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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） ›› 2024, Vol. 21 ›› Issue (03) : 297 -303. doi: 10.3877/cma.j.issn.1672-6448.2024.03.008

腹部超声影像学

肝脏炎性假瘤的超声造影表现及其诊断价值
罗敏华1, 王文平2, 孔文韬1,†()   
  1. 1. 210009　南京，南京大学医学院附属鼓楼医院超声科
    2. 200032　上海，复旦大学附属中山医院超声科
  • 收稿日期:2023-03-29 出版日期:2024-03-01
  • 通信作者: 孔文韬
  • 基金资助:
    “十三五”南京市卫生青年人才培养工程资助项目(QRX17011)

Contrast-enhanced ultrasound findings of hepatic inflammatory pseudotumors and their diagnostic value

Minhua Luo1, Wenping Wang2, Wentao Kong1,†()   

  1. 1. Department of Ultrasound, Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing 210009, China
    2. Department of Ultrasound, Zhongshan Hospital, Fudan University, Shanghai 200032, China
  • Received:2023-03-29 Published:2024-03-01
  • Corresponding author: Wentao Kong
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罗敏华, 王文平, 孔文韬. 肝脏炎性假瘤的超声造影表现及其诊断价值[J]. 中华医学超声杂志（电子版）, 2024, 21(03): 297-303.

Minhua Luo, Wenping Wang, Wentao Kong. Contrast-enhanced ultrasound findings of hepatic inflammatory pseudotumors and their diagnostic value[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(03): 297-303.

目的

分析肝脏炎性假瘤的超声造影表现，并探讨超声造影对炎性假瘤的诊断价值。

方法

回顾性分析南京鼓楼医院和复旦大学附属中山医院自2012年12月至2022年12月76例经病理证实的肝脏炎性假瘤患者的临床及超声造影资料，总结其常规超声及超声造影的特点并评价其诊断准确率。

结果

76例肝脏占位超声造影动脉期可见5种增强模式：整体均匀增强（27.63%，21/76）、整体不均匀增强（26.32%，20/76）、周边环状增强（26.32%，20/76）、蜂窝状增强（14.47%，11/76）和三期无增强（5.26%，4/76）。强化程度为45例高增强，22例等增强，5例低增强，4例无增强。病灶在超声造影门脉期及延迟期呈低回声、混合回声、等回声和无回声的分别有55例、15例、2例、4例。所有病例的开始增强时间、达峰时间和廓清时间分别为15.0（13.0，19.3）s、22.0（19.8，26.3）s、35.0（30.0，50.0）s。有56例（73.68%）在注射造影剂后60 s内出现廓清，呈现“快进快退”模式，其中45例病灶在45 s内廓清。根据超声结果、临床表现及实验室检查，48例（63.16%）病灶被正确诊断为炎性假瘤，而其余28例被误诊为恶性肿瘤（30.26%，23/76）或诊断不确定（6.58%，5/76）。

结论

肝脏炎性假瘤在疾病进展过程中因病理不同而表现出多种强化模式，超声造影特征对其诊断具有一定的价值，同时需结合临床表现与实验室检查有助于提高诊断准确率。

关键词: 超声造影, 肝脏, 炎性假瘤, 增强模式, 鉴别诊断
Objective

To analyze the contrast-enhanced ultrasound (CEUS) findings of hepatic inflammatory pseudotumors (IPTs), and to assess their diagnostic value.

Methods

From December 2012 to December 2022, the clinical and contrast-enhanced ultrasound data of 76 patients with pathologically confirmed hepatic IPTs at Nanjing Drum Tower Hospital and Shanghai Zhongshan Hospital were retrospectively analyzed. The characteristics of conventional ultrasound (US) and contrast-enhanced ultrasound were summarized and their diagnostic accuracy was evaluated.

Results

Five enhancement patterns were observed in 76 liver nodules: homogeneous enhancement (n=21, 27.63%), heterogeneous enhancement (n=20, 26.32%), rim-like enhancement (n=20, 26.32%), honeycomb enhancement (n=11, 14.47%), and no enhancement during vascular phases (n=4, 5.26%). The degree of enhancement was hyper-enhancement in 45 cases, iso-enhancement in 22, hypo-enhancement in 5, and no enhancement in 4. The number of nodules that were hypoechoic, mixed, isoechoic, and anechoic in the portal and delayed phases was 55, 15, 2, and 4, respectively. The median initial enhancement time, time to peak, and wash-out time were 15.0 (13.0, 19.3) s, 22.0 (19.8, 26.3) s, and 35.0 (30.0, 50.0) s, respectively. Fifty-six nodules (73.68%) were hypoechoic within 60 s after contrast medium injection, showing a "quick wash-in and wash-out" pattern, and 45 nodules were hypoechoic within 45 s. Based on ultrasonography, clinical findings, and laboratory examination, 48 nodules (63.16%) were correctly diagnosed as IPTs, while the remaining 28 cases were misdiagnosed as malignancy (n=23, 30.26%) or had an uncertain diagnosis (n=5, 6.58%).

Conclusion

Hepatic IPTs show various enhancement patterns due to pathological changes during the progression of the disease. The features of CEUS have appreciated value in the diagnosis of IPT, and the combination of clinical manifestations and laboratory examination helps to improve the diagnosis coincidence rate.

Key words: Contrast-enhanced ultrasound, Liver, Inflammatory pseudotumor, Enhancement pattern, Differential diagnosis
图1 患者女性，34岁，发热10余天，超声发现肝占位。图a、b：二维超声示肝内多发低回声灶，边缘欠清，彩色多普勒超声示病灶周边可见条状血流信号。图c：超声造影示病灶动脉期呈整体均匀性增强，呈现快进快退造影特征。图d：增强MRI示病灶周边呈环形强化，图e：病理图（HE×200）示肝细胞灶状坏死伴嗜酸性粒细胞浸润，慢性炎症和肉芽肿形成
图2 患者女性，64岁，发热伴呕吐5 d，病理诊断慢性炎症细胞浸润及坏死。图a：二维超声示肝右叶不均质等回声病灶，边缘不清晰。图b：超声造影示病灶动脉期呈蜂窝状增强，内见散在不增强，在超声造影引导下穿刺活检。图c：增强CT示病灶呈不均匀强化，内见散在低密度无强化区。图d~f：磁共振平扫示肝内长T1长T2信号肿块，内见散在小囊状长T1长T2信号，弥散加权成像示肿块内小囊状影明显弥散受限
表1 2组肝脏炎性假瘤的二维超声和超声造影特征比较
超声特征 病灶≤3 cm组（31例） 病灶>3 cm组（45例） 统计值 P值
病灶回声（例） χ2=5.436 0.776
高回声 4 4
低回声 26 34
等回声 1 0
混合回声 0 7
边界（例） χ2=2.999 0.631
清晰 15 13
不清晰 16 32
内部回声（例） χ2=11.554 0.224
均匀 13 4
不均匀 18 41
动脉期增强模式（例） χ2=9.424 0.276
均匀增强 9 12
不均匀增强 5 15
环状增强 12 8
蜂窝状增强 2 9
无增强 3 1
强化后边界（例） χ2=0.440 0.197
清晰 5 10
不清晰 26 35
内部坏死（内部无增强区）（例） χ2=2.322 0.382
有 16 31
无 15 14
病灶的增强时间[s，M（QR）]
开始增强时间 18.0（13.3，20.0） 14.0（12.3，17.8） W=768.5 0.078
达峰时间 22.5（19.3，27.0） 22.0（19.3，26.0） W=623.0 0.940
开始廓清时间 35.0（28.5，50.0） 36.0（30.0，55.5） W=494.5 0.625
强化程度（例） χ2=3.853 0.053
高 20 25
等 6 16
低 2 3
无 3 1
门脉期延迟期呈低回声（例） χ2=8.955 0.276
是 22 33
否 9 12
快进快退（例） χ2=0.505 0.342
是 22 34
否 9 11
诊断结果（例） χ2=0.099 0.066
炎性假瘤 19 29
恶性肿瘤 10 13
不确定 2 3
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