肝硬化相關(guān)結(jié)節(jié)和早期肝癌的影像學(xué)評(píng)價(jià)課件

1、肝硬化相關(guān)結(jié)節(jié)和早期肝癌的影像學(xué)評(píng)價(jià)Cirrhotic Hepatic Nodules & Imaging Diagnosis of Early HCC內(nèi)容提綱 肝硬化結(jié)節(jié)的概念與多步癌變 MRI 在診斷肝硬化結(jié)節(jié)中的優(yōu)勢(shì) 肝硬化結(jié)節(jié)的影像學(xué)表現(xiàn)肝硬化結(jié)節(jié)的概念與多步演變特點(diǎn)肝硬化結(jié)節(jié)多步演變的病理學(xué)特點(diǎn)在組織病理/細(xì)胞病理學(xué)層面重要的組織病理學(xué)改變 腫瘤新生血管生成和血液動(dòng)力學(xué)改變RNHGDNHCC 匯管區(qū)三聯(lián)結(jié)構(gòu)(portal triads)的變化HCC-CD34染色HCC 最重要組織病理特征HCC 的影像學(xué)診斷依據(jù)典型的增強(qiáng)影像學(xué)改變Hepatocellular CarcinomaUSC

2、TMRIAPPVForner A, et al. Hepatology 2008Sangiovanni A, et al. Gut 2010“快進(jìn)快出” HCC的組織病理層面的特征Vascular Diagnostic Criteria of HCC血供標(biāo)準(zhǔn)診斷 HCC 面臨的挑戰(zhàn)30%的HCC是乏血供的，沒(méi)有“快進(jìn)快出”的強(qiáng)化特征肝臟HCC疑似病灶動(dòng)脈期也可以強(qiáng)化肝硬化多步癌變過(guò)程中交界性 (borderline) 結(jié)節(jié)的定性Functional & metabolic changesMorphological changesHCC影像診斷 MRI帶來(lái)的機(jī)遇MRI 在肝癌檢測(cè)與定性診斷中的優(yōu)

3、勢(shì)MRBeyond Morphological & Vascular Criteria Bartolozzi C, et al. Eur Radiol 2007 Bartolozzi C. 2010 ECR Choi BI. 2011 ESGAR評(píng)價(jià)肝硬化結(jié)節(jié)的MRI檢查技術(shù)基礎(chǔ)序列T1W/T2W - 敏感的信號(hào)捕捉和較好的軟組織分辨力化學(xué)位移成像T1同反相位 - 脂肪變性的探測(cè)更敏感 DWI及衍生序列細(xì)胞密度、數(shù)目及排列的改變、纖維組織平衡灌注的影響三維薄層動(dòng)態(tài)增強(qiáng)（LAVA / VIBE / THRIVE）普通釓劑；對(duì)富血供病變更敏感特異性MR對(duì)比劑 (細(xì)胞功能層面)肝細(xì)胞對(duì)比劑：肝細(xì)胞的

4、肝膽功能及膽管發(fā)育/排泌含鐵超順磁性對(duì)比劑：枯否細(xì)胞數(shù)量及其吞噬功能臨床應(yīng)用技術(shù)評(píng)價(jià)肝硬化結(jié)節(jié)的MRI檢查技術(shù)SWI - 鐵沉積、微出血、靜脈血管MRS - 反映代謝產(chǎn)物變化MR彈力成像 - 彌漫肝?。ǜ卫w維化）、肝結(jié)節(jié)T1成像 - 彌漫肝?。ǜ卫w維化）BOLD, ASL, CEST, . 科研MRI納米分子探針 科研科學(xué)研究技術(shù)T2WT1WHCCT2 T1 信號(hào)特點(diǎn) 代謝物異常 結(jié)構(gòu)改變T2WT1WRNMR多參數(shù)/功能與代謝成像的診斷價(jià)值T2W壓脂HCCT1W In-phaseT1W Out-phaseHGDNMRBeyond Morphological & Vascular Criteri

5、a平掃T2*SPIOSPIO+Ga彌漫RNOut phaseIn phaseFat fraction mapF=(Sip-Sop)/2(Sip)DN 伴脂肪變性活體無(wú)創(chuàng)反映病理生理改變與演變MRBeyond Morphological & Vascular CriteriaT2APPVPT1RN CT vs. MRI depictionRN & HCC CT vs. MRI depictionT2T1APPVPMR多序列與多參數(shù)成像MRBeyond Morphological & Vascular CriteriaMR-DWI, Hepatobiliary Phase & SPIO Imagi

6、ngDNMRBeyond Morphological & Vascular Criteria Early HCCMR-DWI, Hepatobiliary Phase & SPIO ImagingMRBeyond Morphological & Vascular CriteriaHGDNEarly HCCMR-DWI, Hepatobiliary Phase & SPIO ImagingMRBeyond Morphological & Vascular CriteriaT2T1APDWI20mT2T1APDWI20mProgressed small HCCLarge RNMR-DWI, Hep

7、atobiliary Phase & SPIO ImagingMRBeyond Morphological & Vascular CriteriaHCCFNHHCCMR-DWI, Hepatobiliary Phase & SPIO ImagingMRBeyond Morphological & Vascular CriteriaCourtesy of Dr. MJ KimMRBeyond Morphological & Vascular CriteriaT1-APT1-PVP20m HCC AP shunt MRBeyond Morphological & Vascular Criteria

8、低分化HCCLarge 再生結(jié)節(jié)APPVPT2APPVPHBPCourtesy of Dr. JM LeeHBP-MRI depicts more HCC lesionsMRBeyond Morphological & Vascular CriteriaAdenoma vs. FNHT2w FS TSET1w IPT1w APT1w PVP T1w HBP Adenoma (HNF1- inactivated) FNHMRBeyond Morphological & Vascular CriteriaT1WT2WT2W+SPIOHGDN increased No. & functionalit

9、y of Kupffer cellsMR-DWI, Hepatobiliary Phase & SPIO ImagingMRBeyond Morphological & Vascular CriteriaHCC absence of Kupffer cellsJin Chung, et al. Magnetic Resonance Imaging 29 (2011) 1235MR-DWI, Hepatobiliary Phase & SPIO ImagingMRBeyond Morphological & Vascular CriteriaHGDN + HCCMR多序列與多參數(shù)成像MRBeyo

10、nd Morphological & Vascular CriteriaACR Li-RADS - v. 2012 動(dòng)脈期強(qiáng)化 結(jié)節(jié)大小 延遲期廓清 假包膜 結(jié)節(jié)生長(zhǎng)肝硬化結(jié)節(jié)的分類(lèi)定性診斷 肝膽期表現(xiàn) 低信號(hào) DWI 高信號(hào)，低ADC值 T2高信號(hào)，T1低信號(hào) 脂肪變性 .特異性ACR Li-RADS - v. 2014，2017敏感性組織病理層面特征細(xì)胞/分子病理層面特征KUDO M. J Gastroenterol 2009, 44 :112118Summary大小T2WT1WDWIT1-APT1-PVPT1-HBPT2-SPIORN1cm低稍高低（-）（-）攝取強(qiáng)化（-）HGDN1-2cm低/等稍高/等低/等稍有強(qiáng)化等/稍低多數(shù)攝取顯著降低HCC1-2cm稍高/等低稍高迅速?gòu)?qiáng)化強(qiáng)化程度降低（大多數(shù)）無(wú)攝取無(wú)降低 MR多序列的綜合分析 結(jié)合臨床和實(shí)驗(yàn)室檢查Summary肝癌的發(fā)生 是多步演變的過(guò)程，表現(xiàn)以下主要病理改變： Size & growth Angiogenesis Changes o