动态三维超声造影评价肝癌射频消融术疗效的价值

doi:10.3877/cma.j.issn.1672-6448.2017.03.007

目的

探讨动态三维超声造影（3D-CEUS）评价肝癌射频消融术疗效的价值。

方法

选择2012年9月至2014年1月中南大学湘雅医院收治的肝癌患者48例共48个病灶。其中30例患者经手术后病理确诊，18例患者经临床诊断。所有患者均行射频消融术。所有患者射频消融术后1个月、3个月行二维超声造影（2D-CEUS）、动态3D-CEUS评价疗效，并与增强CT或磁共振成像（MRI）检查结果进行比较。以活检病理或2种以上影像学检查（超声检查、CT、MRI、PET）、肿瘤标志物水平、患者3个月以上随访结果综合判断的最终诊断结果作为金标准，分别计算CEUS、增强CT或MRI诊断肿瘤灭活的敏感度、特异度、准确性。

结果

射频消融术后，本组48例患者48个病灶中，75.0%（36/48）的病灶应用动态3D-CEUS后能得到更多有价值的信息，有助于操作者评估射频消融术疗效；25.0%（12/48）的病灶应用动态3D-CEUS与应用2D-CEUS相比，对临床结果的影响没有明显差别，动态3D-CEUS没有改变任何一个病灶的诊断或者临床治疗方案。2D-CEUS及动态3D-CEUS显示40个病灶消融区域无增强，提示肿瘤完全消融；8个病灶边缘部分呈结节样不规则高增强，提示肿瘤部分残存。增强CT或MRI示39个病灶消融区域无增强，提示肿瘤完全消融；9个病灶边缘可见不规则强化，提示肿瘤部分残存。CEUS、增强CT或MRI诊断射频消融术后肿瘤灭活的敏感度、特异度、准确性分别为80.0%、100%、95.8%和80.0%、97.4%、93.8%。

结论

动态3D-CEUS在评价射频治疗疗效方面，与2D-CEUS及增强CT或MRI无明显差异，但动态3D-CEUS能提供更多有价值的信息，在评估肝癌射频消融术疗效中具有潜在的价值。

关键词: 肝肿瘤, 超声检查, 造影剂, 消融技术, 治疗结果

Objective

To investigate the value of dynamic three-dimensional contrast-enhanced ultrasound (3D-CEUS) in evaluating therapeutic response of hepatoma treated with radiofrequency ablation (RFA).

Methods

Totally 48 cases of patients with hepatic carcinoma (48 lesions) admitted in Xiangya Hospital of Central South University from September 2012 to January 2014 were selected. All patients underwent radiofrequency ablation, of which 30 patients were diagnosed by pathology after surgery, 18 patients by clinical diagnosis. All patients underwent two-dimensional contrast-enhanced ultrasound (2D-CEUS) and 3D-CEUS 1 month and 3 months after RFA treatment to evaluate the therapeutic response, and the results of contrast-enhanced ultrasound and enhanced computed tomography (CT) [or magnetic resonance imaging (MRI)] were compared . The final diagnostic results of pathologic biopsy or more than two imaging examinations [ultrasonography, CT, MRI, positron emission tomography (PET)], tumor markers, and more than 3 months follow-up of patients were used as the gold standard. The sensitivity, specificity and accuracy of dynamic 3D-CEUS, 2D-CEUS, enhanced CT (or MRI) in the diagnosis of tumor inactivation were calculated respectively.

Results

After radiofrequency ablation, dynamic 3D-CEUS could provide more valuable information in 75.0% (36/48) lesions, which contribute to assess the efficacy of radiofrequency ablation. While compared with 2D-CEUS, 3D-CEUS did not change the diagnosis or clinical management in 12 (25.0%) lesions. 40 of 48 lesions were found no-enhancement in entire CEUS procedure suggesting that the tumor completely inactivated, while 8 lesions showed local enhancement on the edge of lesion suggesting that part of the tumors were active. 39 of 48 lesions showed no-enhancement and other 9 with irregular enhancement on enhanced CT (or MRI). The sensitivity, specificity and accuracy of CEUS and enhanced CT (or MRI) in detection of residual tumor after radiofrequency ablation were 80.0%, 100%, 95.8% and 80.0%, 97.4%, 93.8%, respectively.

Conclusions

There was no statistical significance among 3D-CEUS, 2D-CEUS and enhanced CT or MRI in evaluating therapeutic response of hepatoma treated with radiofrequency ablation. But 3D-CEUS can provide more valuable information, 3D-CEUS has potential usefulness in the evaluation of percutaneous radiofrequency ablation of hepatic tumors..

Key words: Liver neoplasms, Ultrasonography, Contrast media, Ablation techniques, Treatment outcome

表1 CEUS与增强CT或MRI评价射频消融术后疗效（个）

检查方法		最终诊断		合计
检查方法		肿瘤部分残存	肿瘤灭活	合计
CEUS		?	?	?
?	肿瘤部分残存	8	0	8
?	肿瘤灭活	2	38	40
增强CT或MRI		?	?	?
?	肿瘤部分残存	8	1	9
?	肿瘤灭活	2	37	39

表1 CEUS与增强CT或MRI评价射频消融术后疗效（个）

检查方法		最终诊断		合计
检查方法		肿瘤部分残存	肿瘤灭活	合计
CEUS		?	?	?
?	肿瘤部分残存	8	0	8
?	肿瘤灭活	2	38	40
增强CT或MRI		?	?	?
?	肿瘤部分残存	8	1	9
?	肿瘤灭活	2	37	39

图1~3 肝癌射频消融术后，病灶完全消融，消融区形态规则。图1示消融区域二维超声造影动脉期，病灶呈无增强；图2示消融区域二维超声造影动脉期，病灶位于中心，呈无增强，被周边呈等增强的正常肝组织包围；图3示经3D颠倒处理后，"高增强"的病灶清晰显示，形态规则，周边正常组织呈"无增强"

图4~16 肝癌射频消融术后，病灶完全消融，消融区域形态不规则。图4、5示消融灶二维超声造影和三维超声造影动脉期；图6示增强CT动脉期；图7~16示消融灶经MPR技术处理后，可从不同层面连续观察消融灶的形态，并可精确计算消融灶体积

图17~21 肝癌射频术后，病灶部分残存。图17、18分别为二维超声造影和三维超声造影注射造影剂后22 s时，病灶边缘可见团状高增强，范围较小（箭头所示）；图19、20分别为二维超声造影和三维超声造影注射造影剂后25 s时，病灶边缘团状高增强区明显增大；图21示增强磁共振成像动脉期病灶边缘可见高增强区

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Value of dynamic three-dimensional contrast-enhanced ultrasonography in evaluating therapeutic response of hepatoma treated with radiofrequency ablation

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Value of dynamic three-dimensional contrast-enhanced ultrasonography in evaluating therapeutic response of hepatoma treated with radiofrequency ablation