阳性,5例患者甲胎蛋白测定呈阳性;单发病灶患者28例,2个病灶患者2例;32个病灶直径10~76 mm,平均(32.25±16.68)mm。10个良性病灶经随访MR/CT临床诊断,其余22个病灶由手术或穿刺病理确诊。

1.2 仪器与方法

所有患者检查前均签署造影知情同意书。采用东芝公司生产的APLIO 500彩色多普勒超声诊断仪,具备脉冲减影谐波成像技术,探头中心频率3.5 mHz,机械指数0.08~0.10。使用的造影剂为SonoVue(意大利Bracco公司),SonoVue的主要成份为磷脂包裹的六氟化硫(SF6)气体微泡,经周围静脉注入后通过肺循环和体循环经肝动脉和门静脉进入肝脏组织。按药品说明书向瓶内注入5 mL无菌生理盐水并震荡直至冻干粉末完全溶解。先按常规对肝脏及病变进行超声检查,随后使用脉冲减影谐波成像技术行CEUS,抽取2 mL混悬液,通过置于肘前静脉的20 G静脉留置针快速注入,随后注射5 mL生理盐水冲管。注射造影剂的同时启动超声仪内置计时器开始计时,连续、实时、动态地观察病变及周围肝组织增强情况及其变化过程,持续时间360 s并保存整个过程的图像。

1.3 观察指标

参照欧洲超声医学与生物学联合会(EFSUMB)标准[8],将肝脏造影时相分为3个阶段:注射造影剂后8~30 s为动脉期、31~120 s为门静脉期、121~360 s为延迟期。观察病变在以上各个时相的增强特点,并利用时间-强度曲线(time intensity curve,TIC)分析软件分析造影剂在病变内时间-强度分布情况,依据病变开始增强时间、达峰时间、开始消退时间等指标并和周围肝组织的增强情况进行比较来对肿瘤的良、恶性进行诊断。

1.4 统计学分析

采用SPSS 13.0医学软件进行数据统计分析,计量资料采用(x±s)表示,经t检验;计数资料采用χ2检验,P<0.05表示差异有统计学意义。

2 结果

2.1 超声造影对病变良恶性诊断与病理或临床诊断结果(表1)

表1 超声造影对病变良恶性诊断与病理或临床诊断结果(个)

病理或临床诊断 合计恶性病灶良性病灶合计超声造影恶性21 1 22良性0 10 11 21 11 32

以手术或穿刺病理确诊病变类型:恶性病变21个(其中肝细胞性肝癌14个,胆管细胞性肝癌1个,转移性肝癌6个),以穿刺病理或随访MR/CT临床诊断良性病变11个(其中,肝血管瘤9个,肝脏局灶性结节增生1个,肝硬化结节1个)。超声造影检查对良、恶性肝脏占位性病变的诊断率正确诊断恶性病变21个(21/21),正确诊断良性病变10个(10/11)。

2.2 良性、恶性肝脏占位性病变增强及其变化时间比较(表2)

表2 良性、恶性肝脏占位性病变增强及其变化时间比较(x±s)

病变类型良性恶性t值P值病变数/个11 21开始增强时间/s 16.12±3.82 12.76±2.68 32.535 0.000达峰时间/s 42.78±10.46 23.18±3.57 51.213 0.000开始消退时间/s 78.35±14.63 40.69±8.42 80.352 0.000

恶性病变开始增强时间(12.76±2.68 s vs.16.12±3.82 s)、达峰时间(23.18±3.57 s vs.42.78±10.46 s)、开始消退时间(40.69±8.42 s vs.78.35±14.63 s)(图1、图2),大部分恶性病变明显早于良性病变,但有小部分不同类型病变间有交叉。有三个肝脏占位性病变时间-强度曲线表现相似,其中两个病理确诊为高分化肝细胞性肝癌,另一个病理确诊为肝硬化结节,超声造影对于高分化肝细胞性肝癌和肝硬化结节的时间-强度曲线表现有交叉。

图1 原发性肝细胞性肝癌超声造影声像图
A.病灶开始增强时间11 s;B.达峰时间24 s;C.开始消退时间45 s

图2 肝血管瘤超声造影声像图
A.病灶开始增强时间18 s;B.达峰时间52 s;C.开始消退时间90 s

3 讨论

对于肝脏局灶性病变,如肝囊肿、高回声血管瘤、脂肪肝中典型的局灶性脂肪积聚,可通过普通B型特征来识别。多普勒技术可能有助于描述典型轮辐型血管构筑和低阻力指数中心动脉的局灶性结节增生(focal nodular hyperplasia,FNH)。这在普通B超和彩超不能清楚识别的肝脏病变中,CEUS可在肝脏灌注的不同阶段显示特定的血管模式,从早期动脉期到门静脉期再到晚期[9]。在最近报道的一个多中心试验(DEGUM)数据中,在判断良恶性方面,CEUS可以正确诊断90%以上普通B超和彩超不能确定的肝脏肿瘤,尽管后者对恶性病变有较高的预测价值(PPV>95%)[10,11]。本文报告了CEUS根据肿瘤特有的血管化模式对特定肿瘤实体,即血管瘤、局灶性结节增生、转移和肝细胞癌的诊断准确性。所有恶性病变21例全部确诊,11例良性病变中有1例误判为恶性肿瘤。

在动脉期、门静脉期和延迟期对比的基础上,由于典型的血管构筑形成模式,这种模式可以在动态实时检查中评估,从注射对比剂开始,持续5分钟。在动脉期,典型的血管化模式如FNH中的轮辐模式、血管瘤中的结节性周围强化模式或肝细胞癌和高血管转移(如神经内分泌肿瘤)中的不规则高血管化模式已被描述。在低血管性转移瘤(如胃肠腺癌转移瘤)或某些胆管细胞癌中,动脉期的对比增强可能很弱,但仍然可见。然而,肝脏病变的分化并不仅仅基于动脉期[12]。如果在动脉期肝脏病变的造影增强后,在门脉期或延迟期出现造影消失和明显的低增强,这种模式被认为是典型的恶性肝脏病变。如果动脉期造影增强后,门静脉期和晚期(晚期)肝脏病变出现等强化或过强化,这种模式被认为是良性肝脏病变的典型表现,但肝硬化患者除外。在肝硬化中,肝细胞癌的特征是动脉期高增强,晚期等增强或低增强[13]

除了常规超声外,CT和MRI也是最常用的肝脏病变的成像方法。常规超声由于缺乏动态成像对血管形态的描述,无法与动态CT和MRI相匹配,尤其MRI在肝硬化患者HCC的诊断全面优于CT[14]。由于使用新 Sonazoid 造影剂的 CEUS 具有稳定的Kupffer期,经Kupffer细胞吞噬的造影剂进行CEUS对于诊断1 cm以下肝脏病变已证明是高度可靠的工具[15,16]。从肝脏占位性病变造影时间-强度曲线中分析病灶的开始增强时间、达峰时间、增强消退时间,显示恶性病变明显早于良性病变,说明超声造影能反映肝脏占位性病变的血流分布及灌注情况,对肝脏占位性病变良、恶性的鉴别诊断准确率较高[17]。Hsiao等[17]总结66例小于3 cm肝脏肿瘤的成人患者分别接受CEUS、动态CT和MRI检查,结果肝癌的诊断比值比(DOR,95%CI)为:CEUS(52.8,11.4-243),CT(29.29,7.36-116),MRI(19.43,5.44-69.4);转移:CEUS(200,19.1-2095),CT(24,5.05-114),MRI(32,6.56-156);所有肝脏恶性肿瘤:CEUS(260,12.7-5310),CT(2.57,0.55-12.1),MRI(5.22,1.25-21.8),CEUS 获得了最佳的差异化性能。Granata等[18]对接受不可逆电穿孔(IRE)治疗HCC患者进行1个月、3个月和6个月的随访,评估MRI、CT和CEUS检查在IRE治疗后肿瘤变化的诊断准确性。所有时间段的影像学检查结果显示出相似的诊断准确性。

总之,由于超声造影能反映肝脏占位性病变的血流分布及灌注情况,对肝脏占位性病变良、恶性的鉴别诊断准确率较高,我们的结果符合文献报道。

参考文献

[1] Vilgrain V,Boulos L,Vullierme MP,et al.Imaging of atypical hemangiomas of the liver with pathologic correlation[J].Radiographics,2000,20(2):379-397.

[2] Hosten N,Puls R,Bechstein WO,Felix R.Focal liver lesions:Doppler ultrasound[J].Eur Radiol,1999,9(3):428-35.

[3] Lee MG,Auh YH,Cho KS,et al.Color Doppler flow imaging of hepatocellular carcinomas.Comparison with metastatic tumors and hemangiomas by three-step grading for color hues[J].Clin Imaging,1996,20(3):199-203.

[4] Strobel D,Seitz K,Blank W,et al.Tumor-specific vascularization pattern of liver metastasis,hepatocellular carcinoma,hemangioma and focal nodular hyperplasia in the differential diagnosis of 1,349 liver lesions in contrast-enhanced ultrasound(CEUS)[J].Ultraschall Med,2009,30(4):376-382.

[5] Ohlerth S,O’Brien RT.Contrast ultrasound:General principles and veterinary clinical applications[J].Vet J,2007,174(3):501-512.

[6] McArthur C,Baxter GM.Current and potential renal applications of contrast-enhanced ultrasound[J].Clin Radiol,2012,67(9):909-922.

[7] Strobel D,Krodel U,Martus P,et al.Clinical evaluation of contrast-enhanced color Doppler sonography in the differential diagnosis of liver tumors[J].J Clin Ultrasound,2000,28(1):1-13.

[8] Albrecht T,Blomley M,Bolond L,et al.EFSUMB Study Group Guidelines for the use of contrast agents in ultrasound[J].Ultraschall Med,2004,25(4):249-256.

[9] Strobel D,Seitz K,Blank W,et al.Tumor-specific vascularization pattern of liver metastasis,hepatocellular carcinoma,hemangioma and focal nodular hyperplasia in the differential diagnosis of 1,349 liver lesions in contrast-enhanced ultrasound(CEUS)[J].Ultraschall Med,2009,30(4):376-382.

[10] Strobel D,Seitz K,Blank W,et al.Contrast-enhanced ultrasound for the characterization of focal liver lesions--diagnostic accuracy in clinical practice(DEGUM multicenter trial)[J].Ultraschall Med,2008,29(5):499-505.

[11] Tranquart F,Correas JM,Ladam Marcus V,et al.Real-time contrast-enhanced ultrasound in the evaluation of focal liver lesions:diagnostic efficacy and economical issues from a French multicentric study[J].J Radiol,2009,90(1 Pt 2):109-112.

[12] Nicolau C,Vilana R,Catalá V,et al.Importance of evaluating all vascular phases on contrast-enhanced sonography in the differentiation of benign from malignant focal liver lesions[J].AJR Am J Roentgenol,2006,186(1):158-167.

[13] Shin SK,Kim YS,Choi SJ,et al.Contrast-enhanced ultrasound for the differentiation of small atypical hepatocellular carcinomas from dysplastic nodules in cirrhosis[J].Dig Liver Dis,2015,47(9):775-782.

[14] Semaan S,Vietti Violi N,Lewis S,et al.Hepatocellular carcinoma detection in liver cirrhosis:diagnostic performance of contrast-enhanced CT vs.MRI with extracellular contrast vs.gadoxetic acid[J].Eur Radiol,2020,30(2):1020-1030.

[15] D"Onofrio M,Crosara S,De Robertis R,et al.Contrast-Enhanced Ultrasound of Focal Liver Lesions[J].AJR Am J Roentgenol,2015,205(1):W56-66.

[16] Cantisani V,David E,Meloni FM,et al.Recall strategies for patients found to have a nodule in cirrhosis:is there still a role for CEUS?[J].Med Ultrason,2015,17(4):515-520.

[17] Hsiao CY,Chen PD,Huang KW.A Prospective Assessment of the Diagnostic Value of Contrast-Enhanced Ultrasound,Dynamic Computed Tomography and Magnetic Resonance Imaging for Patients with Small Liver Tumors[J].J Clin Med,2019,8(9).

[18] Granata V,de Lutio di Castelguidone E,Fusco R,et al.Irreversible electroporation of hepatocellular carcinoma:preliminary report on the diagnostic accuracy of magnetic resonance,computer tomography,and contrast-enhanced ultrasound in evaluation of the ablated area[J].Radiol Med,2016,121(2):122-131.

Evaluation of contrast-enhanced ultrasound in the diagnosis of focal hepatic lesions

LI Xiong1,LAN Si-rong1,LI Jia2,XU Jian-hui1
1.Department of Ultrasonography;2.Department of Hepatobiliary Surgery,Meizhou People"s Hospital,Meizhou,Guangdong 514031,China

[Abstract] Objective To explore the value of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of benign and malignant liver lesions.Methods From May 2018 to October 2019,30 patients with focal hepatic lesions were performed contrast-enhanced ultrasound(CEUS)examination in our hospital.After SonoVue(a contrast agent)was injected into the peripheral elbow vein,time-topeak,wash-in time,wash-out time were recorded and made the differential diagnosis of benign and malignant lesions,and the data were statistically analyzed.Results Pathological results from operation or fine-needle aspiration biopsy,21cases with malignant lesions(including 14 HCC,1 cholangiocarcinoma and 6 metastatic HCC),11 cases of benign lesions(9 hemangiomas,1 focal nodular hyperplasia,1 cirrhosis).21 malignant lesions and 10 benign lesions were correctly diagnosed by CEUS.The wash-in time was 12.76 ± 2.68 s vs.16.12±3.82 s,time-to-peak 23.18±3.57 s vs.42.78±10.46 s,wash-out time 40.69±8.42 s vs.78.35±14.63 s between malignant lesions and benign lesions,and in which most of the malignant lesions were earlier than the benign ones.Conclusion CEUS is a very reliable technique with a high sensitivity for the differential diagnosis of benign and Malignant local hepatic lesions.

[Key words] contrast-enhanced ultrasound;focal hepatic lesion;differential diagnosis

doi: 10.3969/j.issn.1009-976X.2020.02.009

中图分类号:R445.1

文献标识码:A

基金项目: 2018年度梅州市社会发展科技计划项目(2018B012)

作者单位:广东省梅州市人民医院1.超声科;2.肝胆外科,广东梅州514031

通讯作者:李雄,Email:yb060@163.com

(收稿日期:2020-01-20)

关键词: 肝脏占位性病变, 超声造影, 鉴别诊断

CLC Number: