CT与MRI检查对肝门周围恶性梗阻术前评估准确性的比较

Comparison of accuracy of CT and MRI in the preoperative evaluation of malignant perihilar biliary obstruction

目的 总结肝门周围恶性梗阻CT与MRI检查联合多技术成像的特征,比较两种检查方式在患者术前评估中的作用.方法 回顾性分析2008年1月至2014年4月南京医科大学附属无锡第二医院收治的20例行CT和MRI检查且经病理学检查证实为肝门周围恶性梗阻患者的临床资料.CT联合阴性对比CT胰胆管造影（nCTCP）及CTA检查的图像设为CT组;MRI联合MRCP及MRA检查的图像设为MRI组.由2名阅片者独立分析2组影像学检查图像,分别评估肝门周围恶性梗阻分型、肝动脉和门静脉受侵犯、淋巴结和器官转移情况,评估结果与手术和病理学检查结果进行比较.2组影像学检查对肝门梗阻类型分类准确性比较采用配对χ2检验;血管受侵犯、淋巴结和器官转移评价的准确性（灵敏度和特异度）比较采用受试者操作特性（ROC）曲线分析,其准确性比较ROC下面积（Az值）,并作z score检验.结果 2组影像学图像上胆管受累及典型表现为胆管壁不规则增厚伴逆行肝内胆管扩张;血管受侵犯主要征象为狭窄、闭塞或病灶与血管接触面过半;淋巴结转移典型表现为短径增大或呈类圆形或环形强化征象;器官受侵犯表现为病灶与其分界不清楚、受压或可见器官内低密度坏死灶.20例患者经手术治疗,术中探查结果：肝门部胆管癌13例,胆囊癌7例;肝动脉受侵犯5例,门静脉受侵犯10例;淋巴结转移10例;器官转移4例.CT组中,阅片者1和2准确评价肝门周围恶性梗阻分型、肝动脉受侵犯、门静脉受侵犯、淋巴结及器官转移情况分别为18例/18例、19例/18例、18例/18例、17例/16例和18例/19例;MRI组中准确评价上述特征的例数分别为17例/16例、14例/13例、17例/16例、15例/14例和19例/18例.2组影像学检查就肝门周围恶性梗阻分型、肝动脉和门静脉受侵犯、淋巴结和器官转移评估的准确性比较,差异均无统计学意义（χ2=12.593,8.889,z=1.823,1.956,0.462,0.817,0.977,0.751,0.233,1.403,P＞0.05）.结论 CT和MRI检查肝门周围恶性梗阻的图像特征一致,在评估肝门周围恶性梗阻分型、血管受侵犯、淋巴结和器官转移情况时,CT与MRI检查效能相同.

Objective To summarize the imaging features of computed tomography （CT）and magnetic resonance imaging （MRI） combined with multi-technology imaging and compare its effects in the preoperative evaluation of malignant perihilar biliary obstruction.Methods The clinical data of 20 patients receiving CT and MRI who were diagnosed with malignant perihilar biliary obstruction by pathological examination at the Wuxi Second People＆#39;s Hospital between January 2008 and April 2014 were retrospectively analyzed.Patients receiving CT combined with negative-contrast CT cholangiopancreatography （nCTCP） and computed tomography angiography （CTA） were allocated into the CT group,and patients receiving MRI combined with magnetic resonance cholangiopancreatography （MRCP） and magnetic resonance angiography （MRA） were allocated into the MRI group.The images of the 2 groups were analyzed by 2 independent reviewers.The classification of malignant perihilar biliary obstruction,hepatic artery and portal vein invasions and lymph node and organ metastases were evaluated respectively,and then the results of evaluation were compared with the results of surgery and pathological examinations.The comparison between the accuracy of imaging examination in the 2 groups and accuracy of perihilar biliary obstruction classification were analyzed by the chi-square test.The comparison of evaluating accuracy （sensitivity and specificity） among vascular invasion and lymph node and organ metastases were done by the receiver operating characteristic （ROC） curve analysis,and the comparison of its accuracy were done by the z-score test.Results The imagings of bile duct involvement of the 2 groups showed that there were irregular thickening bile duct wall combined with retrograde intrahepatic bile duct dilatation.The symptoms of vascular invasion included the stricture and occlusion of blood vessels or more than half of vascular contact surface with tumor.The symptoms of lymph node metastasis included the enlarging short-axis or round-like circular enhanced lesions.The symptoms of organ involvement included the unclear boundary of lesions or low-density necrotic foci within organ.All the 20 patients underwent the surgical treatment,including 13 patients with hilar cholangiocarcinoma and 7 patients with gallbladder carcinoma.Hepatic artery invasions were detected in 5 patients,portal vein invasions in 10 patients,lymph node metastases in 10 patients and organ metastases in 4 patients.The cases of classification of perihilar biliary obstruction,hepatic artery invasion,portal vein invasion,lymph node metastasis and organ metastasis which were evaluated respectively by reviewer 1 and 2 were 18/18,19/18,18/18,17/16 and 18/19 in the CT group and 17/16,14/13,17/16,15/14 and 19/18 in the MRI group.The imaging of the 2 groups were compared with the evaluating accuracies of classification of malignant hilar biliary obstruction,hepatic artery and portal vein invasions,lymph node and organ metastases in the 2 groups,showing no significant differences （χ2=12.593,8.889,z=1.823,1.956,0.462,0.817,0.977,0.751,0.233,1.403,P〉0.05）.Conclusion CT and MRI for malignant hilar biliary obstruction had the same imaging features,meanwhile,they can provide an equivalent performance in the classification of malignant hilar biliary obstruction,hepatic artery and portal vein invasions and lymph node and organ metastases.