【作者】 周平；

【导师】 刘浔阳；

【作者基本信息】 中南大学 ， 外科学， 2006， 博士

【摘要】 第一章超声造影在原发性肝癌滋养动脉检测中的价值目的采用超声造影对原发性肝癌滋养动脉进行检测，以探讨超声造影在原发性肝癌滋养动脉检测中的作用及其临床意义。方法采用超声造影对比脉冲序列(CPS)造影成像技术对72例原发性肝癌患者进行检查，观察肿块滋养动脉供血情况，并与彩色多普勒超声进行比较。同时运用超声造影对肿块滋养动脉的供血方式进行分型；运用超声造影对肿块滋养动脉的内径进行测量，比较1～3cm组、～5cm组和～8cm组三组间肿块滋养动脉的内径粗细有无差别。结果超声造影检出肿块滋养动脉68例(94.4％)，而彩色多普勒超声检出肿块滋养动脉者38例(52.8％)，超声造影对肿块滋养动脉检出率明显高于彩色多普勒超声(P＜0.05)。超声造影可将滋养动脉分为包绕型和分支型两型，以DSA作为标准对照，超声造影分型的准确性为93.3％。Kappa值为0.86。肝肿块滋养动脉内径1～3am组明显小于～5cm组(P＜0.05)，～5cm组明显小于～8cm组(P＜0.05)。随着肿块直径的增大，滋养动脉内径也常随之增大。结论超声造影能较好地显示原发性肝癌的滋养动脉，是一种非常敏感的微血管检测技术，具有非常重要的临床意义。第二章超声引导下经酒精和微波联合治疗原发性肝癌的临床研究目的：通过采用无水酒精+微波及无水酒精+微波阻断滋养动脉+微波联合治疗原发性肝癌，探讨联合治疗在原发性肝癌治疗中的价值。方法：将40例患者48个直径2～5cm原发性肝癌病灶分成三组进行介入消融治疗。Ⅰ)微波治疗组(肿块平均直径3.2cm)；Ⅱ)无水酒精+微波治疗组(肿块平均直径3.4cm)；Ⅲ)无水酒精+微波阻断滋养动脉+微波治疗组(肿块平均直径3.3cm)。术后运用增强CT测量肿块凝固最大横径，并评估三组肿块完全坏死率。结果：Ⅰ组肿块凝固最大横径为28±4.6mm、完全坏死率为58.8％(10／17)；Ⅱ组肿块凝固最大横径为36±8.3mm，完全坏死率为73.4％(11／15)；Ⅲ组肿块凝固最大横径为46±8.5mm，完全坏死率为93.8％(15／16)。其中Ⅱ组肿块凝固最大横径及完全坏死率要明显高于Ⅰ组(P＜0.001，P＜0.05)；Ⅲ组肿块凝固最大横径及完全坏死率要明显高于Ⅱ组(P＜0.001，P＜0.05)。三组间主要并发症发生率无明显差异(P＞0.05)。结论：采用无水酒精和微波联合治疗原发性肝癌，尤其是无水酒精+微波阻断滋养动脉+微波联合治疗原发性肝癌能明显提高肿瘤的灭活范围和完全坏死率。目的比较超声造影和增强螺旋CT对原发性肝癌非手术治疗疗效的评判能力，探讨超声造影在原发性肝癌非手术治疗评估中的价值。方法对56例(64灶)经超声引导穿刺活检病理确诊的原发性肝癌患者进行非手术治疗。其中采用TACE 4例、PEI8例、PMCT11例、RFA5例、TACE+PEI4例、TACE+PMCT3例、PEI+PMCT11例、PEI+微波阻断滋养动脉+PMCT10例。非手术治疗后分别进行了超声造影和增强螺旋CT检查，以判断肿瘤的灭活程度，并对两者的判别能力进行分析比较。结果超声造影发现46个病灶没有增强(46／64)，18个病灶有部分增强(18／64)。增强螺旋CT发现48个病灶没有增强(48／64)，16个病灶有部分增强(16／64)。与临床追踪对照，超声造影和增强螺旋CT对非手术治疗疗效判定的敏感性、特异性及准确率分别为94.4％、97.8％、96.9％和83.3％、97.8％、93.8％。两种方法比较差异无显著性意义(P＞0.05)。结论超声造影评估原发性肝癌非手术治疗效果与增强螺旋CT相近，是判定非手术治疗效果的一种敏感而有效的方法。对于行TACE治疗及少数血供不是特别丰富的病灶，超声造影具有较增强螺旋CT更重要的临床价值。更多还原

【Abstract】 Part one Value of contrast-enhanced ultrasonography in detection of feeding artery of hepatocellular carcinomaObjective To evaluate value of contrast-enhanced ultrasonography(CEUS) in detection of feeding artery of hepatocellular carcinoma(HCC).Methods CEUS were performed on 72 patients with HCC to detect feeding artery. The blood flow image of feeding artery was observed and was compared with color Doppler sonography.And the type and diameter of feeding artery were also observed with CEUS.Results A feeding artery was detected in 68 HCCs(94.4%) with CEUS,A feeding artery was detected in 38 HCCs(52.8%) with color Doppler sonography(P＜0.05). The feeding artery of HCCs could be classified into surrounding artery pattern or branching artery pattern.Compared with DSA, the accuracy of CEUS was 93.3% for detecting the feeding artery patterns. Kappa value was 0.86. The diameter of feeding artery in 1～3cm HCCs was smaller than in～5cm HCCs(P＜0.05), the diameter of feeding artery in the～5cm groups was smaller than in the～8cm HCCs (p＜0.05). Conclusion CEUS can image the feeding artery very well,and is a very sensitive technique of detecting micro-vessel, has very important clinical value. Part two Hepatocellular carcinoma ablation by combining percutaneous microwave coagulation therapy and ethanol injectionObjective We sought to determine if larger hepatocellular carcinoma(HCC) ablative volumes could be obtained by combining percutaneous microwave coagulation therapy(PMCT) and ethanol injection(PEI), by PEI followed by PMCT with occlusion of the feeding artery.Methods Forty patients with 48 HCCs(diameter,2-5cm) were treated with (Ⅰ) percutaneous microwave coagulation therapy; (Ⅱ) combined therapy of PEI immediately followed by PMCT; (Ⅲ) combined therapy of PEI immediately followed by PMCT with occlusion of the feeding artery. The coagulated area was measured at the maximum diameter perpendicular to the needle tract on enhanced computed tomography (CT) performed immediately after therapy. The local effect of the treatment was evaluated by follow-up enhanced CT.and the rate of complete necrosis were compared with three treatment groups. Results The coagulation area in groupⅠwere 28±4.6mm, the rate of complete necrosis in groupⅠwere 58.8%(10/17); The coagulation area in groupⅡwere 36±8.3mm, the rate of complete necrosis in groupⅡwere 73.4%(11/15); the coagulation area in groupⅢwere 46±8.5mm, the rate of complete necrosis in groupⅢwere 93.8%(15/16). The difference in the coagulation area and the rate of necrosis were significantly larger in the groupⅡthan groupⅠ(p＜0.001,p＜0.05). Thedifference in the coagulation area and the rate of necrosis were significantly larger in groupⅢthan groupⅡ(p＜0.001,p＜0.05).Conclusions Combined therapy of PEI immediately followed by PMCT, especially combined therapy of PEI immediately followed by PMCT with occlusion of the feeding artery can significantly coagulate larger volumes of tumor and improve the rate of complete necrosis. Part three Evaluation of non-surgical treatment response in hepatocellular carcinomas using contrast-enhanced sonography: comparison with contrast-enhanced helical CTObjective: To compare the efficacy of contrast-enhanced sonography with contrast-enhanced helical CT for non-surgical treatment response in hepatocellular carcinomas.Materials and Methods: Non-surgical therapies were performed on 56 patients with 64 liver neoplasms. Including 4 patients performing TACE, eight patients performing PEI,eleven patients performing PMCT, five patients performing RFA, four patients performing TACE+PEI, three patients performing TACE+PMCT, eleven patients performing PEI+PMCT, ten patients performing PEI+occlusion of the feeding artery +PMCT, and diagnosies were made before non-surgical therapies by US-guided biopsy. Sono Vue enhanced ultrasonography and contrast-enhanced helical CT were performed to assessing the treatment response.Results: Forty-six of 64 lesions were not enhanced with contrast-enhanced sonography.Partial enhancement were demonstrated in 18 lesions. Forty-eight of 64 lesions were not enhanced with contrast- enhanced helical CT.Partial enhancement were demonstrated in 16 lesions.The sensitivity、specificity and accuracy were 94.4%、97.8%、96.9% for contrast-enhanced sonography and 83.3%、97.8%、93.8% for contrast-enhanced helical CT compared with clinic(P＞0.05). There were no significant differences between contrast-enhanced sonography and contrast-enhanced helical CT.Conclusion: Contrast-enhanced sonography is at least comparable with contrast-enhanced helical CT in assessing the non-surgical treatment response in hepatocellular carcinomas and is more sensitive and useful in assessing treatment response of TACE and some patents without residue tumors with contrast-enhanced helical CT.更多还原