Department of Medical Ultrasound, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China.
Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China.
World J Gastroenterol. 2020 Jul 21;26(27):3938-3951. doi: 10.3748/wjg.v26.i27.3938.
Hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) differ in treatment and prognosis, warranting an effective differential diagnosis between them. The LR-M category in the contrast-enhanced ultrasound (CEUS) liver imaging reporting and data system (LI-RADS) was set up for lesions that are malignant but not specific to HCC. However, a substantial number of HCC cases in this category elevated the diagnostic challenge.
To investigate the possibility and efficacy of differentiating ICC from HCC classified in the LR-M category according to the CEUS LI-RADS.
Patients with complete CEUS records together with pathologically confirmed ICC and LR-M HCC (HCC classified in the CEUS LI-RADS LR-M category) between January 2015 and October 2018 were included in this retrospective study. Each ICC was assigned a category as per the CEUS LI-RADS. The enhancement pattern, washout timing, and washout degree between the ICC and LR-M HCC were compared using the test. Logistic regression analysis was used for prediction of ICC. Receiver operating characteristic (ROC) curve analysis was used to investigate the possibility of LR-M criteria and serum tumor markers in differentiating ICC from LR-M HCC.
A total of 228 nodules (99 ICCs and 129 LR-M HCCs) in 228 patients were included. The mean sizes of ICC and LR-M HCC were 6.3 ± 2.8 cm and 5.5 ± 3.5 cm, respectively ( = 0.03). Peripheral rim-like arterial phase hyperenhancement (APHE) was detected in 50.5% (50/99) of ICCs 16.3% (21/129) of LR-M HCCs ( < 0.001). Early washout was found in 93.4% (93/99) of ICCs 96.1% (124/129) of LR-M HCCs ( > 0.05). Marked washout was observed in 23.2% (23/99) of ICCs and 7.8% (10/129) of LR-M HCCs = 0.002), while this feature did not show up alone either in ICC or LR-M HCC. Homogeneous hyperenhancement was detected in 15.2% (15/99) of ICCs and 37.2% (48/129) of LR-M HCCs ( < 0.001). The logistic regression showed that rim APHE, carbohydrate antigen 19-9 (CA 19-9), and alpha fetoprotein (AFP) had significant correlations with ICC ( = 1.251, 3.074, and -2.767, respectively; < 0.01). Rim APHE presented the best enhancement pattern for diagnosing ICC, with an area under the ROC curve (AUC) of 0.70, sensitivity of 70.4%, and specificity of 68.8%. When rim hyperenhancement was coupled with elevated CA 19-9 and normal AFP, the AUC and sensitivity improved to 0.82 and 100%, respectively, with specificity decreasing to 63.9%.
Rim APHE is a key predictor for differentiating ICC from LR-M HCC. Rim APHE plus elevated CA 19-9 and normal AFP is a strong predictor of ICC rather than LR-M HCC. Early washout and marked washout have limited value for the differentiation between the two entities.
肝细胞癌（HCC）和肝内胆管细胞癌（ICC）在治疗和预后方面存在差异，因此需要对它们进行有效的鉴别诊断。对比增强超声（CEUS）肝脏影像报告和数据系统（LI-RADS）中的 LR-M 类别是为了区分那些恶性但不特异于 HCC 的病变而设立的。然而，这一类别中的相当一部分 HCC 病例增加了诊断的挑战。
探讨根据 CEUS LI-RADS 鉴别 ICC 和 LR-M HCC 的可能性和效果。
回顾性分析 2015 年 1 月至 2018 年 10 月期间具有完整 CEUS 记录并经病理证实的 ICC 和 LR-M HCC（CEUS LI-RADS LR-M 类别中的 HCC）患者。根据 CEUS LI-RADS 对每个 ICC 进行分类。采用 检验比较 ICC 和 LR-M HCC 的增强模式、洗脱时间和洗脱程度。采用 logistic 回归分析预测 ICC。采用受试者工作特征（ROC）曲线分析探讨 LR-M 标准和血清肿瘤标志物在鉴别 ICC 与 LR-M HCC 中的可能性。
共纳入 228 例患者的 228 个结节（99 个 ICC 和 129 个 LR-M HCC）。ICC 和 LR-M HCC 的平均大小分别为 6.3±2.8cm 和 5.5±3.5cm（ = 0.03）。50.5%（50/99）的 ICC 和 16.3%（21/129）的 LR-M HCC 出现边缘状动脉期高增强（APHE）（ < 0.001）。93.4%（93/99）的 ICC 和 96.1%（124/129）的 LR-M HCC 出现早期洗脱（ > 0.05）。23.2%（23/99）的 ICC 和 7.8%（10/129）的 LR-M HCC 出现明显洗脱（ = 0.002），而这一特征在 ICC 或 LR-M HCC 中均未单独出现。15.2%（15/99）的 ICC 和 37.2%（48/129）的 LR-M HCC 出现均匀高增强（ < 0.001）。logistic 回归显示，边缘 APHE、糖抗原 19-9（CA 19-9）和甲胎蛋白（AFP）与 ICC 有显著相关性（ = 1.251、3.074 和-2.767，均 < 0.01）。边缘 APHE 对诊断 ICC 的增强模式最佳，ROC 曲线下面积（AUC）为 0.70，灵敏度为 70.4%，特异性为 68.8%。当边缘高增强与 CA 19-9 升高和 AFP 正常结合时，AUC 和灵敏度分别提高至 0.82 和 100%，特异性降至 63.9%。
边缘 APHE 是鉴别 ICC 和 LR-M HCC 的关键预测指标。边缘 APHE 加上 CA 19-9 升高和 AFP 正常是鉴别 ICC 而不是 LR-M HCC 的有力预测指标。早期洗脱和明显洗脱对两者的鉴别价值有限。
