超声造影对提高肝肿瘤穿刺活检诊断率的应用价值

Application of contrast-enhanced ultrasound to increase the diagnostic rate of liver tumor by biopsy

目的 探讨超声造影指导肝肿瘤经皮穿刺活检的临床应用价值。方法北京大学临床肿瘤学院超声科就诊的性质不明的211例肝占位病变随机分为两组，其中96例149灶应用超声造影剂SonoVue行超声造影后采用常规超声引导穿刺活检（CEUS组），115例153灶未行超声造影只采用超声引导穿刺活检（us组）。男129例、女82例；年龄16～81岁，平均53．4岁。两组病灶大小分布差异无统计学意义（P〉0．05）。其中≤2．0cm微小恶性肿瘤计67例75灶（24．8％），CEUS组、us组各占12．9％、11．9％。采用21～18G针手动抽吸活检针或自动活检针穿刺活检，取材量满足病理诊断为取材成功；活检病理诊断结果结合手术、增强CT、磁共振成像（MRI）、血管造影术、甲胎蛋白（AFP）检查或临床随访3～6个月等方法紧密随诊，分析对比两组穿刺活检结果。结果穿刺≤2次即获较满意标本者CEUS组明显多于US组（P=0．0007）。CEUS组149灶取材成功率为98．7％（n=147），确诊率为96．0％（n=143）；US组153灶分别为91．5％（n=140）、87．6％（n=134）（两组比较分别P=0．0096、P=0．0165），差异有统计学意义。≤2．0cm微小恶性肿瘤的确诊率CEUS组（97．4％）明显高于US组（80．6％，P：0．0473）。此外，US组恶性肿瘤112灶中15灶（13．4％）穿刺活检阴性，经超声造影指导再次活检，14个灶被确认恶性，其中7灶≤2．0cm。除US组发生1例气胸外，余无一例并发症。结论超声造影指导穿刺活检，有助于判断恶性病变及微小肿瘤，并确认坏死及液化区，使定位取材比常规超声更准确，从而大大提高了经皮穿刺活检的成功率和恶性病变的确诊率，明显降低穿刺活检的假阴性率，具有重要临床应用价值。

Objective To evaluate the clinical utility of contrast-enhanced ultrasound （CEUS） in percutaneous liver biopsy of focal liver lesions. Methods Two hundred and eleven patients with unidentified space occupying lesions in liver, 112 males and 74 females, aged 52 （16-78） , were randomly divided into 2 groups： CEUS group in which 96 cases with 149 lesions underwent liver biopsy with 21-18 gauge needles directed by real time grey CEUS, and routine ultrasound （US） group in which 115 patients with 153 lesions underwent biopsy guided by conventional ultrasonography. There was no significant difference in the size of lesions between these 2 groups. There were 75 minute malignant lesions with the size of ~〈2.0 cm （24.8%） in 67 patients, 12.9% in the CEUS group and 11.9% in the US group. Obtainment of adequate specimen for pathological examination meant successful biopsy. Definite diagnosis was made by the combination of the results of pathological examination, CEUS, CT, MRI, angiography, serum alpha-fetoprotein, and 3 to 6- month follow-up. Results The proportion of no more than 2 puncture attempts in the CEUS group was 33/ 19, significantly higher than that in the US group （8/153, P = 0. 0007）. The biopsy success rate of the CEUS group was 98.7% , significantly higher than that of the US group （91.5% , P = 0. 0096）. The accurate diagnosis rate of the CEUS group was 96. 0% , significantly higher than that of the US group （87.6% ,P =0.0165）. The accurate diagnosis rate of malignant lesions with the size of ≤2.0 cm in the CEUS group was 97.4% , significantly higher than that in the US group （80.6% , P = 0.0473）. Among the 112 confirmed malignant lesions in the US group 15 had been diagnosed as benign by pathological examination of the biopsy specimens with a false negative rate of 13.4%. The relevant patients underwent CEUS-guided biopsy again and 14 of the 15 lesions were confirmed as malignant finally and the size of 6 of the 14 lesions was ~〈2.0 cm. Except for one case of pneumothorax in the US group no major complication occurred. Conclusion Biopsy guided by CEUS is more accurate in location and diagnosis of malignant lesions and minute tumors in the liver, thus increasing the success rate of biopsy and the confirmed diagnosis rate of malignant lesions.