超声造影在肝硬化结节恶变筛查中的价值

doi:10.3877/cma.j.issn.2095-3232.2018.03.013

目的

探讨超声造影（CEUS）在肝硬化结节恶变筛查中的价值。

方法

回顾性分析2012年1月至2016年12月中山大学附属第三医院行超声检查随访的25例患者临床资料。患者均签署知情同意书，符合医学伦理学规定。患者均为男性；年龄33～82岁，中位年龄55岁；共29个肝硬化结节。所有患者均接受规律的超声检查随访，均接受常规超声和CEUS检查，记录结节的直径、内部血流信号、超声造影增强模式等。结节直径比较采用t检验，超声造影模式比较采用Fisher确切概率法，诊断试验采用受试者工作特征（ROC）曲线。

结果

随访过程中，14个肝硬化结节恶变为肝细胞癌（肝癌）。发生恶变的结节直径（19±8）mm较恶变前(16±7) mm明显增大（t=2.682，P<0.05）。随着结节恶变，结节CEUS动脉期逐渐由等增强（12/14）转变为高增强(13/14)，门静脉期/延迟期由等增强（13/14）转变为低增强（13/14），差异有统计学意义（P<0.05）。AFP、常规超声、CEUS诊断肝硬化结节恶变的曲线下面积分别为0.607、0.679、1，差异有统计学意义（Z=4.837，6.904；P<0.05）。

结论

在肝硬化结节的连续随访过程中，CEUS能早期发现恶变结节内部血流动力学变化，较常规超声具有更好的诊断价值。

关键词: 癌，肝细胞, 肝硬化结节, 随访研究, 超声检查, 血流动力学

Objective

To explore the value of contrast-enhanced ultrasonography (CEUS) in the screening of malignant transformation from cirrhotic nodules.

Methods

Clinical data of 25 patients who were followed up by ultrasonography in the Third Affiliated Hospital of Sun Yat-sen University from January 2012 to December 2016 were analyzed retrospectively. The informed consents of all patients were obtained and the local ethical committee approval was received. All patients were males, aged 33-82 years old, with the median age of 55 years old, and with a total of 29 cirrhotic nodules. All patients were followed up regularly by ultrasonography which included conventional ultrasound and CEUS. The diameter, internal blood flow signal and CEUS features of the nodules were recorded. The diameter was compared by t test, and the CEUS features by Fisher's exact probability test. ROC curve was used for diagnostic test.

Results

During the follow-up, 14 cirrhotic nodules turned into hepatocellular carcinoma (HCC). The diameter of malignant nodule (19±8) mm was significantly higher than (16±7) mm before malignant change (t=2.682, P<0.05). As the nodules transformed to malignancy, in the arterial phase of CEUS, signals changed gradually from equal enhancement (12/14) to hyper enhancement (13/14), and in the portal venous phase or delayed phase, it changed from equal enhancement (13/14) to low enhancement (13/14), where significant difference was observed (P<0.05). The area under the curve of AFP, conventional ultrasound and CEUS in diagnosing malignancy of cirrhotic nodules was 0.607, 0.679 and 1, respectively, where significant differences were observed (Z=4.837, 6.904, P<0.05).

Conclusion

In the continuous follow-up of cirrhotic nodules, CEUS can detect the hemodynamic changes in malignant nodules early, which has better diagnostic value than conventional ultrasound.

Key words: Carcinoma, hepatocellular, Cirrhotic nodule, Follow-up studies, Ultrasonography, Hemodynamic

表1 恶变组和非恶变组肝硬化结节常规超声检查征象动态演变

组别	结节数	结节直径（mm，±s）		t值	P值	回声		P值	结节内血流信号		P值
组别	结节数	初次检查	末次检查	t值	P值	初次检查低/等/高	末次检查低/等/高	P值	初次检查无、静脉信号/动脉信号	末次检查无、静脉信号/动脉信号	P值
恶变组	14	16±7	19±8	2.682	0.019^a	10/1/3	11/1/2	1.0^c	14/0	13/1	1.0^c
非恶变组	15	15±4	16±3	5.554	0.589^a	12/0/3	12/0/3	1.0^c	15/0	15/0	-
t值	?	0.272	1.256	?	?	-	-	?	-	-	?
P值	?	0.787^b	0.220^b	?	?	0.682^c	1.0^c	?	-	0.483^c	?

表1 恶变组和非恶变组肝硬化结节常规超声检查征象动态演变

组别	结节数	结节直径（mm，±s）		t值	P值	回声		P值	结节内血流信号		P值
组别	结节数	初次检查	末次检查	t值	P值	初次检查低/等/高	末次检查低/等/高	P值	初次检查无、静脉信号/动脉信号	末次检查无、静脉信号/动脉信号	P值
恶变组	14	16±7	19±8	2.682	0.019^a	10/1/3	11/1/2	1.0^c	14/0	13/1	1.0^c
非恶变组	15	15±4	16±3	5.554	0.589^a	12/0/3	12/0/3	1.0^c	15/0	15/0	-
t值	?	0.272	1.256	?	?	-	-	?	-	-	?
P值	?	0.787^b	0.220^b	?	?	0.682^c	1.0^c	?	-	0.483^c	?

表2 恶变组和非恶变组肝硬化结节超声造影检查征象动态演变

组别	结节数	动脉期		P值	门静脉期、延迟期		P值
组别	结节数	初次检查等低增强/高增强	末次检查等低增强/高增强	P值	初次检查等增强/低增强	末次检查等增强/低增强	P值
恶变组	14	12/2	1/13	<0.001	13/1	1/13	<0.001
非恶变组	15	15/0	15/0	-	13/2	15/0	0.483
P值	?	0.224	<0.001	?	1.0	<0.001	?

表2 恶变组和非恶变组肝硬化结节超声造影检查征象动态演变

组别	结节数	动脉期		P值	门静脉期、延迟期		P值
组别	结节数	初次检查等低增强/高增强	末次检查等低增强/高增强	P值	初次检查等增强/低增强	末次检查等增强/低增强	P值
恶变组	14	12/2	1/13	<0.001	13/1	1/13	<0.001
非恶变组	15	15/0	15/0	-	13/2	15/0	0.483
P值	?	0.224	<0.001	?	1.0	<0.001	?

图1 肝硬化结节常规超声及超声造影图

图2 AFP、CUS、CEUS诊断肝硬化结节恶变的ROC曲线

[1]	McGuire S. World Cancer Report 2014. Geneva, Switzerland: World Health Organization, International Agency for Research on Cancer, WHO Press, 2015[J]. Adv Nutr, 2016, 7(2):418-419.
[2]	Liu P, Hsu CY, Hsia CY, et al. Surgical resection versus radiofrequency ablation for single hepatocellular carcinoma ≤2 cm in a propensity score model[J]. Ann Surg, 2016, 263(3):538-545.
[3]	Sato T, Tateishi R, Yoshida H, et al. Ultrasound surveillance for early detection of hepatocellular carcinoma among patients with chronic hepatitis C[J]. Hepatol Int, 2009, 3(4):544-550.
[4]	Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma[J]. J Cancer Res Clin Oncol, 2004, 130(7):417-422.
[5]	Del Poggio P, Olmi S, Ciccarese F, et al. Factors that affect efficacy of ultrasound surveillance for early stage hepatocellular carcinoma in patients with cirrhosis[J]. Clin Gastroenterol Hepatol, 2014, 12(11):1927-1933.
[6]	Van Beers BE, Daire JL, Garteiser P. New imaging techniques for liver diseases [J]. J Hepatol, 2015, 62(3):690-700.
[7]	Kobayashi M, Ikeda K, Hosaka T, et al. Dysplastic nodules frequently develop into hepatocellular carcinoma in patients with chronic viral hepatitis and cirrhosis[J]. Cancer, 2006, 106(3):636-647.
[8]	Sato T, Kondo F, Ebara M, et al. Natural history of large regenerative nodules and dysplastic nodules in liver cirrhosis: 28-year follow-up study[J]. Hepatol Int, 2015, 9(2):330-336.
[9]	Wu S, Tu R, Liu G, et al. Dynamic changes in ultrasound characteristics of nodules in cirrhotic liver and their implications in surveillance for malignancy[J]. J Med Ultrason, 2014, 41(2):165-171.
[10]	Bruix J, Sherman M, American Association for the Study of Liver Diseases. Management of hepatocellular carcinoma: an update[J]. Hepatology, 2011, 53(3):1020-1022.
[11]	European Association For the Study of the Liver, European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma[J]. J Hepatol, 2012, 56(4):908-943.
[12]	An C, Rakhmonova G, Choi JY, et al. Liver imaging reporting and data system (LI-RADS) version 2014: understanding and application of the diagnostic algorithm[J]. Clin Mol Hepatol, 2016, 22(2):296-307.
[13]	Fraum TJ, Tsai R, Rohe E, et al. Differentiation of hepatocellular carcinoma from other hepatic malignancies in patients at risk: diagnostic performance of the liver imaging reporting and data system version 2014[J]. Radiology, 2018, 286(1):158-172.
[14]	International Consensus Group for Hepatocellular Neoplasia. Pathologic diagnosis of early hepatocellular carcinoma: a report of the international consensus group for hepatocellular neoplasia[J]. Hepatology, 2009, 49(2):658-664.
[15]	Ojima H, Masugi Y, Tsujikawa H, et al. Early hepatocellular carcinoma with high-grade atypia in small vaguely nodular lesions[J]. Cancer Sci, 2016, 107(4):543-550.
[16]	Boas FE, Do B, Louie JD, et al. Optimal imaging surveillance schedules after liver-directed therapy for hepatocellular carcinoma[J]. J Vasc Interv Radiol, 2015, 26(1):69-73.
[17]	Lin XJ, Chong Y, Guo ZW, et al. A serum microRNA classifier for early detection of hepatocellular carcinoma: a multicentre, retrospective, longitudinal biomarker identification study with a nested case-control study[J]. Lancet Oncol, 2015, 16(7):804-815.
[18]	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.
[19]	Terzi E, Iavarone M, Pompili M, et al. Contrast ultrasound LI-RADS LR-5 identifies hepatocellular carcinoma in cirrhosis in a multicenter restropective study of 1,006 nodules[J]. J Hepatol, 2018, 68(3):485-492.
[20]	Claudon M, Dietrich CF, Choi BI, et al. Guidelines and good clinical practice recommendations for Contrast Enhanced Ultrasound (CEUS) in the liver-update 2012: a WFUMB-EFSUMB initiative in cooperation with representatives of AFSUMB, AIUM, ASUM, FLAUS and ICUS[J]. Ultrasound Med Biol, 2013, 39(2):187-210.
[21]	Wang YC, Chou CT, Lin CP, et al. The value of Gd-EOB-DTPA-enhanced MR imaging in characterizing cirrhotic nodules with atypical enhancement on Gd-DTPA-enhanced MR images[J]. PLoS One, 2017, 12(3):e0174594.

[1]	魏淑婕, 惠品晶, 丁亚芳, 张白, 颜燕红, 周鹏, 黄亚波. 单侧颈内动脉闭塞患者行颞浅动脉-大脑中动脉搭桥术的脑血流动力学评估[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1046-1055.
[2]	张璇, 马宇童, 苗玉倩, 张云, 吴士文, 党晓楚, 陈颖颖, 钟兆明, 王雪娟, 胡淼, 孙岩峰, 马秀珠, 吕发勤, 寇海燕. 超声对Duchenne肌营养不良儿童膈肌功能的评价[J]. 中华医学超声杂志（电子版）, 2023, 20(10): 1068-1073.
[3]	朱连华, 费翔, 韩鹏, 姜波, 李楠, 罗渝昆. 高帧频超声造影在胆囊息肉样病变中的鉴别诊断价值[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 904-910.
[4]	张梅芳, 谭莹, 朱巧珍, 温昕, 袁鹰, 秦越, 郭洪波, 侯伶秀, 黄文兰, 彭桂艳, 李胜利. 早孕期胎儿头臀长正中矢状切面超声图像的人工智能质控研究[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 945-950.
[5]	陈舜, 薛恩生, 叶琴. PDCA在持续改进超声危急值管理制度中的价值[J]. 中华医学超声杂志（电子版）, 2023, 20(09): 974-978.
[6]	周钰菡, 肖欢, 唐毅, 杨春江, 周娟, 朱丽容, 徐娟, 牟芳婷. 超声对儿童髋关节暂时性滑膜炎的诊断价值[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 795-800.
[7]	刘欢颜, 华扬, 贾凌云, 赵新宇, 刘蓓蓓. 颈内动脉闭塞病变管腔结构和血流动力学特征分析[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 809-815.
[8]	郏亚平, 曾书娥. 含鳞状细胞癌成分的乳腺化生性癌的超声与病理特征分析[J]. 中华医学超声杂志（电子版）, 2023, 20(08): 844-848.
[9]	张丽丽, 陈莉, 余美琴, 聂小艳, 王婧玲, 刘婷. PDCA循环法在超声浅表器官亚专科建设中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(07): 717-721.
[10]	罗刚, 泮思林, 陈涛涛, 许茜, 纪志娴, 王思宝, 孙玲玉. 超声心动图在胎儿心脏介入治疗室间隔完整的肺动脉闭锁中的应用[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 605-609.
[11]	黄佳, 石华, 张玉国, 胡佳琪, 陈茜. 胎儿左头臂静脉正常与异常超声图像特征及其临床意义[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 610-617.
[12]	袁泽, 庄丽. 超声检测胎儿脐动脉和大脑中动脉血流对胎儿宫内窘迫的诊断价值[J]. 中华医学超声杂志（电子版）, 2023, 20(06): 618-621.
[13]	李凤仪, 李若凡, 高旭, 张超凡. 目标导向液体干预对老年胃肠道肿瘤患者术后血流动力学、胃肠功能恢复的影响[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 29-32.
[14]	李晓玉, 江庆, 汤海琴, 罗静枝. 围手术期综合管理对胆总管结石并急性胆管炎患者ERCP +LC术后心肌损伤的影响研究[J]. 中华普外科手术学杂志(电子版), 2024, 18(01): 57-60.
[15]	杜锡林, 谭凯, 贺小军, 白亮亮, 赵瑶瑶. 肝细胞癌转化治疗方式[J]. 中华肝脏外科手术学电子杂志, 2023, 12(06): 597-601.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Value of contrast-enhanced ultrasonography in screening of malignancy of liver cirrhotic nodules

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Value of contrast-enhanced ultrasonography in screening of malignancy of liver cirrhotic nodules