动态三维超声造影在肝癌消融疗效评估中的初步研究

目的评价动态三维超声造影（3D-CEUS）在肝癌消融治疗后近期疗效中的诊断价值。方法对75例肝细胞肝癌共89个病灶行超声引导下经皮热消融或化学消融,治疗后1个月行动态3D-CEUS判定局部疗效,以同期对比增强CT（CECT）或对比增强MRI（CEMRI）作为金标准,评估动态3D-CEUS的诊断效能。结果 CECT或CEMRI判定80.9%（72/89）的病灶达到完全消融,19.1%（17/89）的肿瘤消融不全;动态3D-CEUS判定82.0%（73/89）的病灶达到完全消融,18.0%（16/89）的病灶消融不全。与CECT或CEMRI比较,动态3D-CEUS诊断的灵敏度、特异度、阳性预测值、阴性预测值和准确率分别为88.2%（15/17）、98.6%（71/72）、93.8%（15/16）、97.3%（71/73）和96.6%（86/89）。结论动态3D-CEUS在判定肝癌消融局部疗效中,与CECT或CEMRI具有同等的价值。     

CEUS联合MRI实时融合导航技术在评估肝癌消融疗效中的临床应用

目的 探索超声造影联合MRI融合导航技术在评估肝癌消融疗效的临床应用价值。方法 前瞻性纳入三家临床中心自2020年9月至2022年12月行消融的肝细胞肝癌（HCC）患者,随机分为超声造影（CEUS）组和CEUS联合MRI导航组,分别于术前1天及术后30天行超声造影或CEUS联合MRI导航检查。以术后30天普美显增强MRI为标准,判断是否达到安全边界及是否完全消融。结果 本多中心研究最终纳入CEUS组46例患者,46个病灶,CEUS联合MRI导航组31例患者,31个病灶。77个病灶中,27例行射频消融治疗,50例行微波消融治疗。CEUS组46例病灶中,14例未达到安全边界,CEUS联合MRI导航组31例病灶中,4例未达到安全边界,两组无显著差异（P = 0.063）。位于特殊位置（距离肝包膜、大血管旁、胆囊旁、膈肌小于5mm）的病灶中,CEUS组有6例未达到安全边界（6/29）,CEUS联合MRI导航组有2例未达到安全边界（2/17）（P < 0.001）。等回声或边界不清的病灶中,CEUS组有5例未达到安全边界（5/25）,CEUS联合MRI导航组有2例未达到安全边界（2/18）（P < 0.001）。结论 CEUS联合MRI融合导航技术有助于准确判断肝癌消融后的安全边界,尤其是位于特殊位置的病灶及等回声或边界不清的病灶。     

三维超声融合成像可视化技术在引导肝细胞癌热消融精准布针中的初步应用

目的初步探索三维超声融合成像(3DUS FI)可视化技术在引导肝细胞癌(HCC)热消融术中精准布针的临床价值。方法回顾性分析2019年11月至2021年12月于中山大学附属第一医院行3DUS FI引导下热消融治疗的56例HCC患者(59个病灶)。术前采集患者三维超声容积图像并与实时二维超声图像融合配准, 将肿瘤及5 mm安全边界分割标记出来后在三维可视化下进行术前规划并实时引导热消融。术后1个月行增强CT/MRI评估病灶是否消融完全并测量消融边界, 分析消融边界与局部肿瘤进展(LTP)发生率的关系。结果所有病灶术中均可成功配准并三维显示。术后超声造影显示所有病灶均达到完全消融。共有37个病灶可依据术后1个月增强CT/MRI评估消融效果和消融边界, 其中32个(86.5%)病灶达到完全消融且消融边界≥ 5 mm。随访期间, 4个病灶发生LTP, 其中3个发生在消融边界<5 mm处, 所有病灶1年和2年的累积LTP率均为7.1%。所有患者均未发生与热消融治疗相关的严重并发症以及死亡事件。结论 3DUS FI可视化技术引导HCC热消融术中精准布针是可行并且安全的。     

动态三维超声造影评价肝癌射频消融术疗效的价值

目的探讨动态三维超声造影(3D-CEUS)评价肝癌射频消融术疗效的价值。方法选择2012年9月至2014年1月中南大学湘雅医院收治的肝癌患者48例共48个病灶。其中30例患者经手术后病理确诊,18例患者经临床诊断。所有患者均行射频消融术。所有患者射频消融术后1个月、3个月行二维超声造影(2D-CEUS)、动态3D-CEUS评价疗效,并与增强CT或磁共振成像(MRI)检查结果进行比较。以活检病理或2种以上影像学检查(超声检查、CT、MRI、PET)、肿瘤标志物水平、患者3个月以上随访结果综合判断的最终诊断结果作为金标准,分别计算CEUS、增强CT或MRI诊断肿瘤灭活的敏感度、特异度、准确性。结果射频消融术后,本组48例患者48个病灶中,75.0%(36/48)的病灶应用动态3D-CEUS后能得到更多有价值的信息,有助于操作者评估射频消融术疗效;25.0%(12/48)的病灶应用动态3D-CEUS与应用2D-CEUS相比,对临床结果的影响没有明显差别,动态3D-CEUS没有改变任何一个病灶的诊断或者临床治疗方案。2D-CEUS及动态3D-CEUS显示40个病灶消融区域无增强,提示肿瘤完全消融;8个病灶边缘部分呈结节样不规则高增强,提示肿瘤部分残存。增强CT或MRI示39个病灶消融区域无增强,提示肿瘤完全消融;9个病灶边缘可见不规则强化,提示肿瘤部分残存。CEUS、增强CT或MRI诊断射频消融术后肿瘤灭活的敏感度、特异度、准确性分别为80.0%、100%、95.8%和80.0%、97.4%、93.8%。结论动态3D-CEUS在评价射频治疗疗效方面,与2D-CEUS及增强CT或MRI无明显差异,但动态3D-CEUS能提供更多有价值的信息,在评估肝癌射频消融术疗效中具有潜在的价值。     

结直肠癌转移性肝癌与原发性肝癌热消融疗效比较

目的 探讨经皮热消融治疗结直肠癌转移性肝癌(metastatic liver carcinoma,MLC)与原发性肝癌(hepatocellular carcinoma,HCC)局部疗效的差异.方法 回顾性比较热消融治疗MLC 69例108个病灶,HCC 70例92个病灶的局部疗效、并发症和安全边缘.结果 MLC组与HCC组肿瘤完全消融率分别为88.0％和91.3％(P=0.44),局部进展率分别为13.0％和14.1％(P=0.81),中位局部进展时间分别为7.5个月和3.6个月(P=0.36),主要并发症发生率分别为4.3％和2.9％(P=0.68).安全边缘相同时,MLC组和HCC组的残留率和局部进展率相近.MLC组内,安全边缘≤0.5 cm亚组残留率远高于安全边缘＞0.5 cm亚组(P＜0.001);HCC组内,安全边缘≤0.5 cm亚组局部进展率高于安全边缘＞0.5 cm亚组(P=0.03).结论 热消融治疗MLC和HCC局部疗效相似,其治疗肝肿瘤安全、有效.安全边缘达到0.5 cm对减少肿瘤残留和局部进展非常重要.     

CT/MR图像融合评价肝癌消融的安全边界

目的 探讨CT/MR图像融合评价肝癌消融安全边界(AM)的可行性.方法 选取消融术后1个月增强CT/MR提示肿瘤消融完全的肝癌患者39例共44个病灶,利用图像融合系统,在术前CT/MR图像上勾勒肿瘤及AM的范围,与术后CT/MR图像进行对位融合,根据消融灶覆盖肿瘤和AM情况,分为达到AM组和未达AM组.随访术后局部肿瘤进展(LTP)发生情况,比较两组LTP发生率的差异.结果 对43个病灶完成图像融合,成功率97.73％(43/44),图像融合时间4～11 min,平均(7.0士2.0)min;融合图像评估AM用时5～10 min,平均(7.1±1.3)min.43个病灶中,24个消融后达到AM,随访未出现LTP;19个未达AM,随访中4例出现LTP;达到AM组术后LTP发生率明显低于未达到AM组(P=0.031).结论 CT/MR图像融合能较准确地评价肝癌AM,消融术后未达AM者易发生LTP.     

肝癌射频消融后三维超声造影评价疗效的价值

目的探讨肝癌射频消融(RFA)治疗后三维超声造影(3D-CEUS)表现及其诊断价值。方法分析我院行RFA治疗且治疗后24h内行3D-CEUS检查的肝癌患者92例共99个病灶,将其分为残留复发组及完全灭活组,分析两组病灶3D-CEUS表现。结果将3D-CEUS表现分为结节增强型、片状增强型、环状增强型、无增强型。残留复发组与完全灭活组间在结节增强型及环状增强型的差异具有统计学意义(P=0.000、0.026)。结论 4种3D-CEUS分型表现对肝癌RFA后残留或复发灶的诊断具有较大应用价值。     

肝恶性肿瘤超声引导下射频消融短期有效性及影响因素分析

目的 评估肝恶性肿瘤超声引导下射频消融(radiofrequency ablation,RFA)的有效性及影响因素.方法 回顾性分析2011年6月至2012年5月405例行超声引导下肝恶性肿瘤RFA治疗患者的临床资料,以及术前影像学检查和术后至少3个月随访影像学资料,分析肿瘤患者RFA后病灶完全消融率、局部残存率、肿瘤复发率及肿瘤进展率,并分析影响肝恶性肿瘤RFA局部疗效的相关因素.结果 405例患者共行462次RFA治疗,消融病灶数610个,病灶直径(2.5±1.1)cm,术后3个月肿瘤完全消融率89.2％(544/610),肿瘤复发率17.5％(81/462),肿瘤进展率23.8％(110/462).病灶数目(≥3个)、病灶大小(≥3 cm)及肿瘤位置(位于大血管旁)影响肿瘤完全消融率;而病灶数目(≥3个)影响肿瘤复发率及进展率.复发性肝细胞性癌、胃肠道转移癌及非胃肠道转移癌相比原发性肝癌(HCC)有更高的复发率和进展率.结论 超声引导下RFA治疗肝恶性肿瘤可有效控制肿瘤局部进展,病灶数目、大小及位于大血管旁可影响肿瘤完全消融率,病灶数目可影响肿瘤复发率及进展率,复发性HCC及转移性肝癌与原发性HCC相比肿瘤复发率、进展率更高.     

超声造影评估肝癌局部热消融疗效的价值及局部肿瘤进展的影响因素分析

目的 探讨超声造影（CEUS）在肝癌局部热消融疗效评估中的应用价值，分析局部肿瘤进展的影响因素。方法 收集我院行超声引导下热消融治疗的92例肝癌患者（共114个病灶），治疗后均行CEUS和增强磁共振成像（CEMRI）或增强计算机体层成像（CECT）随访，以临床综合诊断为标准，计算并比较CEUS、CEMRI或CECT评估肝癌局部热消融疗效的诊断效能。采用单因素（χ2检验或Fisher确切概率法）及多因素（Logistic回归）分析病灶发生局部肿瘤进展的影响因素。结果 114个病灶随访3～18个月，临床综合诊断提示完全消融93个，肿瘤残余1个，局部肿瘤进展20个。CEUS评估肝癌局部热消融疗效的灵敏度、特异度、阳性预测值、阴性预测值及准确率分别为80.95%、97.85%、89.47%、95.79%及94.73%，CEMRI或CECT检查的灵敏度、特异度、阳性预测值、阴性预测值及准确率分别为95.24%、96.77%、86.96%、98.90%及96.49%，二者诊断效能比较差异均无统计学意义。影响局部肿瘤进展的单因素分析表明，常规超声病灶边界、常规超声病灶形态和病灶最大径对局部肿瘤进展的影响有统计学意义（P＜0.05），多因素分析表明病灶最大径是热消融术后局部肿瘤进展的独立危险因素（P＜0.05）。结论 CEUS评估肝癌局部热消融治疗疗效的价值与CEMRI或CECT相当，可作为一种有效随诊手段；病灶大小是热消融治疗后局部肿瘤进展的独立危险因素。     

人工腹水辅助超声引导下经皮微波消融治疗邻近横膈肝癌的应用价值

目的探讨人工腹水辅助超声引导下经皮微波消融（MWA）治疗邻近横膈肝癌的应用价值。 方法选取浙江中医药大学附属西溪医院2016年1月至2019年10月,行经皮MWA治疗邻近横膈原发性肝癌的患者83例,共96个病灶。83例患者依据是否建立人工腹水分为：人工腹水组（A组）40例;非人工腹水组（B组）43例。依据病灶声像图显示清晰完整度进行评分,比较2组病例声像图质量。术后1个月行增强MRI或增强CT检查以评估近期疗效,后续每隔3~6个月行增强MRI或增强CT评估局部肿瘤进展情况。对2组患者的不良反应、并发症以及术后疗效进行对比观察。 结果术中病灶声像图显示清晰完整度评分A组为（4.81±0.35）分,B组为（3.54±0.48）分,2组差异有统计学意义（t=15.352,P<0.05）。不良反应及并发症：发热A组19例（19/40,47.5%）,B组20例（20/43,46.5%）,2组差异无统计学意义（P=0.928）;上腹部隐痛A组16例（16/40,40.0%）,B组19例（19/43,44.2%）,2组差异无统计学意义（P=0.700）;胸腔积液A组1例（1/40,2.5%）,B组12例（12/43,27.9%）,2组差异有统计学意义（χ²=8.295,P=0.004）;横膈损伤A组0例,B组6例（6/43,14.0%）,2组差异有统计学意义（P=0.026）。消融后1个月,A组完全消融率为97.5%（39/40）,B组完全消融率为95.3%（41/43）,2组差异无统计学意义（P=0.600）。83例患者中位随访时间21个月,A组与B组局部肿瘤进展率分别为5.0%（2/40）、7.0%（3/43）,2组差异无统计学意义（P=0.705）。 结论人工腹水辅助超声引导下经皮MWA治疗邻近横膈肝癌可提高病灶声像图质量且消融安全性更高。     

影像学评估肝癌消融边界的研究进展

消融边界是肝癌消融术后局部肿瘤进展的独立影响因素,准确评估消融边界尤为重要。本文对消融边界评估方式及其研究进展进行综述。     

Can the Entire Ablative Hyperechoic Zone be Regarded as a Necrotic Lesion After Radiofrequency Ablation of the Liver?

Developments in image fusion technology made it possible to visualize the ablative margin on ultrasound (US). The purpose of the present study was to assess the ablative area of radiofrequency ablation for hepatocellular carcinoma and compare it with the ablative hyperechoic zone with a non-enhanced area on contrast-enhanced US/contrast-enhanced computed tomography (CEUS/CECT) in the same cross-section. This retrospective study included 25 patients with 27 hepatocellular carcinomas. The long and short dimensions of the ablative hyperechoic zone were measured using B-mode US, and those of the non-enhanced area were assessed with CEUS/CECT on the same cross-section measured with B-mode US, using image fusion techniques. The technical effectiveness of ablation with an adequate ablative margin in a single session was determined in all patients. The long and short dimensions of the ablative hyperechoic zone ranged between 15.0 and 40.7 mm (mean: 27.3 ± 6.9 mm) and between 14.0 and 33.0 mm (mean: 23.3 ± 5.8 mm), respectively. R values for the long and short dimensions were 0.99 and 0.98, respectively, between B-mode US and CEUS, and 0.96 and 0.92, respectively, between B-mode US and CECT. The ablative hyperechoic zone may be regarded as a necrotic lesion after radiofrequency ablation.     

二维及三维超声造影评估子宫肌瘤射频消融早期疗效的临床价值

目的 探讨二维和三维超声造影技术在评估射频消融(RFA)治疗子宫肌瘤早期疗效中的应用价值.方法 接受RFA治疗的子宫肌瘤患者90例,共150枚肌瘤,其中肌壁间肌瘤138枚,黏膜下肌瘤12枚(5枚为细蒂肌瘤).在RFA前后1 d内进行二维及三维超声造影,观察病灶区血供变化,测量肌瘤体积、消融范围,计算灭活率.结果 5例细蒂黏膜下肌瘤完整取出.145枚在体肌瘤射频治疗后二维超声造影表现为:137枚肌瘤原部位无造影剂灌注,提示消融完全,8枚肌瘤边缘线性增强或瘤内片状增强区,考虑治疗不全;三维超声造影表现为:132枚肌瘤消融后瘤体血管网消失,达到完全凝固,其余13枚肌瘤中7枚病灶内缘有细小枝状低增强,6枚内部不均匀低增强,为肌瘤组织残留.139枚肌瘤消融灭活率达(97.1±12.9)%,另6枚灭活率仅为(46.4±7.0)%.结论 三维超声造影能够显示子宫肌瘤的血管构筑及空间关系,是对二维超声造影的补充,两者联合应用能直观、准确地评估射频治疗子宫肌瘤的早期疗效.     

Imaging evaluation of ablative margin and index tumor immediately after radiofrequency ablation for hepatocellular carcinoma: comparison between multidetector-row CT and MR imaging

Purpose

To prospectively compare multidetector-row CT (MDCT) and MR imaging (MRI) in the assessment of the ablative margin (AM) and index tumor immediately after radiofrequency (RF) ablation for hepatocellular carcinoma (HCC) and assess whether non-contrast MRI with limited sequences (T1- and T2-weighted imaging only) was superior to a conventional MDCT protocol.

Methods

A total of 33 consecutive patients with 42 HCCs were included in this study. Both MDCT and MR images were independently reviewed by two radiologists regarding the ability to visually discriminate between the AM and index tumor, and the AM status within ablation zones. The AM status was classified as AM-plus (AM completely surrounding the tumor), AM-zero (AM was partly discontinuous, without protrusion of the tumor), and AM-minus (AM was partly discontinuous, with protrusion of the tumor). During the follow-up period, the cumulative local tumor progression rates were analyzed using the Kaplan–Meier method and Cox proportional hazards model. To determine the added value of contrast-enhanced MR images, both reviewers separately evaluated the two sets (unenhanced and enhanced) of MR images.

Results

Visual discrimination between the AM and index tumor was possible in four (9.5%) and 34 (81%) of the 42 ablation zones using MDCT and MRI, respectively (p < 0.001). Thirty-eight and four cases were classified as AM-plus and AM-zero on MDCT images, respectively, whereas the ablation zones were categorized as AM-plus (n = 32), AM-zero (n = 9), and AM-minus (n = 1) when examining the MR images. The cumulative incidence of local tumor progression was significantly lower in cases with AM-plus on MRI (p = 0.007). Contrast-enhanced MRI had no added value for the assessment of the AM and index tumor.

Conclusion

MRI was superior to MDCT for the differential assessment of the AM and index tumor immediately after RF ablation for HCC. Non-contrast MRI was also superior to the conventional MDCT protocol.

     

3-D Contrast-Enhanced Ultrasound Fusion Imaging: A New Technique to Evaluate the Ablative Margin of Radiofrequency Ablation for Hepatocellular Carcinoma

To investigate the feasibility of assessing the ablative margin (AM) of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) with 3-D contrast-enhanced ultrasound fusion imaging (3-DCEUS-FI), pre- and post-RFA 3-DCEUS images of 84 patients with HCC were fused for two radiologists to independently assess the AMs. The success rate, duration and influencing factors for registration; inter-observer agreement for AM classification; and local tumor progression (LTP) rate were evaluated. The success rate of the automatic registration (AR), which was completed within 4–12 s, was 57.1% (48/84). The duration and success rate of the interactive registration (IR) were 4.2 ± 1.8 min and 91.7% (77/84) for radiologist A and 4.8 ± 2.1 min and 91.7% (77/84) for radiologist B, respectively. The multivariate analysis demonstrated that the pre-RFA image quality, number of vessels (≥3 mm) and presence of acoustic shadow were independent factors for AR (p < 0.05), while the number of vessels was an independent factor for IR (p = 0.001). The agreement between observers was excellent (kappa = 0.914). LTP rate was significantly higher for AMs <5 mm than for AMs ≥5 mm (p = 0.024). Quantitatively evaluating the AM immediately after RFA for HCC with 3-DCEUS-FI was feasible.     

Linear Enhancement After Radio-Frequency Ablation for Hepatocellular Carcinoma: Is It a Sign of Recurrence?

This prospective study was performed in 179 hepatocellular carcinoma (HCC) lesions treated by radio-frequency ablation (RFA) to explore the clinical outcome of “linear enhancement” on contrast-enhanced sonogram. Thirty-three lesions (18.4%) showed linear enhancement, a linear-shaped positive enhancement in the RFA-treated area. Seventeen of them were followed up with no treatment (remaining 16; dropout in eight, additional RFA in six and ineffective treatment in two) and three lesions (3/17, 17.6%) showed local tumor progression corresponding to linear enhancement at 7, 14, 19 months after RFA. Although there was no significant difference in local recurrence rate between the lesions with (3/17) and without linear enhancement (10/35), local tumor progression inside the ablation zone occurred only in the lesions with linear enhancement. In conclusion, linear enhancement inside the RFA-treated area should be followed up within 7 months because it has a risk of local tumor progression. Histology of linear enhancement and its influence on distant recurrence remain to be solved.     

超声引导激光消融实验兔肾的有效性评估

目的初步评估超声引导激光消融实验兔肾的有效性。方法超声引导下对4只正常新西兰兔肾进行单针或多针激光消融(每根光纤设定功率5W,持续6min,总能量1800J),观察消融过程中和消融结束后二维超声表现及消融结束后消融灶超声造影表现,并观察消融灶大体及镜下病理表现。结果二维超声上消融灶大体呈椭圆形,其中央部分为高回声,周边部分为稍低回声,与周围肾实质分界模糊,内未见血流信号;超声造影示消融灶整体呈无增强;双针消融灶(30mm×15mm)比单针消融灶(13mm×12mm)范围大。大体标本示消融灶中央为碳化区,周边呈粉红色区,与未消融区分界清晰。镜下可见消融灶中央凝固性坏死,周边变性伴间质出血,未消融区组织形态正常且与消融灶分界清晰。结论超声可引导激光对肾脏进行有效消融。结合超声造影,可进一步评估消融效果。多针消融可扩大消融范围。     

CT评价兔VX2肝癌射频消融后局部肿瘤进展模式及部位

目的 探讨兔VX2肝癌射频消融(RFA)后局部肿瘤进展(LTP)模式和部位的CT特征。方法 新西兰大白兔30只,组织块种植法制成兔VX2肝癌模型,肿瘤种植14天后将荷瘤兔随机分为实验组(n=21)和对照组(n=9),进行RFA治疗。实验组:完全消融肿瘤+至少一个边缘瘤周消融范围小于5 mm正常肝组织;对照组:完全消融肿瘤+肿瘤边缘约10 mm正常肝组织。射频后3、7、14天行CT扫描,每次扫描后选7只实验组、3只对照组兔处死。观察射频区及LTP形态和部位。结果 30只兔单发VX2肝癌模型均成功建模,肿瘤平均直径15 mm,其中5只兔于术中及术后死亡(实验组死亡3只,对照组死亡2只),实验组每次CT检查完成后实际处死6只兔,对照组共7只完成实验。对照组7只兔射频区边缘未见肿瘤细胞;实验组18只兔共发现LTP病灶25个。14只兔的18个LTP病灶发生于射频缘距肿瘤边缘不足5 mm区域内。射频针周围较其他部位更易发生LTP(P=0.011)。结论 VX2肝癌RFA后LTP病灶具有一定特征,LTP的发生与射频消融范围不足有关。