肝细胞癌合并肝门部胆管癌栓与肝门部胆管癌的CT鉴别诊断

doi:10.3877/cma.j.issn.1674-0793.2021.01.007

目的

分析肝细胞癌（HCC）合并肝门部胆管癌栓（HBDTT）的CT影像特征，并探讨其与肝门部胆管癌（hilar CC）的CT鉴别诊断。

方法

收集中山大学附属第一医院及江门市新会中医院2013年1月至2018年12月经病理证实的HCC伴HBDTT患者42例（HBDTT组）及hilar CC患者51例（hilar CC组），对两组患者的临床资料及CT影像表现进行比较和分析。

结果

与hilar CC组相比，HBDTT组男性、乙型肝炎病史、上腹部疼痛比例较高，甲胎蛋白（AFP）水平升高更为常见，而hilar CC组CA19-9、癌胚抗原（CEA）升高患者更多（均P<0.05）。两组CT征象在是否同时累及肝实质及胆管、门静脉期"快退"、胆管壁增厚、血管癌栓及脾大等方面差异均有统计学意义（P<0.001），5项征象均具有较高的特异度（82.4%~98.0%），其中前3项诊断敏感度较高（100.0%、92.9%、85.7%）。

结论

利用CT可以对HCC合并HBDTT与hilar CC作出准确的鉴别诊断。病变同时累及肝实质和肝门部胆管、门静脉期"快退"及胆管壁不增厚是HCC伴HBDTT的特征性征象，结合乙型肝炎病毒感染、AFP水平升高等综合分析对鉴别HCC伴HBDTT与hilar CC有重要作用。

关键词: 癌, 肝细胞, 胆管肿瘤, 计算机断层扫描, 肝门部胆管癌栓

Objective

To analyze the computed tomography (CT) characteristics of hepatocellular carcinoma (HCC) with hilar bile duct tumor thrombus (HBDTT) and to investigate the differential imaging features of hilar cholangiocarcinoma (hilar CC).

Methods

From January 2013 to December 2018, fourty-two cases with pathologically proved HCC with HBDTT (HBDTT group) and fifty-one cases of hilar CCs (hilar CC group) from the First Affiliated Hospital of Sun Yat-sen University and Xinhui Traditional Chinese Medicine Hospital were retrospectively collected. The clinical features and CT findings between the two groups were compared and analyzed.

Results

Compared with hilar CC group, the proportion of male, hepatitis B history and upper abdominal pain were higher in HBDTT group, and increased alpha-fetoprotein (AFP) levels were common. However, there were more patients with elevated CA19-9 and carcinoembryonic antigen (CEA) in hilar CC group (P<0.05). On CT imaging characteristics, the presence of both parenchymal lesion with intraductal lesion, washout during the portal venous phase, thickened bile duct wall , intrahepatic vascular embolus, splenomegaly had significant differences between the two groups (P<0.001), all of these five characteristics showed high specificity (82.4%-98.0%), and the first three showed higher sensitivity (100.0%, 92.9%, 85.7%).

Conclusions

CT can be used for accurate differential diagnosis of HCC with HBDTT and hilar CC. The lesion involved both the liver parenchyma and hilar bile duct, washout during portal venous phase and without thickened bile duct wall are characteristic signs of HCC with HBDTT, which are important for the identification of HCC with HBDTT and hilar CC, when combined with hepatitis B virus infection and AFP levels.

Key words: Carcinoma, hepatocellular, Bile duct neoplasms, Computed tomography, CT, Hilar bile duct tumor thrombus

表1 HCC伴HBDTT与hilar CC患者临床资料比较

组别	例数	年龄(岁)^a	性别(例,男/女)	乙型肝炎史	皮肤黄染	上腹部疼痛	AFP (μg/L)	CA19-9 (U/ml)	CA125 (U/ml)	CEA (μg/L)
HBDTT组	42	31~71(48.4±9.5)	37/5	30(71.4)	33(78.6)	24(57.1)	29(69.0)	25(59.5)	8(19.0)	1(2.4)
hilar CC组	51	29~80(58.5±11.4)	35/16	6(11.8)	43(84.3)	18(35.3)	1(2.0)	44(86.3)	14(27.4)	10(19.6)
统计值		-35.4	5.0	34.6	0.5	4.4	47.4	8.6	0.9	6.6
P值		<0.001	0.025	<0.001	0.476	0.035	<0.001	0.003	0.343	0.011^b

表1 HCC伴HBDTT与hilar CC患者临床资料比较

组别	例数	年龄(岁)^a	性别(例,男/女)	乙型肝炎史	皮肤黄染	上腹部疼痛	AFP (μg/L)	CA19-9 (U/ml)	CA125 (U/ml)	CEA (μg/L)
HBDTT组	42	31~71(48.4±9.5)	37/5	30(71.4)	33(78.6)	24(57.1)	29(69.0)	25(59.5)	8(19.0)	1(2.4)
hilar CC组	51	29~80(58.5±11.4)	35/16	6(11.8)	43(84.3)	18(35.3)	1(2.0)	44(86.3)	14(27.4)	10(19.6)
统计值		-35.4	5.0	34.6	0.5	4.4	47.4	8.6	0.9	6.6
P值		<0.001	0.025	<0.001	0.476	0.035	<0.001	0.003	0.343	0.011^b

图1 41岁女性肝细胞癌患者CT图像　CT平扫示HCC病灶（短箭头）及HBDTT（长箭头）呈低密度（A）；增强扫描动脉期不均匀强化（B）；门静脉期呈低密度，胆管壁无增厚（C）；D为组织病理图片（苏木精-伊红染色，×200），显示肝细胞癌中等分化

图2 43岁男性肝细胞癌患者CT图像　箭头所示肝门部胆管癌栓；在CT平扫时呈低密度（A）；增强扫描动脉期轻度强化，与周围肝实质相比呈等密度（B）；门静脉期呈低密度，胆管壁无增厚（C）；D为组织病理显示肝细胞癌中等分化（苏木精-伊红染色，×200）

图3 64岁男性肝门部胆管癌患者CT图像　显示胆管壁增厚（箭头所示）；平扫呈低密度（A）；增强扫描动脉期（B）及门静脉期（C）呈较均匀持续强化；D为组织病理显示胆管癌中-低分化（苏木精-伊红染色，×200）

表2 HCC伴HBDTT与hilar CC患者的CT影像征象对比

CT征象		HBDTT组	hilar CC组	统计值	P值
例数		42	51
肝内结节大小(mm)^a		43.0±23.6	31.2±15.9	-1.2	0.242
胆管内肿物最大径(mm)^a		20.8±5.2	19.0±7.7^b	-1.2	0.218
累及肝实质及胆管		42(100.0)	9(17.6)	63.1	<0.001
肝内病灶与胆管内病灶相连		42(100.0)	9(100.0)^c	63.1	<0.001
肝内胆管扩张		42(100.0)	48(94.1)	1.0	0.313
CT密度
平扫				1.7	0.388^d
	高密度	1(2.4)	0(0)
	等密度	5(11.9)	4(7.8)
	低密度	36(85.7)	47(92.2)
动脉期				2.1	0.368^d
	高密度	33(78.6)	34(66.7)
	等密度	5(11.9)	12(23.5)
	低密度	4(9.5)	5(9.8)
门静脉期				61.3	<0.001
	高密度	4(9.5)	16(31.4)
	等密度	2(4.8)	32(62.7)
	低密度	36(85.7)	3(5.9)
强化方式				53.0	<0.01
	快进快退	28(66.7)	1(2.0)
	延迟强化	8(19.0)	48(94.1)
胆管壁增厚		3(7.1)	49(96.1)	73.9	<0.001
血管癌栓		17(40.5)	4(7.8)	14.0	<0.001
淋巴结肿大		5(11.9)	14(27.5)	3.4	0.064
脾大		18(42.9)	1(2.0)	23.7	<0.001
腹水		1(2.4)	0(0)	1.2	0.452^d
食管胃底静脉曲张		3(7.1)	0(0)	1.8	0.177
肝内胆管结石		1(2.4)	5(9.8)	1.1	0.305

表2 HCC伴HBDTT与hilar CC患者的CT影像征象对比

CT征象		HBDTT组	hilar CC组	统计值	P值
例数		42	51
肝内结节大小(mm)^a		43.0±23.6	31.2±15.9	-1.2	0.242
胆管内肿物最大径(mm)^a		20.8±5.2	19.0±7.7^b	-1.2	0.218
累及肝实质及胆管		42(100.0)	9(17.6)	63.1	<0.001
肝内病灶与胆管内病灶相连		42(100.0)	9(100.0)^c	63.1	<0.001
肝内胆管扩张		42(100.0)	48(94.1)	1.0	0.313
CT密度
平扫				1.7	0.388^d
	高密度	1(2.4)	0(0)
	等密度	5(11.9)	4(7.8)
	低密度	36(85.7)	47(92.2)
动脉期				2.1	0.368^d
	高密度	33(78.6)	34(66.7)
	等密度	5(11.9)	12(23.5)
	低密度	4(9.5)	5(9.8)
门静脉期				61.3	<0.001
	高密度	4(9.5)	16(31.4)
	等密度	2(4.8)	32(62.7)
	低密度	36(85.7)	3(5.9)
强化方式				53.0	<0.01
	快进快退	28(66.7)	1(2.0)
	延迟强化	8(19.0)	48(94.1)
胆管壁增厚		3(7.1)	49(96.1)	73.9	<0.001
血管癌栓		17(40.5)	4(7.8)	14.0	<0.001
淋巴结肿大		5(11.9)	14(27.5)	3.4	0.064
脾大		18(42.9)	1(2.0)	23.7	<0.001
腹水		1(2.4)	0(0)	1.2	0.452^d
食管胃底静脉曲张		3(7.1)	0(0)	1.8	0.177
肝内胆管结石		1(2.4)	5(9.8)	1.1	0.305

表3 HCC伴HBDTT的重要诊断征象效能[例(%)]

CT征象	敏感度	特异度	假阳性率	假阴性率	准确性
累及肝实质及胆管	42(100.0)	42(82.4)	9(17.4)	0(0)	90.3
胆管壁不增厚	39(92.9)	49(96.1)	2(3.9)	3(7.1)	94.6
门静脉期"快退"	36(85.7)	48(94.1)	3(5.9)	6(14.3)	90.3
血管癌栓	17(40.5)	47(92.2)	4(7.8)	25(59.5)	68.8
脾大	18(42.9)	50(98.0)	1(2.0)	24(57.1)	73.1

表3 HCC伴HBDTT的重要诊断征象效能[例(%)]

CT征象	敏感度	特异度	假阳性率	假阴性率	准确性
累及肝实质及胆管	42(100.0)	42(82.4)	9(17.4)	0(0)	90.3
胆管壁不增厚	39(92.9)	49(96.1)	2(3.9)	3(7.1)	94.6
门静脉期"快退"	36(85.7)	48(94.1)	3(5.9)	6(14.3)	90.3
血管癌栓	17(40.5)	47(92.2)	4(7.8)	25(59.5)	68.8
脾大	18(42.9)	50(98.0)	1(2.0)	24(57.1)	73.1

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CT differential diagnosis of hepatocellular carcinoma with hilar cholangiocarcinoma thrombus and hilar cholangiocarcinoma

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CT differential diagnosis of hepatocellular carcinoma with hilar cholangiocarcinoma thrombus and hilar cholangiocarcinoma