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临床研究
肝门部胆管癌合并胆管结石的影像学特征分析
曾焕忠 毛家骥 沈君

曾焕忠,毛家骥,沈君.肝门部胆管癌合并胆管结石的影像学特征分析.磁共振成像, 2016, 7(10): 763-768. DOI:10.12015/issn.1674-8034.2016.10.009.


[摘要] 目的 探讨肝门部胆管癌合并胆管结石的影像学特点。材料与方法 收集经手术或活检病理证实的54例肝门部胆管癌,年龄28~86岁,中位年龄61岁,男34例,女20例,以MRI或CT上有无合并胆管结石分为两组,合并胆管结石11例(A组),无胆管结石43例(B组)。回顾性分析并对比两组肿瘤大体分型、Bismuth-Corlette分型、肝叶萎缩及手术后复发情况。结果 54例肝门部胆管癌患者中,大体分型:A组浸润型3例(27.3%)、肿块型5例(45.4%)、息肉型3例(27.3%);B组浸润型32例(74.4%)、肿块型8例(18.6%)、息肉型3例(7.0%),两组肿瘤大体分型的差异有显著统计学意义(P<0.05)。Bismuth-Corlette分型:A组I型2例(18.2%)、II型1例(9.1%)、IIIa型4例(36.3%)、IIIb型2例(18.2%)、IV型2例(18.2%);B组I型3例(7.0%)、II型14例(32.6%)、IIIa型6例(14.0%)、IIIb型10例(23.2%)、IV型10例(23.2%),两组Bismuth-Corlette分型无统计学意义(P>0.05)。术后复发:A组2例(18.2%),B组8例(18.6%);肝叶萎缩:A组4例(36.3%),B组15例(34.9%),两组术后复发及肝叶萎缩的差异均无统计学意义(P>0.05)。结论 肝门部胆管癌合并胆管结石更多表现为肿块型和息肉型,肝门部胆管癌有无合并胆管结石在Bismuth-Corlette分型、肝叶萎缩及手术后复发情况上表现相似。
[Abstract] Objective: To investigate the CT and MRI features of hepatic hilar cholangiocarcinoma with simultaneous bile duct stones.Materials and Methods: Fifty-four patients with hilar cholangiocarcinoma confirmed by surgical or biopsy pathology were enrolled. Thirty-four males and twenty females with ages between 28 and 86 years old (median age 61 years old), All patients were divided into two groups according to the presence of absence of bile duct stones as detected by MRI or CT. Among 54 patients with hilar cholangiocarcinoma, eleven patients had bile duct stones (group A), the remaining 43 cases had no bile duct stones (group B). Tumor shape, Bismuth-Corlette type, atrophy of liver lobe and postoperative recurrence were retrospectively analyzed and compared between the two groups.Results: For tumor shape, infiltrative type was found in 3 patients (27.3%) vs. 32 patients (74.4%), mass type in 5 patients (45.4%) vs. 8 patients (18.6%), polypoid type in 3 patients (27.3%) vs. 3 patients (7.0%) respectively in group A and group B. Significant difference was found in tumor shape between the two groups (P<0.05). As for Bismuth-Corlette type, there were 2 cases (18.2%) of type I, 1 case (9.1%) of type II, 4 cases (36.3%) of type IIIa, 2 cases (18.2%) of type IIIb, 2 cases (18.2%) of type IV in group A; and 3 cases (7.0%) of type I, 14 cases (32.6%) of type II, 6 cases (14.0%) of type IIIa, 10 cases (23.2%) of type IIIb, 10 cases (23.2%) of type IV in group B. No significant difference was found in Bismuth-Corlette type between the two groups (P>0.05). There were 2 recurrent cases (18.2%) in group A while 8 recurrent cases (18.6%) in group B. There were 4 cases (36.3%) with liver lobe atrophy in group A and 15 cases (34.9%) with liver lobe atrophy in group B. No significant differences were found in postoperative recurrence and liver lobe atrophy between the two groups (P>0.05).Conclusion: Hepatic hilar cholangiocarcinomas accompanied with bile duct stones most often manifest as mass type or polypoid type. Hepatic hilar cholangiocarcinomas accompanied with bile duct stones or not represent similarly in respect of Bismuth-Corlette type, postoperative recurrence and liver lobe atrophy.
[关键词] 胆管肿瘤;胆结石;磁共振成像;体层摄影术,X线计算机
[Keywords] Bile duct neoplasms;Cholelithiasis;Magnetic resonance imaging;Tomography, X-ray computed

曾焕忠 东莞市厚街医院放射科,东莞 523945

毛家骥 中山大学孙逸仙纪念医院放射科,广州 510120

沈君* 中山大学孙逸仙纪念医院放射科,广州 510120

通讯作者:沈君,E-mail:shenjun@mail.sysu.edu.cn


收稿日期:2016-07-25
接受日期:2016-09-21
中图分类号:R445.2; R735.8 
文献标识码:A
DOI: 10.12015/issn.1674-8034.2016.10.009
曾焕忠,毛家骥,沈君.肝门部胆管癌合并胆管结石的影像学特征分析.磁共振成像, 2016, 7(10): 763-768. DOI:10.12015/issn.1674-8034.2016.10.009.

       肝门部胆管癌(hepatic hilar cholangiocarcinoma,HHA)是指累及肝总管、左右肝管及其汇合部的胆管黏膜上皮癌。尸检资料显示胆管癌的发病率约为0.01%~0.20%,HHA占所有胆管癌的40%~60%[1],是胆管癌的最常见类型,且其发病率呈逐年上升的趋势[2]。目前,根治性手术切除是HHA的最佳治疗方法。然而,HHA极具侵袭性及易于早期转移,并且其早期症状不明显且缺乏特征性,致使大多数患者就诊时已经是癌症晚期。即便采用根治性手术切除,HHA的预后依然很差,5年生存率仅为9%~27%[3]。已有的研究表明,胆管结石是肝门部胆管癌的重要危险因素之一[4,5]。目前,有无合并胆管结石的肝门部胆管癌的影像学特征是否有差异尚不明确。本文通过回顾性分析经手术或活检病理证实为HHA的54例患者的CT及MRI影像学资料,以有无合并胆管结石分为两组,对比其肿瘤大体分型、Bismuth-Corlette分型、肝叶萎缩情况及术后复发情况,旨在探讨肝门部胆管癌合并胆管结石的影像学特点。

1 材料与方法

1.1 一般资料

       收集中山大学孙逸仙纪念医院2010年8月至2015年7月经手术切除和术中活检病理证实为HHA的患者资料共54例,年龄28~86岁,中位年龄61岁,其中男性34例,女性20例。临床主要表现为黄疸、右上腹部不适、腹痛、体重减轻、乏力、皮肤瘙痒等症状。

1.2 检查方法

       54例患者中,13例同时行MRI和CT检查,35例仅行MRI检查,6例仅行CT检查。所有患者检查前均签署知情同意书。

       磁共振检查使用PHILIPS Achieva 3.0 T TX超导型核磁共振机扫描仪,采用体部表面线圈,常规使用腹部呼吸门控技术,扫描范围包括肝脏、胆囊及胰腺。扫描序列及参数包括:横断位T2加权成像(T2-weighted imaging,T2WI):TR 1650 ms,TE 80 ms,层厚/层间距=4.5 mm/1 mm,FOV=395 mm×317 mm,NSA=2;横断位T1加权成像(T1-weighted imaging,T1WI):TR 500 ms,TE 50 ms,层厚/层间距=2 mm/0 mm,F0V=375 mm×304 mm,NSA=1;冠状位T1WI成像TR/TE=3.1 ms/1.45 ms,层厚/层间距=3 mm/0 mm,FOV=350 mm×398 mm,NSA=2;弥散加权成像(diffusion weighted imaging,DWI):b=0、800 s/mm2。接着常规采用流动补偿和脂肪抑制技术行磁共振胰胆管造影(magnetic resonance cholangiopancreatography,MRCP)扫描(TR 4576 ms,TE 740 ms,FOV=300 mm×300 mm,NSA=1)。平扫完成后经肘静脉注射钆类对比剂(Gd-DTPA 0.1 ml/kg),再行T1WI横断位与冠状位增强扫描,增强扫描各参数与平扫相同。

       CT检查使用西门子(Somatom Sensation 64)螺旋CT机,扫描参数:管电流200 mAs,管电压120 kV,层厚为1 mm,层间隔为0.75 mm,螺距:1.2,准直宽度:64 mm×0.6 mm,0.5 s/圈,矩阵:512×512。增强扫描:经肘静脉高压团注射非离子型对比剂(碘帕醇,300 mgI/ml),剂量1.5~2.0 ml/kg,注射流率3.0~4.0 ml/s。在腹主动脉腰1椎体水平设置触发阈值(100 Hu),采用自动追踪技术达阈值后启动三期扫描。

1.3 图像分析

       由2名影像科高年资医师分别对每例患者的MRI与CT图像进行分析,评价指标包括MRI和/或CT图像上有无合并胆管结石、有无合并肝叶萎缩、肿块的大体分型、Bismuth-Corlette分型、手术后3年内复发情况,当意见有差异时讨论协商达成一致。采用1975年Bismuth-Corlette方法分型[6],I型:肿瘤局限于肝总管;II型:肿瘤位于肝总管及左右肝管汇合部;IIIa型:肿瘤累及肝总管、左右肝管汇合部和右肝管;IIIb型:肿瘤累及肝总管、左右肝管汇合部和左肝管;IV型:肿瘤位于肝总管、汇合部并同时累及左右肝管。影像学大体分型分为浸润型、肿块型和息肉型3型[7]。54例肝门部胆管癌中,合并胆管结石11例(20.4%,A组),无胆管结石43例(79.6%,B组)。

1.4 统计学处理

       采用SPSS 19.0统计软件处理数据,依据不同资料类型采用不同的统计学方法。计数资料采用χ2检验,两两组间比较采用Bonferroni检验法,等级资料采用Mann-Whitney U检验法,均以P<0.05表示差异有统计学意义。

2 结果

2.1 肿瘤大体分型及影像学表现

       54例中肿瘤大体形态表现为浸润型35例(64.8%,图1),A组3例(27.3%),B组32例(74.4%),影像表现为肝门部胆管壁不均匀增厚并管腔狭窄及远端胆管扩张,CT表现为胆管增粗、密度增高,MR呈等/稍长T1稍长T2信号(图1A图1B),增强扫描增厚的胆管壁显著强化(图1C)。肿块型13例(24.1%,图2),A组5例(45.4%),B组8例(18.6%),表现为肝门部肿块伴胆管狭窄、闭塞,CT上多为等或稍低密度,MR上呈稍长T1稍长T2信号,与周围组织界线欠清(图2A图2B),远端胆管继发扩张,增强扫描动脉期肿块外周晕环状强化,侵犯临近肝实质可呈放射状强化,中央区延迟呈渐进性强化(图2C),坏死少见,肿块弥散受限表观扩散系数(apparent diffusion coefficient,ADC)图呈低信号(图2D)。息肉型6例(11.1%,图3),A组3例(27.3%),B组3例(7.0%),表现为胆管内单发或多发低密度结节或稍长T1稍长T2信号(图3A图3B)结节影,伴远端胆管扩张,扩张胆管内T1WI可见高信号影充填(图3A),增强扫描结节呈不均匀强化(图3C)。胆管结石CT上可呈高或低密度,MRI上多呈长T1短T2信号,亦可呈等或高信号,增强扫描无强化(图3D)。肿瘤侵犯肝动脉和门静脉表现为局部血管管腔狭窄、变形,脉管周围脂肪间隙消失,侵犯肝实质表现为肿块与肝组织界限不清,增强扫描肝实质强化;淋巴结转移表现为短径增大,形态改变伴环形强化,DWI呈高信号。

图1  男性,68岁,浸润型HHA。病变沿肝总管浸润生长,肝总管管壁不规则增厚,管腔偏心性狭窄伴肝内胆管扩张,病灶T1WI (A)呈等/稍低信号;T2WI (B)呈稍高信号;T1WI增强扫描(C)病变段管壁明显强化
图2  男性,43岁,肿块型HHA。肝门区见不规则形肿块伴肝内胆管扩张,肝尾状叶及左叶萎缩,肿块T1WI(A)呈低信号;T2WI (B)呈高信号;T1WI增强扫描(C)呈延迟强化,临近肝动脉、门静脉及肝实质受侵,界限不清;ADC (D)肿块弥散受限呈低信号
图3  男性,60岁,息肉型HHA。左肝管和汇合部见息肉样结节,可见窄蒂与胆管壁相连,伴肝内胆管扩张,结节T1WI (A)呈低信号,周围胆管内见高信号影充填;T2WI (B)呈稍高信号;T1WI增强扫描(C)结节呈不均匀强化;肝左叶胆管内见多发结石形成,增强扫描无强化(D);MRCP (E),左肝管和汇合部见息肉样充盈缺损伴肝内胆管明显扩张呈软藤征
Fig. 1  Male, 68 years old, Hepatic hilar cholangiocarcinoma (HAA) of infiltrative type. The lesion grew along the common bile duct invasively, with irregular thickening and eccentrical narrow of the common bile duct wall, as well as dilation of the intrahepatic bile duct. The lesion showed isointensity/hypointensity on T1WI (A) and slight hyperintensity on T2WI (B). The bile duct wall showed remarkable enhancement (C).
Fig. 2  Male, 43 years old, HAA of mass type. An irregular mass located in the hepatic hilar, with dilation of the intrahepatic bile duct and atrophy of the caudate lobe and the left lobe. The mass represented isointensity on T1WI (A), hyperintensity on T2WI (B), delayed enhancement (C) and hypointensity on ADC map (D), invading the hepatic artery and portal vein and liver parenchyma involvement with an ill-defined margin.
Fig. 3  Male, 60 years old, HAA of polypoid type. A polypoid nodule located in the left intrahepatic bile duct and juction of bile duct, with a narrow stalk attached on the bile duct and dilation of intrahepatic bile duct, The nodule showed hypointensity on T1WI (A) and slight hyperintensity on T2WI (B) and heterogeneous enhancement (C); Multiple stones were shown in the left lobe of liver bile duct (D); A polypoid filling defect in the left intrahepatic bile duct and juction of bile duct and the soft rattan sign was shown on MRCP (E).

2.2 Bismuth-Corlette分型与胆管扩张

       三型HHA肝内胆管均不同程度扩张呈"软藤征",扩张胆管分布依据Bismuth-Corlette分型而不同,I型:左右肝管及汇合部、肝内胆管广泛扩张,II型:左右肝管及肝内胆管扩张,IIIa型:左肝管和右侧二级胆管开口以远肝内胆管扩张,IIIb型:右肝管和左侧二级胆管开口以远肝内胆管扩张,IV型:双侧二级胆管开口以远肝内胆管扩张。MRCP:浸润型显示肝门部胆管不规则狭窄;肿块型显示肝门部胆管截断、闭塞;息肉型显示扩张胆管内充盈缺损(图3E),胆囊萎缩,胆囊管不扩张。

2.3 术后复发情况

       本组术后复发10例,占18.5%,A组2例(18.2%),B组8例(18.6%),其中浸润型复发7例,肿块型复发3例;Bismuth-Corlette I型1例、II型1例、IIIa型1例、IIIb型3例、IV型4例。影像表现为术区新发软组织肿块,CT和MR表现与原发肿瘤类似,增强扫描病灶强化且界限欠清。

2.4 肝叶萎缩情况

       本组肝叶萎缩19例,占35.2%,A组4例(36.3%),B组15例(34.9%),其中左叶萎缩16例,左、右叶均萎缩3例。影像表现为萎缩肝叶体积缩小,代偿侧肝叶体积增大,萎缩侧肝叶CT密度稍高于增生肝叶,MR则表现为等/稍长T1、等/稍长T2信号,DWI呈等/略低信号。

2.5 两组患者大体分型、Bismuth-Corlette分型、复发情况及肝叶萎缩的比较

       54例肝门部胆管癌患者中,A、B两组大体分型情况见表1。分析表明,两组患者大体分型构成比的差异有显著统计学意义(Fisher确切检验法,P=0.008);使用Bonferroni检验进行两两组间比较,结果显示浸润型合并胆管结石的概率比肿块型及息肉型都要低,差异有显著的统计学意义(P<0.05),肿块型与息肉型间合并胆管结石的概率的差异无统计学意义(P>0.05)。两组患者Bismuth-Corlette分型情况见表2,分析表明,两组患者Bismuth-Corlette分型差异无统计学意义(Mann-Whitney U检验法,P=0.8)。复发情况:A组2例,B组8例;肝叶萎缩:A组4例,B组15例,两组间的差异均无统计学意义(χ2检验,P>0.05)。

表1  两组患者大体分型的比较(n=54)
Tab.1  Comparison of tumor shape between the two groups (n=54)
表2  两组患者Bismuth-Corlette分型的比较(n=54)
Tab.2  Comparison of Bismuth-Corlette type between the two groups (n=54)

3 讨论

       肝门部胆管癌是指起源于胆囊管开口至左右肝管之间肝外胆管的恶性肿瘤。目前,已明确的高危因素[8]包括肝内胆管结石、寄生虫感染、原发性硬化性胆管炎(primary sclerosing cholangitis,PSC)、胆管囊肿、肝毒性物质等。在我国,胆道系统结石及肝脏寄生虫感染是HHA发病的主要致病因素[4];PSC则为欧美国家HHA发病的主要危险因素[9]。胆管结石虽为肝门部胆管癌的危险因素,但本研究中A组(合并胆管结石组)较B组(无胆管结石组)病例数少,分析其原因,胆管结石虽为肝门部胆管癌的高危因素,但并非惟一高危因素,笔者并未把其他高危因素纳入研究,所以这与B组病例数更多并不矛盾;另一可能原因是胆管结石出现症状较早,多数患者能够早期得到治疗,未来得及发展为癌。HHA起病隐匿,早期症状不典型,由于其位于左右肝管汇合区出口,故出现阻塞性黄疸较肝内胆管癌早,随着病情进展黄疸进行性加重,可伴皮肤瘙痒,陶土样便,上腹部不适、疼痛、食欲减退,乏力伴体重减轻等症状。

       影像学检查对于HHA的早期诊断、术前分期、术后随访均具有重要的临床价值。多层螺旋CT扫描速度快,层厚薄,受呼吸运动影响小,密度分辨率高。MRI具有很高的软组织分辨率,能够多参数、多平面成像并具备多种功能序列,能够提供更多信息。MRCP能够直观地显示胆管梗阻部位及梗阻端的形态;DWI可更加敏感地显示淋巴结转移和远处转移;近来研究[10,11]表明扩散峰度成像能够提高肿瘤检测率和准确分级,可在活体评价肝外胆管癌的病理分级,有助于早期诊断及定量观察病情进展。

       肝门部胆管癌影像学表现特点与其大体形态相关,最常见的是浸润型,本组54例中浸润型占64.8%,其中B组74.4%为此类型,占比最高。CT和MRI上表现为肿瘤沿胆管壁周围浸润生长,肝门部胆管壁不规则增厚,管腔狭窄伴狭窄段以上肝内胆管扩张。Manfredi等[12]认为当胆管壁增厚超过5 mm时提示胆管癌,CT平扫显示胆管增粗,由于胆管内胆汁被软组织取代密度增高,增强扫描动脉期或门脉期增厚管壁可见显著强化;MRI表现为T1WI呈高于胆汁而略低于肝实质的稍低信号,T2WI呈低于胆汁而高于肝实质的稍高信号,增强扫描强化形式与CT类似。肿块型占24.1%,A组(45.4%)占比高于B组(18.6%),主要表现为肿瘤沿胆管外生长形成肿块,该型容易侵犯周围肝实质及脉管系统,CT三期增强扫描可显示肝动脉、门静脉及肝实质受累情况,增强扫描动脉期病灶周缘可见环形或晕带状强化,门静脉期逐渐向中心弥散,延迟期病灶中央区明显强化,这种强化特点反映了肿块外周以肿瘤细胞成分为主而中央区则富含纤维结缔组织成分,较少发生坏死。息肉型最少见,本组病例仅占11.1%,A组(27.3%)占比高于B组(7.0%),肿瘤向胆管腔内生长形成息肉样结节,增强扫描动脉期不均匀强化,延迟期强化不明显,该强化特点反映了其含纤维结缔组织成分较少;本型较少发生周围浸润,预后较好;息肉型肿瘤可分泌黏蛋白[13],由于黏蛋白过度分泌或原发肿瘤堵塞导致胆道系统明显扩张,胆管内黏蛋白T1WI表现为高信号。本组研究表明,HHA合并胆管结石更好发于肿块型和息肉型,可能与肿块型较早出现周围结构侵犯及胆道闭塞,息肉型易分泌黏蛋白,刺激胆道狭窄及炎症产生导致结石形成有关。胆管结石CT和MRI表现依其成分不同表现不同,CT平扫多数表现为高密度,亦可呈低密度。MRI表现为T1WI和T2WI低信号为主,亦可呈等或高信号,增强扫描无强化。

       肝内胆管明显扩张呈软藤征和胆囊不增大则是肝门部胆管癌的主要间接征象。Bismuth-Corlette分型主要与肝内扩张胆管的分布相关。HHA易侵犯门静脉及其分支造成同侧肝组织血供减少导致肝叶萎缩,对侧肝脏代偿性增生。本组病例中,有无合并胆管结石组的肝叶萎缩发生率的差异无统计学意义,说明胆管结石与肝叶萎缩的发生可能并无直接关系。本组病例浸润型HHA复发最多见,肿块型次之,息肉型未见复发病例,说明术后复发可能与大体分型相关。本研究中,有无合并胆管结石组术后复发率的差异无统计学意义,说明胆管结石存在与否可能不是影响肝门部胆管癌预后的因素。目前的研究表明,影响肝门部胆管癌预后的因素主要是手术方式、术前TNM分期及术前总血清胆红素水平,其中最重要的是根治性切除[14,15]

       本研究的主要局限性是总体病例数不多。分析其原因,由于多数肝门部胆管癌发现时已经无法手术切除,而本研究收集的都是已手术切除或有活检病理资料的病例,因此病例数偏少。目前笔者正在收集更多的有病理证实的肝门部胆管癌病例,准备开展更大样本的研究。

       综上所述,肝门部胆管癌合并胆管结石更多表现为肿块型和息肉型,在影像大体分型表现上有差异,肝门部胆管癌有无合并胆管结石在Bismuth分型、肝叶萎缩及术后复发情况上表现相似。

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