超声造影与钆塞酸二钠增强磁共振检查诊断肝细胞癌的临床价值

Clinical value of contrast⁃enhanced ultrasound and gadolinium⁃ethoxybenzyl⁃diethylenetriamine pentaacetic acid⁃enhanced magnetic resonance imaging in the diagnosis of hepatocellular carcinoma

目的探讨超声造影与钆塞酸二钠增强磁共振检查(Gd⁃EOB⁃DTPA MRI)诊断肝细胞癌的临床价值。方法采用临床诊断性试验研究方法。收集2017年1月至2018年12月陆军军医大学第一附属医院收治的250例(274个病灶)肝脏肿瘤患者的临床病理资料;男204例,女46例;年龄为(52±11)岁,年龄范围为22~78岁。患者均行超声造影和Gd⁃EOB⁃DTPA MRI检查并于1个月内行手术切除或穿刺活组织病理学检查。影像学图像由2位高年资医师对其观察分析后作出诊断。观察指标:(1)超声造影与Gd⁃EOB⁃DTPA MRI检查影像学特征。①超声造影检查影像学特征。②Gd⁃EOB⁃DTPA MRI检查影像学特征。③223个肝细胞癌病灶在各时期增强影像学表现。(2)超声造影与Gd⁃EOB⁃DTPA MRI及两者联合检查诊断肝细胞癌的效能。①3种检查方式诊断肝细胞癌的灵敏度、特异度和准确率。②3种检查方式诊断不同直径病灶为肝细胞癌的灵敏度、特异度和准确率。计数资料以绝对数或百分比表示,组间比较采用χ2检验或Fisher确切概率法。以手术病理学检查结果作为诊断金标准,计算超声造影检查、Gd⁃EOB⁃DTPA MRI检查及两者联合检查诊断肝细胞癌的灵敏度、特异度和准确率。结果(1)超声造影及Gd⁃EOB⁃DTPA MRI检查影像学特征。①超声造影检查影像学特征:274个病灶中,223个肝细胞癌病灶超声造影检查中,167个符合肝细胞癌“快进快出”表现,7个漏诊,49个误诊。51个非肝细胞癌病灶超声造影检查中,7个符合“快进快出”表现,其中3个混合型肝癌、2个肝内胆管细胞癌、1个神经内分泌肿瘤、1个炎性肉芽肿;44个不符合“快进快出”表现。②Gd⁃EOB⁃DTPA MRI检查影像学特征:274个病灶中,223个肝细胞癌病灶Gd⁃EOB⁃DTPA MRI检查中,178个符合“快进快出”表现,1个漏诊,44个误诊。51个非肝细胞癌病灶Gd⁃EOB⁃DTPA MRI检查中,5个符合“快进快出”表现,其中2个肝内胆管细胞癌、1个混合型肝癌、1个神经内分泌肿瘤、1个炎性肉芽肿;46个不符合“快进快出”表现。③223个肝细胞癌病灶在各时期增强影像学表现。动脉期:超声造影检查表现为高增强病灶占比为92.83%(207/223),高于Gd⁃EOB⁃DTPA MRI检查的80.72%(180/223),两者比较,差异有统计学意义(χ2=14.240,P<0.05)。门静脉期或延迟期:超声造影检查表现为低增强病灶占比为78.48%(175/223),低于Gd⁃EOB⁃DTPA MRI检查的96.41%(215/223),两者比较,差异有统计学意义(χ2=32.674,P<0.05)。Gd⁃EOB⁃DTPA MRI检查门静脉期或延迟期表现为低信号的病灶占比为96.41%(215/223),肝胆期为98.21%(219/223),两者比较,差异无统计学意义(χ2=1.370,P>0.05)。(2)超声造影与Gd⁃EOB⁃DTPA MRI及两者联合检查诊断肝细胞癌的效能。①3种检查方式诊断肝细胞癌的灵敏度、特异度和准确率:超声造影检查、Gd⁃EOB⁃DTPA MRI检查、两者联合检查诊断肝细胞癌的灵敏度分别为74.89%(167/223)、79.82%(178/223)、94.62%(211/223),特异度分别为86.27%(44/51)、90.20%(46/51)、80.39%(41/51),准确率分别为77.01%(211/274)、81.75%(224/274)、91.97%(252/274)。3种检查方法的灵敏度和准确率比较,差异均有统计学意义(χ2=33.499,23.345,P<0.05);3种检查方法特异度比较,差异无统计学意义(χ2=2.017,P>0.05)。②3种检查方式诊断不同直径病灶为肝细胞癌的灵敏度、特异度和准确率:274个病灶中,病灶最大径为>3 cm且≤5 cm 128个,>2 cm且≤3 cm 92个,≤2 cm 54个。超声造影检查诊断病灶最大径为>3 cm且≤5 cm、>2 cm且≤3 cm、≤2 cm肝细胞癌的灵敏度分别为81.19%(82/101)、76.92%(60/78)、56.82%(25/44),特异度分别为92.59%(25/27)、71.43%(10/14)、90.00%(9/10),准确率分别为83.59%(107/128)、76.09%(70/92)、62.96%(34/54);Gd⁃EOB⁃DTPA MRI检查的灵敏度分别为83.17%(84/101)、79.49%(62/78)、72.73%(32/44),特异度分别为96.30%(26/27)、85.71%(12/14)、80.00%(8/10),准确率分别为85.94%(110/128)、80.43%(74/92)、74.07%(40/54);两者联合检查的灵敏度分别为95.05%(96/101)、96.15%(75/78)、90.91%(40/44),特异度分别为92.59%(25/27)、57.14%(8/14)、80.00%(8/10),准确率分别为94.53%(121/128)、90.22%(83/92)、88.89%(48/54)。3种检查方法诊断病灶最大径为>3 cm且≤5 cm、>2 cm且≤3 cm、≤2 cm肝细胞癌的灵敏度比较,差异均有统计学意义(χ2=9.703,12.777,13.142,P<0.05);准确率比较,差异均有统计学意义(χ2=8.051,6.600,9.826,P<0.05);特异度比较,差异均无统计学意义(P>0.05)。结论超声造影与Gd⁃EOB⁃DTPA MRI检查对肝细胞癌的诊断效能比较,差异无统计学意义;两者联合检查诊断肝细胞癌可提高其诊断灵敏度和准确率。

Objective To investigate the clinical value of contrast⁃enhanced ultrasound and gadolinium⁃ethoxybenzyl⁃diethylenetriamine pentaacetic acid⁃enhanced magnetic resonance imaging(Gd⁃EOB⁃DTPA MRI)in the diagnosis of hepatocellular carcinoma(HCC).Methods The clinically diagnostic test was conducted.The clinicopathological data of 274 lesions in 250 patients with liver neoplasms who were admitted to the First Hospital Affiliated to Army Medical University from January 2017 to December 2018 were collected.There were 204 males and 46 females,aged(52±11)years,with a range from 22 to 78 years.Patients underwent contrast⁃enhanced ultrasound and Gd⁃EOB⁃DTPA MRI,and they received surgical resection or biopsy within one month.Images was read and analyzed by two senior radiologists for diagnosis.Observation indicators:(1)imaging features of contrast⁃enhanced ultrasound and Gd⁃EOB⁃DTPA MRI,including①imaging features of contrast⁃enhanced ultrasound,②imaging features of Gd⁃EOB⁃DTPA MRI,③enhanced imaging manifestation in different phases of 223 HCC lesions;(2)dignostic performance of contrast⁃enhanced ultrasound,Gd⁃EOB⁃DTPA MRI,or the combined examinations for HCC diagnosis,including①sensitivity,specificity and accuracy rate of the three methods for HCC diagnosis and②sensitivity,specificity and accuracy rate of the three methods for HCC diagnosis in lesions with different diameters.Count data were represented as absolute numbers or percentages,and comparison between groups was analyzed using the chi⁃square test or Fisher exact probability.With the pathological examination as the golden criteria of diagnosis,the sensitivity,specificity and accuracy rate of the contrast⁃enhanced ultrasound,Gd⁃EOB⁃DTPA MRI,or the combined examinations for HCC diagnosis were calculated.Results(1)Imaging features of contrast⁃enhanced ultrasound and Gd⁃EOB⁃DTPA MRI.①Imaging features of contrast⁃enhanced ultrasound:of the 223 HCC lesions on contrast⁃enhanced ultrasound,167 lesions were accorded with fast in fast out of HCC,7 were missed diagnosed and 49 were misdiagnosed.Of the 51 non⁃HCC lesions on contrast⁃enhanced ultrasound,7 lesions were accorded with fast in fast out,including 3 of combined hepatocellular⁃cholangiocarcinoma,2 of intrahepatic cholangiocarcinoma,1 of neuroendocrine tumor,1 of inflammatory granuloma,44 lesions were no fast in fast out.②Imaging features of Gd⁃EOB⁃DTPA MRI:of the 223 HCC lesions on Gd⁃EOB⁃DTPA MRI,178 lesions were accorded with fast in fast out of HCC,1 was missed diagnosed and 44 were misdiagnosed.Of the 51 non⁃HCC lesions on Gd⁃EOB⁃DTPA MRI,5 lesions were accorded with fast in fast out,inlcuding 2 of intrahepatic cholangiocarcinoma,1 of combined hepatocellular⁃cholangiocarcinoma,1 of neuroendocrine tumor,1 of inflammatory granuloma,46 lesions were no fast in fast out.③Enhanced imaging manifestation in different phases of 223 HCC lesions.In arterial phase,92.83%(207/223)of the lesions displayed hyper⁃enhanced on contrast⁃enhanced ultrasound,and 80.72%(180/223)of the lesions displayed hyper⁃enhanced on Gd⁃EOB⁃DTPA MRI,showing a significant difference(χ2=14.240,P<0.05).In portal vein phase or late phase,78.48%(175/223)of the lesions displayed hypo⁃enhanced on contrast⁃enhanced ultrasound,and 96.41%(215/223)of the lesions displayed hypo⁃enhanced on Gd⁃EOB⁃DTPA MRI,showing a significant difference(χ2=32.674,P<0.05).On Gd⁃EOB⁃DTPA MRI,96.41%(215/223)of the lesions displayed low signals in portal⁃vein phase or late phase,and 98.21%(219/223)of the lesions displayed low signals in hepatobiliary phase,showing no significant difference(χ2=1.370,P>0.05).(2)Dignostic performance of contrast⁃enhanced ultrasound,Gd⁃EOB⁃DTPA MRI,or the combined examinations for HCC diagnosis.①Sensitivity,specificity and accuracy rate of the three methods for HCC diagnosis:the sensitivities of contrastenhanced ultrasound,Gd⁃EOB⁃DTPA MRI,or the combined examinations for HCC diagnosis were 74.89%(167/223),79.82%(178/223),94.62%(211/223),respectively.The specificities of contrast⁃enhanced ultrasound,Gd⁃EOB⁃DTPA MRI,or the combined examinations for HCC diagnosis were 86.27%(44/51),90.20%(46/51),80.39%(41/51).The accuracy rates of contrast⁃enhanced ultrasound,Gd⁃EOB⁃DTPA MRI,or the combined examinations for HCC diagnosis were 77.01%(211/274),81.75%(224/274),91.97%(252/274).There were significant differences in the sensitivity and accuracy rate among the three methods(χ2=33.499,23.345,P<0.05).There was no significant difference in the specificity among the three methods(χ2=2.017,P>0.05).②Sensitivity,specificity and accuracy rate of the three methods for HCC diagnosis in lesions with different diameters:128 of 274 lesions had the maximun diameter>3 cm and≤5 cm,92 lesions had the maximun diameter>2 cm and≤3 cm,54 lesions had the maximun diameter≤2 cm.The sensitivities of contrast⁃enhanced ultrasound for HCC diagnosis in lesions with the maximun diameter>3 cm and≤5 cm,>2 cm and≤3 cm,≤2 cm were 81.19%(82/101),76.92%(60/78),56.82%(25/44),the specificities were 92.59%(25/27),71.43%(10/14),90.00%(9/10),and the accuracy rates were 83.59%(107/128),76.09%(70/92),62.96%(34/54),respectively.The sensitivities of Gd⁃EOB⁃DTPA MRI for HCC diagnosis in lesions with the maximun diameter>3 cm and≤5 cm,>2 cm and≤3 cm,≤2 cm were 83.17%(84/101),79.49%(62/78),72.73%(32/44),the specificities were 96.30%(26/27),85.71%(12/14),80.00%(8/10),and the accuracy rates were 85.94%(110/128),80.43%(74/92),74.07%(40/54),respectively.The sensitivities of contrast⁃enhanced ultrasound combined with Gd⁃EOB⁃DTPA MRI for HCC diagnosis in lesions with the maximun diameter>3 cm and≤5 cm,>2 cm and≤3 cm,≤2 cm were 95.05%(96/101),96.15%(75/78),90.91%(40/44),the specificities were 92.59%(25/27),57.14%(8/14),80.00%(8/10),and the accuracy rates were 94.53%(121/128),90.22%(83/92),88.89%(48/54),respectively.There were significant differences in the sensitivities for HCC diagnosis in lesions with the maximun diameter>3 cm and≤5 cm,>2 cm and≤3 cm,≤2 cm among the three methods(χ2=9.703,12.777,13.142,P<0.05).There were also significant differences in the accuracy rates(χ2=8.051,6.600,9.826,P<0.05).There was no significant difference in the specificies(P>0.05).Conclusions There was no significant difference in the dignostic performance for HCC diagnosis between contrast⁃enhanced ultrasound and Gd⁃EOB⁃DTPA MRI,and the combination of contrast⁃enhanced ultrasound and Gd⁃EOB⁃DTPA MRI can improve the diagnostic sensitivity and accuracy rate of HCC.