肝门部胆管癌MSCT表现与手术病理对照研究
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摘要
目的
肝门部胆管癌早期临床表现缺乏特异性,大多数患者就诊时已为中、晚期,预后较差。因此胆管癌仍是当前外科治疗上的难题。本研究通过对肝门部胆管癌的CT表现、临床及病理特征的比较为胆管癌的诊断及治疗、预后评价提供参考,通过研究增强CT对肝门部胆管显示情况；评价多层螺旋CT对肝门部胆管癌的诊断价值。
材料与方法
采用GE lightspeed或西门子Sensation16扫描仪,36例肝门部胆管癌患者行多层螺旋CT平扫及动态增强扫描,在ADW4.2工作站及西门子工作站对扫描数据进行后处理,并与手术及病理结果对照。
结果
肝门部胆管癌典型表现为肝内胆管扩张、肝门部肿块及肝门部胆管狭窄、中断,大部分肝门肿块以延迟强化为主；肿块均经手术切除、病理证实,结果显示28例为中高分化腺癌,8例为低分化腺癌。
讨论
肝门部胆管癌的初发症状多为梗阻性黄疸,外科治疗是目前唯一有效的方法。MSCT对肝门部胆管癌的定位及定性有重要意义,对制定手术方案也有重要作用。MSCT能够显示肝门部胆管癌的直接和间接征象,但在判断肿瘤周围浸润程度时有一定局限性。
Objective
There are no typical manifestations in the early stage of hilar cholangiocarcinoma. Most patients do not go to hospital until the advanced stage or late stage of disease. Hilar cholangiocarcinoma is still the sticky issue of surgical treatment. This study is to compare the CT findings, clinical and pathological character, to provide information for diagnose, treatment and prognosis, and to discuss the diagnostic value of MSCT in diagnosing hilar cholangiocarcinoma.
Materials and Methods
36 cases of hilar cholangiocarcinoma were examined with 16 slice CT scanner (GE lightspeed 16, USA, SIEMENS Sensation 16, Germany). All the cases were scanned with plain and dynamic contrast enhancement. The data were processed with workstation ADW4.2 or SIEMENS processing software. The diagnosis was conformed with surgical pathology.
Results
The initial symptoms of hilar cholangiocarcinoma are intrahepatic cholangiectasis, mass of hepatic porta and narrow or absence of bile duct in the region of the hepatic porta. Most of mass shown delayed enhancement; 28 cases were high-differentiated gland cancer and eight cases were low-differentiated gland cancer in surgical pathology.
Conclusion
The initial symptoms of hilar cholangiocarcinoma are obstructive jaundice, and the surgical treatment is the only effective method. MSCT plays an important role in qualitative analysis, determining the location and the surgical method. MSCT can show direct and indirect signs of hilar cholangiocarcinoma. But it also has limits in estimating infiltration of tumor.
肝门部胆管癌早期临床表现缺乏特异性,大多数患者就诊时已为中、晚期,预后较差。因此胆管癌仍是当前外科治疗上的难题。本研究通过对肝门部胆管癌的CT表现、临床及病理特征的比较为胆管癌的诊断及治疗、预后评价提供参考,通过研究增强CT对肝门部胆管显示情况；评价多层螺旋CT对肝门部胆管癌的诊断价值。
材料与方法
采用GE lightspeed或西门子Sensation16扫描仪,36例肝门部胆管癌患者行多层螺旋CT平扫及动态增强扫描,在ADW4.2工作站及西门子工作站对扫描数据进行后处理,并与手术及病理结果对照。
结果
肝门部胆管癌典型表现为肝内胆管扩张、肝门部肿块及肝门部胆管狭窄、中断,大部分肝门肿块以延迟强化为主；肿块均经手术切除、病理证实,结果显示28例为中高分化腺癌,8例为低分化腺癌。
讨论
肝门部胆管癌的初发症状多为梗阻性黄疸,外科治疗是目前唯一有效的方法。MSCT对肝门部胆管癌的定位及定性有重要意义,对制定手术方案也有重要作用。MSCT能够显示肝门部胆管癌的直接和间接征象,但在判断肿瘤周围浸润程度时有一定局限性。
Objective
There are no typical manifestations in the early stage of hilar cholangiocarcinoma. Most patients do not go to hospital until the advanced stage or late stage of disease. Hilar cholangiocarcinoma is still the sticky issue of surgical treatment. This study is to compare the CT findings, clinical and pathological character, to provide information for diagnose, treatment and prognosis, and to discuss the diagnostic value of MSCT in diagnosing hilar cholangiocarcinoma.
Materials and Methods
36 cases of hilar cholangiocarcinoma were examined with 16 slice CT scanner (GE lightspeed 16, USA, SIEMENS Sensation 16, Germany). All the cases were scanned with plain and dynamic contrast enhancement. The data were processed with workstation ADW4.2 or SIEMENS processing software. The diagnosis was conformed with surgical pathology.
Results
The initial symptoms of hilar cholangiocarcinoma are intrahepatic cholangiectasis, mass of hepatic porta and narrow or absence of bile duct in the region of the hepatic porta. Most of mass shown delayed enhancement; 28 cases were high-differentiated gland cancer and eight cases were low-differentiated gland cancer in surgical pathology.
Conclusion
The initial symptoms of hilar cholangiocarcinoma are obstructive jaundice, and the surgical treatment is the only effective method. MSCT plays an important role in qualitative analysis, determining the location and the surgical method. MSCT can show direct and indirect signs of hilar cholangiocarcinoma. But it also has limits in estimating infiltration of tumor.
引文
[1]Lilemoe KD, Yeo CJ, Camemn JL. Pancreatic cancer:state of the art care [J]. CA Cancer J Clin,2000,50(4):241-268.
[2]Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma [J]. Ann Surg,1992,215:31-38.
[3]Klatskin G. Carcinoma of the hepatic duct at its bifurcation within the porta hepatis:an unusual tumor with distinctive clinical and pathological features [J]. Am J Med,1965,38:241-256.
[4]Launois B, Wemyss-Holden S, Maddern GJ. Current and future trends in management and treatment of Klatskin tumor [J]. Int J Clin Oncol,2002,7: 91-102.
[5]吴尘轩,杜智,王毅军.肝门胆管癌的外科治疗进展[J].河北医药,2006,28：326-328.
[6]周胜法,林旭明,程健敏.21例肝内胆管癌CT分析[J].肝胆胰外科杂志,2002,14：241-242.
[7]Takano T, Ohe Y, Sakamoto H, et al. Epidermal growth factor receptor gene mutations and increased copy numbers predict gefitinib sensitivity in patients with recurrent non-small-cell lung cancer [J]. J Clin Oncol,2005, 23(28):6829-6837.
[8]管红梅,杨亚芳,承禾等.肝门部胆管细胞癌螺旋CT三期增强的表现[J].实用医技杂志,2002,9(9)：656.2001,35(9)：683.
[9]李建丁,染晨阳,张华等.CT增强延迟扫描对肝门胆管细胞癌的诊断价值的评价[J].中华放射学杂志,2001,35(9)：683-685
[10]杨立,杨州,赵绍宏,等.肝门区胆管细胞癌的多层螺旋CT表现[J].中华放射学杂志,2005,39(11)：1181.
[11]Ohshio G, Manabe T, Watanabe Y, et al. Comparative studies of DU-PAN 2, carcinoembryoric antigen, and CA19-9 in the serum and bile of patients with pancreatic and biliary tract diease:evaluation of the influence of obstructive jaundice [J]. Am J Gastroenterol,1990,85:1370-1376.
[12]Ramage JK. Serum tumor markers for the diagnosis of CCA in primary sclerosing cholangitis [J]. Gastroenterology 1995,108:865-869
[13]Tangkijvanich P, Thongngam D, Theambllnlers A, et al. Diagnosis role of serum interleukin 6 and CA19-9 in patients with cholangiocarcinoma [J].Hepatogastroenterlolgy,2004,51(55):15-19.
[14]Qin XL, Wang ZR, Shi JS, et al. Utility of CA19-9 in diagnosis of cholan-giocarcinima:In comparison with CEA [J]. World J Gastroenterology,2004, 10(3):427-432.
[15]Pasanen PA. Clinical value of serum tumor markers CEA, CA50 and CA242 in the distinction between malignant versus benign diseases causing jaundice and cholestasis; results from a prospective study [J]. Anticancer Res 1992,12:1687-1693.
[16]Watanabe M, Chigusa M, Takahashi H, et al. High level of CA19-9, CA50, and CEA-producible human cholangiocarcinoma cell changes in the secretion ratios in vitro or in. vivo [J].In Vitro Cell Dev Biol Anim,2000, 36(2):104-109.
[17]Nakeeb A. Biliary carcinoembryonic antigen level are a marker for cholangiocarcinoma [J].Am J Surg 1996,171:147-153.
[18]Okami L. Genetic detection for micrometastasis in lymph node of biliary tract carcinoma [J].Clin Cancer Res 2000,6(6):2326-2332.
[19]周胜法,林旭明,程建敏.21例肝门胆管细胞癌的分析[J].肝胆胰外科杂志,2003,14(4)：241.
[20]Siqueira E, Schoen RE, Silverman W, et al. Detecting cholangiocar-cinoma in patients with primary sclerosing cholangitis [J].Gastrointest Endosc,2002,56(1):40-47.
[21]Figueras J, Liado L, Valls C, et al. Changing strategies in diagnosis and management of hilar cholangiocarcinoma [J]. Liver Transpl,2000,6(6):786-794.
[22]孔响泉,徐海波,彭振军等.门脉癌栓的MRI及其门脉造影的诊断价值[J].中华放射学杂志,1999,33：689-691.
[23]Li JH, PARK CK. Pathlolgy of cholangiocarcinoma [J]. Abdom Imaging, 2004,29:540-547.
[24]Schulte SJ, Baron RL, Teefey SA, et al. CT of the Extrahepatic Bile Ducts: Wall Thickness and Contrast Enhancement in Normal and Abnormal Duct [J]. AJR,1990,154(4):79.
[25]曾蒙苏,李轫晨,周康荣,等.小胆总管癌的螺旋CT诊断[J].临床放射学杂 志,2002,21(9)：704-706.
[26]矫娜,孔祥泉,史河水等.肝门部胆管癌CT与MRI诊断价值[J].临床放射学杂志杂志,2006,25(7)：639-643.
[27]柳澄.多层螺旋CT应用中应当注意的几个问题[J].中国中西结合影像学杂志,2008,6(1)：2-4.
[28]Choi BI, Lee JM, Han JK. Imaging of intrahepatic and hilar cholangiocarci-noma [J]. Abdom Imaging,2004,29(5):545-549.
[29]张卫东,冯敏.肝门小胆管癌的多层CT分析[J].医学影像学杂志,2007,17(1)：46-48.
[30]Fred R, Hirsch M, Varella G, et al. Epidermal growth factor receptor in non-small-cell lung carcinomas:correlation between gene copy number and protein expression and impact on prognosis [J]. J Clin Oncol,2003,21: 3798.
[1]郝希山,王殿.腹部外科学[M].第一版.北京：人民卫生出版社,2003,963-975.
[2]吕新生.肝门部胆管细胞癌的诊断和治疗[J].中国普通外科学杂志,2007,16(2)：161-166.
[3]Clary B, Jamigan W, Pitt H, et al. Hilar cholangiocarcinoma [J]. J Gastroi-ntest Surg,2004,8(3):298-302.
[4]Kim HJ, Lee DH, Lim JW. Multi-detector computed tomography in the preoperative workup of hilar cholangiocarcinoma [J]. Acta Radiol.2009, 50(8):845-53.
[5]Yamada M, Shiroeda H, Shiroeda S, et al. CT of hilar cholangiocarcin-oma: late contrast enhancement in six patients [J]. Intern Med.2009,48 (24): 2097-2100.
[6]Ardengh JC, Paulo GA, Nakao FS, et al. Endoscopic ultrasound guided fine-needle aspiration core biopsy:comparison between anautomatic biopsy device and two conventional needle systems [J]. Acta Gastroenterol Latinoam,2008,38(2):105-115.
[7]程红岩,李斯婕.非创伤性影像学诊断胆管癌[J].实用肿瘤杂志,2007,22(2)：101-103
[8]管红梅,杨亚芳,承禾等.肝门部胆管细胞癌螺旋CT三期增强的表现[J].实用医技杂志,2002,9(9)：656-657.
[9]Tillich M, Mischinger HJ, Preisegger KH, et al. Mutiphasic helical CT in diagnosis and staging of hilar cholangiocarcinoma [J]. Ann J Roentgenol, 1998,171(3):651-658.
[10]Feydy A, Vilgrain V, Denys A, et al. Helical CT assessmetnt in hilar cholangiocarcinoma:correlation with surgical and pathologic findings [J]. AJR,1999,127(1):73-75.
[11]吴文浩.多层螺旋CT三维重建技术在肝外胆管癌诊断中的应用[J].中国实用医药,2009,32,57-58.
[12]Park SJ, Han JK, Kim TK, et al. Three-dimensional spiral CT cholangiogr-aphy with minim intensity projection in patients with suspected obstructive biliary diease:comparison with percutaneous transhepatic cholangiography [J].Abdom Imaging,2001,26(3):281-286.
[13]Xu AM, Cheng HY, Jiang WB, et al. Multi-Slice three-dimensional spiral CT cholangiography:a new technique for diagnosis of biliary diseases [J]. Hepatobiliary Pancreat Dis Int,2002,1(4):595-603.
[14]孟宪民.梗阻性黄胆的诊断[J].中国实用外科杂志,1996,16(1)：7-8.
[15]Christensen M, Matzen P, Schulze S, et al. Complications of ERCP:A prospective study [J]. Gastrointest Endosc,2004,60(5):721-731.
[16]Zech CJ, Schoenberg SO, Reiser M, et al. Cross-sectional imaging of biliary tumors:Current clinical status and future developments [J]. Eur Radiol,2004,14(7):1174-1187.
[17]Frendenry LS, Antock G, Beger A, et al. Combined PET/CT imaging:first clinical experience at University of Essen [J].Hosp Radiol,2003,3(1):4-8.
[2]Bismuth H, Nakache R, Diamond T. Management strategies in resection for hilar cholangiocarcinoma [J]. Ann Surg,1992,215:31-38.
[3]Klatskin G. Carcinoma of the hepatic duct at its bifurcation within the porta hepatis:an unusual tumor with distinctive clinical and pathological features [J]. Am J Med,1965,38:241-256.
[4]Launois B, Wemyss-Holden S, Maddern GJ. Current and future trends in management and treatment of Klatskin tumor [J]. Int J Clin Oncol,2002,7: 91-102.
[5]吴尘轩,杜智,王毅军.肝门胆管癌的外科治疗进展[J].河北医药,2006,28：326-328.
[6]周胜法,林旭明,程健敏.21例肝内胆管癌CT分析[J].肝胆胰外科杂志,2002,14：241-242.
[7]Takano T, Ohe Y, Sakamoto H, et al. Epidermal growth factor receptor gene mutations and increased copy numbers predict gefitinib sensitivity in patients with recurrent non-small-cell lung cancer [J]. J Clin Oncol,2005, 23(28):6829-6837.
[8]管红梅,杨亚芳,承禾等.肝门部胆管细胞癌螺旋CT三期增强的表现[J].实用医技杂志,2002,9(9)：656.2001,35(9)：683.
[9]李建丁,染晨阳,张华等.CT增强延迟扫描对肝门胆管细胞癌的诊断价值的评价[J].中华放射学杂志,2001,35(9)：683-685
[10]杨立,杨州,赵绍宏,等.肝门区胆管细胞癌的多层螺旋CT表现[J].中华放射学杂志,2005,39(11)：1181.
[11]Ohshio G, Manabe T, Watanabe Y, et al. Comparative studies of DU-PAN 2, carcinoembryoric antigen, and CA19-9 in the serum and bile of patients with pancreatic and biliary tract diease:evaluation of the influence of obstructive jaundice [J]. Am J Gastroenterol,1990,85:1370-1376.
[12]Ramage JK. Serum tumor markers for the diagnosis of CCA in primary sclerosing cholangitis [J]. Gastroenterology 1995,108:865-869
[13]Tangkijvanich P, Thongngam D, Theambllnlers A, et al. Diagnosis role of serum interleukin 6 and CA19-9 in patients with cholangiocarcinoma [J].Hepatogastroenterlolgy,2004,51(55):15-19.
[14]Qin XL, Wang ZR, Shi JS, et al. Utility of CA19-9 in diagnosis of cholan-giocarcinima:In comparison with CEA [J]. World J Gastroenterology,2004, 10(3):427-432.
[15]Pasanen PA. Clinical value of serum tumor markers CEA, CA50 and CA242 in the distinction between malignant versus benign diseases causing jaundice and cholestasis; results from a prospective study [J]. Anticancer Res 1992,12:1687-1693.
[16]Watanabe M, Chigusa M, Takahashi H, et al. High level of CA19-9, CA50, and CEA-producible human cholangiocarcinoma cell changes in the secretion ratios in vitro or in. vivo [J].In Vitro Cell Dev Biol Anim,2000, 36(2):104-109.
[17]Nakeeb A. Biliary carcinoembryonic antigen level are a marker for cholangiocarcinoma [J].Am J Surg 1996,171:147-153.
[18]Okami L. Genetic detection for micrometastasis in lymph node of biliary tract carcinoma [J].Clin Cancer Res 2000,6(6):2326-2332.
[19]周胜法,林旭明,程建敏.21例肝门胆管细胞癌的分析[J].肝胆胰外科杂志,2003,14(4)：241.
[20]Siqueira E, Schoen RE, Silverman W, et al. Detecting cholangiocar-cinoma in patients with primary sclerosing cholangitis [J].Gastrointest Endosc,2002,56(1):40-47.
[21]Figueras J, Liado L, Valls C, et al. Changing strategies in diagnosis and management of hilar cholangiocarcinoma [J]. Liver Transpl,2000,6(6):786-794.
[22]孔响泉,徐海波,彭振军等.门脉癌栓的MRI及其门脉造影的诊断价值[J].中华放射学杂志,1999,33：689-691.
[23]Li JH, PARK CK. Pathlolgy of cholangiocarcinoma [J]. Abdom Imaging, 2004,29:540-547.
[24]Schulte SJ, Baron RL, Teefey SA, et al. CT of the Extrahepatic Bile Ducts: Wall Thickness and Contrast Enhancement in Normal and Abnormal Duct [J]. AJR,1990,154(4):79.
[25]曾蒙苏,李轫晨,周康荣,等.小胆总管癌的螺旋CT诊断[J].临床放射学杂 志,2002,21(9)：704-706.
[26]矫娜,孔祥泉,史河水等.肝门部胆管癌CT与MRI诊断价值[J].临床放射学杂志杂志,2006,25(7)：639-643.
[27]柳澄.多层螺旋CT应用中应当注意的几个问题[J].中国中西结合影像学杂志,2008,6(1)：2-4.
[28]Choi BI, Lee JM, Han JK. Imaging of intrahepatic and hilar cholangiocarci-noma [J]. Abdom Imaging,2004,29(5):545-549.
[29]张卫东,冯敏.肝门小胆管癌的多层CT分析[J].医学影像学杂志,2007,17(1)：46-48.
[30]Fred R, Hirsch M, Varella G, et al. Epidermal growth factor receptor in non-small-cell lung carcinomas:correlation between gene copy number and protein expression and impact on prognosis [J]. J Clin Oncol,2003,21: 3798.
[1]郝希山,王殿.腹部外科学[M].第一版.北京：人民卫生出版社,2003,963-975.
[2]吕新生.肝门部胆管细胞癌的诊断和治疗[J].中国普通外科学杂志,2007,16(2)：161-166.
[3]Clary B, Jamigan W, Pitt H, et al. Hilar cholangiocarcinoma [J]. J Gastroi-ntest Surg,2004,8(3):298-302.
[4]Kim HJ, Lee DH, Lim JW. Multi-detector computed tomography in the preoperative workup of hilar cholangiocarcinoma [J]. Acta Radiol.2009, 50(8):845-53.
[5]Yamada M, Shiroeda H, Shiroeda S, et al. CT of hilar cholangiocarcin-oma: late contrast enhancement in six patients [J]. Intern Med.2009,48 (24): 2097-2100.
[6]Ardengh JC, Paulo GA, Nakao FS, et al. Endoscopic ultrasound guided fine-needle aspiration core biopsy:comparison between anautomatic biopsy device and two conventional needle systems [J]. Acta Gastroenterol Latinoam,2008,38(2):105-115.
[7]程红岩,李斯婕.非创伤性影像学诊断胆管癌[J].实用肿瘤杂志,2007,22(2)：101-103
[8]管红梅,杨亚芳,承禾等.肝门部胆管细胞癌螺旋CT三期增强的表现[J].实用医技杂志,2002,9(9)：656-657.
[9]Tillich M, Mischinger HJ, Preisegger KH, et al. Mutiphasic helical CT in diagnosis and staging of hilar cholangiocarcinoma [J]. Ann J Roentgenol, 1998,171(3):651-658.
[10]Feydy A, Vilgrain V, Denys A, et al. Helical CT assessmetnt in hilar cholangiocarcinoma:correlation with surgical and pathologic findings [J]. AJR,1999,127(1):73-75.
[11]吴文浩.多层螺旋CT三维重建技术在肝外胆管癌诊断中的应用[J].中国实用医药,2009,32,57-58.
[12]Park SJ, Han JK, Kim TK, et al. Three-dimensional spiral CT cholangiogr-aphy with minim intensity projection in patients with suspected obstructive biliary diease:comparison with percutaneous transhepatic cholangiography [J].Abdom Imaging,2001,26(3):281-286.
[13]Xu AM, Cheng HY, Jiang WB, et al. Multi-Slice three-dimensional spiral CT cholangiography:a new technique for diagnosis of biliary diseases [J]. Hepatobiliary Pancreat Dis Int,2002,1(4):595-603.
[14]孟宪民.梗阻性黄胆的诊断[J].中国实用外科杂志,1996,16(1)：7-8.
[15]Christensen M, Matzen P, Schulze S, et al. Complications of ERCP:A prospective study [J]. Gastrointest Endosc,2004,60(5):721-731.
[16]Zech CJ, Schoenberg SO, Reiser M, et al. Cross-sectional imaging of biliary tumors:Current clinical status and future developments [J]. Eur Radiol,2004,14(7):1174-1187.
[17]Frendenry LS, Antock G, Beger A, et al. Combined PET/CT imaging:first clinical experience at University of Essen [J].Hosp Radiol,2003,3(1):4-8.