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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2017, Vol. 14 ›› Issue (04) : 297 -301. doi: 10.3877/cma.j.issn.1672-6448.2017.04.012

所属专题： 文献；

腹部超声影像学

常规二维超声联合超声造影对肝硬化背景肝内结节分类及临床应用价值
黄斌1,†(), 孙希希1, 荀运浩1, 刘芳1, 刘德林1, 孔梓祥1   
  1. 1. 310023　浙江中医药大学附属杭州西溪医院　杭州市西溪医院超声科
  • 收稿日期:2017-02-27 出版日期:2017-04-01
  • 通信作者: 黄斌
  • 基金资助:
    浙江省自然科学基金(LY13H180015); 杭州市科技局重点专病专科项目(20160533B53)

Clinical value and classification of two dimensional ultrasonography combined with contrast-enhanced ultrasonography in cirrhotic paitients with intrahepatic nodules

Bin Huang1,†(), Xixi Sun1, Yunhao Xun1, Fang Liu1, Delin Liu1, Zixiang Kong1   

  1. 1. Department of Ultrasonography, Xixi Hospital of Hangzhou, Hangzhou 310023, China
  • Received:2017-02-27 Published:2017-04-01
  • Corresponding author: Bin Huang
  • About author:
    Corresponding author: Huang Bin, Email:
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引用本文：

黄斌, 孙希希, 荀运浩, 刘芳, 刘德林, 孔梓祥. 常规二维超声联合超声造影对肝硬化背景肝内结节分类及临床应用价值[J]. 中华医学超声杂志（电子版）, 2017, 14(04): 297-301.

Bin Huang, Xixi Sun, Yunhao Xun, Fang Liu, Delin Liu, Zixiang Kong. Clinical value and classification of two dimensional ultrasonography combined with contrast-enhanced ultrasonography in cirrhotic paitients with intrahepatic nodules[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2017, 14(04): 297-301.

目的

采用常规二维超声联合超声造影对肝硬化背景肝内结节分类并进行评估。

方法

选取2015年11月至2016年12月浙江中医药大学附属杭州西溪医院行常规磁共振成像、CT检查无恶性肿瘤典型影像学特征的109例肝硬化患者，共142个肝内结节。所有患者均经超声引导下穿刺活检病理证实。所有患者均行常规二维超声和超声造影检查。评估内容包括：（1）结节大小；（2）结节回声是否均匀；（3）超声造影动脉期增强模式。根据肝硬化背景肝内结节常规二维超声表现和超声造影增强模式，进一步将肝硬化背景肝内结节分为Ⅰ、Ⅱ、Ⅲ、Ⅳ4类。采用χ2检验比较不同大小、超声造影不同增强模式肝硬化背景肝内结节肝细胞癌（HCC）检出率的差异；采用χ2检验比较Ⅲ、Ⅳ类结节与Ⅰ、Ⅱ类结节HCC检出率、高级别不典型增生结节（HGDN）检出率差异。

结果

本组142个结节中，HCC16个、肝内胆管细胞癌（ICC）2个、HGDN41个、低级别不典型增生结节（LGDN）40个和再生结节（RN）43个。直径>2.0 cm结节6个，均为HCC；1.5~2.0 cm结节40个，8个为HCC，28个为HGDN；1.0~1.4 cm结节93个，其中HCC1个、ICC2个、HGDN13个；<1.0 cm结节3个，其中HCC1个；不同大小肝硬化背景肝内结节HCC检出率差异有统计学意义（χ2=61.425，P<0.001）。动脉期快速增强结节14个，12个为HCC；动脉期缓慢增强结节56个，4个为HCC；超声造影不同增强模式肝硬化背景肝内结节HCC检出率差异具有统计学意义（χ2=75.752，P<0.001）。Ⅲ、Ⅳ类结节HCC、HGDN检出率均高于Ⅰ、Ⅱ类结节[21.9%（16/73）vs 0（0/65），53.4%（39/73） vs 3.1%（2/65）]，且差异均有统计学意义（χ2=15.222、38.842，P均<0.001）。

结论

常规二维超声联合超声造影对肝硬化背景肝内结节进行分类对肝硬化背景上的原发性肝癌早期诊断有一定帮助。

关键词: 超声检查, 造影剂, 肝肿瘤
Objective

To evaluate the role of two-dimensional ultrasound combined with contrast-enhanced ultrasonography (CEUS) in the classification of liver nodules in cirrhotic patients.

Methods

Consecutively cirrhotic patients with intrahepatic nodules at Xixi Hospital of Hangzhou were included from November 2015 to December 2016. All (142 nodules in 109 patiens) presented as non-cancerous focal lesions on conventional magnetic resonance imaging and CT examination and had available information of liver biopsy. Each lesion was percutaneous biopsied under the guidance of two-dimensional ultrasound. Ultrasonographic parameters evaluated were as following: (1) sizes of nodules under US; (2) ultrasonographic characteristics of the nodular; (3) CEUS enhancement features of the nodules. Four types of hepatic nodule suggesting different histology were defined according to the ultrasonographic parameters. χ2 test was used to compare the difference of hepatocellular carcinoma (HCC) incidence among liver nodules with varying sizes and nodules with different enhancement features under CEUS. As for the statistical differences of HCC and high-grade dysplastic nodule (HGDN) incidence between type Ⅲ & Ⅳ nodules and type Ⅰ & Ⅱ nodules, χ2 test was also used for analysis.

Results

A total of 142 eligible nodules were detected in 109 patients with cirrhosis, including 16 HCCs, 2 intrahepatic cholangiocellular carcinomas (ICC), 41 HGDNs, 40 low-grade dysplastic nodules (LGDN) and 43 regenerative nodules (RN). In terms of diameter, all (6/6) the nodules larger than 2.0 cm, 20.0% (8/40) of middle size nodules (1.5-2.0 cm), were HCCs. The remained 2 lesions of HCC came from two subgroups with even small size nodules [1.0-1.4 cm (n=93), and <1.0 cm (n=3), in diameter], respectively. Two lesions of ICC were attributed to nodules with a 1.0-1.4 cm diameter. About 28 nodules with a diameter of 1.5-2.0 cm, 13 nodules with a diameter of 1.0-1.4 cm were HGDN. HCC incidences between these 4 groups were different significantly (χ2=61.425, P<0.001). As for the CEUS, 14 nodules exhibited a rapid enhancement feature in arterial phase, 12 of which were HCC. In 56 nodules with a slow enhancement feature, 4 nodules were HCC. HCC incidences between these 3 groups were different significantly (χ2=75.752, P<0.001). Under the combined ultrasonography, HCC incidences of type Ⅲ and type IV nodules were significantly higher than that of type Ⅰ and type Ⅱ lesions [21.9% (16/73) vs 0 (0/65), χ2=15.222, P<0.001], similar result was observed in the comparison of HGDN incidences between type Ⅲ & IV and type Ⅰ & Ⅱ nodules[53.4% (39/73) vs 3.1% (2/65), χ2=38.842, P<0.001].

Conclusion

The classification presented by this study, combining the three ultrasonographic parameters, which is nodule size, nodular echo characteristics and enhancement features of the nodules under CEUS, could be helpful for the diagnosis of HCC in cirrhotic patients with ill-defined nodule on routine image examination.

Key words: Ultrasonography, Contrast media, Liver neoplasms, Liver cirrhosis
表1 不同大小肝硬化背景肝内结节病理结果比较（个）
结节直径 个数 HCC ICC HGDN LGDN RN
<1.0 cm 3 1 0 0 0 2
1.0~1.4 cm 93 1 2 13 37 40
1.5~2.0 cm 40 8 0 28 3 1
>2.0 cm 6 6 0 0 0 0
合计 ? 16 2 41 40 43
表2 超声造影不同增强模式肝硬化背景肝内结节病理结果比较（个）
超声造影增强模式 个数 HCC ICC HGDN LGDN RN
快速增强 14 12 0 2 0 0
等增强 72 0 2 2 34 34
延迟增强 56 4 0 37 6 9
合计 ? 16 2 41 40 43
图3 病理检查提示肝细胞癌（HE，×400）。镜下见排列呈实性巢团状或梁索状的异型细胞，细胞板增厚，肝窦消失，血管纤维化，细胞核大而深染，胞质嗜双色或脂肪变性。免疫组化：HSP70（＋）Glypican-3（＋）CD34（血管＋）CK-7（-）Ki-67（10%＋）Arginase（＋）HBsAg（-）HepPar1（＋）
表3 基于常规二维超声和超声造影肝硬化背景肝内结节分类病理结果比较（个）
结节分类 个数 HCC ICC HGDN LGDN RN
Ⅰ类 2 0 0 0 0 2
Ⅱ类 63 0 0 2 29 32
Ⅲ类 57 4 0 37 11 9
Ⅳ类 16 12 2 2 0 0
合计 ? 16 2 41 40 43
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