【作者】 于金芬；

【导师】 刘林祥；

【作者基本信息】 泰山医学院 ， 影像医学与核医学， 2010， 硕士

【摘要】 目的探讨超声、CT与MRI检查在肝门部胆管癌诊断中综合运用的价值。材料与方法收集64例肝门部胆管癌病人,临床均有不同程度的黄疸、上腹部不适、胀痛,食欲不振,恶心,呕吐,乏力及消瘦等症状。部分病人反复出现胆管感染症状,并发全身皮肤瘙痒,上腹胀痛,陶土色大便。分别进行超声、CT和MRI检查。采用超声诊断仪为飞利浦IE33、西门子公司Emotion 16层螺旋CT和GE公司1.5T signa超导型磁共振扫描仪。患者做CT检查前4h～6h常规禁食,扫描前0.5h口服温开水800ml,检查前肌肉注射654-2 10ml,再次口服温开水300ml～500ml。扫描范围自膈顶至肾脏下极,扫描方式为螺旋扫描,矩阵512×512,110KV,120mA,层厚5.0mm,螺距1.375:1,均作平扫、双期动态增强及延迟扫描,非离子型碘造影剂碘比醇(300mgI/ml),速度3.0ml/s,总量80-100ml,于开始注射后25s、60s、180s分别进行动脉期、门脉期及延迟期扫描。以轴位图像为基础,将薄层容积扫描数据,在工作站进行后重建处理,获得兴趣区的MPR图像、CPR(曲面重组)图像、MIP(最大密度投影图像)。患者做MRI检查前10分钟口服枸椽酸铁铵,肌肉注射654-2 10ml;采用体部相阵控列(Body phased-array)线圈,扫描序列:①轴位SE序列T1WI(TR 500-600ms,TE 14-21ms)和T2WI(TR6000-8000ms,TE 85ms),自膈顶至肝下缘扫描,层厚6mm,层间距2mm;②轴矢冠位2D FIESTA扫描(TR 4.2ms,TE 1.7ms);③MRCP采用2D冠状位扫描(TR 12000-15000ms,TE 220ms)或3D(TR 4000ms,TE 671ms)重建;④扰相梯度回波(SPGR)动态增强序列(TR 150-180ms,TE 2.0ms,翻转角60°),在一次屏气12-18S内完成全肝扫描,造影剂为Gd-DTPA,剂量15-20ml,速度3ml/s,自开始注射起15s、30s、60s、90s、120s、150s、180s后各扫描一次。分别对肝内胆管扩张病因、梗阻部位及转移程度做出诊断,然后与手术及术后病理结果进行逐一对照。比较两阅片者在单独观察CT图像与CT图像结合其他影像资料诊断肝门胆管癌的诊断符合率,两阅片者双盲法阅片的诊断一致性,肝门部胆管癌诊断的信心指数评分,分别评价CT及各种影像检查手段综合运用诊断肝门部胆管癌的灵敏度、特异度、阳性预测值、阴性预测值、判断准确率、You den指数、阳性似然比及阴性似然比。结果两阅片者在单独观察CT图像和CT图像结合其他影像资料图像诊断肝门部胆管癌时,两种方法的诊断符合率分别为91.2%和95.2%,两者间没有统计学差异(χ~2=2.14,P=0.1432﹥0.05值),但是不同阅片者的诊断一致性进一步提高(K值分别为0.61、0.72),两种方法间信心指数评分间存在统计学差异(p=0.0285﹤0.05)。运用CT图像结合MR图像诊断肝门部胆管癌的信心评分明显提高。各种影像检查手段综合运用诊断肝门部胆管癌的敏感度、特异度、阳性预测值、阴性预测值及判断准确率分别为94.8%、96.3%、98.4%、88.1%、95.2%;You den指数=91.1%;阳性似然比=25.6;阴性似然比=0.04。各种影像学检查手段综合运用对肝门部胆管癌及转移程度的诊断符合率分别为94.8%、83.9%,对肝门部胆管癌的诊断符合率略高,但两者的诊断符合率间无统计学差异(χ~2=3.4592,p=0.0629)。在64例中,B超提示肝门部胆管癌46例,确诊率71.86%(46/64);CT提示肝门部胆管癌54例,表现为肝门部软组织肿块和肝内胆管扩张,确诊率84.37 %(54/64);MRI均可见肝门包块,肝内胆管扩张,动态增强扫描显示60例包块呈逐渐强化。4例动脉期显示强化。MRCP检查均成功,提示肝内胆管、肝门部胆管扩张形态、梗阻部位,定位诊断率100%。结论两阅片者在单独观察CT图像和CT图像结合其他影像资料图像诊断肝门部胆管癌符合率间无统计学差异,但综合运用多种影像检查手段能够增加肝门部胆管癌的诊断信心,并可使不同阅片者间诊断一致性增加。超声、CT与MRI均是肝门区胆管癌的有效检查方法,对肝门部胆管癌的诊断和治疗方案的确定,可以选择B超与CT检查联用;MRI在显示肝门区肿块大小、范围、胆管壁浸润程度、门静脉受累以及淋巴结肿大方面比CT、超声更具有价值。MRI平扫及动态增强扫描并与MRCP结合对肝门部胆管癌有较高的诊断价值。更多还原

【Abstract】 ObjectiveTo investigate the value of combinative utilization of Ultrasonography, CT and MRI in the hailer cholangiocarcinoma diagnosis.Materials and methods64 cases of cholangiocarcinoma were collected as the research subjects. All the cases have different degree of jaundice, discomfort in upper abdomen, bursting pain, lacking of appetite, vomiting and sick, fatigue and the patients become thinner. Some patients suffer from the symptoms of recurrent bile duct infections, prorates, bursting pain in upper abdomen, clay color of stool. They were examined by Ultrasonography (Philips, IE33), CT (Siemens, Emotion 16), and MRI (GE, Signa 1.5T), respectively.The patients had to take 4h to 6h conventional fast before CT examination. 800ml water is drunk by the patient half hour before the scanning. An intramuscular injection with 654-210ml is given to the patient, following by another intake of 300ml to 500ml water. The scanning range is from phoenix top to kidney lower pole, the scanning method is helical scan, matrix 512×512, 110KV, 120MA, thickness 5.0mm, pitch 1.375:1, plain scanning, dual-phase dynamic contrast-enhanced scanning and delayed scanning, non-ionic iodine contrast agent Iobitridol (300mgI/mL), speed 3.0 ML/S, total usage 80-100mL., scanning is made 25S, 60S and 180S after the injection done, according to arterial, portal venous phase and extension phase scanning. Based upon the axial image, reconstruction treatment is taken to the thin volume data in workstation. The MPR images from region of interest, CPR (curved planar reformation) images, MIP (maximum intensity projection) images are obtained through this stage.Patients will take an intramuscular injection of 654-2 by 10ml and oral intake Ferric Ammonium iron (III) citrate by 10ml 10minutes before the examination. Department of phased array body coil control column is used for the scanning. Scanning sequence is as following:①Axial SE sequence T1W1 (TR500-600ms, TE 14-21ms) ,T2WI (TR6000-8000ms, TE85ms), starting scanning from phoenix top to the lower edge of the liver, thickness 6mm, spacing 2mm;②coronal axis vector 2D FIESTA scanning (TR 4.2ms, TE 1.7ms);③MRCP has exploited 2D coronal scan (TR 12000-1500ms, TE220ms), or 3D (TR4000ms, TE672ms) reconstructi- on.④Spoiled gradient echo (SPGR) dynamic contrast-enhanced sequence (TR150-180ms, TE2.0ms, flip angle 60 degree) , finish the total hepatic scan within one breath-hold (12-18S), contrast agent is GD-DTPA, dose 15-20ml, speed 3ml/s, since the start of injection, operate scanning after 15S, 30S, 60S, 90S, 120S, 150S and 180S.The diagnosis is made respectively for the cause of intrahepatic biliary dilatation, site of obstruction and the degree of metastasis. The results will be compared to the surgery and pathology one by one. Two independent film readers will observe the CT images and other image data to make diagnosis of hilar cholangiocarcinoma on their own. Double-Blind film reading methods is applied for both of the film readers to find out the diagnose accordance rate. The confidence scores will be evaluated to the two film readers and methods accordingly. The estimate will be made to the sensitivity, specificity, positive predictive value, negative predictive value, the accuracy rate, You den Index, positive likelihood ratio and negative likelihood ratio of the diagnosis of hilar cholangiocarcinoma combining usage of CT and other image data.ResultsWhen the two independent film readers make the diagnosis individually using CT images only or combining CT image and other image data, the accordance rate is 91.2% and 95.2% respectively. There is no statistical significance (χ~2=2.14,P=0.1432﹥0.05). However, the diagnosis consistency is increased between two film readers (K-Value 0.61 and 0.72). The confidence scores have statistical significance between two different diagnosis methods (p=0.0285﹤0.05). The confidence score is significantly increased using CT images combined with MR image to diagnose the hilar cholangiocarcinoma. Based on comprehensive use of various imaging data to make the diagnosis of hilar cholangiocarcinoma, the sensitivity, specificity, positive predictive value, negative predictive value, the accuracy rate are 94.8%, 96.3%, 98.4%, 88.1%, 95.2% respectively. You den Index is 91.1%, positive likelihood ratio is 25.6 and negative likelihood ratio is 0.04.The diagnosis accordance rate is 94.8% and 83.9% based on using comprehensive use of various imaging data to diagnose hilar cholangiocarcino- ma and the degree of metastasis. This diagnosis accordance rare is slightly higher. However, there is no statistical significance between the two methods (χ~2=3.4592,p=0.0629).Among the 64 cases, Ultra Sound points out 46 cases of hilar cholangiocarc- inoma, the diagnosis rate is 71.86% (46/64). CT points out 54 cases out of 64 and the diagnosis rate is 84.37%. CT images show hilar soft tissue lumps and intrahepatic bile duct dilatation. The MRI images show clearly hilar soft tissue masses and intrahepatic bile duct dilatation. Dynamic MR imaging also shows the masses are increased gradually in 60 cases. Other 4 cases, it shows artery phase is enhanced. All the examination using MRCP is successful. The diagnosis rate is 100% in locating the site of obstruction and description of intrahepatic bile duct dilatation.ConclusionThere is no statistical significance between two independent film readers based on CT Images only or comprehensive use of various imaging data to diagnose the hilar cholangiocarcinoma. Nevertheless, comprehensive use of various imaging data can increase the diagnosis confidence and also improve the diagnosis accordance between different film readers.Ultrasound, CT and MRT are all the effective examination methods for hilar cholangiocarcinoma. Ultrasound and CT examination can be combined together to confirm diagnosis and treatment programme. MRI is more valuable in revealing the size of the lumps in Klatskin section, the range of the lumps, infiltration of bile duct wall, portal vein involvement and enlargement of lymph nodes than CT and Ultrasound. MRI plain scan and dynamic enhanced MRI scan combing MRCP has relatively high Diagnostic value.更多还原