多模态影像融合技术在肝内胆管癌诊断与治疗中的应用价值

Application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma

目的探讨多模态影像融合技术在肝内胆管癌(ICC)诊断与治疗中的应用价值。方法采用回顾性描述性研究方法。收集2018年1-9月南方医科大学珠江医院收治的11例ICC患者的临床病理资料;男5例,女6例;年龄为(55±12)岁,年龄范围为30~74岁。收集患者上腹部增强CT检查和钆塞酸二钠(Gd-EOB-DTPA)增强MRI检查数据,构建基于CT-MRI融合图像的肝脏3D模型。根据不同模态影像学检查技术制订术前规划。吲哚菁绿(ICG)分子荧光成像技术和增强现实手术导航系统分别运用于肝切除术中。观察指标:(1)术前评估。(2)术中情况。(3)不同模态影像学技术制订手术规划方案与实际手术方式的比较。(4)随访情况。采用门诊或电话方式进行术后随访,随访患者术后并发症发生情况。随访时间截至2018年11月。正态分布的计量资料以Mean±SD表示,偏态分布的计量资料以M(范围)表示。计数资料以绝对数或百分比表示,比较采用配对χ2检验。结果(1)术前评估:增强CT检查清晰显示门静脉、肝静脉系统三级及以上分支血管比例,肿瘤边界比例分别为11/11和4/11,MRI检查分别为5/11和11/11,两种检查上述指标比较,差异均有统计学意义(χ^2=4.16,5.14,P<0.05)。增强CT检查显示肝脏病灶11个,增强MRI检查显示病灶13个(含增强CT检查未显示的2个病灶,最大直径≤10mm)。基于CT-MRI融合图像的肝脏3D模型:均能立体、直观、全面显示肝脏病灶位置、数目、浸润范围(肿瘤边界),肝内血管走行、变异情况以及与病灶的空间关系。(2)术中情况:11例患者中,术中肉眼探查发现11个病灶;通过ICG分子荧光影像技术检查出13个病灶,包含2个术前MRI检查肝胆特异期提示的低摄取病灶,病理学检查为肝内转移癌。11例患者中,结扎肝门相应血管出现肉眼可见明显缺血分界线6例;使用ICG分子荧光影像技术检查显示10例行解剖性肝切除术患者的肝段或半肝边界,其中正染法2例、反染法8例。11例患者中,行左半肝切除术3例(1例联合肝Ⅷ段转移灶局部切除术),左肝外叶切除术2例,右半肝切除术2例,扩大右半肝切除术、右肝后叶切除术、部分肝Ⅷ段切除术、肝中叶切除术各1例。11例患者中,7例联合区域淋巴结清扫,4例行单纯淋巴结活组织检查。11例患者中,1例术中诊断为肝脏断面胆汁漏,予以4-0Prolene线缝扎处理;10例未发生术中胆汁漏。11例患者手术切缘均为阴性,手术时间为(240±118)min,术中出血量为(275±249)mL,住院时间为(13±8)d,围术期均未输血治疗。(3)不同模态影像学技术制订手术规划方案与实际手术方式的比较:CT、MRI检查和基于CT-MRI融合图像的肝脏3D模型手术规划方案与实际手术方式一致分别为6、9、11例。(4)随访情况:11例患者术后均获得随访,随访时间为2~10个月,中位随访时间为6个月。3例患者发生术后并发症,Clavien-DindoⅠ、Ⅱ级并发症2例,其中胸腔积液1例,胸腔积液+腹腔积液1例,均经保守治疗后好转;Clavien-DindoⅢ级并发症1例(术后腹腔出血),行经皮股动脉穿刺选择性动脉栓塞术治疗后好转。11例患者均未发生术后胆汁漏、肝衰竭和死亡。结论多模态影像融合技术可优化术前手术规范方案,术中能实时辅助识别肝脏重要血管并为肝切除术实时导航,提高手术安全性。

Objective To explore the application value of multimodal image fusion technology in the diagnosis and treatment of intrahepatic cholangiocarcinoma (ICC).MethodsThe retrospective descriptive study was conducted. The clinicopathological data of 11 patients with ICC who were admitted to Zhujiang Hospital of Southern Medical University between January and September 2018 were collected. There were 5 males and 6 females, aged (55±12)years, with a range from 30 to 74 years. The data of contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) with gadoxetate disodium (Gd-EOB-DTPA) of the upper abdomen were respectively collected, and three-dimensional (3D) model of liver was constructed based on CT-MRI fusion images. The preoperative evaluation and surgical planning were carried out based on the different modal imaging examination technologies. The indocyanine green (ICG) molecular fluorescence imaging system and augmented reality navigation system were used to guide hepatectomy. Observation indicators: (1) preoperative evaluation;(2) intraoperative situations;(3) comparison between surgical planning based on the different model imaging technologies and actual surgical method;(4) follow-up. Follow-up using outpatient examination and telephone interview was performed to detect postoperative complications up to November 2018. Measurement data with normal distribution were represented as Mean±SD, measurement data with skewed distribution were represented as M (range). Count data were described as absolute number or percentage and comparisons were analyzed using the paired chi-square test.Results(1) Preoperative evaluation: the proportions of grade 3 and above branch vessels of the portal vein and hepatic vein system and tumor margin by enhanced CT examination and enhanced MRI examination were respectively 11/11, 4/11 and 5/11, 11/11, with statistically significant differences in above indicators (χ^2=4.16, 5.14, P<0.05). The enhanced CT showed 11 liver cancer lesions and enhanced MRI showed 13 lesions (including 2 lesions not demonstrated by enhanced CT, with a maximum diameter ≤10 mm). The 3D model of liver based on CT-MRI fusion image: location, number, infiltrating range (tumor boundary), intrahepatic vascular distribution, variation and its spatial relationship with lesions could be stereoscopically, intuitively and comprehensively displayed. (2) Intraoperative situations: of 11 patients, 11 lesions were explored with naked eyes;13 lesions were detected by ICG molecular fluorescence imaging system, including 2 lesions showing low uptake lesions in liver and gallbladder specific period by preoperative MRI examinations and intrahepatic metastasis cancer by pathologic examination. Of 11 patients, 6 had naked-eye ischemia boundaries around related vessels of hepatic portal ligation;10 with anatomical hepatectomy had hepatic segments or hemihepatic boundary by ICG molecular fluorescence imaging system, including 2 using positive staining and 8 using anti-staining. Among 11 patients, 3 (1 combined with local resection of hepatic segment Ⅷ metastases), 2, 2, 1, 1, 1 and 1 underwent respectively left hepatectomy, left lateral lobectomy of liver, right hepatectomy, extended right hepatectomy, right lobectomy of liver, resection of partial hepatic segment Ⅷ and mesohepatectomy. Seven of 11 patients received regional lymph node dissection and 4 received simple lymph node biopsy. Of 11 patients, 1 diagnosed as with bile leakage of liver section underwent suture and ligation treatment with 4-0 Prolene;10 didn′t occurred bile leakage. The surgical margin of 11 patients was negative. The operation time, volume of intraoperative blood loss and duration of hospital stay were (240±118)minutes, (275±249)mL and (13±8)days, respectively. There was no blood transfusion in the perioperative period. (3) Comparison between surgical planning based on the different model imaging technologies and actual surgical method: surgical planning of 3D model based on CT, MRI and CT-MRI fusion image in 6, 9 and 11 patients was respectively consistent with actual surgical method. (4) Follow-up: 11 patients were followed up for 2-10 months, with a median time of 6 months. Three patients had postoperative complications, 2 of which were found in Clavien-DindoⅠ and Ⅱ, including 1 with pleural effusion + peritoneal effusion and 1 with pleural effusion, they were improved after conservative treatment;1 with complication of Clavien-Dindo Ⅲ (postoperative intra-abdominal bleeding) was improved by selective arterial embolization using percutaneous femoral artery puncture. There was no postoperative bile leakage, hepatic failure and death.ConclusionMultimodal image fusion technique is helpful to optimize the preoperative surgical planning, which can assist the recognition of important vessels and real-time navigation of hepatectomy during operation, and improve the safety of operation.