(优选)肝脏常见实质性占位性病变的诊断及鉴别

肝脏占位性病变的影像学检查周康荣 摘要:肝脏占位性病变的影像学检查,近年来取得了很大进展,无论是病灶的检出率和定性诊断准确率都有很大提高,对肝脏和肝脏病变的血供研究进一步深入。

US和C T在肝脏占位病变的检测中应用最为普遍,敏感性也相仿,但螺旋CT双期或多期增强扫描的定性能力更强,动脉期扫描的价值得到充分肯定,但动脉期的标准、起始时间、持续时间,以及与造影剂注射计划的关系,文献报道比较混乱,作者根据多年的临床和科研资料积累,作了较详细的讨论。

磁共振成像SE T1W、T2W加上快速梯度回波序列动态增强对肝脏占位病灶的诊断尤其定性能力略优于SCT,尤其对小的血管瘤、RN、DN的鉴别意义更大。

作者把肝内占位病变分成多血供和少血供两大类,并对常见病变的CT、M R表现与特征作了扼要介绍。

最后还对肝脏特异性M R造影剂的发展前景以及多层螺旋CT的临床应用价值作了论述。

Imaging Examination of Hepatic Space Occupying LesionsZhou K angrongDepartment of Radiology,ZhongS han Hospital,Shanghai200032Abstract:I n recent years,imag ing examina tio n of the liver,mainly focused on the space occupying or focal le-sions has been developing very fast.W hatever the detectability o r the accuracy of the preo perative diagnosis of the fo-cal liver lesion were sig nificantly improved.T he study on the bloo d supply to the liver and hepatic lesions w as further deepened.U S and the most commonly applied imaging modalities in the examnina tio n of the liver,bo th have similar sensitivity in the detection of the lesions,but dual phase dy namic enhancement SCT is better in the characterization of the lesions,and particularly,its arterial phase is approved to be very valuble.How ever,it is still and quite confus-ing problem as to what is the criteria,initial time,ending time and duration of the enhancement of the arterial phase, as well as the relation w ith the contrast injection protocol.The author discussed it in detail on the basis of his o wn clinical and research data collected in a few years.It is also considered by the author that M RI including SE T1W, T2W and dynamic enhancement with F M PSPGR sequence mig ht be superior to SCT in the diagnosis of the focal liv er lesions,especially small hemangioma,RN and DN.A ccording to the deg ree of the blood supply,the lesio ns can be divided into tw o catego ries:hy pervascular and hypov ascular.T ha t may be helpful fo r differentiation of the diseases on the images.CT findings and features of some co mmon diseases of the liver were presented briefly in this series.Final-ly,the futute development of specific liver M R contrast agents such as M n-DPDP,SPIO,and the present or future applicatio n of the new CT scanner,namely multislice SCT were also involved in the discussion and evaluation. 随着U S、CT和M RI等影像学检查技术的不断发展,以及临床经验的积累,肝脏占位性病变尤其小病灶的检出率明显提高,术前诊断准确性也得以提高。

《肝脏良性占位性病变的诊断与治疗专家共识》要点随着影像学技术的发展，肝脏良性占位性病变（benign occupation of the liver，BOL)的检出率不断提高，但在其诊断与治疗方面却尚无规范可循。

1 循证医学证据级别与推荐强度2 BOL的分类BOL的分类参照2010版WHO提出的消化系统肿瘤组织学分类进行命名。

值得注意的是，肝脏不典型增生结节、肝脏胆管细胞乳头状瘤、肝脏胆管细胞囊腺瘤（BCA）、肝腺瘤、肝血管平滑肌脂肪瘤（HAML）等属癌前病变。

3 BOL的诊断要点BOL的诊断应重视肝病背景和流行病学背景。

我国＞80％的原发性肝癌合并肝炎或肝硬化病史，而除肝脏不典型增生结节以外的BOL极少合并肝硬化。

腹部超声检查通常用于BOL筛查和随访。

多排螺旋CT （MDCT）或MRI平扫加增强扫描则用于确诊BOL，且两者可为互补。

MRI检查鉴别肝硬化增生、不典型增生结节及小肝癌方面更具优势，尤其是新型对比剂钆塞酸二钠的应用可明显提高小肝癌的诊断准确性。

PET/CT 检查鉴别诊断良恶性肝脏肿瘤有一定价值，可选择性应用。

实验室检查对大多数BOL诊断无帮助，但肝包虫病血清学试验对诊断有决定性意义，AFP、CA19-9、CEA等肿瘤标志物有助于良恶性占位性病变的鉴别诊断。

当临床治疗决策必要而影像学检查无法确诊时，可行肝穿刺活组织病理学检查以明确诊断。

对于特定类型的BOL，肝穿刺活组织还可行免疫组织化学染色检测以获取组织学分型并指导治疗。

4 BOL的鉴别诊断BOL的诊断须建立在排除肝脏恶性肿瘤基础上。

因此，诊断BOL的过程也是与恶性肿瘤相鉴别的过程。

实性BOL需与原发性肝癌、转移性肝癌、肝胆管细胞癌等鉴别；囊性BOL需与肝脏胆管囊腺癌（BCAC）等相鉴别。

肿瘤影像学特征，生长速度，肝炎及肝硬化病史，AFP、CEA、CA19-9等肿瘤标志物是鉴别诊断的主要依据。

5 BOL的处理原则推荐1：BOL的诊断必须结合病史，影像学及实验室检查进行综合分析，并在排除肝脏恶性肿瘤的基础上作出诊断（证据级别Ⅰ，推荐等级强）。

螺旋CT扫描对肝脏占位性病变的诊断及鉴别诊断价值王兆彬王晓辉哈尔滨医科大学附属肿瘤医院放射科【摘要】目的探讨螺旋CT扫描对肝脏占位性病变的诊断及鉴别诊断价值。

方法对56例患者螺旋CT平扫和增强扫描。

结果对肝脏占位性病变基本能做定性诊断和鉴别诊断。

结论螺旋CT扫描对肝脏占位性病变的诊断及鉴别诊断具有重要价值。

【关键词】螺旋CT 扫描肝脏占位性病变The value of helical CT in the diagnosis and distinctivediagnosis of hepatic lesions.WANG Zhaobin WANG Xiaohui(Department of Radiology, The Affiliated Tumor Hospital of Harbin Medical University,Harbin 150010,China)Abstract: Objective To evaluate helical CT in the diagnosis and distinctive diagnosis of hepatic lesions. Methods Dual phase scanning of the liver in 56 patients with lesions was carried out with a helical CT scanner. Results Basic qualitative and distinctive diagnosis of hepatic lesions can be made. Conclusion Helical CT has important value in the diagnosis and distinctive diagnosis of hepatic lesions.Key words: helical CT; scanning; hepatic lesion肝脏占位性病变在肝脏的所有疾病中所占比例非常大，本组资料（56）例仅对典型病例进行讨论，具体如下：1.资料与方法1.1一般资料共收集我院2008年3月——2009年8月经临床及手术病理证实（手术病灶切除，穿刺取病理）的肝内占位性病灶56例，男46例，女10例，年龄20-70岁，平均45岁，其中肝细胞癌12例，血管瘤10例。