本文選題：肝臟孤立性壞死結(jié)節(jié) + 肝細(xì)胞癌��； 參考：《山東大學(xué)》2017年碩士論文

【摘要】：研究背景肝臟孤立性壞死結(jié)節(jié)(solitary necrotic nodule of the liver,SNNL)是一種罕見的良性腫瘤樣病變。肝臟孤立性壞死結(jié)節(jié)的病因尚不清楚,可能與創(chuàng)傷、寄生蟲感染、肝血管瘤、腫瘤所引起的變態(tài)反應(yīng)和缺血等因素有關(guān)。肝臟孤立性壞死結(jié)節(jié)具有明顯的良性生物學(xué)行為,病灶大小可長(zhǎng)期無(wú)明顯改變或自發(fā)性減小甚至完全消失,且目前沒(méi)有肝臟孤立性壞死結(jié)節(jié)發(fā)生惡性轉(zhuǎn)化和引起嚴(yán)重并發(fā)癥的報(bào)道,故臨床上其治療以對(duì)癥治療為主,因而明確診斷可避免不必要的手術(shù)。肝臟孤立性壞死結(jié)節(jié)患者的臨床表現(xiàn)和體征并無(wú)特異性,臨床上亦無(wú)特殊的實(shí)驗(yàn)室檢查指標(biāo)可輔助其診斷。影像學(xué)檢查中MRI被認(rèn)為是最具診斷價(jià)值的檢查手段,然而肝臟孤立性壞死結(jié)節(jié)在MRI上的特征性影像學(xué)表現(xiàn)存在爭(zhēng)議,有學(xué)者認(rèn)為肝臟孤立性壞死結(jié)節(jié)在增強(qiáng)MRI上的特征性表現(xiàn)為肝動(dòng)脈期、門靜脈期和延遲期上均無(wú)強(qiáng)化,而亦有學(xué)者認(rèn)為病灶邊緣在延遲期出現(xiàn)環(huán)形強(qiáng)化而病灶中心三期均無(wú)強(qiáng)化是病灶的特征性表現(xiàn)。這些相互矛盾的結(jié)論以及非特異性的臨床資料導(dǎo)致目前基于患者的臨床表現(xiàn)、病史、影像學(xué)表現(xiàn)和實(shí)驗(yàn)室檢查肝臟孤立性壞死結(jié)節(jié)的術(shù)前疑診率僅約7.8%。雖然特征性影像學(xué)表現(xiàn)尚存爭(zhēng)議,但肝臟孤立性壞死結(jié)節(jié)的病理表現(xiàn)具有特征性,即病灶中心完全性、凝固性壞死,病灶周圍有薄層纖維包膜包繞,包膜內(nèi)有漿細(xì)胞、單核細(xì)胞和淋巴細(xì)胞等慢性炎癥細(xì)胞浸潤(rùn)。鑒于纖維組織和延遲強(qiáng)化的密切關(guān)系,且常規(guī)增強(qiáng)MRI上延遲強(qiáng)化時(shí)間不超過(guò)5分鐘,因此我們推斷肝臟孤立性壞死結(jié)節(jié)邊緣無(wú)環(huán)形強(qiáng)化的原因是因?yàn)橄鄬?duì)短的延遲時(shí)間。故我們用延遲時(shí)間達(dá)2小時(shí)的長(zhǎng)延遲增強(qiáng)MRI掃描以獲得肝臟孤立性壞死結(jié)節(jié)的特異性影像學(xué)表現(xiàn),提高肝臟孤立性壞死結(jié)節(jié)的診斷率。研究目的通過(guò)應(yīng)用MRI長(zhǎng)時(shí)間延遲多期增強(qiáng)掃描獲得肝臟孤立性壞死結(jié)節(jié)的特征性影像學(xué)表現(xiàn)并將這些影像學(xué)表現(xiàn)與肝內(nèi)三種主要相似惡性疾病的影像學(xué)表現(xiàn)進(jìn)行對(duì)比,以探究MRI長(zhǎng)時(shí)間延遲多期增強(qiáng)掃描在肝臟孤立性壞死結(jié)節(jié)的診斷和鑒別診斷中的應(yīng)用價(jià)值。研究方法對(duì)16例臨床疑診為肝臟孤立性壞死結(jié)節(jié)、后被病理證實(shí)的患者進(jìn)行平掃及三期增強(qiáng)CT掃描以及平掃和動(dòng)態(tài)對(duì)比增強(qiáng)MRI成像,MRI的延遲時(shí)間分別為對(duì)比劑(Gd-DTPA)注射后3分鐘、5分鐘、10分鐘、15分鐘、30分鐘、1小時(shí)和2小時(shí)。同時(shí),將23例具有肝內(nèi)相似惡性病灶的患者設(shè)定為對(duì)照組,包括7例肝細(xì)胞癌患者(8個(gè)病灶)、5例肝內(nèi)膽管細(xì)胞癌患者(5個(gè)病灶)和11例肝轉(zhuǎn)移癌患者,利用同樣的MRI技術(shù)進(jìn)行掃描,但當(dāng)觀察到病灶邊緣強(qiáng)化退出后,后續(xù)的延遲掃描便不再進(jìn)行。在CT和MRI上病灶的影像學(xué)觀測(cè)指標(biāo)包括:病灶的數(shù)目、位置、形狀、大小、密度、信號(hào)強(qiáng)度、增強(qiáng)程度、邊緣強(qiáng)化出現(xiàn)時(shí)間和消失時(shí)間等,圖像的分析和評(píng)估由兩位具有十年以上經(jīng)驗(yàn)的放射科醫(yī)師在不知研究?jī)?nèi)容的情況下進(jìn)行評(píng)估并記錄。本研究獲得醫(yī)院倫理委員會(huì)批準(zhǔn)并獲得所有患者或家屬的知情同意。研究結(jié)果在16例肝臟孤立性壞死結(jié)節(jié)患者中,影像學(xué)檢查共發(fā)現(xiàn)16個(gè)病灶,當(dāng)延遲時(shí)間≤5分鐘時(shí),16個(gè)病灶中分別有4個(gè)(25%)和8個(gè)(50%)病灶在常規(guī)CT和MRI延遲期上表現(xiàn)為邊緣輕度環(huán)形強(qiáng)化。隨著增強(qiáng)MRI的延遲時(shí)間被延長(zhǎng),腫瘤邊緣/瘤內(nèi)間隔的強(qiáng)化逐漸增厚、強(qiáng)化程度逐漸增加。當(dāng)延遲時(shí)間達(dá)到1小時(shí)時(shí),所有病灶(100%)均表現(xiàn)為中度至明顯邊緣環(huán)形強(qiáng)化伴中心無(wú)強(qiáng)化低信號(hào)區(qū)。在對(duì)照組中,當(dāng)延遲時(shí)間≤5分鐘時(shí),所有肝細(xì)胞癌、肝內(nèi)膽管細(xì)胞癌及大多數(shù)肝轉(zhuǎn)移癌病灶在傳統(tǒng)MRI延遲期上表現(xiàn)為中度至明顯邊緣環(huán)形強(qiáng)化。然而,當(dāng)對(duì)比劑注射后10分鐘-15分鐘時(shí),7個(gè)(87.5%)肝細(xì)胞癌病灶以及除3個(gè)外的所有肝轉(zhuǎn)移癌病灶邊緣強(qiáng)化退出,當(dāng)對(duì)比劑注射后30分鐘時(shí),1個(gè)(20%)肝內(nèi)膽管細(xì)胞癌病灶邊緣強(qiáng)化退出,對(duì)比劑注射后1小時(shí)時(shí),其余4個(gè)(80%)肝內(nèi)膽管細(xì)胞癌病灶邊緣強(qiáng)化退出。另外,肝內(nèi)膽管細(xì)胞癌和肝轉(zhuǎn)移癌病灶在邊緣強(qiáng)化退出時(shí)通常伴有對(duì)比劑向病灶中心彌散,表現(xiàn)為病灶中心斑片狀強(qiáng)化。結(jié)論延遲時(shí)間為1小時(shí)或2小時(shí)的長(zhǎng)延遲增強(qiáng)MRI在肝臟孤立性壞死結(jié)節(jié)的診斷及其與肝內(nèi)相似疾病的鑒別診斷中具有重要意義。肝臟孤立性壞死結(jié)節(jié)在長(zhǎng)延遲增強(qiáng)MRI上的特征性影像學(xué)表現(xiàn)為病灶邊緣/瘤內(nèi)間隔明顯強(qiáng)化伴中心無(wú)強(qiáng)化低信號(hào)區(qū),而肝癌、膽管癌和轉(zhuǎn)移瘤則在1小時(shí)時(shí)邊緣的對(duì)比劑退出。如果在整個(gè)長(zhǎng)延遲過(guò)程中病灶均未表現(xiàn)出強(qiáng)化,則可以排除肝臟孤立性壞死結(jié)節(jié)的診斷。
[Abstract]:Background hepatic solitary necrotic nodules (solitary necrotic nodule of the liver, SNNL) is a rare benign tumor like lesion. The etiology of solitary necrotic nodules of the liver is unclear. It may be related to the factors such as trauma, parasitic infection, hepatic hemangioma, allergy and ischemia caused by tumors. Solitary necrotic nodules of the liver. With obvious benign biological behavior, the size of the lesion can not be changed or spontaneously decreased for a long time or even completely disappeared, and there is no report on the malignant transformation of the solitary necrotic nodules of the liver and the report of serious complications. Therefore, the clinical treatment is mainly for symptomatic treatment, so the definite diagnosis can avoid unnecessary operation. There is no specific clinical manifestation and physical signs in patients with solitary necrotic nodules. There is no special laboratory test for diagnosis. MRI is considered as the most diagnostic method in imaging examination. However, the characteristic imaging findings of isolated necrotic nodules in the liver are controversial, and some scholars believe the liver is in the liver. The characteristic manifestations of the solitary necrotic nodules on the enhanced MRI were the hepatic arterial phase, the portal venous phase and the delay period were not enhanced, while some scholars believed that the edge of the lesion had a circular enhancement in the delay period and the three stage of the focus was not enhanced. These contradictory conclusions and non specific clinical data were found. The present rate of diagnosis based on the clinical manifestation, history, imaging and laboratory examination of solitary necrotic nodules of the liver is only about 7.8%., although the characteristic imaging manifestations of the liver are still controversial, but the pathological manifestations of the solitary necrotic nodules of the liver are characteristic, that is, the central integrity of the lesion, the coagulation necrosis, and the thin lesions around the focus. There are chronic inflammatory cells, such as plasma cells, mononuclear cells and lymphocytes in the envelope, in the envelope. In view of the close relationship between the fibrous tissue and the delayed enhancement, and the delayed enhancement time of the conventional enhanced MRI is not more than 5 minutes. Therefore, we infer that the reason for the non ring enhancement on the edge of the solitary liver is because it is relatively short. Delay time. Therefore, we use long delay enhanced MRI scan with delayed time of 2 hours to obtain specific imaging findings of solitary necrotic nodules of the liver, and improve the diagnostic rate of solitary necrotic nodules of the liver. Objective to obtain the characteristic image of hepatic solitary necrotic nodules by MRI long time delayed multiphase enhanced scan. The findings were compared with the imaging findings of the three major similar malignant diseases in the liver to explore the value of MRI long time delayed multiphase enhanced scan in the diagnosis and differential diagnosis of solitary necrotic nodules of the liver. 16 cases were clinically suspected as solitary necrotic nodules of the liver, and then pathologically. The confirmed patients underwent plain and three phase enhanced CT scans as well as plain and dynamic contrast enhanced MRI imaging. The delay time of MRI was 3 minutes, 5 minutes, 10 minutes, 15 minutes, 30 minutes, 1 hours and 2 hours after the contrast agent (Gd-DTPA). At the same time, 23 patients with intrahepatic similar malignant lesions were set as the control group, including 7 liver fine. Patients with cell carcinoma (8 lesions), 5 cases of intrahepatic cholangiocarcinoma (5 lesions) and 11 patients with liver metastases were scanned with the same MRI technique, but the follow-up delayed scans were no longer carried out when the lesions were fortified. The number, position, shape, size of the focus on CT and MRI were observed. The analysis and evaluation of the image was evaluated and recorded by two radiologists with more than ten years of experience without knowing the content of the study. This study was approved by the hospital ethics committee and obtained the informed consent of all patients or family members. Results in 16 patients with solitary necrotic nodules of the liver, 16 lesions were found in the imaging examination. When the delay time was less than 5 minutes, 4 (25%) and 8 (50%) of the 16 lesions, respectively, showed marginal annular intensification at the conventional CT and MRI delays. With the prolongation of the intensification of MRI, the tumor margin / intratumoral septum was prolonged. When the delay time was 1 hours, all lesions (100%) showed moderate to obvious marginal annular enhancement with central non intensification low signal region. In the control group, all hepatocellular carcinoma, intrahepatic bile duct carcinoma and most liver metastases were in the traditional MR when the delay time was less than 5 minutes. The I delay period showed moderate to obvious marginal annular enhancement. However, when the contrast agent was injected 10 minutes -15 minutes, 7 (87.5%) hepatocellular carcinoma lesions and all the liver metastases except 3 outside were exited, and 1 (20%) of the intrahepatic cholangiocarcinoma were fortified at the edge of the contrast agent at 30 minutes after the contrast injection, and the contrast agent was injected. At the next 1 hours, the other 4 (80%) intrahepatic cholangiocarcinoma lesions were withdrawn. In addition, intrahepatic cholangiocarcinoma and hepatic metastases were usually accompanied by contrast agent diffusion to the center of the lesion, showing central plaque enhancement in the focus. Conclusion the delay time was 1 hours or 2 hours of long delayed enhanced MRI in the liver. The diagnosis of erect necrotic nodules is of great significance in the differential diagnosis of intrahepatic similar diseases. The characteristic imaging of hepatic solitary necrotic nodules on long delayed enhanced MRI shows that the marginal / intratumoral septum is obviously enhanced with the central non enhanced low signal region, while the liver, cholangiocarcinoma and metastatic tumors are at the edge of 1 hours. If the lesion does not show enhancement during the whole long delay, the diagnosis of solitary necrotic nodule of the liver can be ruled out.
【學(xué)位授予單位】：山東大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R575;R445.2

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3 王迪;MRI“揪”出更多乳腺癌病例[N];醫(yī)藥經(jīng)濟(jì)報(bào);2004年

4 張忠霞;美癌癥學(xué)會(huì)建議：乳腺癌高危女性每年做一次MRI[N];醫(yī)藥經(jīng)濟(jì)報(bào);2007年

5 馬艷紅;北京安貞醫(yī)院建立國(guó)內(nèi)最大冠心病MRI數(shù)據(jù)庫(kù)[N];中國(guó)醫(yī)藥報(bào);2007年

6 衣曉峰 李華妍;步行負(fù)荷診斷腰椎狹窄與MRI相當(dāng)[N];中國(guó)醫(yī)藥報(bào);2013年

7 秦篤烈;MRI和起搏器可以兼得[N];健康報(bào);2003年

8 記者 閆煈;衛(wèi)生部加強(qiáng)PET—MRI配置管理[N];健康報(bào);2011年

9 楊文利;千億MRI市場(chǎng)能否重新洗牌[N];中國(guó)高新技術(shù)產(chǎn)業(yè)導(dǎo)報(bào);2006年

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10 馮霞;鼻咽癌放療后常規(guī)MRI顯示陰性的腦功能磁共振成像研究[D];南方醫(yī)科大學(xué);2013年

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