本文選題：肝細胞癌 + 微小病變�。� 參考：《廣西醫(yī)科大學(xué)》2017年博士論文

【摘要】：第一部分:肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強在肝細胞癌微小病變檢出的前瞻性對比研究目的:對比探討肝動脈造影(digital subtraction angiography,DSA)與核磁共振成像(magnetic resonance imaging,MRI)動態(tài)釓噴酸葡胺增強對肝細胞癌微小病變(直徑≤2cm)檢出率的診斷價值。材料與方法:前瞻性分析我院符合入組標準,其他檢查顯示出肝臟內(nèi)單發(fā)或多發(fā)病變中包含有微小病灶(即直徑≤2cm)的病例術(shù)前兩周內(nèi)同時行肝動脈DSA和MRI動態(tài)釓噴酸葡胺增強檢查。年齡最小25歲,最大75歲,中位年齡51歲。47例88個病灶經(jīng)手術(shù)切除證實,3例4個病灶由病理穿刺活檢證實,7例15個病灶經(jīng)肝動脈化療栓塞術(shù)后碘油沉積并術(shù)后實驗室檢查和影像學(xué)隨訪證實。采用SPSS16.0軟件包對肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強的檢出率進行Mc Nmar卡方檢驗、Kappa一致性檢驗,應(yīng)用獨立樣本t檢驗和受試者運行特征曲線分析肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強對被檢出的肝細胞癌微小病變直徑的大小。結(jié)果:57例107個微小病灶,其中63個病灶直徑≤1cm,44個病灶直徑1cm;富血供型91個,乏血供型16個,44個見包膜征。肝動脈DSA共檢出92個,其中乏血供型1個;MRI共檢出76個,其中乏血供型6個。肝動脈DSA、MRI動態(tài)釓噴酸葡胺增強的檢出率分別為86.0%(92/107)、71.0%(76/107),Mc Nmar檢驗結(jié)果P0.05,Kappa值為0.303(P=0.001),兩者差異顯著。乏血供型微小病灶,MRI動態(tài)釓噴酸葡胺增強的檢出率為37.5%(6/16),肝動脈DSA的檢出率為0.1%(1/16),Fisher’s確切概率法顯示P0.05。微小病變直徑≤1cm時,MRI的檢出率為52.4%(33/63),肝動脈DSA的檢出率為81.0%(51/63),病變直徑大于1cm且小于或等于2cm時,MRI的檢出率為97.7%(43/44),肝動脈DSA的檢出率為93.2%(41/44)。結(jié)論:肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強對肝細胞癌微小病變的檢出均具有較高的診斷價值,肝動脈DSA對于富血供型微小病變的檢出明顯優(yōu)于MRI動態(tài)釓噴酸葡胺增強檢查,而且肝動脈DSA可進行后續(xù)的栓塞化療術(shù),對于肝細胞癌的精準分期及預(yù)后具有重要的臨床意義。第二部分肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強對肝細胞癌巴塞羅那分期的應(yīng)用價值研究目的:探討肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強對肝細胞癌巴塞羅那分期的應(yīng)用價值。材料與方法:同第一部分。通過CT檢查評估為BCLC-A期,其他檢查未發(fā)現(xiàn)而臨床高度懷疑或者其他檢查顯示出肝臟內(nèi)單發(fā)或多發(fā)病變中包含有微小病灶(即直徑≤2cm)的病例,術(shù)前同時行肝動脈DSA及MRI動態(tài)釓噴酸葡胺增強檢查。結(jié)果:經(jīng)卡方檢驗,肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強檢查結(jié)果分期相同115例,MRI動態(tài)釓噴酸葡胺增強分期之后經(jīng)肝動脈DSA檢查發(fā)現(xiàn)分期改變有62例,改變分期的占總的達33.3%(62/186),肝動脈DSA分期之后經(jīng)MRI動態(tài)釓噴酸葡胺增強檢查發(fā)現(xiàn)分期改變有9例,改變分期的占總的達4.8%(9/186),肝動脈DSA對巴塞羅那分期的判斷顯著優(yōu)于MRI動態(tài)釓噴酸葡胺增強檢查,差異有統(tǒng)計學(xué)意義(P=0.03)。結(jié)論:肝動脈DSA在肝細胞癌巴塞羅那分期應(yīng)用方面優(yōu)于MRI動態(tài)釓噴酸葡胺增強檢查。第三部分肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強對肝細胞癌微小病變檢出的成本效果分析目的:建立肝細胞癌微小病變檢出的衛(wèi)生經(jīng)濟學(xué)評價模型。方法:根據(jù)肝動脈DSA與MRI動態(tài)釓噴酸葡胺增強檢查方法,分為肝動脈DSA診斷組和MRI動態(tài)釓噴酸葡胺增強診斷組。收集兩組治療方案直接醫(yī)療成本,統(tǒng)計兩組的檢出率,對兩組進行成本效果分析、增量成本效果分析和敏感性分析。結(jié)果:肝動脈DSA診斷組的成本效果比為69.46元/%,MRI動態(tài)釓噴酸葡胺增強診斷組的成本效果比為22.24元/%,肝動脈DSA診斷組是MRI動態(tài)釓噴酸葡胺增強診斷組的3.1倍;以MRI動態(tài)釓噴酸葡胺增強診斷組為基礎(chǔ),增量成本效果比為293.8元/%,表示從MRI動態(tài)釓噴酸葡胺增強診斷方案改換為肝動脈DSA診斷方案,診斷靈敏度每增加1%,費用增加293.8元。本研究假設(shè)檢查費、材料費及藥物費下降10%,肝動脈DSA診斷組的成本效果比為62.55元/%,MRI動態(tài)釓噴酸葡胺增強診斷組的成本效果比為20.04元/%,肝動脈DSA診斷組仍是MRI動態(tài)釓噴酸葡胺增強診斷組的3.1倍;以MRI動態(tài)釓噴酸葡胺增強診斷組為基礎(chǔ),增量成本效果比為264.51元/%,表示從MRI動態(tài)釓噴酸葡胺增強診斷方案改換為肝動脈DSA診斷方案,診斷靈敏度每增加1%,費用增加264.51元。結(jié)論:從衛(wèi)生經(jīng)濟學(xué)角度,肝細胞癌微小病變的檢出,常規(guī)MRI檢查可能是最優(yōu)的檢查方法。第四部分:肝動脈DSA與MRI釓塞酸二鈉增強技術(shù)在肝細胞癌微小病變檢出的前瞻性對比研究目的:對比分析肝動脈DSA與MRI釓塞酸二鈉增強對肝細胞癌微小病變(直徑≤2cm)的檢出率,探討兩者的應(yīng)用價值。材料與方法:前瞻性隨機分析術(shù)前同時行肝動脈DSA與MRI釓塞酸二鈉增強檢查。年齡最小31歲,最大66歲,平均年齡49.6±8.9歲。MRI檢查和肝動脈DSA檢查間隔時間不超過2周。35例64個病灶經(jīng)手術(shù)切除證實,2例3個病灶由病理穿刺活檢證實,5例10個病灶經(jīng)肝動脈化療栓塞術(shù)后碘油沉積并術(shù)后實驗室檢查和影像學(xué)隨訪證實。采用SPSS 16.0軟件包行Mc Nmar檢驗、Kappa一致性檢驗、獨立樣本t檢驗和受試者運行特征曲線分析對兩組進行統(tǒng)計學(xué)分析。結(jié)果:共42例77個病灶,其中42個病灶直徑≤1cm,35個病灶直徑1cm;肝動脈DSA共檢出67個微小病灶,均為富血供型;MRI釓塞酸二鈉增強共檢出72個微小病灶。肝動脈DSA、MRI釓塞酸二鈉增強的檢出率分別為87.0%、93.5%,Mc Nmar檢驗P=0.0620.05,Kappa值為0.635,P0.05,兩種方法一致性較好。乏血供型微小病變中,肝動脈DSA檢出率為0%,MRI的檢出率為70%。Fisher’s精確概率檢驗結(jié)果顯示P=0.0160.05。MRI釓塞酸二鈉增強檢出病變的最小直徑約為0.4cm,肝動脈DSA檢出病變的最小直徑約為0.5cm。病變直徑≤1 cm時,肝動脈DSA的檢出率為76.2%(32/42),MRI釓塞酸二鈉增強的檢出率為88.1%(37/42),兩者之間的差異不具有統(tǒng)計學(xué)意義;病變直徑1cm又≤2cm時,肝動脈DSA與MRI釓塞酸二鈉增強的檢出率均為100%。結(jié)論:肝動脈DSA與MRI釓塞酸二鈉增強對肝細胞癌微小病變的檢出率差別不具有統(tǒng)計學(xué)意義,具有較好的一致性;MRI釓塞酸二鈉增強對乏血供型微小病變的檢出率顯著優(yōu)于肝動脈DSA檢查。從不同的禁忌癥和后續(xù)治療等方面進行科學(xué)的合理的選擇微小病變的檢出方法,不僅有助于肝細胞癌精準分期,為患者治療和預(yù)后提供最有價值的信息,而且還可以為病人避免不必要的檢查所帶來的痛苦。第五部分:前瞻性隨機對照肝動脈DSA與MRI釓塞酸二鈉動態(tài)增強對肝癌微小病變檢出研究目的:隨機對比分析肝動脈DSA與MRI釓塞酸二鈉增強對肝細胞癌微小病變(直徑≤2cm)的檢出率,探討兩者的應(yīng)用價值。材料與方法:前瞻性隨機收集術(shù)前行MRI動態(tài)釓塞酸二鈉增強或肝動脈DSA檢查。MRI動態(tài)釓塞酸二鈉增強123例,其中男108例,女15例;年齡最小20歲,最大81歲,平均年齡50.5±12.5歲,103例133個微小病灶經(jīng)手術(shù)切除證實,9例24個微小病灶經(jīng)肝動脈化療栓塞(TACE)術(shù)后碘油沉積并術(shù)后實驗室檢查和影像學(xué)隨訪證實,11例34個微小病灶經(jīng)臨床處理影像學(xué)隨訪驗證。肝動脈DSA檢查共66例,其中男56例,女10例。年齡最小27歲,最大78歲,平均年齡50.5±10.6歲。手術(shù)切除34例共44個微小病灶,TACE術(shù)29例共63個微小病灶,3個10個微小病灶經(jīng)臨床和影像學(xué)隨訪證實。采用SPSS16.0軟件包行卡方檢驗對兩組進行統(tǒng)計學(xué)分析。結(jié)果:肝動脈DSA、MRI釓塞酸二鈉增強對微小病灶的檢出率分別為91.5%、89.5%。兩者檢出率經(jīng)卡方檢驗,χ2=0.29(p=0.59),差異不具有統(tǒng)計學(xué)意義。病變直徑≤1cm時,肝動脈DSA的檢出率為75.8%,MRI釓塞酸二鈉增強的檢出率為64.9%,卡方檢驗χ2=1.147(p=0.284),兩者之間的差異不具有統(tǒng)計學(xué)意義;病變直徑1cm時,MRI釓塞酸二鈉增強的檢出率為100%。結(jié)論:肝動脈DSA與MRI釓塞酸二鈉增強對肝癌微小病變的檢出率差別不具有統(tǒng)計學(xué)意義,從肝動脈DSA與MRI釓塞酸二鈉增強所提供的信息不同而選取較優(yōu)的檢查方法,在精準分期的同時,又可以減輕患者不必要檢查所帶來的痛苦。
[Abstract]:The first part: the prospective comparative study of hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine enhancement in the detection of small lesions of hepatocellular carcinoma: comparison of digital subtraction angiography (DSA) and magnetic resonance imaging (magnetic resonance imaging, MRI) dynamic gadolinium enhanced gadolinium acid (gadolinium chloride) enhanced microlesions of hepatocellular carcinoma Diagnostic value of detection rate of diameter less than 2cm). Materials and methods: prospective analysis our hospital conforms to the standard of entry group. Other tests show that the liver artery DSA and MRI dynamic gadolinium enhanced gadolinium enhancement examination were performed within two weeks before the operation of single or multiple lesions in the liver. The minimum age was 25 years and the maximum was 75 years old. 88 lesions of the median age of 51 years were confirmed by surgical excision. 3 cases of 4 lesions were confirmed by pathological biopsy. 7 cases of 15 lesions were deposited after hepatic arterial chemoembolization and confirmed by laboratory examination and imaging follow-up. The detection rate of DSA and MRI dynamic gadolinium enhanced by DSA and MRI was Mc Nma R chi square test, Kappa consistency test, independent sample t test and subject running characteristic curve analysis of the size of hepatic artery DSA and MRI dynamic gadolinium gadolinium acid meglumine enhanced microlesion diameter of hepatocellular carcinoma detected by MRI. Results: 57 cases of 107 small lesions, 63 of which were straight diameter less than 1cm, 1cm in diameter of 44 lesions, 91 of rich blood donors. There were 16 blood supply types and 44 envelope signs. There were 92 DSA in the hepatic artery, of which 1 were used for blood supply, 76 were MRI, 6 of the donor blood supply, DSA of the hepatic artery, and 86% (92/107), 71% (76/107), Mc Nmar test fruit P0.05 and Kappa value 0.303 (P=0.001). The difference was significant. The difference of blood supply was significant. The detection rate of MRI dynamic gadolinium enhanced meglumine was 37.5% (6/16), and the detection rate of DSA in hepatic artery was 0.1% (1/16). The exact probability of Fisher 's showed that the detection rate of MRI was 52.4% (33/63) when the diameter of P0.05. small lesion was less than 1cm. The detection rate of hepatic artery DSA was 81% (51/63), and the lesion diameter was larger than or equal to that of the 1cm. The rate of extraction was 97.7% (43/44) and the detection rate of hepatic artery DSA was 93.2% (41/44). Conclusion: both hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine have a high diagnostic value for the detection of micropathological changes of hepatocellular carcinoma. The detection of DSA in hepatic artery for blood donor microlesions is superior to MRI dynamic gadolinium acid gadolinium enhanced examination, and hepatic artery DSA Follow-up embolization chemotherapy is of great clinical significance for the accurate staging and prognosis of hepatocellular carcinoma. Second the application value of the second part of the hepatic artery DSA and MRI dynamic gadolinium acid gadolinium enhancement in the Barcelona staging of hepatocellular carcinoma: To explore the enhancement of hepatic artery DSA and MRI dynamic gadolinium acid glucosamine to the Barcelona of hepatocellular carcinoma The application value of the staging. Materials and methods: with the first part. The CT examination was evaluated for the BCLC-A phase, other examinations were not found and the clinical highly suspected or other examination showed that there were small lesions (that is, diameter less than 2cm) in the single or multiple lesions of the liver, and the hepatic artery DSA and MRI dynamic gadolinium acid glucoamine increased before the operation. Results: after the chi square test, 115 cases of the hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine enhanced examination were in the same staging. After the MRI dynamic gadolinium gadolinium enhanced staging, 62 cases were found to be changed by the hepatic artery DSA examination. The changes of the stages were 33.3% (62/186), and the DSA staging of the hepatic artery was enhanced by MRI dynamic gadolinium acid gadolinium enhancement. It was found that 9 cases were changed by staging and 4.8% (9/186) were changed by stage. The judgment of hepatic artery DSA to Barcelona staging was significantly better than that of MRI dynamic gadolinium acid gadolinium enhanced examination. The difference was statistically significant (P=0.03). Conclusion: hepatic artery DSA is superior to MRI dynamic gadolinium acid gadolinium enhancement examination in the application of hepatic artery DSA The cost-effectiveness analysis of the third partial hepatic artery DSA and MRI dynamic gadolinium enhanced meglumine in detection of microlesions of hepatocellular carcinoma: Objective: to establish a health economic evaluation model for the detection of microlesions of hepatocellular carcinoma. Methods: Based on the enhanced examination of DSA and MRI dynamic gadolinium acid meglumine, the hepatic artery DSA diagnosis group and the MRI dynamics were divided. The diagnostic unit of gadolinium acid meglumine was collected. The cost of direct medical treatment in two groups was collected, the detection rate of two groups was counted, the cost effect analysis, the incremental cost effect analysis and sensitivity analysis were carried out in the two groups. The result: the cost effect ratio of the DSA diagnosis group of the hepatic artery was 69.46 yuan /%, and the cost effect ratio of the MRI dynamic gadolinium acid glucoacid enhanced diagnosis group was 22. 24 yuan /%, the DSA diagnosis group of the hepatic artery was 3.1 times that of the MRI dynamic gadolinium acid gadolinium enhanced diagnostic group; based on the MRI dynamic gadolinium acid gadolinium enhanced diagnostic group, the incremental cost effect ratio was 293.8 yuan /%, indicating that the MRI dynamic gadolinium enhanced diagnostic scheme was changed to the DSA diagnosis of the hepatic artery, the diagnostic sensitivity increased by 1%, and the cost increased 293.8 This study assumed that the examination fee, material fee and drug charge decreased by 10%, the cost effect of the DSA diagnosis group of the hepatic artery was 62.55 yuan /%, the cost effect of the MRI dynamic gadolinium acid gadolinium enhanced diagnostic group was 20.04 yuan /%, the DSA diagnosis group of the hepatic artery was 3.1 times more than that of the MRI dynamic gadolinium acid gadolinium acid glucosamine enhanced diagnosis group; and the diagnosis of MRI dynamic gadolinium acid glucoamine enhanced diagnosis. On the basis of the group, the incremental cost effect ratio was 264.51 yuan /%, indicating that the MRI dynamic gadolinium acid gadolinium enhanced diagnostic scheme was changed to the DSA diagnosis of hepatic artery, the diagnostic sensitivity increased by 1% and the cost increased by 264.51 yuan. Conclusion: from the point of view of health economics, the detection of small lesions of hepatocellular carcinoma and routine MRI examination may be the best method of examination. The four part: the prospective comparative study of hepatic artery DSA and MRI gadolinium acid sodium enhanced technique in detection of small lesions in hepatocellular carcinoma Objective: To compare and analyze the detection rate of hepatic artery DSA and MRI gadolinium two sodium increased to small lesions of hepatocellular carcinoma (diameter less than 2cm) and to explore the application value of both. The DSA and MRI gadolinium two sodium enhanced examination. The age was 31 years old, the maximum was 66 years old, the average age was 49.6 + 8.9 years old.MRI examination and the interval time of DSA examination of the hepatic artery was not more than 2 weeks. 64 lesions were confirmed by surgical excision. 2 cases of 3 lesions were confirmed by pathological biopsy, 5 cases of 10 lesions were treated with iodide after transcatheter arterial chemoembolization. SPSS 16 software package Mc Nmar test, Kappa conformance test, independent sample t test and operation characteristic curve analysis were used to analyze two groups with statistical analysis. Results: there were 42 cases of 77 lesions, of which 42 lesions were straight diameter less than 1cm, and 35 lesions were 1cm in diameter; the hepatic artery DSA was detected altogether. 67 small lesions were both rich in blood supply and 72 small lesions were detected by MRI gadolinium two sodium enhancement. The detection rates of liver artery DSA, MRI gadolinium two sodium enhancement were 87%, 93.5%, Mc Nmar test P=0.0620.05, Kappa value 0.635, P0.05, and good consistency of the two methods. The detection rate of hepatic artery DSA was 0%, MRI detection was 0%. The result of 70%.Fisher 's accurate probability test showed that the minimum diameter of P=0.0160.05.MRI gadolinium acid two sodium enhanced detection was about 0.4cm. The detection rate of hepatic artery DSA was 76.2% (32/42), and the detection rate of MRI gadolinium two sodium enhanced by DSA was 88.1% (37/42), two The difference between the 1cm and the MRI gadolinium acid two of the hepatic artery was 100%. conclusion: the contrast between the hepatic artery DSA and the MRI gadolinium two sodium enhanced the detection rate of the microlesions of the hepatocellular carcinoma was not statistically significant, with a better consistency, and the enhancement of MRI gadolinium acid two sodium was enhanced. The detection rate of blood donor micro lesions is significantly better than that of the hepatic artery DSA. The scientific and rational selection of small lesions from different contraindications and follow-up treatments will not only help the accurate staging of hepatocellular carcinoma, provide the most valuable information for the treatment and prognosis of the patients, but also avoid the patients. The pain caused by necessary examination. The fifth part: the objective of a prospective randomized controlled randomized controlled hepatic artery DSA and MRI gadolinium two sodium dynamic enhancement for the detection of micropathological changes in liver cancer: a randomized comparative analysis of the detection rates of hepatic artery DSA and MRI gadolinium two sodium (diameter < < 2cm) for hepatocellular carcinoma (diameter less than 2cm), and to explore the application value of the two. And methods: before prospective randomized collection, 123 cases of MRI dynamic gadolinium acid two sodium enhancement or hepatic artery DSA examination of.MRI dynamic gadolinium two were enhanced, including 108 males and 15 women; the minimum age 20 years old, the maximum age of 81, the average age 50.5 + 12.5 years old, 103 cases of 133 micro lesions confirmed by hand operation, 9 cases of 24 small lesions via the hepatic artery chemotherapeutic embolus After TACE, the deposition of iodide oil and postoperative laboratory examination and imaging follow-up confirmed that 11 cases of 34 tiny lesions were followed up and verified by clinical imaging. 66 cases of hepatic artery DSA were examined, including 56 males and 10 females. The age was 27 years old, the maximum age was 78 years, and the average age was 50.5 + 10.6 years. 34 cases were excised and 34 cases altogether 44 minor lesions, 29 cases 63 in TACE operation 63. 3 10 tiny lesions were followed up by clinical and imaging follow-up. The two groups were analyzed statistically with the SPSS16.0 software package test. Results: the detection rates of DSA and MRI gadolinium two in the liver were 91.5%, respectively. The detection rates of 89.5%. were examined by chi square test and 2=0.29 (p=0.59), and the difference was not of the series. When the lesion diameter was less than 1cm, the detection rate of hepatic artery DSA was 75.8%, the detection rate of MRI gadolinium two sodium enhancement was 64.9%, chi square test Chi 2=1.147 (p=0.284), the difference between the two was not statistically significant; when the diameter of the lesion was 1cm, the detection rate of MRI gadolinium two sodium enhancement was 100%. conclusion: hepatic artery DSA and MRI gadolinium two sodium enhancement The difference in detection rate of small lesions of liver cancer is not statistically significant. A better method is selected from the information provided by the enhancement of the hepatic artery DSA and the information provided by the MRI gadolinium acid two sodium. It can also reduce the pain caused by the unnecessary examination of the patient at the same time.

【學(xué)位授予單位】：廣西醫(yī)科大學(xué)
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R735.7

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