钆塞酸二钠增强MRI在高分化小肝癌和不典型增生结节鉴别诊断中的应用

doi:10.3877/cma.j.issn.2095-3232.2025.06.010

目的

探讨钆塞酸二钠（Gd-EOB-DTPA）增强MRI对肝硬化背景下不典型增生结节（DN）与高分化小肝细胞癌（sWDHCC）的鉴别诊断价值，并构建鉴别诊断模型。

方法

回顾性分析2015年1月至2020年12月在中山大学附属第三医院经病理检查证实为DN或sWDHCC 的116例患者临床影像学资料。患者均签署知情同意书，符合医学伦理学规定。其中男98例，女18例；年龄31~74岁，中位年龄59岁。患者均采用Gd-EOB-DTPA增强MRI检查，评估病灶在正反相位T1WI、脂肪抑制T1WI、脂肪抑制T2WI、弥散加权成像（DWI）、动脉期、静脉期、肝胆期图像的影像特征，同时评估病灶边界是否清晰。两组患者图像特征比较采用χ²检验；采用Logistic多因素回归分析鉴别诊断的独立影响因素，并构建回归模型。采用ROC曲线评估模型对sWDHCC和DN的鉴别诊断效能。

结果

Gd-EOB-DTPA增强MRI检查显示，116例患者116个病灶，其中DN病灶44例，sWDHCC病灶72例。单因素分析显示，sWDHCC组具有动脉期高强化（APHE）、DWI高信号、T2WI高信号影像特征患者比例明显高于DN组（χ²=68.280，7.408，5.500；P<0.05）。Logistic多因素回归分析显示，APHE（OR=0.001，95%CI：0.000~0.009）和静脉期廓清（OR=0.058，95%CI：0.010~0.353）是鉴别sWDHCC和DN的独立影响因素（P<0.05）。构建回归模型：Y=3.836-6.588×动脉期特征-2.840×静脉期特征。回归模型鉴别sWDHCC与DN的ROC曲线下面积（AUC）为0.94，敏感度为0.90，特异度为0.89。APHE、DWI高信号、T2WI高信号3个特征的AUC分别为0.86、0.63、0.61。回归模型AUC明显大于APHE、DWI高信号、T2WI高信号单一特征的AUC（Z=3.103，6.176，6.795；P<0.05）。

结论

Gd-EOB-DTPA增强MRI的APHE及静脉期廓清为sWDHCC和DN鉴别诊断的影像学特征，基于影像学特征构建的回归模型具有较高的鉴别诊断价值。

关键词: 癌，肝细胞, 高分化, 小肝癌, 不典型增生结节, 钆塞酸二钠, 磁共振成像

Objective

To evaluate the value of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) enhanced MRI in differential diagnosis of dysplastic nodules (DN) and small well-differentiated hepatocellular carcinoma (sWDHCC) induced by liver cirrhosis, and to construct a differential diagnosis model.

Methods

Clinical imaging data of 116 patients pathologically diagnosed with DN or sWDHCC in the Third Affiliated Hospital of Sun Yat-sen University from January 2015 to December 2020 were retrospectively analyzed. The informed consents of all patients were obtained and the local ethical committee approval was received. Among them, 98 patients were male and 18 female, aged from 31 to 74 years, with a median age of 59 years. All patients received Gd-EOB-DTPA enhanced MRI to evaluate the imaging features of the lesions in in-phase and out-of-phase MRI, fat-suppression T1WI, fat-suppression T2WI, diffusion-weighted imaging (DWI), arterial phase, venous phase and hepatobiliary phase, and to assess whether the margins of the lesions were clear. Imaging characteristics between two groups were compared by Chi-square test. The independent influencing factors of differential diagnosis were identified by multivariate Logistic regression analysis and a regression model was constructed. The differential diagnostic efficiency of this model for sWDHCC and DN was evaluated by the ROC curve.

Results

Gd-EOB-DTPA enhanced MRI showed that 116 lesions from 116 patients included 44 DN and 72 sWDHCC. Univariate analysis showed that the proportion of patients with arterial phase hyperenhancement (APHE), DWI hyperintensity and T2WI hyperintensity in the sWDHCC group was significantly higher than that in the DN group (χ²=68.280, 7.408, 5.500; all P<0.05). Multivariate Logistic regression analysis demonstrated that APHE (OR=0.001, 95%CI: 0.000-0.009) and washout in venous phase (OR=0.058, 95%CI: 0.010-0.353) were the independent influencing factors in differentiating sWDHCC from DN (both P<0.05). The regression model was constructed: Y=3.836-6.588× arterial phase features-2.840×venous phase features. The area under the ROC curve (AUC), sensitivity and specificity of this model in differentiating sWDHCC from DN were 0.94, 0.90 and 0.89, respectively. The AUC of APHE, DWI hyperintensity and T2WI hyperintensity was 0.86, 0.63 and 0.61, respectively. The AUC of the regression model was significantly larger than that of APHE, DWI hyperintensity and T2WI hyperintensity (Z=3.103, 6.176, 6.795; all P<0.05).

Conclusions

Washout during APHE and venous phase of Gd-EOB-DTPA enhanced MRI are the imaging features for differential diagnosis between sWDHCC and DN. This regression model based on imaging features possesses high differential diagnostic value.

Key words: Carcinoma,hepatocellular, Well-differentiated, Small hepatocellular carcinoma, Dysplastic nodule, Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA), Magnetic resonance imaging

表1 DN和sWDHCC两组患者一般资料和影像特征比较

指标	DN	sWDHCC	统计值	P值
性别(例, 男/女)	38/6	60/12	χ²=0.191	0.662
年龄(岁, $x ¯$ ±s)	57±9	59±8	t=0.021	0.884
病灶大小(mm, $x ¯$ ±s)	17±5	18±6	t=4.730	0.032
病灶边界清晰(例)	40	56	χ²=3.300	0.069
APHE(例)	12	71	χ²=68.280	<0.001
T1低信号(例)	11	31	χ²=3.855	0.050
T2高信号(例)	23	53	χ²=5.500	0.019
DWI高信号(例)	20	51	χ²=7.408	0.006
静脉期廓清(例)	24	50	χ²=2.625	0.105
肝胆期低信号(例)	7	7	χ²=0.930	0.335
强化包膜(例)	1	43	χ²=0.449	0.503
病灶内脂肪信号(例)	14	18	χ²=0.636	0.425

表1 DN和sWDHCC两组患者一般资料和影像特征比较

指标	DN	sWDHCC	统计值	P值
性别(例, 男/女)	38/6	60/12	χ²=0.191	0.662
年龄(岁, $x ¯$ ±s)	57±9	59±8	t=0.021	0.884
病灶大小(mm, $x ¯$ ±s)	17±5	18±6	t=4.730	0.032
病灶边界清晰(例)	40	56	χ²=3.300	0.069
APHE(例)	12	71	χ²=68.280	<0.001
T1低信号(例)	11	31	χ²=3.855	0.050
T2高信号(例)	23	53	χ²=5.500	0.019
DWI高信号(例)	20	51	χ²=7.408	0.006
静脉期廓清(例)	24	50	χ²=2.625	0.105
肝胆期低信号(例)	7	7	χ²=0.930	0.335
强化包膜(例)	1	43	χ²=0.449	0.503
病灶内脂肪信号(例)	14	18	χ²=0.636	0.425

图1 回归模型与其他影像学指标对sWDHCC和DN鉴别的ROC曲线注：DN为不典型增生结节，sWDHCC为高分化小肝细胞癌，DWI为弥散加权成像，APHE为动脉期高强化

表2 回归模型与其他影像学指标对sWDHCC和DN鉴别的诊断效能

指标	AUC	95%CI	敏感度	95%CI	特异度	95%CI	Z值	P值
APHE	0.86	0.78~0.92	0.99	0.93~1.00	0.73	0.57~0.85	3.103	<0.05
DWI高信号	0.63	0.53~0.72	0.71	0.59~0.81	0.55	0.39~0.70	6.176	<0.05
T2高信号	0.61	0.51~0.70	0.74	0.62~0.83	0.48	0.33~0.63	6.795	<0.05
回归模型	0.94	0.89~0.98	0.90	0.81~0.96	0.89	0.75~0.96	/	/

表2 回归模型与其他影像学指标对sWDHCC和DN鉴别的诊断效能

指标	AUC	95%CI	敏感度	95%CI	特异度	95%CI	Z值	P值
APHE	0.86	0.78~0.92	0.99	0.93~1.00	0.73	0.57~0.85	3.103	<0.05
DWI高信号	0.63	0.53~0.72	0.71	0.59~0.81	0.55	0.39~0.70	6.176	<0.05
T2高信号	0.61	0.51~0.70	0.74	0.62~0.83	0.48	0.33~0.63	6.795	<0.05
回归模型	0.94	0.89~0.98	0.90	0.81~0.96	0.89	0.75~0.96	/	/

图2 一例肝右后叶sWDHCC患者MRI图像注：a为脂肪抑制T1WI为低信号；b为脂肪抑制T2WI为高信号；c为DWI高信号；d为APHE；e为静脉期廓清；f为肝胆期为低信号；APHE为动脉期高强化，DWI为弥散加权成像，sWDHCC为高分化小肝细胞癌

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Application of Gd-EOB-DTPA enhanced MRI in differential diagnosis of small well-differentiated hepatocellular carcinoma and dysplastic nodules

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Application of Gd-EOB-DTPA enhanced MRI in differential diagnosis of small well-differentiated hepatocellular carcinoma and dysplastic nodules