1.徐州医科大学附属淮安医院 肝胆胰外科，江苏 淮安 223002;2.南京大学医学院附属鼓楼医院 影像科， 江苏 南京 210008;3.南京大学医学院附属鼓楼医院 肝胆外科， 江苏 南京 210008
1.Department of Hepatopancreatobiliary Surgery, the Affiliated Huai'an Hospital of Xuzhou Medical University, Huai'an, Jiangsu 223002, China;2.Department of Radiology , the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China;3.Department of Hepatopancreatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China
背景与目的 微血管侵犯（MVI）是肝细胞癌（HCC）患者术后早期复发的重要危险因素，对合并有MVI的HCC行解剖性肝切除或较宽切缘的肝切除可能切除更多的MVI，从而减少复发率，改善患者的无瘤生存率和总生存率。但MVI是基于术后组织病理学的诊断，因此术前准确预测MVI对HCC个体化治疗方案的制定有着重要价值。普美显（Gd-EOB-DTPA）最大优势在于肝胆期的特异性影像表现，因此，在肝胆期行普美显增强磁共振（EOB-MRI）能清晰显示病灶的边界，大大提高了对病灶的显示及诊断能力。本研究通过分析术前EOB-MRI影像学特征，探讨其对HCC患者MVI的预测价值。方法 回顾2014年7月—2017年6月南京大学医学院附属鼓楼医院肝胆外科147例术前行EOB-MRI检查并接受根治性肝切除的HCC患者临床病理及影像资料。分析预测MVI的危险因素，并检测EOB-MRI的预测效能。结果 在147例患者中，MVI阳性49例，MVI阴性98例。单因素分析显示，肿瘤直径（P=0.001）、肝胆期非结节型肿瘤（P<0.001）、动脉期瘤周强化（P=0.016）、动脉期瘤周高信号环（P=0.014）、肝胆期肿瘤混杂信号（P=0.001）和肝胆期瘤周低信号（P<0.001）是MVI的预测因素。多因素分析显示，肝胆期非结节型肿瘤（OR=5.075，95% CI=1.587~16.223，P=0.006）、肝胆期肿瘤混杂信号（OR=2.750，95% CI=1.102~6.866，P=0.030）和肝胆期瘤周低信号（OR=7.130，95% CI=2.679~18.977，P<0.001）是MVI的独立预测因素。3种EOB-MRI影像学特征（肿瘤大体分型、肝胆期肿瘤混杂信号、肝胆期瘤周低信号）预测MVI的敏感度分别为89.8%，57.1%和61.2%；特异度分别为51.0%，72.4%和89.8%。当3种EOB-MRI影像学特征同时具备时，其特异度高达98.0%。结论 肝胆期非结节型肿瘤、肿瘤混杂信号和瘤周低信号是预测MVI的独立危险因素。当同时具备3种EOB-MRI影像学特征时，预测MVI具有较高的特异度。
Background and Aims Microvascular invasion (MVI) is an important risk factor for early postoperative recurrence of hepatocellular carcinoma (HCC). For HCC accompanied by MVI, anatomic liver resection or hepatectomy with a wide resection margin may increase the elimination rate of MVI, thereby reduce the recurrence and improve the disease-free and overall survival of patients. However, the diagnosis of MVI is based on postoperative histopathology, so accurate preoperative prediction of MVI is of great value for the development of individualized treatment plans for HCC. The greatest advantage of gadolinium-ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) lies in the specific imaging performance during the hepatobiliary phase. Therefore, the Gd-EOB-DTPA enhanced magnetic resonance imaging (EOB-MRI) performed in the hepatobiliary phase can clearly show the boundary of the lesion, and greatly improve the ability of the lesion display and diagnosis. This study was conducted to analyzed the preoperative EOB-MRI imaging characteristics and determine its predictive value for MVI in HCC patients.Methods The clinicopathologic and imaging data of 147 HCC patients who underwent preoperative EOB-MRI examination and radical hepatectomy from July 2014 to June 2017 in the Department of Hepatobiliary Surgery of Drum Tower Hospital of Nanjing University were reviewed. The risk factors for MVI were analyzed, and the predictive effectiveness of EOB-MRI was determined.Results Among the 147 patients, 49 cases were MVI positive and 98 cases were MVI negative. The results of univariate analysis showed that tumor size (P=0.001), non-nodular type tumor on the hepatobiliary phase (P<0.001), peritumoral enhancement in arterial phase (P=0.016), rim enhancement in arterial phase (P=0.014), mixed signal intensity of tumor on hepatobiliary phase (P=0.001) and peritumoral hypointensity on hepatobiliary phase (P<0.001) were predictors for MVI. The results of multivariate analysis showed that non-nodular type tumor on hepatobiliary phase (OR=5.075, 95% CI=1.587-16.223, P=0.006), mixed signal intensity of tumor on hepatobiliary phase (OR=2.750, 95% CI=2.679-18.977, P=0.030), peritumoral hypointensity on hepatobiliary phase (OR=7.130, 95% CI=2.679-18.977, P<0.001) were independent predictors for MVI. For predicting MVI, the sensitivity of the three EOB-MRI imaging features (the gross type of tumor, mixed signal intensity of tumor on hepatobiliary phase and peritumoral hypointensity on hepatobiliary phase) was 89.8%, 57.1% and 61.2%, and their specificity was 51.0%, 72.4% and 89.8%, respectively. The specificity reached 98.0% by simultaneous presence of the three EOB-MRI imaging features.Conclusion Non-nodular type tumor, mixed signal intensity of tumor and peritumoral hypointensity on hepatobiliary phase are independent predictors for MVI. The simultaneous presence of the three EOB-MRI imaging features has a high specificity for predicting MVI.