【作者】 范瑾；

【导师】 于晓玲；

【作者基本信息】 中国人民解放军军医进修学院 ， 影像医学与核医学， 2008， 硕士

【摘要】 第一部分超声造影与增强MRI评价肝癌局部消融疗效的对比研究目的对比研究超声造影与增强MRI在评价肝癌局部消融疗效及诊断残癌或局部复发的应用价值。材料与方法59例患者共77个病灶微波治疗后行超声造影检查和同期(0±14d)增强MRI检查评价疗效。所有病例术前均经穿刺活检或手术病理证实,其中包括原发性肝癌53例71灶,肝转移癌6例。微波治疗后消融病灶内部及周边三期均无增强,始终呈“黑洞”表现诊断为肿瘤完全灭活;消融病灶周边出现动脉期结节样增强,随后造影剂快速廓清,呈低增强诊断为肿瘤残存或局部复发。最终诊断依据6个月以上随访观察,穿刺活检或两种以上增强影像学检查并结合血清肿瘤标志物水平进行综合判断。结果以最终诊断为金标准,肿瘤灭活完全者64灶,局部残存或复发者13灶。77灶中超声造影与增强MRI诊断一致者共69灶,完全灭活62灶,局部残存或复发7灶。超声造影67灶(87.1%)、增强MRI65灶(84.4%)各时相均未强化,提示肿瘤完全灭活,超声造影10灶(12.9%)、增强MRI12灶(15.6%)边缘局部动脉期增强,提示肿瘤残存或复发。超声造影和增强MRI诊断肝癌灭活程度的敏感性分别为69.2%、76.9%,特异性为98.4%、96.8%,准确性为93.5%、93.5%。超声造影与增强MRI评价肝癌消融疗效差异无显著性意义(X~2=0.125,p值=0.724＞0.05)。超声造影与增强MRI并联诊断评价肝癌局部消融疗效的敏感性和特异性分别为92.9%和95.3%,敏感性较单一检查方法提高。结论肿瘤内血流的检测是评估疗效的手段,超声造影可较灵敏的显示局部消融治疗后肿瘤的血供状态,较准确地判断微波消融后肿瘤灭活程度,有较高临床应用价值。超声造影与增强MRI并联诊断试验可提高诊断的敏感性,有望在临床推广应用。第二部分肝癌微波治疗后超声造影征象及病灶近期转归之间的联系初探目的初步探讨肝癌微波消融治疗后不同超声造影征象与病灶近期转归之间的联系。资料与方法2005年8月至2008年3月解放军总医院超声科共对480例肝癌患者进行超声引导下微波治疗,其中96例患者共108个病灶微波治疗后1个月进行超声造影检查评价疗效,重点观察病灶如下超声造影征象:1消融区内部或周边有无异常增强区;2异常增强区域的增强模式;3消融区形态是否规则;4充血带形态是否规则;5病灶内部或周边的异常增强区是否靠近重要脏器或管道。超声造影诊断结果分为消融完全、局部残存或复发及性质待定三类。最终诊断依据3个月以上随访观察、穿刺活检或两种以上增强影像学检查并结合血清肿瘤标志物水平进行综合判断,探讨超声造影征象及病灶近期转归之间的联系。结果超声造影诊断完全灭活共72个病灶,局部残存或复发病灶9个,性质待定27个。以最终诊断为金标准,108例病灶中16例诊断为肿瘤残存或复发,92例病灶诊断为完全灭活。进行超声造影征象与病变转归之间的单因素分析,肿瘤完全灭活组与肿瘤残存或复发组之间消融区形态(p=0.8017)、充血带形态(p=0.4663)差异无统计学意义。两组间消融区内部或周边有无异常增强(p=0.000),是否靠近重要脏器或管道(p=0.026)以及异常增强的模式(p=0.004)差异具有统计学意义。将与病灶近期转归相关的三个超声造影征象代入Logistic模型分析仅异常增强模式是与病灶近期转归相关的独立危险因素。结论肝癌局部消融治疗后超声造影征象复杂多样,消融区内部或周边有无异常增强,异常增强的模式及其是否靠近重要脏器或管道等造影征象对于疗效评价及预测转归具有一定的指导意义,但仅异常增强模式是与病灶近期转归相关的独立危险因素。部分不典型病例密切随访观察或穿刺活检对于残存或复发病灶的早发现、早诊断、早治疗是必要的。更多还原

【Abstract】 PART ONEA comparative study of contrast-enhanced ultrasound and contrast-enhaced MRI in evaluating the therapeutic response of liver cancer treated by microwave ablationObjective To investigate the role of contrast-enhanced ultrasound and contrast-enhanced MRI in evaluating the therapeutic response of liver cancer treated by microwave ablation (MA).Materiala and Methods Fifty-nine patients with a total of 77 lesions underwent contrast-enhanced ultrasound using the microbubble contrast agent Sonovue after focal ablation treatment. All of the lesions were confirmed by fine-needle biopsy or operation. Before treatment 53 patients of 71 lesions were diagnosed as hepatocelluar carcinoma,6 patients of 6 lesions were metastases. The results of contrast-enhanced ultrasound was compared with those of contrast-enhanced MRI with 2 weeks. The absence of enhancement in or around ablation zone was diagnosed as completely necrosis.However,the presence of enhancement in or around the ablation zone was diagnosed as focal remnant or recurrence. The final diagnosis should be made by two kinds of contrast-enhanced imaging exzamination combining the level of blood serum tumor marker, fine-needle biopsy guided by ultrasound or follow-up at least 6 months.Result Taking the final diagnosis as the gold standard, 64 lesions were diagnosed as completely necrosis, 13 lesions were diagnosed as remnant or recurrencement. 69 lesions of the 77 have reached agreement by two exzaminations.62 have got adequate treatment, 7 were not.67 lesions (87.1%)and 65 lesions (84.4%) were diagnosed as necrosis by CEUS and CEMRI respectively. 10 lesions (12.9%)and 12 lesions (15.6%) showing local enhancement in arterial phase and abaissement in late phase were diagnosed as necrosis by CEUS and CEMRI respectively. The sensitivity in evaluating the therapeutic effect of malignant hepatic masses with CEUS and CEMRI were 68.4% vs 73.7%; specificity 98.1% vs 96.3%; accuracy 90.4% vs 90.4%.There were no significant statistical disparity between CEUS and CEMRI (P > 0.05).The sensitivity and specificity in evaluation the therapeutic effect of malignant hepatic masses has been 92.9%和95.3% when combining with CEUS and CEMRI in enaluating therapeutic response (P>0.05) .Conclusion Detecting blood signal in the tumor is one of the measures to access therapeutic response of maligment hepatic masses treated by local ablation therapy. CEUS can show the hemoperfusion of lesions treated by local ablation sensitively, and is of certain evaluation in clinical applycation. Combining with CEUS and CEMRI can greatly increase the sensitivity of diagnosis, so it would be of promising prospect in clinic.PART TWOA Primary study on relationship between contrast-enhanced ultrasonography signs and turnover of malignant hepatic masses treated with local microwave ablation.Purpose To sduty the relationship between contrast-enhanced ultrasound signs and turnover of tumors treated with focalmicrowave ablation.Materials and methods Contrast-enhanced ultrasound were performed on 96 patients with a total of 108 tumors treated by microwave ablation after 1 month. Observing these signs such as:1、enhancement in or around the microwave area; 2、the enhancement style of those abnormal area; 3、the shape of the lesion; 4、the magin of hyperemia; 5、whether those enhancement areas are adjecent to important organs or not. The final diagnosis are confirmed by fine-needle biopsy guided by ultrasound or more than 3 months follow-up. 16 lesions were certified as focal remnant or recurrence.92 lesions were confirmed totally necrosis. Results Single-variable analysis showed that the shape of microwave ablation area(p=0.943) and hyperemia (p=0.823) has no analysis discrepancy between the localrenament or recurrent group and non-recurrent group. Enhancement in or around themicrowave area (p=0.000), the enhancement style of those abnormal area (p=0.004)and wether those enhancement arers are adjecent to important organs or not(p=0.026) has statistical discrepency.Conclusion Contrast-enhanced ultrasound show different signs of hepatic neoplasms treated by local ablation therapy, these signs has certain guide significance to assess the therapeutic effect and turnover,but some untypical lesions should still be follow-up intimately or confirmed by fine-needle biopsy guided by ultrasound.更多还原