超声造影在肝细胞肝癌血供分析及微波消融疗效评价中的应用

发布时间：2018-03-30 14:34

本文选题：超声造影　切入点：肝细胞肝癌　出处：《兰州大学》2017年硕士论文

【摘要】：目的:联合常规超声和超声造影重点观察肝癌病灶数目、形态、大小、血供等情况,了解患者基本状况、指导微波消融治疗并评价肿瘤消融的情况。方法:回顾性分析2014年11月至2016年12月期间在我院行超声引导下微波消融和门静脉穿刺灌注化疗药物的45例肝细胞肝癌患者的临床资料,所有患者均经两种以上影像学诊断和穿刺活检病理确诊,其中男性32例,女性13例,年龄31~79岁,平均(54±6.08)岁。37例患者患有慢性病毒性肝炎,31例合并肝硬化,乙肝病毒标记物阳性的30例,丙肝病毒标记物阳性的7例,1例为自身免疫性肝炎;12例患者合并高血压,3例患有糖尿病。所有患者介入治疗术前均行超声造影和增强核磁(CE-MRI)检查,了解肿块的数目、大小、位置、形态、内部回声、彩色血流及周边有无重要脏器或大血管,掌握病灶滋养血管及其分支的情况、患者肝状况及余肝内有无卫星病灶等。45例患者经超声造影和CE-MRI检查共检出53个病灶。超声引导下门静脉穿刺灌注化疗药物和微波消融术后约15-20分钟(微波消融强回声气泡消失散尽),所有患者均做超声造影评估肿瘤消融程度,对消融不完全部位及时补充治疗,条件不允许者择期行补充治疗。术后1-12月内按手术后复查要求做超声造影、CE-MRI以及临床综合检查,评价肝细胞肝癌介入治疗的效果。超声造影检查提示消融完全表现为:病灶整体无造影剂灌注;消融不完全表现为:病灶内部或边缘动脉期仍有斑片状增强区,门静脉期及延迟期有快速退出表现。CE-MRI检查提示消融完全表现为:消融区内无增强,呈低信号;消融不完全者表现为:病灶残存部分动脉期程度不一的强化,延迟期消退呈低增强,呈快进快出表现。结果:1.48个原发性肝细胞肝癌病灶在超声造影上表现为典型的增强模式:动脉期呈高增强,门静脉期或延迟期消退为低增强,表现为“灯泡样快进快出”的特点;4个直径小于2cm的小肝癌病灶在动脉期呈高增强,门静脉期或延迟期消退不明显,表现为等增强。2.术前检查中,45例患者由常规超声检测出病灶结节个数为46个,超声造影检出52个,CE-MRI检出53个,在筛查肝癌病灶个数方面,常规超声与超声造影比较差异有统计学意义(X2=4.867,P=0.027,p0.05),超声造影与CE-MRI比较差异无统计学意义(X2=1.010,P=0.315,p0.05)。微波消融治疗前后病灶范围的测量:肝内结节微波消融术前,超声造影测得其长径和短径均值分别为3.01±1.05、2.60±1.22,消融术后分别为4.40±1.61、4.20±1.23;CE-MRI术前测得长径和短径均值分别为3.06±1.08、2.30±1.19,消融术后分别为5.00±1.89、4.00±1.21,在病灶范围测量方面,超声造影与CE-MRI比较差异无统计学意义(P0.0.5)。3.53个微波消融病灶,术后即刻做超声造影,46个病灶显示消融完全;7个病灶内部或周围动脉期显示为不规则的高增强区,门静脉期或延迟期有快速退出表现,提示其微波消融不彻底;补充消融后再次复查CE-US,显示消融完全。4.经过补充消融的7个病灶,其中有2例患者CE-MRI提示病灶边缘结节影在动脉期表现为程度不一强化,延迟期廓清,提示有肿瘤残存,融合成像定点后行穿刺活检证实有肿瘤残存,限期内给予再次消融术;余51个病灶均提示消融完全。5.超声造影和CE-MRI均提示消融完全的51个病灶中,有2例患者(均为单发灶)在后期随访过程中血清AFP不降、反而持续高于200μg/L,术后1-2月内复查CE-MRI提示病灶有残留,融合成像定点后行穿刺活检证实有肿瘤残存。最终诊断:49个病灶消融彻底,4个有局部肿瘤残存。超声造影提示53个病灶均消融完全;CE-MRI提示51个病灶消融完全,2个病灶有残存。采用配对四格表资料的kappa系数检验结果(k=1.00,P0.05),证明在肝癌微波消融术后评价中,超声造影与CE-MRI比较无统计学差异。结论:对于肝内癌灶进行微波消融治疗成功的关键就是整个肿瘤被完全灭活,因此消融后对于目标肿瘤的灭活程度的判断就显得非常重要。而超声造影不仅能鉴别肝内病灶的良恶性,而且能清晰显示出病灶浸润范围,以及与周围大血管及重要脏器的关系,尤其是肿瘤滋养血管进入肿瘤的具体位置及其分支分布情况;能指导微波消融进针方向及消融范围,还可以判断病灶的消融程度。与CE-MRI相比,既对患者要求低、操作简单、价格低廉,又能在短时间内反复多次检查,是评价肝癌介入治疗疗效的有效方法。
[Abstract]:Objective: combined conventional ultrasound and contrast-enhanced ultrasound observation on HCC lesions number, morphology, size, blood supply and so on, to understand the basic status of the patients, guided microwave ablation therapy and evaluation of tumor ablation. Methods: a retrospective analysis of clinical data during the period from November 2014 to December 2016 to guide 45 cases of patients with hepatocellular carcinoma and portal vein puncture under microwave ablation chemotherapy in our hospital underwent ultrasound. All patients were treated more than two kinds of imaging diagnosis and biopsy were diagnosed, including 32 cases of male, female 13 cases, age 31~79 years old, average age (54 + 6.08).37 patients with chronic viral hepatitis, 31 cases of cirrhosis, 30 cases of hepatitis B virus marker positive, HCV markers positive in 7 cases, 1 cases of autoimmune hepatitis; 12 cases of patients with hypertension, 3 cases with diabetes treatment intervention. All patients underwent contrast-enhanced ultrasound And enhanced magnetic resonance (CE-MRI) examination, understand the mass number, size, position, shape, internal echo, color flow and surrounding the availability of important organs or blood vessels, vessels and branches of the master lesions, liver and liver than patients with no satellite lesions in.45 patients by ultrasound and CE-MRI examination there were 53 lesions. Ultrasound guided portal vein infusion chemotherapy and microwave ablation for about 15-20 minutes (microwave ablation of strong echo bubbles disappear cleared), all patients underwent contrast-enhanced ultrasonography in evaluating the extent of tumor ablation, ablation incomplete parts timely supplementary treatment, the conditions do not allow those undergoing replacement therapy after operation. 1-12 months after surgery according to review requirements of contrast-enhanced ultrasound, CE-MRI and clinical examination, evaluate the curative effect of hepatocellular carcinoma. Interventional ultrasound examination showed complete ablation tip lesions integral Contrast perfusion ablation; incomplete performance: internal lesions or the edge of the arterial phase is still patchy enhancement, portal venous phase and delayed phase of rapid exit.CE-MRI examination showed complete ablation performance: the ablation area increased, showed low signal; incomplete ablation was performed: lesions remaining part of the arterial phase enhancement the level of delay period, regression showed low enhancement, a fast performance. Results: 1.48 hepatocellular carcinoma lesions in CEUS for the typical enhancement pattern: high enhanced in arterial phase, portal venous phase and delayed phase fade to low enhancement, featuring "bulb like fast forward fast"; high enhancement 4 smaller than 2cm in diameter in HCC lesions in arterial phase, portal venous phase and delayed phase was obvious, such as enhanced.2. examination before operation, 45 patients by conventional ultrasound detected number of nodules was 46, Ultrasound detected 52, CE-MRI detected 53, the number of screening HCC lesions, statistically significant differences between conventional ultrasound and contrast-enhanced ultrasound (X2=4.867, P=0.027, P0.05), there was no significant difference compared with CE-MRI ultrasound (X2=1.010, P=0.315, P0.05). The measurement of microwave ablation of liver lesions before and after range. Nodules before microwave ablation, ultrasound measured the long diameter and short diameter was 3.01 + 1.05,2.60 + 1.22, after ablation were 4.40 + 1.61,4.20 + 1.23; CE-MRI preoperative measured long diameter and short diameter was 3.06 + 1.08,2.30 + 1.19, after ablation was 5 + 1.89,4.00 + 1.21. In the measuring range of lesions, there was no significant difference between CE-MRI and contrast-enhanced ultrasound (P0.0.5).3.53 microwave ablation lesions, surgery done immediately after contrast-enhanced ultrasound, 46 lesions showed complete ablation; 7 lesions inside or around the arterial phase significantly Shows the high enhanced area of irregular, portal venous phase and delayed phase exit fast, suggesting that the microwave ablation is not complete; ablation again after review of CE-US,.4. showed 7 lesions after ablation of ablation, including 2 cases of patients with CE-MRI suggests that the lesion edge nodules in the arterial phase showed no degree a delayed phase enhancement, dissection, suggestive of tumor remnants, fusion imaging underwent biopsy confirmed a point within the residual tumor, giving more than once again ablation; 51 lesions showed complete ablation of.5. ultrasound contrast and CE-MRI showed 51 lesions in complete ablation, 2 patients (were solitary lesion) in the late in the follow-up of serum AFP did not fall, but continued higher than 200 g/L, after 1-2 months of CE-MRI suggest that the lesions have residues, designated after fusion imaging biopsy confirmed tumor remnants. The final diagnosis: 49 lesion ablation penetration At the end of 4, a local residual tumor. Ultrasonic angiography showed that 53 lesions were ablated completely; 51 CE-MRI showed that the lesion ablation completely, 2 lesions remained. Four paired data table kappa coefficient test results (k=1.00, P0.05), proved in hepatocellular carcinoma after microwave ablation evaluation, no significant differences between ultrasound angiography and CE-MRI. Conclusion: the liver cancer by microwave ablation is the key to successful treatment of the tumor was completely inactivated, so after ablation of tumor target for judging the extent of inactivation is very important. Ultrasound can not only distinguish the benign and malignant hepatic lesions, and can clearly show the range of tumor invasion well, with large blood vessels and vital organs, especially the specific location and distribution of tumor vessels into the tumor; can guide the microwave ablation needle direction and ablation range, can also be The degree of ablation of the lesion is judged. Compared with CE-MRI, it is not only a low requirement for patients, simple operation, low cost, but also can be repeated many times in a short time. It is an effective method to evaluate the efficacy of interventional therapy for hepatocellular carcinoma.

【学位授予单位】：兰州大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.7;R445.1

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