目的：比较肝细胞特异性对比剂普美显与非特异性细胞外间隙对比剂钆喷葡胺（Gd-DTPA）对肝脏动脉期一过性强化灶（Transient hepatic parenchymal enhancement，THPE）与小肝癌（Small hepatocelluar carcinoma，SHCC）鉴别诊断的能力。同时分析THPE及SHCC的形态、信号特征及应用两种对比剂的强化特征。方法：由两名影像医师共同对46名肝硬化患者的58个肝内局限性动脉期强化灶进行分析。主要分析在分别应用非特异性细胞外间隙对比剂Gd-DTPA及肝细胞特异性对比剂普美显（Gd-EOB-DTPA）的情况下各强化灶的信号、形态特征，以及增强扫描时强化方式的差别，进而综合判断病灶的性质。以手术或穿刺病理结果、介入血管造影或6月以上随诊观察等指标作为金标准，回顾性分析比较两种对比剂对于肝脏THPE和SHCC的诊断及鉴别能力。统计学方法采用卡方检验，比较THPE与SHCC在形态、位置、信号及强化方式上的差异；比较THPE的强化方式在应用两种对比剂时是否存在差异；比较SHCC的强化方式在应用两种对比剂时是否存在差异。分别比较研究总体58个肝内局限性动脉期强化灶组、36个结节状肝内局限性动脉期强化灶组和23个最大径＜1 cm的肝内局限性动脉期强化灶组，应用两种对比剂诊断的灵敏度、特异度，计算ROC曲线下面积，从而比较两种对比剂的诊断效能。P＜0.05为差异具有统计学意义。39例THPE中，33例经随诊6月得到确认，6例经介入血管造影得到确认。19例SHCC，10例由手术后病理得到证实，1例经皮肝脏穿刺活检并结合血管造影得到确认，另有8例由血管造影结合AFP指标得到证实。结果：在不同分组下，普美显的灵敏度、特异度及ROC曲线下面积均高于钆喷葡胺。THPE与SHCC在形态、位置、信号、强化方式上存在差异（P＜0.05）。THPE的强化方式在应用两种对比剂时无统计学差异（P＞0.05），SHCC的强化方式在应用两种对比剂时亦无统计学差异（P＞0.05）。结论：①MRI诊断中，THPE与SHCC在形态、信号、位置及强化方式上存在差异；THPE的强化方式在应用两种对比剂时无明显差异；SHCC的强化方式在应用两种对比剂时也无明显差异。②磁共振肝胆细胞特异性对比剂Gd-EOB-DTPA，有助于THPE与SHCC的诊断及鉴别，其诊断能力较Gd-DTPA更佳。
Abstract
Objective: To compare the ability of hepatocyte specific contrast agent Gd-EOB-DTPA with non-specific extracellular contrast agent Gd-DTPA in differential diagnosis of transient hepatic parenchymal enhancement(THPE) and small hepatocelluar carcinoma(small HCC). And to analyze the lesion shape, signal intensity, and enhancement pattern with two agents. Methods: Two radiologists analyzed the imaging characteristics of 58 focal liver lesions(FLL) from 46 patients with cirrhosis. The analysis focused on morphology, signal intensity and the patterns of enhancement in different phases with Gd-DTPA and Gd-EOB-DTPA respectively, and then the property of each focal liver lesion was inferred and compared with the final results. A retrospective analysis about the ability of two contrast mediums in detection and differential diagnosis of THPE and small HCC was performed with pathologic findings, angiography or follow-up over 6 months as reference and gold standard. The Chi-square test was used for comparisons of shape, location, signal intensity and pattern of enhancement between THPE and small HCC, comparison of enhancement pattern of THPE with the two MRI contrast agents, and comparison of enhancement pattern of small HCC with the two MRI contrast agents. Sensitivities, specificities and AUCs(area under curve) of ROCs of the two agents were figured out in the groups of total 58 FLL, 36 nodular FLL and 23 FLL whose maximum diameter＜1 cm, respectively, and thus calculating their diagnostic performance. Significance was set at P＜0.05. Among 39 THPEs, there were 33 cases confirmed by 6 months’ following up, and others were confirmed by angiography. Among 19 small HCCs, 10 cases were confirmed by postoperative pathology, 1 case was identified by percutaneous biopsy and angiography, and other 8 cases were confirmed by combining gangiography and AFP. Results: In different groups, the sensitivity, specificity and the AUC of Gd-EOB-DTPA were all higher than those of Gd-DTPA. Significant differences in shape, location, signal intensity and patterns of enhancement were observed between THPE and small HCC(P＜0.05). The patterns of enhancement of THPE with two agents showed no difference(P＞0.05), and the patterns of enhancement of small HCC with two agents showed no difference too. Conclusion: ①In magnetic resonance imaging(MRI), there are significant differences in shape, signal intensity, location and patterns of enhancement between THPE and small HCC, while the two MRI contrast agents show no statistical difference in the enhancement pattern of all focal liver lesions. ②Gd-EOB-DTPA has more advantages in distinguishing THPE from small HCC so it has a higher diagnostic performance than traditional contrast agent.
关键词
肝肿瘤 /
磁共振成像
Key words
Liver neoplasms /
Magnetic resonance imaging
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参考文献
[1]Choi BI, Lee KH, Han JK, et al. Hepatic arterioportal shuts: Dynamic CT and MR features[J]. Korean J Radiol, 2002, 3(1): 1-15.
[2]全冠民，袁涛，魏志刚，等. 肝脏血流灌注异常的多层螺旋CT评价[J]. 放射学实践，2009，24（7）：698-703.
[3]Motosugi U, Ichikawa T, Sou H, et al. Distinguishing hypervascular pseudolesions of the liver from hypervascular hepatocellular carcinomas with gadoxetic acid-enhanced MR imaging[J]. Radiology, 2010, 256(1): 151-158.
[4]Tian JL, Zhang JS. Hepatic perfusion disorders: etiopathogenesis and related diseases[J]. World J Gastroenterol, 2006, 12(20): 3265-3270.
[5]Jeong MG, Yu JS, Kim KW. Hepaticcavernous hemangioma: temporal peritumoral enhancement during multiphase dynamic MR imaging[J]. Radiology, 2000, 216(3): 692-697.
[6]Wachsberg RH, Bahramipour P, Sofocleous CT, et al. Hepatofugal flow in the portal venous system: pathophysiology, imaging findings and diagnostic pitfalls[J]. Radiographics, 2002, 22(1): 123-140.
[7]Shimizu A, Ito K, Koike S, et al. Cirrhosis or chronic hepatitis: evaluation of small(<or=2 cm) early-enhancing hepatic lesions with serial contrast-enhanced dynamic MR imaging[J]. Radiology, 2003, 226(2): 550-555.
[8]Sun HY, Lee JM, Shin CI, et al. Gadoxetic acid-enhanced magnetic resonance imaging for differentiating small hepatocellular carcinomas(<or=2 cm in diameter) from arterial enhancing pseudolesions: special emphasis on hepatobiliary phase imaging[J]. Invest Radiol, 2010, 45(2): 96-103.
[9]Bruix J, Sherman M, Practice Guidelines Committee, et al. Management of hepatocellular carcinoma[J]. Hepatology, 2005, 42(5): 1208-1236.
[10]Yu JS, Kim KW, Jeong MG, et al. Nontumorous hepatic arterial-portal venous shunts: MR imaging findings[J]. Radiology, 2000, 217(3): 750-756.
[11]Okuda K, Musha H, Yamasaki T, et al. Angiographic demonstration of intrahepatic arterio-portal anastomoses in hepatocellular carcinoma[J]. Radiology, 1977, 122(1): 53-58.
[12]Semelka RC, Helmberger TKG. Contrast agents for MR imaging of the liver[J]. Radiology, 2001, 218(1): 27-38.
[13]田野，郭丽丽，付旷. 普美显增强磁共振成像在肝脏局灶性病变中的诊断应用[J]. 临床荟萃，2014，29（4）：472-474.
[14]Purysko AS, Remr EM, Veniero JC. Focal liver lesion detection and characterization with Gd-EOB-DTPA[J]. Clin Radiol, 2011, 66(7): 673-684．
[15]Harem B, Staks T, Mühler A, et al. Phase Ⅰ clinical evaluation of Gd-EOB-DTPA as a hepatobiliary MR contrast agent: safety, pharmacokinetic, and MR imaging[J]. Radiology， 1995, 195(3): 785-792．
[16]梁文娟，王倩，李文华. 肝胆特异性对比剂在肝脏局灶性病变鉴别诊断中的价值[J]. 中国中西医结合影像学杂志，2014，12（5）：539-542.
[17]Kanki A, Tamada T, Higaki A, et al. Hepaticparenchymal enhancement at Gd-EOB-DTPA-enhanced MR imaging: correlation with morphological grading of severity in cirrhosis and chronic hepatitis[J]. Magn Reson Imaging, 2012, 30(3): 356-360.
[18]Goodwin MD, Dobson JE, Sirlin CB, et al. Diagnostic challenges and pitfalls in MR imaging with hepatocyte-specific contrast agents[J]. Radiographics, 2011, 31(6): 1547-1568.
[19]Choi D, Mitchell DG, Verma SK, et al. Hepatocellular carcinoma with indeterminate or false-negative findings at initial MR imaging: effect on eligibility for curative treatment initial observations[J]. Radiology, 2007, 244(3): 776-783.
[20]Holland A, Hecht E, Hahn W, et al. Importance of small (<or=20 mm) enhancing lesions seen only during the hepatic arterial phase at MR imaging of the cirrhotic liver: evaluation and comparison with whole explanted liver[J]. Radiology, 2005, 237(3): 938-944.
