术中Sonazoid超声造影在特殊部位肝细胞癌经腹腔镜微波消融中的应用价值
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1.湖南省人民医院/湖南师范大学附属第一医院,肝胆外科,湖南 长沙 410002;2.湖南省人民医院/湖南师范大学附属第一医院,超声科,湖南 长沙 410002

作者简介:

段文斌,湖南省人民医院/湖南师范大学附属第一医院主治医师,主要从事肝癌诊治及肝胆术中超声(造影)方面的研究。

通信作者:

杨建辉,Email: yangjianhui403@126.com

基金项目:

湖南省卫健委省级疑难病诊疗中心建设基金资助项目(湘卫医政医管处便函[2019]118号)。


Application value of intraoperative Sonazoid-enhanced ultrasonography in laparoscopic microwave ablation of hepatocellular carcinoma in special locations
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Affiliation:

1.Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital/the First Affiliated Hospital of Hunan Normal University, Changsha 410002, China;2.Department of Ultrasonic Diagnosis, Hunan Provincial People's Hospital/the First Affiliated Hospital of Hunan Normal University, Changsha 410002, China

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    摘要:

    背景与目的 超声常用于引导微波消融(MWA)治疗肝细胞癌(HCC)。部分MWA可经皮完成,对于特殊部位HCC,则常选择通过腹腔镜完成。腹腔镜下MWA亦存在局限,对于小肝癌、等回声结节或合并肝硬化背景等情况,灰阶超声(GSUS)定位靶病灶常存在困难,此时可应用超声造影来增加病灶与肝实质的显影对比,提高靶病灶可视性。但目前临床常用的造影剂如声诺维等增强时间窗较短暂,因而在HCC消融术中的引导作用有限。Sonazoid于2019年在中国上市,相比其他造影剂,Sonazoid的优势在于其能被肝脏Kupffer细胞摄取,在注射造影剂约10 min后进入其特有的枯否相,此期肝脏实质显像增强,且文献报告枯否相可持续至少1 h。HCC因缺乏Kupffer细胞则呈低增强或增强缺失,因此,术中Sonazoid超声造影(S-CEUS)理论上有利于靶病灶的定位,且能为MWA提供充足的时间窗。本研究主要探讨S-CEUS相较于GSUS在针对特殊部位HCC行腹腔镜MWA术中对于肿瘤定位的优势,并分析S-CEUS对于消融治疗的实时引导作用。方法 连续选取2020年6月—2021年12月湖南省人民医院/湖南师范大学附属第一医院肝胆外科49例靶病灶位于特殊部位行腹腔镜MWA的HCC患者,术中分别行GSUS与S-CEUS,分析术中靶病灶的定位情况,采用5分信心量表法对靶病灶的可视度进行评分,比较GSUS与S-CEUS对靶病灶的可视度差异;同时观察靶病灶枯否相持续时间,以及在枯否相行MWA的效果。结果 49例患者术前MRI发现病灶56个,术中S-CEUS发现病灶59个,穿刺活检均证实为HCC。GSUS扫描时,靶病灶的可视度评分为2.86±0.96;S-CEUS动脉相,靶病灶的可视度评分为3.90±0.78;S-CEUS枯否相,靶病灶的可视度评分为4.25±0.60。S-CEUS动脉相、枯否相对靶病灶的可视度评分均优于GSUS(均P<0.001);S-CEUS枯否相对靶病灶的可视度评分优于S-CEUS动脉相(P<0.001)。靶病灶枯否相持续时间超过1 h;术前已知多个病灶的病例均只注射1次造影剂即完成所有病灶的定位;3个术前影像学检查未发现的隐匿性病灶均在枯否相发现;所有病灶均在枯否相进行MWA。消融后15 min再次注射Sonazoid即时评估及术后1个月增强MRI检查均显示所有病灶消融完全。结论 针对特殊部位HCC的腹腔镜MWA,靶病灶在S-CEUS动脉相、枯否相的可视度均优于GSUS,有利于靶病灶的定位;S-CEUS枯否相有利于MWA的实时引导。

    Abstract:

    Background and Aims Microwave ablation (MWA) for the treatment of hepatocellular carcinoma (HCC) is often performed under ultrasound guidance. MWA in some cases can be completed via a percutaneous approach, while a laparoscopic approach is usually chosen for HCC in special locations. However, laparoscopic MWA also has limitations. For small HCC, isoechoic nodules or target lesions within a cirrhotic background, gray-scale ultrasound (GSUS) is sometimes difficult to locate the target lesions. At this time, contrast-enhanced ultrasound can be used to increase the contrast between the lesions and the liver parenchyma and improve the visibility of the target lesions. However, the time window of enhancement imaging with commonly used contrast agents such as SonoVue is relatively short, so its guiding role in HCC ablation is limited. Sonazoid was approved for use in China in 2019. Compared with other contrast agents, the advantage of Sonazoid is that it can be phagocytosed by Kupffer cells in the liver and has its unique Kupffer phase about 10 min after the injection of contrast agent. At this stage, the ultrasonic imaging of liver parenchyma is enhanced, and previous literature has reported that that Kupffer phase can last for at least 1 h. Meanwhile HCC exhibits low enhancement or no enhancement due to the lack of Kupffer cells. Therefore, intraoperative contrast enhanced ultrasound with Sonazoid (S-CEUS) is theoretically helpful for the localization of the target lesions, and can provide a sufficient time window for MWA. This study was performed to investigate the advantages of S-CEUS in tumor localization compared with GSUS in laparoscopic MWA for HCC in special locations, and analyzed the real-time guiding capability of S-CEUS for ablation.Methods From June 2020 to December 2021, 49 HCC patients undergoing laparoscopic MWA with target lesions located in special areas in Department of Hepatobiliary Surgery, Hunan Provincial People's Hospital/the First Affiliated Hospital of Hunan Normal University were consecutively selected. GSUS and S-CEUS were respectively performed during laparoscopic MWA. The positioning accuracy of the target lesions was analyzed. The 5-point confidence scale was used to evaluate the visibility of the target lesion and the difference of the visibility of the target lesions between GSUS and S-CEUS was compared. At the same time, the duration of Kupffer phase was observed, and the efficacy of MWA performed in this phase was evaluated.Results In the 49 patients, 56 lesions were found by preoperative MRI examination, and 59 lesions were detected by S-CEUS during operation, which were all identified as HCC by aspiration biopsy. The visibility score of target lesions was 2.86±0.96 for GSUS, and was 3.90±0.78 in arterial phase and 4.25±0.60 in Kupffer phase for S-CEUS. The visibility scores of target lesions in both arterial phase and Kupffer phase were better than that in GSUS (both P<0.001), and the visibility score of target lesions in Kupffer phase is better than that in arterial phase (P<0.001). The Kupffer phase lasted more than 1 h; the localization of all lesions in patients with multiple lesions known before operation was completed by injection of the contrast agent in one session; three occult tumors that were not found by preoperative imaging examination were all found in Kupffer phase; all lesions underwent MWA in Kupffer phase. Both immediate evaluation by Sonazoid injection again 15 min after ablation and enhanced MRI examination one month after operation showed that all lesions were ablated completely.Conclusion For laparoscopic MWA of HCC in special locations, the visibilities of target lesions in arterial phase and Kupffer phase of S-CEUS are better than that of GSUS, which is helpful for the localization of target lesions. The Kupffer phase of S-CEUS is helpful for the real-time guidance during performing MWA.

    表 1 各时相靶病灶可视性(n)Table 1 Visuality of the target lesion in each phase (n)
    图1 利用枯否相引导微波消融针插入靶病灶(箭头所示为消融针)Fig.1 Guiding the insertion of the ablation needle into the lesion during Kupffer phase (arrow showing the ablation needle)
    图2 消融术后15 min S-CEUS即时评估消融效果(箭头所示造影显示非强化区覆盖肿瘤及其周边0.5 cm,病灶区域无局部高增强灶,考虑消融完全)Fig.2 Immediate evaluation of the ablation efficacy by S-CEUS injection 15 min after ablation (coverage of the tumor and surrounding 0.5 cm area by the non-enhancement area shown by the arrow, indicating complete ablation for the absent of highly enhanced foci within the lesion area)
    图3 因肝硬化多结节干扰,靶病灶(箭头所示)在GSUS期不可见,而在S-CEUS动脉相及枯否相均可视度良好 A:在动脉相,靶病灶呈快速高增强;B:在枯否相,靶病灶呈增强缺失Fig.3 Interference by a background of hepatic cirrhosis with multiple nodules, and invisibility of in GSUS, but good visibility in both arterial phase and Kupffer phase of S-CEUS of the target lesion (shown by the arrow) A: The target lesion presenting rapid high enhancement in arterial phase; B: The target lesion showing loss of enhancement in Kupffer phase
    图4 靶病灶(箭头所示)在GSUS期呈等回声而不可见,而在S-CEUS动脉相及枯否相均可视度良好 A:在动脉相,靶病灶呈快速向心性高增强;B:在枯否相,靶病灶呈增强缺失Fig.4 Isoechoic texture and invisibility in GSUS, but good visibility in both arterial phase and Kupffer phase of S-CEUS of the target lesion (shown by the arrow) A: The target lesion presenting rapid centripetal high enhancement in arterial phase; B: The target lesion showing loss of enhancement in Kupffer phase
    图5 靶病灶(箭头所示)因≤1 cm且在GSUS期呈等回声而不可见,而在S-CEUS动脉相及枯否相均可视度良好 A:在动脉相,靶病灶呈快速向心性高增强;B:在枯否相,靶病灶呈增强缺失Fig.5 Isoechoic texture and invisibility in GSUS, but good visibility in both arterial phase and Kupffer phase of S-CEUS of the target lesion ≤1 cm (shown by the arrow) A: The target lesion presenting rapid centripetal high enhancement in arterial phase; B: The target lesion showing loss of enhancement in Kupffer phase
    图6 靶病灶(箭头所示)在动脉相中呈等增强而不可见,在枯否相可视度良好 A:靶病灶在动脉相呈等增强;B:靶病灶在枯否相呈增强缺失Fig.6 Isoenhancement and invisibility in arterial phase, but good visibility in Kupffer phase of the target lesion (shown by the arrow) A: Isoenhancement of the target lesion arterial phase; B: No enhancement of the target lesion in Kupffer phase
    图7 各时相靶病灶评分Fig.7 Visibility score of target lesions in each phase
    图8 枯否相持续近1 h 后(白色三角形所示为注射造影剂后59 min 49 s),靶病灶(箭头所示)仍清晰显示Fig.8 Clear display of the target lesion (shown by the arrow) in Kupffer phase lasting for approximately 1 h (triangle showing 59 min 49 s after injection of the contrast agent)
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段文斌,薛蓉,王子承,杨建辉,毛先海.术中Sonazoid超声造影在特殊部位肝细胞癌经腹腔镜微波消融中的应用价值[J].中国普通外科杂志,2022,31(7):880-889.
DOI:10.7659/j. issn.1005-6947.2022.07.004

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  • 收稿日期:2022-03-30
  • 最后修改日期:2022-06-21
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  • 在线发布日期: 2022-07-31