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  分子影像学杂志  2018, Vol. 41 Issue (2): 165-168  DOI: 10.3969/j.issn.1674-4500.2018.02.07
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钟景云, 梁满球, 聂悦富, 黎宁 . 肝硬化并发原发性肝癌合并肝囊肿患者的影像学特征[J]. 分子影像学杂志, 2018, 41(2): 165-168. DOI: 10.3969/j.issn.1674-4500.2018.02.07
ZHONG Jingyun, LIANG Manqiu, NIE Yuefu, LI Ning . Imaging characteristics of hereditary hepatic carcinoma combined with cirrhosis in patients with hepatic cysts[J]. Journal of Molecular Imaging, 2018, 41(2): 165-168. DOI: 10.3969/j.issn.1674-4500.2018.02.07

作者简介

钟景云,主治医师,E-mail: xinhuicjy@126.com

文章历史

收稿日期:2018-02-12
肝硬化并发原发性肝癌合并肝囊肿患者的影像学特征
钟景云1, 梁满球2, 聂悦富1, 黎宁1     
1 江门市新会人民医院放射科,广东  江门  529100;
2 东莞市人民医院放射科,广东  东莞  523059
摘要目的 总结肝硬化并发原发性肝癌合并肝囊肿(HHC)患者的影像学特征。方法 分析106例HHC患者的上腹部增强CT,观察其临床特征、囊肿的直径、所在肝段、CT值等,并以109例无合并原发性肝癌的肝硬化肝囊肿患者作为对照。结果 与无合并肝癌的对照组比较,HHC组的年龄偏大(P=0.039)、肝炎合并比例高(P=0.036)且肝硬化病程长(P=0.043);HHC组的囊肿为2~9个,而对照组为1~5个,两组的囊肿总数差异具有统计学意义(P<0.05);HHC组患者囊肿直径3~11 cm,而对照组为2~6 cm,两组的囊肿直径差异具有统计学意义(P<0.05);对照组的CT值多在15 Hu以内,而HHC组约半数超过15 Hu,两组差异具有统计学意义(P<0.05);HHC组的囊肿病灶总体以右半肝为主,尤其是S6段及S8段偏多,左半肝则以S3段偏多;对照组患者囊肿病灶以左半肝为主,尤其S3及S4偏多,两组的囊肿肝段分布差异具有统计学意义(χ2=2.572,P=0.011)。结论 年龄、肝炎、肝硬化可能是原发性肝癌患者合并肝囊肿的危险因素;多发、右叶多见、直径大、易发生坏死,是HHC患者的囊肿形态学特征。
关键词:原发性肝癌    肝硬化    肝囊肿    上腹部CT    
Imaging characteristics of hereditary hepatic carcinoma combined with cirrhosis in patients with hepatic cysts
ZHONG Jingyun1, LIANG Manqiu2, NIE Yuefu1, LI Ning1     
1 Department of Radiology, Jiangmen Xinhui People’s Hospital,Jiangmeng 529100,China;
2 Department of Radiology, Dongguan People’s Hospital,Dongguan 523059,China
Abstract: Objective To summarize the imaging features of hereditary hepatic carcinoma (HHC) combined with cirrhosis in patients with hepatic cysts. Methods 106 HHC cases were included as the HCC group and undertook upper abdominal enhanced CT examination, while 109 cirrhosis patients with hepatic cysts were included as the control group. CT findings, including HHC’s clinical features, diameter of the cyst, hepatic segment where cysts locate, CT value, were observed and compared with that of the control group. Results Compared with the control group, patients in HHC group were significantly older (P=0.039) and had a higher proportion of hepatitis (P=0.036)and longer course of cirrhosis (P=0.043); he total number of cyst differed significantly between HHC group and the control group (2-9 in HHC group, 1-5 in control group)(P=0.036);the cyst diameter differed significantly between two groups, with it being 3~11cm in HHC group and 2~6cm in the control group(P=0.041); the difference of CT value between two groups was significant, with it being within 15hu in the control group and over 15hu in about half of the HHC group (P=0.023); the segment of cyst distribution differed significantly between the two groups, as the majority of cysts in HCC group located in the right liver, especially in the S6 and S8 section, while that of the control group located in the left half liver, especially in the S3 segment (χ2=2.572, P=2.572). Conclusion Age, hepatitis, cirrhosis of the liver may be risk factors for hepatic cysts in HCC patients. The morphological features of hepatic cysts in HCC patients include multiple lesions, frequent occurrence in the right lobe see, large diameter, and high susceptibility to necrosis.
Key words: primary liver cancer     cirrhosis of the liver     liver cyst     abdominal computed tomography    

肝囊肿是常见的影像学形态,且肝硬化及原发性肝癌患者往往合并肝囊肿,尤其在复杂或多发囊肿的情况下,癌组织病灶可能由于囊肿的包绕而导致漏诊[1-3]。然而,目前多数观点认为囊肿与先天性的因素关系较大,因此临床医师及影像诊断医师较少归纳肝囊肿与肝脏原发疾病的关系[4-5],目前国内外关于肝硬化并发原发性肝癌合并肝囊肿患者影像学的相关研究多为病例报导,缺乏相关归纳研究。为此,本研究总结了106例肝硬化并发原发性肝癌合并肝囊肿(HHC)患者的上腹部CT特征,并发现其在危险因素、部位、形态等方面均呈一定的规律,对深化认识囊肿的影像学特征具有参考作用。

1 资料与方法 1.1 一般资料

采用回顾性分析设计,选取2011年1月~2017年12月期间我院及东莞市人民医院的肝囊肿患者作为研究对象,纳入标准:确诊HCC;合并门脉性肝硬化;合并肝囊肿;均行上腹部增强CT检查[6]。共入选106例,将其首次上腹部CT的资料进行入选;以同期的无肝癌的肝硬化合并肝囊肿的患者作为对照组,共入选109例。

1.2 指标比较

(1)一般情况:性别、年龄、肝炎病史及肝硬化病程;(2)囊肿参数:比较两组的囊肿总数、最大直径及CT值;(3)分布:比例两组囊肿在S1-S8肝段的分布情况[7]

1.3 统计学处理

定量资料采用均数±标准差表示。采用单因素方差分析进行组间的定量资料分析,采用H检验对组间的计数资料进行分析。采用Pearson法对定量资料间的相关性进行分析,采用Speaman法对计数资料间的相关性进行分析。运用统计软件包SPSS15.0对数据进行处理,P<0.05为差异有统计学意义。

2 结果 2.1 一般情况比较

两组患者的性别差异无统计学意义(P>0.05);而与对照组比较,HHC组的年龄显著偏大,肝炎合并比例高,且肝硬化病程长(P<0.05,表1)。

表1 两组患者一般情况比较(n, Mean±SD)
2.2 两组患者的囊肿参数比较

HHC组的囊肿为2~9个,而对照组为1~5个,两组的囊肿总数差异具有统计学意义(P<0.05);HHC组患者囊肿直径3~11 cm,而对照组为2~6 cm,两组的囊肿直径差异具有统计学意义(P<0.05);对照组的CT多在15 Hu以内,而HHC组约半数超过15 Hu,两组的囊肿CT值差异具有统计学意义(P<0.05,表2)。

表2 两组患者囊肿特征比较(Mean±SD)
2.3 囊肿所在位置比较

HHC组的囊肿病灶总体以右半肝为主,尤其是S6段及S8段偏多,左半肝则以S3段偏多。对照组患者囊肿病灶以左半肝为主,尤其S3及S4偏多(尤其为S4b者多见)。两组的囊肿肝段分布差异具有统计学意义(χ2=2.572,P=0.011)。

2.4 典型案例

患者男性,56岁,因“右上腹部疼痛半伴消瘦3月余”入院,既往有乙型肝炎病史30余年。上腹部增强CT是:肝脏形态缩小,表面呈波浪状,各叶比例失调(图1A),门脉主干扩张增粗。肝VI段可见一类圆形的稍低密度影,增强扫描病灶动脉期明显强化,平衡期及延迟期呈低密度,大小5.5 cm×4.7 cm(图1B);门静脉及肝静脉显示良好,另肝内可见多个大小不等的不强化,低密度影(图1CD)。食管下段及胃壁增厚,增强扫描呈结节状强化。胆囊不大,内未见异常密度影。胃小弯及后腹膜可见走形扭曲、扩张的血管影。脾脏增大,密度未见异常,增强后未见明显异常强化灶。CT诊断:(1)S6段肝癌;(2)肝硬化伴食管下段及胃底静脉曲张;(3)肝内多发囊肿。

图 1 肝硬化并发原发性肝癌合并肝囊肿患者患者上腹部增强CT图像 A: 肝脏形态缩小, 表面呈波浪状, 各叶比例失调, 门脉主干扩张增粗; B: 肝VI段可见一类圆形的稍低密度影, 增强扫描病灶动脉期明显强化, 平衡期及延迟期呈低密度, 大小5.5 cm×4.7 cm; C, D: 门静脉及肝静脉显示良好, 另肝内可见多个大小不等的不强化, 低密度影.
3 讨论

影像学所观察到的发生于肝脏内的囊肿包括诸多类型,可以大致分为非肿瘤性囊肿及肿瘤性囊肿,前者包括囊腺瘤及囊腺癌等;而非肿瘤性包括寄生虫、血肿等,但其有一个共性的特点:非强化的囊肿往往内含多种液体充分,包括浆液、粘液、蛋白质、胆汁诊治血液等[8-10]。然而,在影像学诊断报告多以“囊肿”统称,这对于囊肿的细化诊断是不利的。美国有研究在使用酒精联合致癌物质二乙基亚硝胺诱发成年肝癌大鼠模型,并使用MRI监测肝脏的形态学变化,并发现在瘤体形成前肝内出现多发囊肿[11],该动物实验提示囊肿可能与肿瘤存在一定的相关性。不少情况下,囊肿与肝脏血管瘤较难鉴别,因此有学者建议使用MRI甚至3.0 T的MRI进行鉴别诊断[12-13];有研究使用T1及T2的弛豫时间比值进行囊肿/血管瘤诊断的敏感性改良,且认为当该比值为5.8时,其鉴别诊断的敏感性及特异性最佳[14]。但是对于观察肝脏的密度、轮廓及血管方面,CT仍保持者绝对的优势[14],因此本研究以HHC患者的上腹部增强CT作为分析对象。

本研究发现,HHC患者年龄较无合并肝癌的对照组偏大,且前者的肝炎合并比例高、肝硬化病程长,这初步提示年龄大、合并肝炎以及长肝硬化病程可能是发生囊肿的危险因素,这些因素都可能增加了肝癌的风险。在囊肿的CT特征方面,HHC组的囊肿呈显著的多发表现,而对照组为1~5个,尽管部分为多发,但对照组的囊肿数量显著少于HHC患者。与Qian等[8]报道的特征具有相似性。在囊肿的尺寸方面,HHC组囊肿直径3~11 cm,显著大于对照组的范围2~6 cm。CT值是囊肿鉴别诊断的基本参数,在正常情况下囊肿的CT值多在0~15[15],本研究发现对照组的CT多在15 Hu以内,而HHC组约半数超过15 Hu,两组的囊肿CT值差异具有统计学意义,与Arslanoglu等[16]的报道有所类似,原因可能是HHC患者的囊肿内并发了感染或坏死,炎症物质的集聚使囊肿病灶密度增高[17-19]。目前关于肝癌患者肝囊肿的分布的探索较少,本研究发现HHC组的囊肿病灶总体以右半肝为主,尤其是S6段及S8段偏多,而对照组患者囊肿病灶以左半肝为主,尤其S3及S4偏多,导致以上的分布差异的原因尚不清楚,可能与HHC组的门静脉高压、肝包膜下炎症等因素相关[20-22],也可能与其他合并症无错构瘤等相关[23-24]

本研究认为,年龄、肝炎、肝硬化可能是原发性肝癌患者合并肝囊肿的危险因素,因此临床医师需重视此类群体患者的囊肿病灶;在影像学特征方面,多发性、右叶多见、直径大、易发生坏死,是HHC患者的囊肿形态学表现,因此影像诊断医师在观察到肝硬化患者此类病灶时,需高度警惕合并原发性肝癌的可能。本研究还存在不足,主要是样本量不够大、囊肿的类型需细分等,将在后续的研究加以改善。

参考文献
[1] Kawada M, Hayami N, Suwabe T, et al. Hepatocellular carcinoma in a patient with polycystic liver disease[J]. Jpn J Med, 2015, 54(15): 1891–6.
[2] Bae KT, Zhu F, Chapman AB, et al. Magnetic resonance imaging evaluation of hepatic cysts in early Autosomal-Dominant polycystic kidney disease: the consortium for radiologic imaging studies of polycystic kidney disease cohort[J]. Clin J Am Soc Nephrol, 2006, 1(1): 64–7.
[3] Recinos A, Zahouani T, Guillen J, et al. Congenital hepatic cyst[J]. Clin Med Insights Pediatr, 2017, 41(5): 699–703.
[4] 张雪峰, 易大勇, 李孝舜. 肝脏巨大黏液型恶性纤维组织细胞瘤CT表现一例[J]. 中华放射学杂志, 2014, 48(12): 1056–7. DOI:10.3760/cma.j.issn.1005-1201.2014.12.023
[5] Vannucchi A, Masi A, Vestrini G, et al. Extraperitoneal hemorrhagic rupture of a simple hepatic cyst. A case report and literature review[J]. Ann Ital Chir, 2016, 27(11): 87–93.
[6] 张卫兵, 陈 建, 颜朝晖, 等. 超声引导下聚桂醇与无水乙醇硬化治疗单纯性肝囊肿的比较[J]. 实用医学杂志, 2014, 30(8): 1312–4.
[7] 刘吉平, 张国胜, 高志伟. 腹腔镜带蒂大网膜填塞术治疗直径>10 cm肝囊肿36例[J]. 中国微创外科杂志, 2015, 23(07): 632–4. DOI:10.3969/j.issn.1009-6604.2015.07.016
[8] Qian LJ, Zhu J, Zhuang ZG, et al. Spectrum of multilocular cystic hepatic lesions: CT and Mr imaging findings with pathologic correlation[J]. Radiographics, 2013, 33(5): 1419–33. DOI:10.1148/rg.335125063
[9] Lantinga MA, Geudens A, Gevers T, et al. Systematic review: the management of hepatic cyst infection[J]. Aliment Pharmacol Ther, 2015, 41(3): 253–61. DOI:10.1111/apt.13047
[10] Scherer K, Gupta N, Caine WP, et al. Differential diagnosis and management of a recurrent hepatic cyst: a case report and review of literature[J]. J Gen Intern Med, 2009, 24(10): 1161–5. DOI:10.1007/s11606-009-1062-1
[11] Aditya, Ambade, Abhishek, et al. Adult mouse model of early hepatocellular carcinoma promoted by alcoholic liver disease[J]. World J Gastroenterol, 2016, 22(16): 4091–108. DOI:10.3748/wjg.v22.i16.4091
[12] Nakamura Y, Higaki T, Akiyama Y, et al. Diffusion-weighted Mr imaging of non-complicated hepatic cysts: Value of 3T computed diffusion-weighted imaging[J]. European J Radiol Open, 2016, 3(9): 138–44.
[13] 房泽辉. 肝囊肿和血管瘤的磁共振扩散加权成像诊断及鉴别诊断价值[J]. 实用医学影像杂志, 2016, 17(05): 409–13.
[14] Farraher SW, Jara H, Chang KJ, et al. Differentiation of hepatocellular carcinoma and hepatic metastasis from cysts and hemangiomas with calculated T2 relaxation times and the T1/T2 relaxation times ratio[J]. J Magn Reson Imaging, 2006, 24(6): 1333–41. DOI:10.1002/(ISSN)1522-2586
[15] 包作伟, 张伟民, 邵 珍, 等. 超声引导下聚桂醇硬化治疗单纯性肝囊肿疗效及安全性分析[J]. 介入放射学杂志, 2014, 23(6): 520–2.
[16] Arslanoglu A, Chalian H, Sodagari F, et al. Threshold for enhancement in treated hepatocellular carcinoma on MDCT: effect on necrosis quantification[J]. AJR Am J Roentgenol, 2016, 206(3): 536–43. DOI:10.2214/AJR.15.15339
[17] Bouras J, Truant S, Zerrweck CA, et al. Image of the month cystic hepatocellular carcinoma[J]. Arch Surg, 2011, 146(6): 755–6. DOI:10.1001/archsurg.2011.124-a
[18] Sawada N, Endo T, Mikami K, et al. Kidney injury due to ureteral obstruction caused by compression from infected simple hepatic cyst[J]. Case Rep Gastroenterol, 2017, 11(2): 312–9. DOI:10.1159/000475919
[19] Morii K, Yamamoto T, Nakamura S, et al. Infectious hepatic cyst: an underestimated complication[J]. Intern Med, 2018, 35(7): 139–43.
[20] Kübeck M, Stöckl V, Stainer W, et al. Cystic echinococcosis and hepatocellular carcinoma--a coincidence? A case report[J]. Zeitschrift Für Gastroenterologie, 2014, 52(7): 657–62. DOI:10.1055/s-00000094
[21] Taguchi E, Nakanishi N, Nakao K, et al. Inferior Vena Cava thrombi caused by enlarged, solitary hepatic cyst[J]. Circ J, 2018, 82(2): 604–5. DOI:10.1253/circj.CJ-17-0160
[22] Panchal M, Alansari A, Wallack M, et al. Hepatic cyst compressing the right atrial and ventricular inflow tract: an uncommon cardiac complication[J]. Ann Hepatol, 2018, 17(1): 165–8.
[23] Terada T. Hepatic nodular hamartoma containing liver cysts, ductal plate malformations and peribiliary glands[J]. Hepatology Research, 2011, 41(1): 93–8. DOI:10.1111/hep.2011.41.issue-1
[24] Parapar AL, Anton GS, Arguelles MV, et al. Hypersplenism secondary to splenoportal axis compression by a giant hepatic cyst[J]. Rev Esp Enferm Dig, 2018, 110(1): 51–8.