肝内胆管细胞癌增强CT_扫描特征及其诊断价值分析

∗基金项目:新疆维吾尔自治区喀什地区科技局科研项目(编号:KS2018050)
作者单位:844000新疆维吾尔自治区喀什市喀什中医医院影像科(师玉);中山大学附属喀什医院影像中心(孟令辉);喀什地区第一人民医院影像中心(王禄马)
第一作者:师玉,女,38岁,大学本科,主治医师㊂E-mail: sy6543210516@
通讯作者:王禄马,E-mail:27508646@ ㊃肝癌㊃
肝内胆管细胞癌增强CT扫描特征及其诊断价值分析∗
师玉,孟令辉,王禄马
㊀㊀ʌ摘要ɔ㊀目的㊀分析肝内胆管细胞癌(ICC)的CT增强扫描特征,探讨其诊断价值㊂方法㊀2020年3月~2023年3月我院诊治的376例经超声检查发现的肝脏占位性病变患者,均行CT平扫和多期增强扫描检查,所有患者接受穿刺活检或手术组织病理学检查诊断㊂采用kappa系数检验CT扫描的诊断价值㊂结果㊀在376例肝占位性病变患者中,经病理学检查诊断为良性病变149例和恶性病变227例,后者包括ICC者18例和肝细胞癌(HCC)者209例;CT增强扫描检出良性病变151例,恶性病变225例;CT扫描诊断ICC患者21例,均为单发病灶,肝左叶病灶占61.9%,病灶直径为(6.7ʃ
1.8)cm,肿块型病灶占57.1%㊂肿块型动脉期主要为病灶边缘薄层轻度强化,静脉期均显示病灶边缘薄层轻度强化,延
迟期均显示病灶强化加强;腔内生长型动脉期主要为肝门附近局部软组织病灶轻度强化,静脉期均显示病灶进一步强化,延迟期均显示病灶缓慢持续强化;浸润型动脉期主要为肝内胆管壁轻度强化,静脉期均显示病灶进一步强化,延迟期均显示病灶缓慢持续强化;在CT增强扫描检出的225例恶性病变患者中,经病理学检查诊断为非ICC者208例,ICC者17例;
多期CT增强扫描检出非ICC者204例,ICC者21例,其诊断ICC与病理组织学检查一致性检验的Kappa值为0.766,其准确率㊁敏感度㊁特异度㊁阳性预测值和阴性预测值分别为94.1%㊁97.6%㊁97.3%㊁76.2%和99.5%㊂结论㊀多期CT增强扫描诊断ICC的准确度较高,其扫描特征对指导临床手术方案的选择具有重要的意义㊂
㊀㊀ʌ关键词ɔ㊀肝内胆管细胞癌;CT平扫和增强;特征;诊断
㊀㊀DOI:10.3969/j.issn.1672-5069.2024.03.032
㊀㊀CT enhancement scan imaging feature of cholangiocellular carcinoma:An analysis of18cases㊀Shi Yu,Meng Linghui, Wang Luma.Department of Radiology,Traditional Chinese Medicine Hospital,Kashgar844000,Xinjiang Uygur Autonomous Region,China
㊀㊀ʌAbstractɔ㊀Objective㊀The aim of this study was to analyze the CT enhancement scan imaging feature of cholangiocellular carcinoma(CCC)in a series of patients with intrahepatic space-occupying lesions(ihSOL).Methods㊀A total of consecutive376 patients with ihSOL revealed by ultrasonography were encountered in our hospital between March2020and March2023,and all underwent CT plain scan and multi-phase enhancement scan.The diagnosis was made based on pathology from tissues obtained by laparoscopic radical operation or fine needle aspiration biopsy.The diagnostic performance of multi-phase CT enhancement scan was analyzed by Kappa coefficient test.Results㊀Out of the376patients with ihSOL,the pathological examination showed that there were149cases with benign lesions and227cases with malignant lesions,including CCC in18cases and hepatocellular carcinoma(HCC)in209cases;the multi-phase CT enhancement scan diagnosed benign lesions in151cases and malignant lesions in225cases,including ICC in21cases,all single lesion,61.9%of them located in left lobe,57.1%of them shaped in mass,with the diameters of(6.7ʃ1.8)cm;the edges of mass tumors mildly intensified at arterial phase and portal phase,while vigorously intensified at delayed phase;the intra-lumen tumors adjacent to porta hepatis mildly intensified at arterial phase, gradually further intensified at portal and delayed phases;intrahepatic infiltrating tumors at bile duct walls mildly intensified, gradually persistently intensified at portal and delayed phases;out of the225patients with malignant lesions[intrahepatic cholangiocellular carcinoma(ICC)in21and HCC in204cases]demonstrated by CT scan,the pathological examination diagnosed
ICC in17cases and HCC in208cases(Kappa=0.766),with
the diagnostic accuracy,sensitivity,specificity,positive
predictive value and negative predictive value of94.1%,97.6%,
97.3%,76.2%and99.5%.Conclusion㊀The feature of ICC
by multi-phase CT enhancement scan is characteristic,which
might help the clinicians make a plan for management.
㊀㊀ʌKey wordsɔ㊀Cholangiocellular carcinoma;CT plain
and enhancement scan;Feature;Diagnosis
㊀㊀胆管细胞癌(cholangiocellular carcinoma,CCC)是消化系统恶性肿瘤,其发病有明显的地域性㊂西方国家CCC发病率较低,在肝胆寄生虫感染多发的亚洲地区其发病率则明显增高㊂该病多发于50~70岁的成人[1,2]㊂CCC分为肝内胆管细胞癌(intrahepatic cholangiocellular carcinoma,ICC)和肝外胆管细胞癌(extrahepatic cholangiocellular carcinoma, ECC),均以腺癌最为常见[3]㊂由于CCC患者症状不典型㊁病变部位深等原因,通常发现时病情已较晚,往往出现较广泛的淋巴结转移或远处转移,已错过最佳的手术治疗时机,常无法行根治性肿瘤切除术治疗,总体预后不良[4]㊂CCC患者生存期与患者自身情况和肿瘤发现的早晚有关㊂未经治疗的CCC 患者在有明显的典型症状后,一般生存时间不会超过半年[5]㊂因此,早期诊断,合理㊁彻底的手术治疗对于改善CCC患者预后有重要的价值㊂随着现代影像学设备和技术的不断发展,越来越多的方法被应用于临床诊断㊂CT是目前临床上应用非常广泛的一种影像学检查方法,可应用于全身多个脏器病变的诊断,可以检查腹部脏器,如肝脏㊁脾脏㊁胆囊和胰腺等相关部位的病变,也可以检查肺部,了解是否有肺部炎症㊁结核㊁肿瘤㊁脓肿㊁支气管扩张㊁胸腔积液和胸膜肥厚等[6-8]㊂临床常对肝脏进行多期CT 增强扫描,以鉴别诊断多种肝脏肿瘤,可以显示肿瘤直径㊁强化㊁浸润程度等,其诊断价值较大[9,10]㊂本研究分析了CCC患者多期CT增强扫描的特征变化,旨在进一步提高其诊断价值,现报道如下㊂
1㊀资料与方法
1.1一般资料㊀2020年3月~2023年3月我院诊治的经超声检查发现的肝内占位性病变患者376例,男267例,女109例;年龄为45~70岁,平均年龄为(58.6ʃ8.3)岁㊂临床表现为上腹痛214例,黄疸22例,另伴有发热㊁消瘦㊁乏力㊁食欲不振和皮肤瘙痒等症状㊂所有患者均经手术或穿刺病理学检查诊断㊂排除标准:既往存在其他恶性肿瘤史;存在精神性疾病㊂
1.2CT检查㊀使用德国西门子公司生产的双源CT 扫描机㊂在检查前,确认患者近一个星期内未服用过钡剂㊂在行腹部CT检查前30min,嘱患者饮水500~1000mL,充盈胃部㊂首先,常规行CT平扫,行横断面连续扫描,以管电压120kV,管电流250mA,视野(field of view,FOV):20~25cm,扫描层厚/层间隔为5mm,薄层为0.625mm㊂随后,行三期CT 增强扫描,经肘静脉注射非离子型含碘对比剂碘海醇注射液(扬子江药业集团有限公司,国药准字
H10970358,300mgI/mL)80~100mL,速率为3mL/s㊂在注射后25~30s㊁60~70s和180~300s分别进行动脉期㊁门静脉期和实质期扫描㊂最长延迟8min㊂分析图像㊂
1.3统计学方法㊀应用SPSS25.0软件对数据进行统计学分析,计数资料以%表示,采用x2检验;以Kappa系数评价多期增强扫描诊断与组织病理学检查结果的一致性㊂P<0.05表示差异有统计学意义㊂2㊀结果
2.1病理学诊断情况㊀在376例肝占位性病变患者中,经病理学检查,诊断为良性病变149例,其中26例肝硬化再生结节,11例肝腺瘤,19例肝脓肿,67例肝血管瘤,26例肝局灶性结节性增生;恶性病变227例,其中18例ICC,209例肝细胞癌(HCC)㊂2.2CT平扫特征表现㊀CT扫描诊断ICC患者21例,均为单发病灶,病灶直径为(6.7ʃ1.8)cm(范围为
3.1~10.9cm);CT平扫主要特征为分叶状低密度肿块,密度不均匀,边缘模糊或不清楚,周边有时可见肝内胆管不规则扩张,呈软藤样改变,部分出现肝局部包膜萎缩(表1)㊂
表1㊀ICC病灶CT平扫表现特征(%)
例数例数
病灶部位肝内胆管结石5(23.8)㊀㊀肝左叶13(61.9)肝左叶萎缩4(19.0)㊀㊀肝右叶8(38.1)局部肝包膜回缩2(9.5)病灶类型
㊀㊀肿块型12(57.1)
㊀㊀腔内生长型6(28.6)
㊀㊀浸润型3(14.3)
2.3ICC病灶多期CT增强扫描特征表现㊀不同病灶类型多期CT增强扫描特征表现不同(表2㊁图1)㊂2.4CT增强扫描诊断与病理学检查诊断结果的一致性情况㊀CT增强扫描检出良性病变151例,恶性病变225例;CT增强扫描诊断肝癌与金标准一致性检验的Kappa值为0.834,其准确率㊁敏感度㊁特异度㊁阳性预测值和阴性预测值分别为92.0%㊁9
3.0%㊁90.6%㊁93.8%和89.4%(表3);在CT增强扫描检出的225例恶性病变患者中,经病理学检查诊断为非ICC肝癌208例,ICC17例;CT增强扫描检出为非ICC肝癌204例,ICC21例;CT增强扫描诊断ICC
与金标准一致性检验的Kappa值为0.828,其准确
率㊁敏感度㊁特异度㊁阳性预测值和阴性预测值分别
为94.1%㊁97.6%㊁97.3%㊁76.2%和99.5%(表4)㊂
表2㊀ICC病灶多期CT增强扫描特征表现
病灶类型例数动脉期静脉期延迟期
肿块型1266.7%为病灶边缘薄层轻度强化,
33.3%为病灶中心呈网状强化均显示病灶边缘薄层轻度强化,
33.3%病灶进一步强化均显示病灶明显强化
腔内生长型6肝门附近局部软组织病灶轻度强化均显示病灶进一步强化均显示病灶缓慢持续强化
浸润型3肝内胆管壁轻度强化均显示病灶进一步强化
均显示病灶缓慢持续强化
图1㊀ICC患者腹部CT表现
A:平扫示肝脏体积缩小,边缘不规则,肝实质密度不均匀,肝左叶斑片状稍低密度影,肝周围可见积液征;B:动脉期示肝左叶团块状软组织影,边界不清,形态不规则;C:静脉期显示低密度影
表3㊀CT扫描与病理学检查诊断情况
CT扫描病理学检查
恶性良性
合计恶性21114225
良性16135151
合计227149376
表4㊀CT增强扫描与病理学检查诊断ICC情况
CT扫描病理学检查
ICC非ICC合计ICC16521
非ICC1203204
合计17208225
3㊀讨论
ICC是二级胆管和分支上皮出现的腺癌,在肝脏原发恶性肿瘤中占比仅次于HCC[9-11]㊂男性和女性发病率无显著性差异,中老年人发病率高[12]㊂本研究376例经超声检查发现的肝脏占位性病变患者,经病理学诊断ICC患者18例㊂ICC的发病原因尚未明确,目前认为主要危险因素涉及先天性胆总管囊肿㊁寄生虫感染和胆石症等,也可能与基因突变或遗传因素有关[13]㊂随着病情的发展,可逐渐出现腹部不适㊁恶心呕吐和夜间盗汗等全身性反应[14,15]㊂目前,对于ICC的诊断,可根据病史㊁症状㊁体格检查㊁实验室检查和影像学检查及病理学检查结果等进行综合判断,其中影像学检查加肿瘤活检病理学检查对诊断是否患有胆管细胞癌有至关重要的意义㊂相关研究[16,17]发现,CT增强扫描鉴别诊断ICC 与肝细胞癌有较好的效能㊂本研究分析了ICC的多期CT增强扫描特征及其诊断价值㊂
本研究CT增强扫描检出225例恶性病变患者(HCC204例和ICC21例),经病理学检查诊断为非肝细胞癌208例和ICC17例㊂CT增强扫描诊断ICC与金标准一致性检验的Kappa值为0.828,其准确率㊁敏感度㊁特异度㊁阳性预测值和阴性预测值分别为94.1%㊁97.6%㊁97.3%㊁76.2%和99.5%,提示多期CT增强扫描诊断ICC有较高的准确性,有利于临床结合影像学特征制定手术方案㊂
ICC患者CT平扫表现为分叶状㊁不规则低密度肿物,无包膜,肿块内或周围可见扩张胆管形成的条索状更低密度影,邻近肝包膜凹陷,肝叶萎缩[18]㊂病灶主要为肿块型㊁腔内生长型和浸润型,其中肿块型较常见[19]㊂本研究CT平扫检测ICC患者均为单发病灶,病灶直径为(6.7ʃ1.8)cm,多数为肝左叶病灶和肿块型病灶㊂本研究CT平扫主要特征为分叶状低密度肿块,密度不均匀,边缘模糊或不清楚,周边有时可见肝内胆管不规则扩张,呈软藤样改变,部分出现肝局部包膜萎缩改变,增强后呈渐进性强化,强化范围扩大㊂研究[20]表明,胆管细胞癌最主要的危险因素是胆管结石㊂本组CT平扫显示肝左叶萎缩患者占比为19.0%,可能是由于肿瘤浸润生长,内部大量纤维组织形成,导致肝叶萎缩㊂
本组不同病灶类型多期CT增强扫描特征表现也不尽相同㊂肿块型肿瘤在动脉期主要为病灶边缘薄层轻度强化,静脉期均显示病灶边缘薄层轻度强化,延迟期均显示病灶强化加强㊂由此可见,肿块型病灶多期CT增强扫描具有特征性的从病灶的边缘
开始结节样强化,逐渐向病灶中心扩展,呈现 慢进慢出 的特征性改变㊂腔内生长型肿瘤在动脉期主要为肝门附近局部软组织病灶轻度强化,静脉期均显示病灶进一步强化,延迟期均显示病灶缓慢持续强化㊂浸润型肿瘤动脉期主要为肝内胆管壁轻度强化,静脉期均显示病灶进一步强化,延迟期均显示病灶缓慢持续强化㊂上述结果与既往研究[21,22]报道相似㊂
综上所述,多期CT增强扫描诊断ICC的准确度较高,主要扫描特征为肿块型病灶多期CT增强扫描具有特征性的从病灶的边缘开始结节样强化,逐渐向病灶中心扩展,呈现 慢进慢出 的特征性改变;腔内生长型动脉期主要为肝门附近局部软组织病灶轻度强化,静脉期均显示病灶进一步强化,延迟期均显示病灶缓慢持续强化;浸润型动脉期主要为肝内胆管壁轻度强化,静脉期均显示病灶进一步强化,延迟期均显示病灶缓慢持续强化㊂多期CT增强扫描诊断ICC有较高的价值,其扫描特征对临床指导手术方案的制定具有重要的意义㊂
本研究也存在一定的局限性,回顾性研究可能存在选择偏倚㊂由于回顾性资料的限制,未考虑临床和病理学特征对诊断效能的影响㊂有些病例的诊断系穿刺获得的少量组织检查,可能对诊断有一定的影响㊂
ʌ参考文献ɔ
[1]Banales JM,Marin JJG,Lamarca A,et al.Cholangiocarcinoma
2020:the next horizon in mechanisms and management.Nat Rev Gastroenterol Hepatol,2020,17(9):557-588.
[2]Beaufrère A,Calderaro J,Paradis bined hepatocellular-cholan-
giocarcinoma:An update.J Hepatol,2021,74(5):1212-1224. [3]Kendall T,Verheij J,Gaudio E,et al.Anatomical,histomorpho-
logical and molecular classification of cholangiocarcinoma.Liver Int,2019,39(1):7-18.
[4]Elvevi A,Laffusa A,Scaravaglio M,et al.Clinical treatment of
cholangiocarcinoma:an updated comprehensive review.Ann Hepa-tol,2022,27(5):100737.
[5]Mosconi C,Calandri M,Javle M,et al.Interventional radiology
approaches for intra-hepatic cholangiocarcinoma.Chin Clin Oncol, 2020,9(1):8-12.
[6]Nakamura Y,Higaki T,Honda Y,et al.Advanced CT techniques
for assessing hepatocellular carcinoma.Radiol Med,2020,126(7): 925-935.
[7]Goo HW.Four-Dimensional thoracicCT in free-breathing children.
Korean J Radiol,2019,20(1):50-57.
[8]Agostini A,Borgheresi A,Bruno F,et al.New advances in CT im-
aging of pancreas diseases:a narrative review.Gland Surg,2020,9
(6):2283-2294.
[9]Buus TW,Rasmussen F,Nellemann HM,et parison of
contrast-enhanced CT,dual-layer detector spectral CT,and whole -body MRI in suspected metastatic breast cancer:a prospective di-agnostic accuracy study.Eur Radiol,202,31(12):8838-8849.
[10]Husmann L,Huellner MW,Gruenig H,et al.Imaging characteris-
tics and diagnostic accuracy of FDG-PET/CT,contrast enhanced CT and combined imaging in patients with suspected mycotic or in-flammatory abdominal aortic aneurysms.PLoS One,2022,17(8): 272772-272779.
[11]Mejia JC,Pasko J.Primaryliver cancers:Intrahepatic cholangiocar-
cinoma and hepatocellular carcinoma.Surg Clin North Am,2020, 100(3):535-549.
[12]Macias RIR,Monte MJ,Serrano MA,et al.Impact of aging on pri-
mary liver cancer:epidemiology,pathogenesis and therapeutics.
Aging(Albany NY),2021,13(19):23416-23434. [13]Khan SA,Tavolari S,Brandi G.Cholangiocarcinoma:
Epidemiology and risk factors.Liver Int,201,39(1):19-31. [14]Dondossola D,Ghidini M,Grossi F,et al.Practical review for di-
agnosis and clinical management of perihilar cholangiocarcinoma.
World J Gastroenterol,2020,26(25):3542-3561. [15]Lee YT,Wang JJ,Luu M,et parison of clinical features
and outcomes between intrahepatic cholangiocarcinoma and hepato-cellular carcinoma in the united states.Hepatology,2021,74(5): 2622-2632.
[16]Mar WA,Chan HK,Trivedi SB,et al.Imaging ofintrahepatic cholan-
giocarcinoma.Semin Ultrasound CT MR,2020,42(4):366-380. [17]Mahmoudi S,Bernatz S,Althoff FC,et al.Dual-energy CT based
material decomposition to differentiate intrahepatic cholangiocarcinoma from hepatocellular carcinoma.Eur J Radiol, 2022,156(1):110556-110562.
[18]Wakiya T,Ishido K,Kimura N,et al.CT-based deep learning en-
ables early postoperative recurrence prediction for intrahepatic cholangiocarcinoma.Sci Rep,2022,12(1):8428-8435. [19]Fiz F,Masci C,Costa G,et al.PET/CT-based radiomics of mass
-forming intrahepatic cholangiocarcinoma improves prediction of pa-thology data and survival.Eur J Nucl Med Mol Imaging,2022,49
(10):3387-3400.
[20]Clements O,Eliahoo J,Kim JU,et al.Risk factors for intrahepatic
and extrahepatic cholangiocarcinoma:A systematic review and meta -analysis.J Hepatol,2020,72(1):95-103.
[21]Xue B,Wu S,Zhang M,et al.A radiomic-based model of
different contrast-enhanced CT phase for differentiate intrahepatic cholangiocarcinoma from inflammatory mass with hepatolithiasis.
Abdom Radiol(NY),2021,46(8):3835-3844. [22]Zhao F,Pang G,Li X,et al.Value of perfusion parameters histo-
gram analysis of triphasic CT in differentiating intrahepatic mass forming cholangiocarcinoma from hepatocellular carcinoma.Sci Rep,2021,11(1):23163-23169.
(收稿:2023-05-22)
(本文编辑:陈宗炳)。