肝脏局灶性病变的超声造影研究

【作者】 夏宇；

【导师】 姜玉新；

【作者基本信息】 中国协和医科大学 ， 影像医学与核医学， 2007， 博士

【摘要】 第一部分超声造影对肝脏局灶性病变的诊断价值:与增强CT对比研究目的探讨超声造影在肝脏局灶性病变中诊断价值,与增强CT进行比较,分析二种成像方法的不同特点及互补性。资料和方法2004年12月至2007年5月,对81个肝脏局灶性病变进行超声造影检查和增强CT检查,进行诊断评分,评价病灶在不同成像方法下的表现,分析两种方法的诊断价值与互补性,分析超声造影增强模式的诊断意义。结果超声造影和增强CT对肝脏局灶性病变的诊断能力均很好,两种方法的敏感性、特异性、准确性无显著差异(P＞0.05),两种影像学方法有很好的互补性。肝转移瘤超声造影动脉期显示为多血供的比例显著高于增强CT(P＜0.05)。超声造影动脉期离心性增强不能作为肝脏良恶性病变的鉴别点,超声造影向心性增强对血管瘤诊断的敏感性85.7%、特异性100%、阳性预测值100%、阴性预测值98.7%、准确性98.8%。环状增强对于转移瘤诊断的敏感性80%、特异性98.2%、阳性预测值95.2%、阴性预测值91.7%、准确性92.6%。结论超声造影和增强CT在肝脏局灶性病变中均具有很好的诊断价值,二者有很好的互补性;离心性增强常见于局灶结节样增生,但也可见于HCC;超声造影向心性增强和坏状增强对于诊断肝血管瘤和肝转移瘤有很好的应用价值。第二部分肝细胞肝癌超声造影廓清时间与MVD面积百分比及MVC的相关性研究目的分析肝细胞肝癌超声造影廓清时间与抗CD34染色微血管计数(MicrovesselCount,MVC)及微血管密度(Microvessel Density,MVD)面积百分比的相关性,探讨肝细胞癌超声造影廓清的微血管因素。资料和方法2004年12月至2007年4月,北京协和医院诊治的肝脏局灶性病变患者中在东芝Toshiba Aplio80超声诊断仪上接受了超声造影检查并由手术病理证实的肝细胞肝癌患者31例列入研究对象。记录超声造影病灶开始增强时间,增强程度最高时间,造影剂廓清回声开始低于肝实质时间。造影剂廓清回声开始低于肝实质时间定义为廓清时间,对肝细胞肝癌手术标本进行抗CD34免疫组织化学染色后,计算MVC及MVD面积百分比,分析肝细胞肝癌超声造影廓清时间与MVC及MVD面积百分比的相关性。结果肝细胞肝癌超声造影廓清时间与MVD面积百分比有线性正相关关系(r=0.45),与MVC无相关关系(r=—0.007)。结论肝细胞肝癌超声造影廓清时间与MVD面积百分比成线性正相关,MVD面积百分比大者廓清慢,MVD面积百分比小者廓清快;廓清时间与MVC无关。第三部分肝脏局灶性病变超声造影影响成像因素分析目的分析总结影响肝脏局灶性病变超声造影成像的有关因素,总结规律,提高超声造影成像水平。资料与方法研究对象为2004年12月至2007年5月间,在北京协和医院超声诊断科未能一次顺利进行超声造影检查的肝脏局灶性病灶患者11例,共计11个肿块。其中男性4例,女性7例,年龄48岁至71岁,平均年龄52±10.1岁,中位年龄61岁。排除标准:无明确最终诊断者及超声造影资料不完整者。超声造影检查禁忌征:有冠心病病病史、多种药物过敏史者或年龄不到18周岁。出现以下两种情况中的任何一种定义为超声造影成像不满意:①常规超声不能显示病灶,试行超声造影才能确定病灶位置;②低机械指数超声造影成像条件下未能完整显示病灶的动脉期增强过程、门脉期和延迟期表现。由有超声造影经验的医生在超声造影检查后即刻评价超声造影检查是否一次顺利完成,成像不满意则进行原因分析,提出解决方案。结果共有三类因素影响超声造影成像:肝实质背景因素,操作者因素,忠者呼吸配合因素。肝实质背景因素2例(2/11,18.2%),经试行超声造影显示病灶;操作者因素5例(5/11,45.5%),在低机械指数超声造影模式下未能显示病灶开始增强过程,其中3变个病灶在动脉期末开始显示,2个病灶在门脉期开始显示,超声造影不能明确病灶的增强模式及廓清过程,通过调整成像切面或重复超声造影,5例患者中的4例(80%)最终完成超声造影;患者呼吸配合因素共4例(4/11,36.4%):患者呼吸不稳,低机械指数造影模式下未能显示病灶开始增强过程,门脉期、延迟期无法稳定显示病灶,病灶时隐时现,4例中1例通过调整成像切面并使用contrast/side by side显示完整造影过程;另1例通过使用contrast/side by side显示完整造影过程,其余2例通过重复超声造影和调整成像切面仍未能显示超声造影全过程,4例呼吸配合原因成像困难的病例中2例(50%)重新造影成功。结论常规超声不能显示的病灶通过试行超声造影可能会显示;使用受呼吸或体位变化的影响小的切面、重复超声造影以及使用可以基波图像和超声造影谐波图像双幅同时显示的成像技术进行超声造影更容易成功。更多还原

【Abstract】 PartⅠDiagnostic Value of Focal Liver Lesions by Contrast-enhanced Ultrasound:Compare with Contrast-enhanced CTPurposeTo investigate the diagnostic value of Contrast-enhanced ultrasound(CEUS) and compare the diagnostic value and features of CEUS with Contrast-enhanced CT(CECT).Material and methodsFrom Dec 2004 to May 2007,81 focal liver lesions(FLLs) were evaluated with CEUS and CECT,diagnostic value of two modalities were calculated and compared,and the value of CEUS enhancement pattern were investigated in focal nodular hyperplasia,haemangioma and metastases.ResultsThe diagnostic value of CEUS and CECT are similar,CEUS could show more hypervascular metastases in arterial phase than CECT(P＜0.05). Centrifugal enhancement pattern should not be regarded as a specific feature of focal nodular hyperplasia;sensitivity,specificity,PPV,NPV and accuracy of centripetal enhancement for the diagnosis of haemangioma were 87.5%,100%,100%,98.7%,98.8%respectively.Sensitivity, specificity,PPV,NPV and accuracy of circular enhancement for the diagnosis of metastases were 80%,98.2%,95.2%,91.7%and 92.6% respectively.ConclusionsThe diagnostic value of CEUS and CECT in FLLs are satisfying,and there is no difference between them.Centrifugal enhancement pattern should not be regarded as a specific manifestation of focal nodular hyperplasia; centripetal enhancement and circular enhancement were highly suggestive of liver haemangioma and liver metastases respectively. PartⅡComparison of Wash-out Time of Hepatocelluar Carcinoma on Contrast-enhanced Ultrasonography with Pathological Result of Anti-CD34 Histoimmunological StainPurposeTo investigate the relationship between wash-out time and MVC,and investigate the relationship between wash-out time and MVD area proportion.Material and methodsFrom Dec 2004 to Apr 2007,a total of 329 focal liver lesions with 31 hepatolcellular carcinomas which were confirmed by operation result were prospectively evaluated with contrast-enhanced ultrasonography, wash-in and wash-out time,peak time were recorded,take advantage of CD34 histoimmunological stain in the resected specimen to do MVC and calculate MVD area proportion;investigate relationship between wash-out time and MVC,wash-out time and MVD area proportion.ResultsWash-time and MVD area proportion are positively correlated(r=0.45); there are no relationship between wash-out time and MFC(r=-.007).ConclusionWash out time and MVD area proportion are positively correlated; there are no relationship between wash-time and MVC. PartⅢPrimary study of influence factors on contrast-enhanced ultrasonography in patients with focal liver lesionsPurposeTo analyze factors that could affect contrast-enhanced ultrasonography procedure of focal liver lesion,and try to investigate methods to solve the problems.Material and methodsFrom Nov 2004 to May 2007,totally,there were 11 CEUS that could not be accomplished successfully by one procedure,4 patients are male,and 7 patients are female.Age ranged:48 to 71,mean age:52±10.1,middle age:61.Patients without final diagnosis and intact CEUS data were excluded.Contraindication of CEUS:history of coronary heart disease, allergy tendency and people less than 18 years old.In 2 situations listed below,if one thing happened,the procedure defined as unsuccessful procedure:①could not locate the lesion without aids of ultrasound contrast.②enhancement pattern could not be appreciated completely or the location of the lesion could not be appreciated in portal phase and late phase.Once the CEUS finished,the procedures were evaluated instantly,try to analyze the reasons of failed cases,and then try to improve imaging methods and try the CEUS again.Results2 lesions that could not be located by conventional US are relocated with the help of ultrasound contrast.5 tough CEUS for operator reason were tried again by adjusting access direction or just repeating the procedure,4 of 5 failed cases(4/5,80%) were accomplished.4 tough CEUS for the reason of unsuccessful breath cooperation were tried again,by adjusting access direction or by using contrast/side by side preset,2 of them(2/4,50%) were accomplished.ConclusionsCEUS could help to locate the lesion which could not be detected by conventional US;Adjusting the access direction,repeating CEUS and using contrast/side by side preset may be helpful for the tough cases。更多还原