肝动脉造影对肝细胞癌微小病变检出的应用价值研究

发布时间：2018-05-16 05:44

本文选题：肝细胞癌 + 微小病变　；参考：《广西医科大学》2017年博士论文

【摘要】：第一部分:肝动脉DSA与MRI动态钆喷酸葡胺增强在肝细胞癌微小病变检出的前瞻性对比研究目的:对比探讨肝动脉造影(digital subtraction angiography,DSA)与核磁共振成像(magnetic resonance imaging,MRI)动态钆喷酸葡胺增强对肝细胞癌微小病变(直径≤2cm)检出率的诊断价值。材料与方法:前瞻性分析我院符合入组标准,其他检查显示出肝脏内单发或多发病变中包含有微小病灶(即直径≤2cm)的病例术前两周内同时行肝动脉DSA和MRI动态钆喷酸葡胺增强检查。年龄最小25岁,最大75岁,中位年龄51岁。47例88个病灶经手术切除证实,3例4个病灶由病理穿刺活检证实,7例15个病灶经肝动脉化疗栓塞术后碘油沉积并术后实验室检查和影像学随访证实。采用SPSS16.0软件包对肝动脉DSA与MRI动态钆喷酸葡胺增强的检出率进行Mc Nmar卡方检验、Kappa一致性检验,应用独立样本t检验和受试者运行特征曲线分析肝动脉DSA与MRI动态钆喷酸葡胺增强对被检出的肝细胞癌微小病变直径的大小。结果:57例107个微小病灶,其中63个病灶直径≤1cm,44个病灶直径1cm;富血供型91个,乏血供型16个,44个见包膜征。肝动脉DSA共检出92个,其中乏血供型1个;MRI共检出76个,其中乏血供型6个。肝动脉DSA、MRI动态钆喷酸葡胺增强的检出率分别为86.0%(92/107)、71.0%(76/107),Mc Nmar检验结果P0.05,Kappa值为0.303(P=0.001),两者差异显著。乏血供型微小病灶,MRI动态钆喷酸葡胺增强的检出率为37.5%(6/16),肝动脉DSA的检出率为0.1%(1/16),Fisher’s确切概率法显示P0.05。微小病变直径≤1cm时,MRI的检出率为52.4%(33/63),肝动脉DSA的检出率为81.0%(51/63),病变直径大于1cm且小于或等于2cm时,MRI的检出率为97.7%(43/44),肝动脉DSA的检出率为93.2%(41/44)。结论:肝动脉DSA与MRI动态钆喷酸葡胺增强对肝细胞癌微小病变的检出均具有较高的诊断价值,肝动脉DSA对于富血供型微小病变的检出明显优于MRI动态钆喷酸葡胺增强检查,而且肝动脉DSA可进行后续的栓塞化疗术,对于肝细胞癌的精准分期及预后具有重要的临床意义。第二部分肝动脉DSA与MRI动态钆喷酸葡胺增强对肝细胞癌巴塞罗那分期的应用价值研究目的:探讨肝动脉DSA与MRI动态钆喷酸葡胺增强对肝细胞癌巴塞罗那分期的应用价值。材料与方法:同第一部分。通过CT检查评估为BCLC-A期,其他检查未发现而临床高度怀疑或者其他检查显示出肝脏内单发或多发病变中包含有微小病灶(即直径≤2cm)的病例,术前同时行肝动脉DSA及MRI动态钆喷酸葡胺增强检查。结果:经卡方检验,肝动脉DSA与MRI动态钆喷酸葡胺增强检查结果分期相同115例,MRI动态钆喷酸葡胺增强分期之后经肝动脉DSA检查发现分期改变有62例,改变分期的占总的达33.3%(62/186),肝动脉DSA分期之后经MRI动态钆喷酸葡胺增强检查发现分期改变有9例,改变分期的占总的达4.8%(9/186),肝动脉DSA对巴塞罗那分期的判断显著优于MRI动态钆喷酸葡胺增强检查,差异有统计学意义(P=0.03)。结论:肝动脉DSA在肝细胞癌巴塞罗那分期应用方面优于MRI动态钆喷酸葡胺增强检查。第三部分肝动脉DSA与MRI动态钆喷酸葡胺增强对肝细胞癌微小病变检出的成本效果分析目的:建立肝细胞癌微小病变检出的卫生经济学评价模型。方法:根据肝动脉DSA与MRI动态钆喷酸葡胺增强检查方法,分为肝动脉DSA诊断组和MRI动态钆喷酸葡胺增强诊断组。收集两组治疗方案直接医疗成本,统计两组的检出率,对两组进行成本效果分析、增量成本效果分析和敏感性分析。结果:肝动脉DSA诊断组的成本效果比为69.46元/%,MRI动态钆喷酸葡胺增强诊断组的成本效果比为22.24元/%,肝动脉DSA诊断组是MRI动态钆喷酸葡胺增强诊断组的3.1倍;以MRI动态钆喷酸葡胺增强诊断组为基础,增量成本效果比为293.8元/%,表示从MRI动态钆喷酸葡胺增强诊断方案改换为肝动脉DSA诊断方案,诊断灵敏度每增加1%,费用增加293.8元。本研究假设检查费、材料费及药物费下降10%,肝动脉DSA诊断组的成本效果比为62.55元/%,MRI动态钆喷酸葡胺增强诊断组的成本效果比为20.04元/%,肝动脉DSA诊断组仍是MRI动态钆喷酸葡胺增强诊断组的3.1倍;以MRI动态钆喷酸葡胺增强诊断组为基础,增量成本效果比为264.51元/%,表示从MRI动态钆喷酸葡胺增强诊断方案改换为肝动脉DSA诊断方案,诊断灵敏度每增加1%,费用增加264.51元。结论:从卫生经济学角度,肝细胞癌微小病变的检出,常规MRI检查可能是最优的检查方法。第四部分:肝动脉DSA与MRI钆塞酸二钠增强技术在肝细胞癌微小病变检出的前瞻性对比研究目的:对比分析肝动脉DSA与MRI钆塞酸二钠增强对肝细胞癌微小病变(直径≤2cm)的检出率,探讨两者的应用价值。材料与方法:前瞻性随机分析术前同时行肝动脉DSA与MRI钆塞酸二钠增强检查。年龄最小31岁,最大66岁,平均年龄49.6±8.9岁。MRI检查和肝动脉DSA检查间隔时间不超过2周。35例64个病灶经手术切除证实,2例3个病灶由病理穿刺活检证实,5例10个病灶经肝动脉化疗栓塞术后碘油沉积并术后实验室检查和影像学随访证实。采用SPSS 16.0软件包行Mc Nmar检验、Kappa一致性检验、独立样本t检验和受试者运行特征曲线分析对两组进行统计学分析。结果:共42例77个病灶,其中42个病灶直径≤1cm,35个病灶直径1cm;肝动脉DSA共检出67个微小病灶,均为富血供型;MRI钆塞酸二钠增强共检出72个微小病灶。肝动脉DSA、MRI钆塞酸二钠增强的检出率分别为87.0%、93.5%,Mc Nmar检验P=0.0620.05,Kappa值为0.635,P0.05,两种方法一致性较好。乏血供型微小病变中,肝动脉DSA检出率为0%,MRI的检出率为70%。Fisher’s精确概率检验结果显示P=0.0160.05。MRI钆塞酸二钠增强检出病变的最小直径约为0.4cm,肝动脉DSA检出病变的最小直径约为0.5cm。病变直径≤1 cm时,肝动脉DSA的检出率为76.2%(32/42),MRI钆塞酸二钠增强的检出率为88.1%(37/42),两者之间的差异不具有统计学意义;病变直径1cm又≤2cm时,肝动脉DSA与MRI钆塞酸二钠增强的检出率均为100%。结论:肝动脉DSA与MRI钆塞酸二钠增强对肝细胞癌微小病变的检出率差别不具有统计学意义,具有较好的一致性;MRI钆塞酸二钠增强对乏血供型微小病变的检出率显著优于肝动脉DSA检查。从不同的禁忌症和后续治疗等方面进行科学的合理的选择微小病变的检出方法,不仅有助于肝细胞癌精准分期,为患者治疗和预后提供最有价值的信息,而且还可以为病人避免不必要的检查所带来的痛苦。第五部分:前瞻性随机对照肝动脉DSA与MRI钆塞酸二钠动态增强对肝癌微小病变检出研究目的:随机对比分析肝动脉DSA与MRI钆塞酸二钠增强对肝细胞癌微小病变(直径≤2cm)的检出率,探讨两者的应用价值。材料与方法:前瞻性随机收集术前行MRI动态钆塞酸二钠增强或肝动脉DSA检查。MRI动态钆塞酸二钠增强123例,其中男108例,女15例;年龄最小20岁,最大81岁,平均年龄50.5±12.5岁,103例133个微小病灶经手术切除证实,9例24个微小病灶经肝动脉化疗栓塞(TACE)术后碘油沉积并术后实验室检查和影像学随访证实,11例34个微小病灶经临床处理影像学随访验证。肝动脉DSA检查共66例,其中男56例,女10例。年龄最小27岁,最大78岁,平均年龄50.5±10.6岁。手术切除34例共44个微小病灶,TACE术29例共63个微小病灶,3个10个微小病灶经临床和影像学随访证实。采用SPSS16.0软件包行卡方检验对两组进行统计学分析。结果:肝动脉DSA、MRI钆塞酸二钠增强对微小病灶的检出率分别为91.5%、89.5%。两者检出率经卡方检验,χ2=0.29(p=0.59),差异不具有统计学意义。病变直径≤1cm时,肝动脉DSA的检出率为75.8%,MRI钆塞酸二钠增强的检出率为64.9%,卡方检验χ2=1.147(p=0.284),两者之间的差异不具有统计学意义;病变直径1cm时,MRI钆塞酸二钠增强的检出率为100%。结论:肝动脉DSA与MRI钆塞酸二钠增强对肝癌微小病变的检出率差别不具有统计学意义,从肝动脉DSA与MRI钆塞酸二钠增强所提供的信息不同而选取较优的检查方法,在精准分期的同时,又可以减轻患者不必要检查所带来的痛苦。
[Abstract]:The first part: the prospective comparative study of hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine enhancement in the detection of small lesions of hepatocellular carcinoma: comparison of digital subtraction angiography (DSA) and magnetic resonance imaging (magnetic resonance imaging, MRI) dynamic gadolinium enhanced gadolinium acid (gadolinium chloride) enhanced microlesions of hepatocellular carcinoma Diagnostic value of detection rate of diameter less than 2cm). Materials and methods: prospective analysis our hospital conforms to the standard of entry group. Other tests show that the liver artery DSA and MRI dynamic gadolinium enhanced gadolinium enhancement examination were performed within two weeks before the operation of single or multiple lesions in the liver. The minimum age was 25 years and the maximum was 75 years old. 88 lesions of the median age of 51 years were confirmed by surgical excision. 3 cases of 4 lesions were confirmed by pathological biopsy. 7 cases of 15 lesions were deposited after hepatic arterial chemoembolization and confirmed by laboratory examination and imaging follow-up. The detection rate of DSA and MRI dynamic gadolinium enhanced by DSA and MRI was Mc Nma R chi square test, Kappa consistency test, independent sample t test and subject running characteristic curve analysis of the size of hepatic artery DSA and MRI dynamic gadolinium gadolinium acid meglumine enhanced microlesion diameter of hepatocellular carcinoma detected by MRI. Results: 57 cases of 107 small lesions, 63 of which were straight diameter less than 1cm, 1cm in diameter of 44 lesions, 91 of rich blood donors. There were 16 blood supply types and 44 envelope signs. There were 92 DSA in the hepatic artery, of which 1 were used for blood supply, 76 were MRI, 6 of the donor blood supply, DSA of the hepatic artery, and 86% (92/107), 71% (76/107), Mc Nmar test fruit P0.05 and Kappa value 0.303 (P=0.001). The difference was significant. The difference of blood supply was significant. The detection rate of MRI dynamic gadolinium enhanced meglumine was 37.5% (6/16), and the detection rate of DSA in hepatic artery was 0.1% (1/16). The exact probability of Fisher 's showed that the detection rate of MRI was 52.4% (33/63) when the diameter of P0.05. small lesion was less than 1cm. The detection rate of hepatic artery DSA was 81% (51/63), and the lesion diameter was larger than or equal to that of the 1cm. The rate of extraction was 97.7% (43/44) and the detection rate of hepatic artery DSA was 93.2% (41/44). Conclusion: both hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine have a high diagnostic value for the detection of micropathological changes of hepatocellular carcinoma. The detection of DSA in hepatic artery for blood donor microlesions is superior to MRI dynamic gadolinium acid gadolinium enhanced examination, and hepatic artery DSA Follow-up embolization chemotherapy is of great clinical significance for the accurate staging and prognosis of hepatocellular carcinoma. Second the application value of the second part of the hepatic artery DSA and MRI dynamic gadolinium acid gadolinium enhancement in the Barcelona staging of hepatocellular carcinoma: To explore the enhancement of hepatic artery DSA and MRI dynamic gadolinium acid glucosamine to the Barcelona of hepatocellular carcinoma The application value of the staging. Materials and methods: with the first part. The CT examination was evaluated for the BCLC-A phase, other examinations were not found and the clinical highly suspected or other examination showed that there were small lesions (that is, diameter less than 2cm) in the single or multiple lesions of the liver, and the hepatic artery DSA and MRI dynamic gadolinium acid glucoamine increased before the operation. Results: after the chi square test, 115 cases of the hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine enhanced examination were in the same staging. After the MRI dynamic gadolinium gadolinium enhanced staging, 62 cases were found to be changed by the hepatic artery DSA examination. The changes of the stages were 33.3% (62/186), and the DSA staging of the hepatic artery was enhanced by MRI dynamic gadolinium acid gadolinium enhancement. It was found that 9 cases were changed by staging and 4.8% (9/186) were changed by stage. The judgment of hepatic artery DSA to Barcelona staging was significantly better than that of MRI dynamic gadolinium acid gadolinium enhanced examination. The difference was statistically significant (P=0.03). Conclusion: hepatic artery DSA is superior to MRI dynamic gadolinium acid gadolinium enhancement examination in the application of hepatic artery DSA The cost-effectiveness analysis of the third partial hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine in detection of microlesions of hepatocellular carcinoma: Objective: to establish a health economic evaluation model for the detection of microlesions of hepatocellular carcinoma. Methods: Based on the enhanced examination of DSA and MRI dynamic gadolinium acid meglumine, the hepatic artery DSA diagnosis group and the MRI dynamics were divided. The diagnostic unit of gadolinium acid meglumine was collected. The cost of direct medical treatment in two groups was collected, the detection rate of two groups was counted, the cost effect analysis, the incremental cost effect analysis and sensitivity analysis were carried out in the two groups. The result: the cost effect ratio of the DSA diagnosis group of the hepatic artery was 69.46 yuan /%, and the cost effect ratio of the MRI dynamic gadolinium acid glucoacid enhanced diagnosis group was 22. 24 yuan /%, the DSA diagnosis group of the hepatic artery was 3.1 times that of the MRI dynamic gadolinium acid gadolinium enhanced diagnostic group; based on the MRI dynamic gadolinium acid gadolinium enhanced diagnostic group, the incremental cost effect ratio was 293.8 yuan /%, indicating that the MRI dynamic gadolinium enhanced diagnostic scheme was changed to the DSA diagnosis of the hepatic artery, the diagnostic sensitivity increased by 1%, and the cost increased 293.8 This study assumed that the examination fee, material fee and drug charge decreased by 10%, the cost effect of the DSA diagnosis group of the hepatic artery was 62.55 yuan /%, the cost effect of the MRI dynamic gadolinium acid gadolinium enhanced diagnostic group was 20.04 yuan /%, the DSA diagnosis group of the hepatic artery was 3.1 times more than that of the MRI dynamic gadolinium acid gadolinium acid glucosamine enhanced diagnosis group; and the diagnosis of MRI dynamic gadolinium acid glucoamine enhanced diagnosis. On the basis of the group, the incremental cost effect ratio was 264.51 yuan /%, indicating that the MRI dynamic gadolinium acid gadolinium enhanced diagnostic scheme was changed to the DSA diagnosis of hepatic artery, the diagnostic sensitivity increased by 1% and the cost increased by 264.51 yuan. Conclusion: from the point of view of health economics, the detection of small lesions of hepatocellular carcinoma and routine MRI examination may be the best method of examination. The four part: the prospective comparative study of hepatic artery DSA and MRI gadolinium acid sodium enhanced technique in detection of small lesions in hepatocellular carcinoma Objective: To compare and analyze the detection rate of hepatic artery DSA and MRI gadolinium two sodium increased to small lesions of hepatocellular carcinoma (diameter less than 2cm) and to explore the application value of both. The DSA and MRI gadolinium two sodium enhanced examination. The age was 31 years old, the maximum was 66 years old, the average age was 49.6 + 8.9 years old.MRI examination and the interval time of DSA examination of the hepatic artery was not more than 2 weeks. 64 lesions were confirmed by surgical excision. 2 cases of 3 lesions were confirmed by pathological biopsy, 5 cases of 10 lesions were treated with iodide after transcatheter arterial chemoembolization. SPSS 16 software package Mc Nmar test, Kappa conformance test, independent sample t test and operation characteristic curve analysis were used to analyze two groups with statistical analysis. Results: there were 42 cases of 77 lesions, of which 42 lesions were straight diameter less than 1cm, and 35 lesions were 1cm in diameter; the hepatic artery DSA was detected altogether. 67 small lesions were both rich in blood supply and 72 small lesions were detected by MRI gadolinium two sodium enhancement. The detection rates of liver artery DSA, MRI gadolinium two sodium enhancement were 87%, 93.5%, Mc Nmar test P=0.0620.05, Kappa value 0.635, P0.05, and good consistency of the two methods. The detection rate of hepatic artery DSA was 0%, MRI detection was 0%. The result of 70%.Fisher 's accurate probability test showed that the minimum diameter of P=0.0160.05.MRI gadolinium acid two sodium enhanced detection was about 0.4cm. The detection rate of hepatic artery DSA was 76.2% (32/42), and the detection rate of MRI gadolinium two sodium enhanced by DSA was 88.1% (37/42), two The difference between the 1cm and the MRI gadolinium acid two of the hepatic artery was 100%. conclusion: the contrast between the hepatic artery DSA and the MRI gadolinium two sodium enhanced the detection rate of the microlesions of the hepatocellular carcinoma was not statistically significant, with a better consistency, and the enhancement of MRI gadolinium acid two sodium was enhanced. The detection rate of blood donor micro lesions is significantly better than that of the hepatic artery DSA. The scientific and rational selection of small lesions from different contraindications and follow-up treatments will not only help the accurate staging of hepatocellular carcinoma, provide the most valuable information for the treatment and prognosis of the patients, but also avoid the patients. The pain caused by necessary examination. The fifth part: the objective of a prospective randomized controlled randomized controlled hepatic artery DSA and MRI gadolinium two sodium dynamic enhancement for the detection of micropathological changes in liver cancer: a randomized comparative analysis of the detection rates of hepatic artery DSA and MRI gadolinium two sodium (diameter < < 2cm) for hepatocellular carcinoma (diameter less than 2cm), and to explore the application value of the two. And methods: before prospective randomized collection, 123 cases of MRI dynamic gadolinium acid two sodium enhancement or hepatic artery DSA examination of.MRI dynamic gadolinium two were enhanced, including 108 males and 15 women; the minimum age 20 years old, the maximum age of 81, the average age 50.5 + 12.5 years old, 103 cases of 133 micro lesions confirmed by hand operation, 9 cases of 24 small lesions via the hepatic artery chemotherapeutic embolus After TACE, the deposition of iodide oil and postoperative laboratory examination and imaging follow-up confirmed that 11 cases of 34 tiny lesions were followed up and verified by clinical imaging. 66 cases of hepatic artery DSA were examined, including 56 males and 10 females. The age was 27 years old, the maximum age was 78 years, and the average age was 50.5 + 10.6 years. 34 cases were excised and 34 cases altogether 44 minor lesions, 29 cases 63 in TACE operation 63. 3 10 tiny lesions were followed up by clinical and imaging follow-up. The two groups were analyzed statistically with the SPSS16.0 software package test. Results: the detection rates of DSA and MRI gadolinium two in the liver were 91.5%, respectively. The detection rates of 89.5%. were examined by chi square test and 2=0.29 (p=0.59), and the difference was not of the series. When the lesion diameter was less than 1cm, the detection rate of hepatic artery DSA was 75.8%, the detection rate of MRI gadolinium two sodium enhancement was 64.9%, chi square test Chi 2=1.147 (p=0.284), the difference between the two was not statistically significant; when the diameter of the lesion was 1cm, the detection rate of MRI gadolinium two sodium enhancement was 100%. conclusion: hepatic artery DSA and MRI gadolinium two sodium enhancement The difference in detection rate of small lesions of liver cancer is not statistically significant. A better method is selected from the information provided by the enhancement of the hepatic artery DSA and the information provided by the MRI gadolinium acid two sodium. It can also reduce the pain caused by the unnecessary examination of the patient at the same time.

【学位授予单位】：广西医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R735.7

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