摘要
目的探讨肝脏实质背景对肝内局灶性病变超声造影的影响。
方法选取因肝局灶性病变住院并行灰阶超声造影检查的患者共113例(肝癌69例、肝血管瘤30例、肝局灶性结节性增生14例)为研究对象，根据肝实质背景分为四组：正常肝实质背景组45例(A组)、代偿性肝硬化背景组22例(B_1组)、失代偿性肝硬化背景组24例(B_2组)、脂肪肝背景组22例(C组)。肝癌69例中，A组23例，B_1组22例，B_2组24例；肝血管瘤30例中，A组16例，C组14例；肝局灶性结节性增生14例中，A组6例，C组8例。比较不同肝脏背景超声造影的始增时间、增强持续时间以及不同肝脏背景下同一性质局灶性病变自身的始增时间、峰值时间、增强持续时间，对比观察不同肝脏背景下同性质局灶性病变在门静脉相、动脉相、延迟相的灌注过程、回声变化规律以及超声造影增强模式。
结果正常肝实质背景组(A组)、代偿性肝硬化组(B_1组)、失代偿性肝硬化组(B_2组)、脂肪肝组(C组)的肝脏背景超声造影始增时间分别为(21.7±5.4)s、(25.6±4.5)s、(29.7±3.9)s与(26.2±4.3)s，增强持续时间分别为(211.3±25.2)s、(218.4±20.4)s、(156.3±18.9)s与(296.2±16.6)s。B_1组、B_2组与C组的始增时间均比A组的长(P＜0.01)，其中B_2组的最长。四组的增强持续时间中，A组的与B_1组的相比没有差异(P＞0.05)，B_2组的最短，C组的最长。不同肝脏背景下同性质病灶超声造影的始增时间、峰值时间、增强持续时间相应的比较均无明显差异(P均＞0.05)。23例正常肝脏实质背景与22例代偿性肝硬化背景下原发性肝癌(HCC)分别有87.0％(20／23)与95.5％(21／22)于动脉相快速强化，门静脉相呈等增强或低增强、延迟相均呈低增强，均表现为“快进快退”超声造影增强模式，但13.0％(3／23)正常肝实质背景与4.5％(1／22)代偿性肝硬化背景下HCC延迟相表现为等增强甚至高增强，呈“快进慢退”超声造影增强模式；而24例肝癌伴失代偿性肝硬化背景中，83.3％(20／24)动脉相呈高增强，门静脉相呈等增强，延迟相则呈相对等增强甚至高增强，表现为“快进慢退”超声造影增强模式，另16.7％(4／24)延迟相呈低增强，表现为“快进快退”超声造影增强模式。16例肝血管瘤(HCH)伴正常肝实质背景与14例HCH伴脂肪肝背景动脉相均呈周边增强或环状向心性增强，门静脉相均呈等增强，但前者延迟相呈高增强，而后者延迟相却呈低增强。6例局灶性结节性增生(FNH)伴正常肝实质背景与8例FNH伴脂肪肝背景动脉相均呈典型的轮辐状增强或整体增强，门脉相均呈等增强，但前者延迟相均呈高增强，后者延迟相晚期则均呈低增强。
结论正常肝实质背景与肝硬化背景、脂肪肝背景超声造影的始增时间以及增强持续时间不同。同性质病灶在不同肝实质背景中其自身的增强时相差别不显著(P均＞0.05)。代偿性肝硬化背景与正常肝背景的肝癌超声造影增强模式相似，绝大部分呈“快进快退”增强模式，而失代偿性肝硬化背景的超声造影模式绝大部分呈“快进慢退”增强模式。脂肪肝背景可使病灶延迟相呈低增强而影响其超声造影增强模式。因此，对肝内局灶性病变诊断除需重视病变自身的病理与生物学特性外，尚应充分考虑肝脏实质背景的影响，并注意观察病灶动脉相的增强形态，以提高超声造影对肝内局灶性病变的诊断正确率，必要时行经皮肝穿刺活检进一步提高诊断准确性。
Aim: To probe the influence of hepatic background in diagnosing hepatic focalnodules using Contrast-enchancement ultrasound(CEUS)
Methods: 119 in-patients with hepatic leisions (69 cases with hepatocellularcarcinoma,30cases with hemagioma,14cases with focal nodular hyperplasis)underwent CEUS were admited and classified into four categories on the basis ofhepatic background.The first group was the normal hepatic backgroud(Agroup),containing 45 cases.The second group was the compensatory corrhosisbackgroud (B_1 group), containing 22 cases.The third group was decompensatedcorrhosis background (B_2 group), containing 27 cases.The last group was fatty hepaticbackgroud.(C group),containing 25 cases.T.Among 69 cases with hepatocellularcarcinoma,A group contained 23 cases, B_1 group contained 22 cases, B_2 groupcontained 24 cases.Among 30 cases with hemagioma, A group contained 16 cases,C group contained 14 cases. Among 14 cases with focal nodular hyperplasis, Agroup contained 6 cases, C group contained 8 cases. 3 cases focal fatty sparingbelong to C group. 3 cases regenerative nodules belong to B_2group.Both the startingenhancement time and the lasting enhancement time of different hepatic backgroundwere compared.Moreover, the starting enhancement time,the peak enhancement timeand the lasting enhancement time of hepatic leisions with the same quality underdifferent hepatic backgound were contrast.In addition,the perfusion,the echodiversification and the enhancement mode of hepatic leisions with same quality indifferent hepatic background were compared.
Results: The starting enhancement time of A group, B_1 group, B_2 group and C groupwere (21.7±5.4)s、(25.6±4.5)s、(29.7±3.9)s、(26.2±4.3)s, respectively.What is more, the lasting enhancement time of A group, B_1 group, B_2 group and Cgroupwere (211.3±25.2)s、(218.4±20.4) s、(156.3±18.9) s与(296.2±16.6)s, respectively. The starting enhancement time of B_1 group, B_2 group and C group waslonger than that of A group. Among four group's starting enhancement time, B_2 group's was the longest. A group's lasting enhancement time made no differencecomparing with that of B_1 group. Among four group's lasting enhancement time, B_2group's lasting enhancement time was the shortest,while C group's lastingenhancement time was the longest. The starting enhancement time,the peakenhancement time and the lasting enhancement time of hepatic focal nodules with thesame quality in different hepatic background made no differences comparing witheach other. 87.0％(20/23) hepatocellular carcinomas with the normal hepaticbackground and 95.5％(21/22) hepatocellular carcinomas with the compensatoryhepatic cirrhosis background displayed rapid enhancement in the arteryphase,showed hyperechoic or hypoechoic enhancement in the portal veinphase,appered hypoechoic enhancement in the delayed phase,presented "fast-in andfast-out" enhancement model.However, 13.0％(3/23) hepatocellular carcinomas withthe normal hepatic background and 4.5％(1/22) hepatocellular carcinomas with thecompensatory hepatic cirrhosis background appered equivalent even hyperechoicenhancement in the delayed phase,presented "fast-in and slow-out" enhancementmodel Among 24 hepatocellular carcinomas with decompensated cirrhosisbackground, 83.3％(20/24) showed hyperechoic enhancement in the arteryphase,displayed equivalent enhancement in both the portal vein phase and thedelayed phase, presented "fast-in and slow-out" enhancement model.While 16.7％(4/24) displayed hyperechoic enhancement in the artery phase,appered hypoechoicenhancement in both the portal vein phase and the delayed phase, presented "fast-inand fast-out" enhancement model..16 hepatic haemangiomas with normal hepaticbackground and 14 hepatic haemangiomas with fatty hepatic background enhanced ina pattern of ring and centripetal fill-in in the artery phase, displayed equivalentenhancement in the portal vein phase,whle the former even presented hyperechoicenhancement in the delayed phase.However, the latter apperred hypoechoicenhancement in the delayed phase. 6 focal nodular hyperplasias with the normalhepatic background and 8 focal nodular hyperplasias with fatty hepatic backgroundpresented wheel-like or holistic enhancement in the artery phase,showed equivalentenhancement in the portal vein phase, while the former manifested hyperechoic enhancement in the delayed phase, whereas the latter manifested hypoechoicenhancement in the terminal delayed phase.
Conclusion: The perfusion of both hepatic cirrhosis background and fatty hepaticbackgroud were different from that of the normal hepatic background. Theenhancement of hepatic leisions itself didn't be affect under different hepaticbackground.The enhancement mode of hepatocellular carcinoma with thecompensatory corrhosis background was similar to that of hepatocellular carcinomawith the normal hepatic background,most of The enhancement mode were "fast-inand fast-out".Whereas the majority of enhancement mode of hepatocellularcarcinoma with the decompensated corrhosis background were "fast-in and slow-out"The fatty hepatic background did make the enhancement mode of hepatic leisionsuntypical by affecting the manifestion of hepatic focal nodules in the delayedphase.Therefore,in the process of diagnosing hepatic focal nodules using CEUS,noonly the hepatic focal nodules' pathaology and biological characteristic should bethink highly of,but also should the hepatic background be take into account.Theenhancement type of hepatic focal nodules was helpful to diagnosing the disease.Ifenhancement manifestion was untypical,ultrasound-guided biopsy ought to be carryout to confirm the hepatic focal nodules.
引文
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4．陈晓宇，赵宝珍．肝脏影像的超声造影剂及造影技术．中国临床医学影像杂志，2005，16(8)：461—483．
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10．林礼务，林学英，薛恩生，等．灰阶超声造影对复发性肝癌的诊断价值．中华医学超声杂志(电子版)，2005，2(5)：283—285．
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