發(fā)布時(shí)間：2018-03-30 14:34

  本文選題：超聲造影　切入點(diǎn)：肝細(xì)胞肝癌　出處：《蘭州大學(xué)》2017年碩士論文

【摘要】：目的:聯(lián)合常規(guī)超聲和超聲造影重點(diǎn)觀察肝癌病灶數(shù)目、形態(tài)、大小、血供等情況,了解患者基本狀況、指導(dǎo)微波消融治療并評(píng)價(jià)腫瘤消融的情況。方法:回顧性分析2014年11月至2016年12月期間在我院行超聲引導(dǎo)下微波消融和門(mén)靜脈穿刺灌注化療藥物的45例肝細(xì)胞肝癌患者的臨床資料,所有患者均經(jīng)兩種以上影像學(xué)診斷和穿刺活檢病理確診,其中男性32例,女性13例,年齡31~79歲,平均(54±6.08)歲。37例患者患有慢性病毒性肝炎,31例合并肝硬化,乙肝病毒標(biāo)記物陽(yáng)性的30例,丙肝病毒標(biāo)記物陽(yáng)性的7例,1例為自身免疫性肝炎;12例患者合并高血壓,3例患有糖尿病。所有患者介入治療術(shù)前均行超聲造影和增強(qiáng)核磁(CE-MRI)檢查,了解腫塊的數(shù)目、大小、位置、形態(tài)、內(nèi)部回聲、彩色血流及周邊有無(wú)重要臟器或大血管,掌握病灶滋養(yǎng)血管及其分支的情況、患者肝狀況及余肝內(nèi)有無(wú)衛(wèi)星病灶等。45例患者經(jīng)超聲造影和CE-MRI檢查共檢出53個(gè)病灶。超聲引導(dǎo)下門(mén)靜脈穿刺灌注化療藥物和微波消融術(shù)后約15-20分鐘(微波消融強(qiáng)回聲氣泡消失散盡),所有患者均做超聲造影評(píng)估腫瘤消融程度,對(duì)消融不完全部位及時(shí)補(bǔ)充治療,條件不允許者擇期行補(bǔ)充治療。術(shù)后1-12月內(nèi)按手術(shù)后復(fù)查要求做超聲造影、CE-MRI以及臨床綜合檢查,評(píng)價(jià)肝細(xì)胞肝癌介入治療的效果。超聲造影檢查提示消融完全表現(xiàn)為:病灶整體無(wú)造影劑灌注;消融不完全表現(xiàn)為:病灶內(nèi)部或邊緣動(dòng)脈期仍有斑片狀增強(qiáng)區(qū),門(mén)靜脈期及延遲期有快速退出表現(xiàn)。CE-MRI檢查提示消融完全表現(xiàn)為:消融區(qū)內(nèi)無(wú)增強(qiáng),呈低信號(hào);消融不完全者表現(xiàn)為:病灶殘存部分動(dòng)脈期程度不一的強(qiáng)化,延遲期消退呈低增強(qiáng),呈快進(jìn)快出表現(xiàn)。結(jié)果:1.48個(gè)原發(fā)性肝細(xì)胞肝癌病灶在超聲造影上表現(xiàn)為典型的增強(qiáng)模式:動(dòng)脈期呈高增強(qiáng),門(mén)靜脈期或延遲期消退為低增強(qiáng),表現(xiàn)為“燈泡樣快進(jìn)快出”的特點(diǎn);4個(gè)直徑小于2cm的小肝癌病灶在動(dòng)脈期呈高增強(qiáng),門(mén)靜脈期或延遲期消退不明顯,表現(xiàn)為等增強(qiáng)。2.術(shù)前檢查中,45例患者由常規(guī)超聲檢測(cè)出病灶結(jié)節(jié)個(gè)數(shù)為46個(gè),超聲造影檢出52個(gè),CE-MRI檢出53個(gè),在篩查肝癌病灶個(gè)數(shù)方面,常規(guī)超聲與超聲造影比較差異有統(tǒng)計(jì)學(xué)意義(X2=4.867,P=0.027,p0.05),超聲造影與CE-MRI比較差異無(wú)統(tǒng)計(jì)學(xué)意義(X2=1.010,P=0.315,p0.05)。微波消融治療前后病灶范圍的測(cè)量:肝內(nèi)結(jié)節(jié)微波消融術(shù)前,超聲造影測(cè)得其長(zhǎng)徑和短徑均值分別為3.01±1.05、2.60±1.22,消融術(shù)后分別為4.40±1.61、4.20±1.23;CE-MRI術(shù)前測(cè)得長(zhǎng)徑和短徑均值分別為3.06±1.08、2.30±1.19,消融術(shù)后分別為5.00±1.89、4.00±1.21,在病灶范圍測(cè)量方面,超聲造影與CE-MRI比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.0.5)。3.53個(gè)微波消融病灶,術(shù)后即刻做超聲造影,46個(gè)病灶顯示消融完全;7個(gè)病灶內(nèi)部或周?chē)鷦?dòng)脈期顯示為不規(guī)則的高增強(qiáng)區(qū),門(mén)靜脈期或延遲期有快速退出表現(xiàn),提示其微波消融不徹底;補(bǔ)充消融后再次復(fù)查CE-US,顯示消融完全。4.經(jīng)過(guò)補(bǔ)充消融的7個(gè)病灶,其中有2例患者CE-MRI提示病灶邊緣結(jié)節(jié)影在動(dòng)脈期表現(xiàn)為程度不一強(qiáng)化,延遲期廓清,提示有腫瘤殘存,融合成像定點(diǎn)后行穿刺活檢證實(shí)有腫瘤殘存,限期內(nèi)給予再次消融術(shù);余51個(gè)病灶均提示消融完全。5.超聲造影和CE-MRI均提示消融完全的51個(gè)病灶中,有2例患者(均為單發(fā)灶)在后期隨訪過(guò)程中血清AFP不降、反而持續(xù)高于200μg/L,術(shù)后1-2月內(nèi)復(fù)查CE-MRI提示病灶有殘留,融合成像定點(diǎn)后行穿刺活檢證實(shí)有腫瘤殘存。最終診斷:49個(gè)病灶消融徹底,4個(gè)有局部腫瘤殘存。超聲造影提示53個(gè)病灶均消融完全;CE-MRI提示51個(gè)病灶消融完全,2個(gè)病灶有殘存。采用配對(duì)四格表資料的kappa系數(shù)檢驗(yàn)結(jié)果(k=1.00,P0.05),證明在肝癌微波消融術(shù)后評(píng)價(jià)中,超聲造影與CE-MRI比較無(wú)統(tǒng)計(jì)學(xué)差異。結(jié)論:對(duì)于肝內(nèi)癌灶進(jìn)行微波消融治療成功的關(guān)鍵就是整個(gè)腫瘤被完全滅活,因此消融后對(duì)于目標(biāo)腫瘤的滅活程度的判斷就顯得非常重要。而超聲造影不僅能鑒別肝內(nèi)病灶的良惡性,而且能清晰顯示出病灶浸潤(rùn)范圍,以及與周?chē)笱芗爸匾K器的關(guān)系,尤其是腫瘤滋養(yǎng)血管進(jìn)入腫瘤的具體位置及其分支分布情況;能指導(dǎo)微波消融進(jìn)針?lè)较蚣跋诜秶?還可以判斷病灶的消融程度。與CE-MRI相比,既對(duì)患者要求低、操作簡(jiǎn)單、價(jià)格低廉,又能在短時(shí)間內(nèi)反復(fù)多次檢查,是評(píng)價(jià)肝癌介入治療療效的有效方法。
[Abstract]:Objective: combined conventional ultrasound and contrast-enhanced ultrasound observation on HCC lesions number, morphology, size, blood supply and so on, to understand the basic status of the patients, guided microwave ablation therapy and evaluation of tumor ablation. Methods: a retrospective analysis of clinical data during the period from November 2014 to December 2016 to guide 45 cases of patients with hepatocellular carcinoma and portal vein puncture under microwave ablation chemotherapy in our hospital underwent ultrasound. All patients were treated more than two kinds of imaging diagnosis and biopsy were diagnosed, including 32 cases of male, female 13 cases, age 31~79 years old, average age (54 + 6.08).37 patients with chronic viral hepatitis, 31 cases of cirrhosis, 30 cases of hepatitis B virus marker positive, HCV markers positive in 7 cases, 1 cases of autoimmune hepatitis; 12 cases of patients with hypertension, 3 cases with diabetes treatment intervention. All patients underwent contrast-enhanced ultrasound And enhanced magnetic resonance (CE-MRI) examination, understand the mass number, size, position, shape, internal echo, color flow and surrounding the availability of important organs or blood vessels, vessels and branches of the master lesions, liver and liver than patients with no satellite lesions in.45 patients by ultrasound and CE-MRI examination there were 53 lesions. Ultrasound guided portal vein infusion chemotherapy and microwave ablation for about 15-20 minutes (microwave ablation of strong echo bubbles disappear cleared), all patients underwent contrast-enhanced ultrasonography in evaluating the extent of tumor ablation, ablation incomplete parts timely supplementary treatment, the conditions do not allow those undergoing replacement therapy after operation. 1-12 months after surgery according to review requirements of contrast-enhanced ultrasound, CE-MRI and clinical examination, evaluate the curative effect of hepatocellular carcinoma. Interventional ultrasound examination showed complete ablation tip lesions integral Contrast perfusion ablation; incomplete performance: internal lesions or the edge of the arterial phase is still patchy enhancement, portal venous phase and delayed phase of rapid exit.CE-MRI examination showed complete ablation performance: the ablation area increased, showed low signal; incomplete ablation was performed: lesions remaining part of the arterial phase enhancement the level of delay period, regression showed low enhancement, a fast performance. Results: 1.48 hepatocellular carcinoma lesions in CEUS for the typical enhancement pattern: high enhanced in arterial phase, portal venous phase and delayed phase fade to low enhancement, featuring "bulb like fast forward fast"; high enhancement 4 smaller than 2cm in diameter in HCC lesions in arterial phase, portal venous phase and delayed phase was obvious, such as enhanced.2. examination before operation, 45 patients by conventional ultrasound detected number of nodules was 46, Ultrasound detected 52, CE-MRI detected 53, the number of screening HCC lesions, statistically significant differences between conventional ultrasound and contrast-enhanced ultrasound (X2=4.867, P=0.027, P0.05), there was no significant difference compared with CE-MRI ultrasound (X2=1.010, P=0.315, P0.05). The measurement of microwave ablation of liver lesions before and after range. Nodules before microwave ablation, ultrasound measured the long diameter and short diameter was 3.01 + 1.05,2.60 + 1.22, after ablation were 4.40 + 1.61,4.20 + 1.23; CE-MRI preoperative measured long diameter and short diameter was 3.06 + 1.08,2.30 + 1.19, after ablation was 5 + 1.89,4.00 + 1.21. In the measuring range of lesions, there was no significant difference between CE-MRI and contrast-enhanced ultrasound (P0.0.5).3.53 microwave ablation lesions, surgery done immediately after contrast-enhanced ultrasound, 46 lesions showed complete ablation; 7 lesions inside or around the arterial phase significantly Shows the high enhanced area of irregular, portal venous phase and delayed phase exit fast, suggesting that the microwave ablation is not complete; ablation again after review of CE-US,.4. showed 7 lesions after ablation of ablation, including 2 cases of patients with CE-MRI suggests that the lesion edge nodules in the arterial phase showed no degree a delayed phase enhancement, dissection, suggestive of tumor remnants, fusion imaging underwent biopsy confirmed a point within the residual tumor, giving more than once again ablation; 51 lesions showed complete ablation of.5. ultrasound contrast and CE-MRI showed 51 lesions in complete ablation, 2 patients (were solitary lesion) in the late in the follow-up of serum AFP did not fall, but continued higher than 200 g/L, after 1-2 months of CE-MRI suggest that the lesions have residues, designated after fusion imaging biopsy confirmed tumor remnants. The final diagnosis: 49 lesion ablation penetration At the end of 4, a local residual tumor. Ultrasonic angiography showed that 53 lesions were ablated completely; 51 CE-MRI showed that the lesion ablation completely, 2 lesions remained. Four paired data table kappa coefficient test results (k=1.00, P0.05), proved in hepatocellular carcinoma after microwave ablation evaluation, no significant differences between ultrasound angiography and CE-MRI. Conclusion: the liver cancer by microwave ablation is the key to successful treatment of the tumor was completely inactivated, so after ablation of tumor target for judging the extent of inactivation is very important. Ultrasound can not only distinguish the benign and malignant hepatic lesions, and can clearly show the range of tumor invasion well, with large blood vessels and vital organs, especially the specific location and distribution of tumor vessels into the tumor; can guide the microwave ablation needle direction and ablation range, can also be The degree of ablation of the lesion is judged. Compared with CE-MRI, it is not only a low requirement for patients, simple operation, low cost, but also can be repeated many times in a short time. It is an effective method to evaluate the efficacy of interventional therapy for hepatocellular carcinoma.

【學(xué)位授予單位】：蘭州大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類(lèi)號(hào)】：R735.7;R445.1

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