肝脏少见良性占位性病变的临床特征与诊治：附43例报告

背景与目的:随着医学影像学技术的发展进步以及居民体检保健意识不断增强,临床上肝脏良性肿瘤的检出率逐渐提高。因其体积不随时间变化而明显改变,一般不需要治疗。然而大部分肝脏少见良性占位术前往往难以明确其病变性质,有时不易与肝脏恶性肿瘤相鉴别。因此需要适时的临床干预。本研究旨在探讨肝脏少见良性肿瘤的诊断、治疗,以及不同肿瘤的临床特点、影像学特征、病理特征、发展与演变,以减少误诊、制定合理的治疗方案,尤其是明确外科手术指征,进而避免过度治疗。方法:回顾南昌大学第一附属医院2014年5月—2019年5月收治的43例肝脏少见良性肿瘤病例(肝脏局灶性结节性增生20例,肝脏血管平滑肌脂肪瘤14例,肝细胞腺瘤4例,炎性假瘤2例,肝脏纤维瘤、肝脏神经鞘瘤、肝脏髓脂肪瘤各1例)临床资料,分析临床诊断及治疗效果。结果:患者术前临床症状缺乏特异性,11例患者出现相关的临床症状,以腹痛腹胀,压迫胃肠道引起的恶心呕吐最为常见。术前影像学检查总体诊断准确率为51.2%(22/43),最易误诊为肝癌。手术方式包括开腹手术和腹腔镜手术(开腹手术31例,腹腔镜手术12例)。手术平均时间(195.5±80.3)min,手术平均出血量(419.7±362.3)mL。7例(16.3%)术后输血,平均输血4 U。术后3例(7.0%)出现并发症(1例胆汁漏,1例肺部感染并双侧胸腔积液,1例感染发热),无再手术及手术死亡病例。术后住院时间3~17 d。与开腹手术患者比较,腹腔镜手术患者术中出血量明显降低(468.4 mL vs.287.5 mL,P=0.027)、术后住院时间明显更短(7.7 d vs.6.2 d,P=0.040),其余指标差异无统计学意义(均P>0.05)。术后随访17.6~77.5个月,期间未见肿瘤复发,11例术前有症状患者中10例症状消失或缓解。结论:肝脏少见良性占位性病变临床症状缺乏特异性,术前诊断多依赖影像学检查,诊断正确率较低,最易误诊为肝癌,影像组学可提高诊断准确性。应充分认识肝脏少见良性占位性病变的临床特点及特征,避免误诊。外科手术是最有效的治疗方法,推荐使用腹腔镜肝切除。应严格把握手术指征,避免过度治疗,根据患者具体情况做出个体化治疗选择,提高肝脏良性肿瘤的外科诊治水平。

Clinical characteristics and management of rare benign space-occupying liver lesions: a report of 43 cases

Background and Aims With the development and progress of medical imaging technology as well as the strengthening awareness of health maintenance examination among the population, the detection rate of benign liver tumors is continually increasing in clinical practice. Because the lesion volume changes slightly over time, treatment is generally not required. However, it is often difficult to identify the nature of the rare benign space-occupying liver lesions, and sometimes it is difficult to distinguish them from malignant liver tumors. Therefore, timely clinical intervention is necessary. The purpose of this study was to investigate the diagnosis and treatment of rare benign tumors of the liver, and discuss the clinical characteristics, imaging features, pathological features, development and evolution of different tumors, so as to reduce misdiagnosis and make reasonable treatment plan, especially clarify the surgical indications and thereby, avoid overtreatment.Methods The clinical data of 43 patients with rare benign liver tumor (20 cases of hepatic focal nodular hyperplasia, 14 cases of hepatic angiomyolipoma, 4 cases of hepatocellular adenoma, 2 cases of inflammatory pseudotumor, and one case each of liver fibroma, liver schwannoma and liver medullary lipoma) treated in the First Affiliated Hospital of Nan Chang University during May 2014 to May 2019 were reviewed. The clinical diagnosis and treatment results were analyzed.Results The preoperative clinical symptoms of the patients had no specificity, and 11 patients showed related clinical symptoms, of which the most common were abdominal pain, abdominal distension and nausea and vomiting caused by compression of the gastrointestinal tract. The overall diagnostic accuracy of preoperative imaging examination was 51.2% (22/43), and the most frequent misdiagnosis was liver cancer. The surgical methods included open surgery and laparoscopic surgery (31 cases of open surgery and 12 cases of laparoscopic surgery). The average operative time was (195.5±80.3) min, and the average intraoperative blood loss was (419.7±362.3) mL. Postoperative blood transfusion was required for 7 patients, with an average of 4 U. Postoperative complications occurred in 3 (7.0%) patients (1 case of bile leakage, 1 case of pulmonary infection with bilateral pleural effusion, and 1 case of infectious fever), and there was no reoperation or death. Postoperative hospital stay was 3-17 d. In patients undergoing laparoscopic surgery compared with those undergoing open surgery, the intraoperative blood loss of was significantly decreased (468.4 mL vs. 287.5 mL, P=0.027) and the length of postoperative hospital stay was significantly reduced (7.7 d vs. 6.2 d, P=0.040), while no significant differences were noted in other variables (all P>0.05). Follow-up period was conducted for 17.6-77.5 months, during which time no tumor recurrence was observed, and in 10 cases of the 11 the symptomatic patients, the symptoms regressed or disappeared.Conclusion The clinical symptoms of rare benign space-occupying liver lesions lack specificity. Preoperative diagnosis mostly relies on imaging examination, and the diagnostic accuracy is low. The most common misdiagnosis is liver cancer, and imaging omics approach can improve the diagnostic accuracy. Full understanding of the clinical characteristics and features of rare benign space-occupying liver lesions should be prepared to avoid misdiagnosis. Surgery is the most effective treatment, and laparoscopic hepatectomy is recommended. The surgical indications should be strictly grasped, excessive treatment should be avoided, and individualized treatment should be made according to the specific conditions of patients, to improve the level of surgical diagnosis and treatment of rare benign space-occupying liver lesions.