摘要
目的：探讨彩色多普勒超声对肝泡型包虫病的诊断价值及其准确性，并总结肝泡型包虫病病灶超声造影典型的特征性的增强表现及造影前后病灶范围的变化，并对大鼠肝泡型包虫病模型进行超声造影及微血管密度的相关性研究，评价肝泡型包虫病周边浸润增殖区的造影增强的病理学依据。方法：1）总结我院自2004年7月1日～2010年6月30日期间于我院肝胆外科就诊的临床初步诊断为肝泡型包虫病的129例疑似患者的临床资料，采用彩色多普勒超声检查，对病灶的大小、位置、内部回声、钙化、血流信号、液化坏死、肝内胆管及血管的侵犯等结果与肝泡状棘球蚴病诊断的金标准进行对照，并计算彩色多普勒超声诊断肝泡型包虫病的敏感度（Sen）、特异度（Spe）、阳性预测值（PV+）、阴性预测值（PV-）、阳性似然比（LR+）、阴性似然比（LR-）以及它们的95%可信区间（95%CI）；2）对临床已经确诊且未采取过任何治疗措施的肝泡型包虫病患者17例，共计19个病灶分别进行二维超声、彩色多普勒超声及超声造影检查，所有的数据进行比较分析，包括造影前后的大小变化、彩色多普勒血流分布及超声造影的增强模式等；3）对接种成功的23只肝泡状棘球蚴大鼠行超声造影后，取得大鼠肝脏标本23个，其中HAE病灶27个，按照标本和超声造影增强结果一一对应的方法取样并制成蜡块119个，取样组织包含泡球蚴结节及其周边肝组织，然后进行MVD及HIF-1α的免疫组化对比分析，采用免疫组化的染色方法测定大鼠肝泡型包虫病灶周边浸润增殖区及临近肝组织的HIF-1α的表达及用CD34标记的微血管密度的计数，对HIF-1α的表达及微血管密度之间的相关性进行分析，进一步探讨肝泡状棘球蚴病灶周边浸润增殖区微血管密度以得到超声增强的病理学基础。结果：1）按照纳入标准最初入选患者136例，根据排除标准在研究的各阶段共排除了7例，最终参与分析的129例，其中超声诊断正确者95例，占全部研究对象的73.6％。彩色多普勒超声诊断肝泡型包虫病的Sen为95.0%（90.7%～99.3%），Spe为20.7%（6.0%～35.4%），PV＋为80.5％，PV-为54.5％，LR+为1.2，LR-为0.2，漏诊患者5例，误诊患者23例，本研究的诊断符合率为78.3%；2）17例肝泡型包虫病患者共计19个病灶，其中47.4%（9/19）为不均质高回声的实块型病灶，52.6%（10/19）为混合型病灶，病灶中央可见不规则液化坏死区；彩色多普勒成像显示所有19个病灶内部均未见任何形式的血流信号，18个病灶周边可见短棒状或条状血流信号于进入病灶处呈“截断状”，另1例最小的病灶周边可见点状血流信号；超声造影结果显示所有病灶周边于动脉早期即出现厚薄不一的边框样的增强带并持续至实质相，而病灶内部均未见任何形式的超声造影剂充盈，因此表现为造影剂充盈缺损的“黑洞征”，超声造影图像显示出肝泡球蚴病灶的清晰、不规则而确切的边界，在同一切面同一水平段测量超声造影之后的病灶大小，结果均大于二维图像上测量的病灶大小，二者的差异有统计学意义（P＜0.05）；3）①HIF-1α在HAE病灶周边浸润区的的阳性表达率为97.5%，其中强阳性者占13.4%，中度阳性者占64.7%，阳性者占19.3%，阴性者占2.5%；正常肝组织内HIF-1α的阳性表达率为8.4%，其中强阳性者占0%，中度阳性者占2.5%，阳性者占5.9%，阴性者占91.6%；HAE病灶周边浸润区HIF-1α的表达明显高于肝组织内的表达，二者之间比较差异有统计学意义（P＜0.05）。②在HAE病灶周边浸润区的MVD的阳性表达率为99.2%，其中强阳性者占17.6%，中度阳性者占73.1%，阳性者占8.4%，阴性者占0.8%；正常肝组织内HIF-1α的阳性表达率为25.2%，其中强阳性者占0%，中度阳性者占4.2%，阳性者占21.0%，阴性者占74.8%；HAE病灶周边浸润区MVD的表达明显高于肝组织内的表达，二者之间比较差异有统计学意义（P＜0.05）。③肝泡型包虫病灶周边浸润增殖区内HIF-1α的表达和MVD计数之间的表达呈正相关（r=0.151，P＜0.05）。④MVD计数与肝泡型包虫病浸润增殖区造影增强超声图像的平均灰阶值和临近肝组织平均灰阶值的比值之间的相关性分析，两者间呈正相关（r=0.238，P＜0.05）。结论：1）彩色多普勒超声诊断肝泡型包虫病的敏感度较高，但特异度尚不理想。彩色多普勒超声对肝泡型包虫病的诊断和鉴别诊断具有一定临床价值，可作为肝泡型包虫病影像学诊断手段以及病灶术前可根治性切除影像学评估的一个重要的工具，其不仅可确定肝泡型包虫病灶的位置、大小、数目、血流状况等，为手术前的定位及手术方式的确定提供依据，并且还可以提供病灶对第一二肝门的侵犯程度以及是否累及肝内外胆道系统进行评价。肝泡型包虫病灶与血管及胆管的关系是评估手术能否完整切除HAE病灶的关键，而大部分病灶不能完整切除的重要原因是肝泡型包虫病灶侵犯了第一、二肝门区的重要的血管及/或胆管，超声对于评估HAE病灶能否做到根治性的切除起到重要的作用；2）超声造影可以优化肝泡型包虫病灶周边的清晰显示，使病灶范围的测量更加准确，形态学评估明显优于二维超声，并为手术范围的确定及周边浸润增殖区的范围界定提供更加准确的证据，并且对肝泡型包虫病灶的微血供状态及血流灌注状况的显示均具有独特的优势。超声造影技术成像简单，且安全有效，具有较高的效价比，可以重复使用；3）大鼠HAE病灶周边在超声造影后的环状增强区与MVD的结果一一对应，提供了病灶浸润增殖区微血供的病理学依据；肝泡球蚴病灶周边浸润增殖区HIF-1α与CD34均呈高表达状态，表明周边浸润增殖区存在着丰富的微血供，说明肝泡状棘球蚴病灶对周边肝组织是以挤压及压迫为主，主要表现为周边肝组织的缺氧缺血的病理表现，HIF-1α对说明肝泡型包虫病周边浸润增殖区的微血供状态有较大的临床价值。
Object: To assess the accuracy of color Doppler ultrasonography in diagnosinghepatic alveolar echinococcosis, and evaluate the clear boundary and microvesselperfusion of the lesions and demonstrate the characteristic imaging and clinicalsignificance of HAE lesions by contrast-enhanced ultrasonography (CEUS), and tofurther investigate the expression of hypoxia inducible factor-1α (HIF-1α) andmicrovascular density (MVD) in the surrounding invasion range of HAE lesions andget the pathological basis of CEUS in HAE. Methods:1)129patients wereexamined at the First Affiliated Hospital of Xinjiang Medical University betweenJuly2004and June2010. Those patients suspected of having hepatic alveolarechinococcosis were examined and diagnosed by color Doppler ultrasound. All thecases were compared with the Gold Standard. The findings of their sensitivity,specificity, positive predictive value, negative predictive value, positive likelihoodratio, negative likelihood ratio, and95%confidence interval were recorded.2)Seventeen patients with19HAE lesions were examined in sequence with US, colorDoppler flow imaging (CDFI), and then CEUS before any treatment. All the datawere compared before surgery.3)23rats with hepatic echinococcus multilocularisinfection were examined by contrast-enhanced ultrasonography, and then obtainedtheir livers which had27HAE lesions. In accordance with the result of CEUS, thespecimens segments were made from119paraffin blocks. Tissue samples containedthe HAE nodules and the hepatic peranchyma of its surrounding and then proceededto the comparative analysis of immunohistochemical SP method. Results:1)Sensitivity:95%（95%confidence interval:90.7%~99.3%）; specificity:20.7%（95%confidence interval:6.0%~35.4%）; positive predictive value:80.5%; negative predictive value:54.5%; positive likelihood ratio:1.2: negative likelihood ratio:0.2.2) Examined by fundamental US,47.4%of HAE lesions showed irregularhyperechoic substantive areas,52.6%appeared as having a mixed echotype withirregular anechoic areas in the central portion of the lesions. The CDFI methodindicated no blood flow signals inside any of the19lesions. By CEUS, all19lesionsdisplayed circular rim enhancement in the peripheral segments, and absentenhancement within the central areas of the lesions (a ‘black hole’ effect). As a result,the lesions' margins were clear, irregular and distinct. In general, the sizes of all theHAE lesions observed by CEUS were larger than those obtained by fundamental US.There was a significant difference among the two groups （P<0.05）.3) The twoimmunohistochemical staining methods were applied to the specimens segments ofthe HAE rats in this animal experiment, CD34and HIF-1α, and Expression ofHIF-1α and MVD were compared in surrounding invasion range and the hepaticperanchyma. The relationship between the expression of HIF-1α and MVD valuewas also calculated. HIF-1α positive expression rate was97.5%（116/119） andMVD was99.2%（118/119）. The expression of HIF-1α in the active multipliedinfiltrative region of the HAE lesion was significantly increased, compared with thehepatic peranchyma（P<0.05）. The expression of MVD in the active multipliedinfiltrative region of the HAE lesion was also significantly higher than the hepaticperanchyma（P<0.05）. And there was positive correlated between HIF-1α positiveexpression and MVD（P<0.05）. Conclutions:1) Our study indicates that colorDoppler ultrasonography, when used in diagnosing hepatic alveolar echinococcosis,has high sensitivity although specificity is low. Color Doppler ultrasound is thusconsidered to be an efficient means for diagnosing hepatic alveolar echinococcosis.2)CEUS is a simple imaging method and can be a helpful tool for more accurate sizingof HAE lesions and their surrounding invasion range, and the proper cut-off marginwhen radical hepatectomy is needed.3) The overexpression of HIF-α in the activemultiplied infiltrative region of the HAE lesion of the rats is closely related withangiogensis and microvasculature. HIF-1α is very sensitive and representation. It canindicate that the invasion range of HAE lesions was based on extrusion andcompression and caused the hepatic tissue anoxic and ischemic. It is valuableindexes in evaluating activity of HAE.
引文
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