胆管癌误诊和漏诊的影像学分析

目的：分析胆管癌误诊和漏诊的原因，评价不同检查方法对肝门区胆管癌诊断的价值，提高胆管癌的影像学诊断和鉴别诊断水平。方法：收集31例临床和病理诊断为胆管癌的病例(ERCP检查31例，B超检查31例，25例CT检查，11例行MRCP检查)，回顾性分析不同检查方法的影像学表现。结果：31例中发生在肝门区的胆管癌25例。2例初次ERCP显示胆管内出血，再次行鼻胆管造影后诊断为胆管癌，4例合并有总胆管结石。6例为总胆管中下段癌。初次诊断准确性为90．3％。11例MRCP中9例显示病变，2例显示不满意，7例显示胆管或胆囊结石。25例CT中23例显示肝内胆管扩张，9例显示肝门区肿块，2例见后腹膜转移淋巴结，1例见肝内多发性转移瘤。12例初次诊断正确(48％)。B超检查23例提示肝内胆管扩张，6例提示总胆管结石，18例诊断为胆囊炎、胆囊结石，8例提示胆管占位(25．8％)。结论：良好的直接胆管造影是诊断胆管癌的金标准，MRCP可以在一定程度上准确显示病变的范围，是ERCP的良好补充，很大程度上取代了诊断性ERCP；CT诊断的关键在于显示扩张的胆管和梗阻的定位，肝门区梗阻多为胆管癌所致。多种影像检查方法的结合明显提高了诊断的准确性，对胆管癌治疗方案的选择有重要价值。     

肝细胞癌合并胆管癌栓的影像表现

目的 探讨胆管癌栓的影像表现,以提高影像诊断水平.方法 回顾性分析经手术病理证实的肝细胞癌(HCC)胆管癌栓13例患者资料,其中3例进行了CT和MR检查,2例仅行CT检查,8例仅行MR检查,7例进行了MR胰胆管成像检查,13例均进行了超声检查.采用四格表Fisher 确切概率检验方法比较超声与CT、MR诊断HCC胆管癌栓的准确性.结果 13例HCC肿瘤及胆管癌栓均在CT或MRI上显示.4例胆管癌栓在CT上表现为胆管内软组织块影,动脉期可见癌栓轻度增强,癌栓远端胆管扩张.11例胆管癌栓在T1 WI上均呈稍低信号,T2 WI为稍高信号,增强后可见轻、中度强化.MR胰胆管成像上胆管癌栓表现为:胆管阻塞中断、狭窄或不规则充盈缺损伴有梗阻上方胆管扩张,胆管突然截断或呈"鼠尾"状(5例);肝内胆管扩张,癌栓充满整个胆总管.胆总管不显示(2例).超声检查准确诊断胆管癌栓7例,误、漏诊6例.CT、MRI准确诊断12例,误诊4例,超声与CT、MRI诊断胆管癌栓差异无统计学意义(P=0.270).结论 CT或MRI对诊断HCC合并胆管癌栓及明确癌栓范围有价值.     

ERCP、CT、B超对胰胆管下段疾病的诊断准确性

目的 比较ERCP、CT、B超对胰胆管下段疾病的诊断准确性。方法 100例临床表现为梗阻性黄疸，反复上腹痛、恶心呕吐的患均经ERCP、CT及B超检查本组患经手术病理或活检证实为良性病变(胆总管结石)57例，恶性肿瘤31例，其中胆总管癌11例，胰头癌13例，以及壶腹癌8例。上述3种方法术前的定性诊断准确率均与手术病理结果对照。结果 对胆总管结石的定性诊断准确率：ERCP为98％(n=56)，CT为72％(n=41)，B超为61％(n=35)；对恶性肿瘤的定性诊断准确率：ERCP为97％(n=31)，CT为78％(n=25)，B超为63％(n=20）。结论 ERCP对胰胆管下段良恶性病变的定性诊断准确率明显高于CT和B超，但因CT与B超均属无创性操作且对某些恶性肿瘤也有较高的定性诊断准确率，因此在影像诊断中应考虑3项技术优势互补。     

Early bile duct carcinoma: comparison of imaging features with pathologic findings

PURPOSE: To retrospectively evaluate the imaging features of early bile duct carcinoma and to compare these features with histopathologic findings. MATERIALS AND METHODS: The institutional review board did not require its approval or informed patient consent for this study. Twenty-one patients (13 men, eight women; mean age, 60 years; range, 48-75 years) with early bile duct carcinoma that was surgically resected and histopathologically confirmed were included. Ultrasonography (US) was performed in 15 patients, computed tomography (CT) in 21, cholangiography in 18, and magnetic resonance (MR) cholangiography in six. Two radiologists retrospectively reviewed imaging features by consensus; they compared growth pattern of tumors, integrity of the bile duct wall that harbored the tumor, and periductal infiltration with histopathologic findings. RESULTS: Pathologic specimens showed intraluminal tumor growth in all cases. Tumors were confined to the mucosa in 11 patients and involved the fibromuscular layer in 10 patients. In four of the 10 intrahepatic cholangiocarcinomas, four of the five hilar cholangiocarcinomas, and six of the six extrahepatic cholangiocarcinomas, there were intraductal tumor masses and the wall of the tumor-bearing bile ducts was preserved without periductal infiltration on US and CT images. On cholangiograms and MR cholangiograms, tumors were better delineated but the wall invasion could not be evaluated. No difference in image findings was found between carcinoma confined to the mucosa and carcinoma involving the fibromuscular layer. CONCLUSION: Imaging features of early bile duct carcinoma are a tumor mass in the bile duct lumen and integrity of the tumor-bearing bile duct wall without infiltration outside the wall.     

Papillary neoplasms of the bile duct that mimic biliary stone disease.

Papillary tumors of the bile duct are intraductal tumors with innumerable minute, frondlike papillary projections. These tumors may be either fixed to or detached from the bile duct wall. However, because the papillary projections on the surface of papillary tumors are long and slender, the tumors are friable and slough easily. The sloughed tumor fragments may float within the bile ducts, resulting in intermittent partial biliary obstruction and mimicking bile duct stones at clinical examination and at ultrasonography (US), computed tomography (CT), and cholangiography. A tumor manifests radiologically as thickening and irregularity of the bile duct wall or as a fixed or sloughed intraductal mass. A nonshadowing intraductal echogenic cast seen at US, an intraductal noncalcified soft-tissue mass with asymmetric wall thickening seen at CT, and an intraductal mass with a papillary surface and a serrated bile duct margin seen at cholangiography are all appearances that suggest a papillary tumor and may be helpful in differentiating a tumor from a bile duct stone.     

肝脏囊性恶性肿瘤的CT诊断

目的：探讨肝脏囊性恶性肿瘤的ＣＴ诊断价值。材料与方法：经手术病理和临床证这的肝脏囊性恶性肿瘤２９例，术前均行ＣＴ检查，其中转移瘤１５例，肝细胞性裂直肉瘤２例，囊腺癌４例（包括囊腺癌肉瘤１例），胆管癌３例和Ｃａｒｏｌｉ病癌变１例，结果：囊性转移瘤远较其他肝囊性恶性肿瘤常见，表现多样化，以多发囊性或囊性实质性病灶共存为其特点，小病料可完全囊变；囊性肝癌表现为单发不均或均匀厚壁型肝志；囊怀肝肉瘤为单房或     

胆胰管十二指肠连接区小肿瘤CT诊断及鉴别

目的 探讨胆胰管十二指肠连接区小肿瘤的ＣＴ诊断及其鉴别点,提高ＣＴ诊断的敏感性和准确性。材料与方法 连接区小癌２２例,包括胰头癌１２例（其中６例位于胰钩突）,Ｖａｔｅｒ’ｓ壶腹癌５例,胆总管下端癌５例;另胰头区炎症５例,以作对照分析,全部病例均经手术病理证实。结果 （１）连接区小癌ＣＴ表现为胰头或钩突增大变形、密度改变及十二指肠内侧壁结节,胆总管壁增厚或下端结节;胰头癌突出表现为低密度区;Ｖａｔｅ     

Autoimmune pancreatitis: imaging features

PURPOSE: To retrospectively determine imaging findings in patients with autoimmune pancreatitis. MATERIALS AND METHODS: Twenty-nine patients (25 male and four female; mean age, 56 years; range, 15-82 years) with histopathologic diagnosis of autoimmune pancreatitis were examined. Data were reviewed by two radiologists in consensus. Imaging findings for review included those from helical computed tomography (CT), 25 patients; magnetic resonance (MR) imaging with MR cholangiopancreatography (MRCP), four patients; endoscopic ultrasonography (US), 21 patients; endoscopic retrograde cholangiopancreatography (ERCP), 19 patients; and percutaneous transhepatic cholangiography, one patient. Images were analyzed for appearances of pancreas, biliary and pancreatic ducts, and other findings, such as peripancreatic inflammation, encasement of vessels, mass effect, pancreatic calcification, peripancreatic nodes, and peripancreatic fluid collection. Follow-up images were available in nine patients. Serologic markers such as serum immunoglobulin G (IgG) and antinuclear antibody levels were available in 12 patients. RESULTS: CT showed diffuse (n = 14) and focal (n = 7) enlargement of pancreas. Seven patients had minimal peripancreatic stranding, with lack of vascular encasement, calcification, or peripancreatic fluid collection. Nine patients had enlarged peripancreatic lymph nodes. MR imaging showed focal (n = 2) and diffuse (n = 2) enlargement with rimlike enhancement in one. MRCP revealed pancreatic duct strictures in two and sclerosing cholangitis-like appearance in one. Endoscopic US showed diffuse enlargement of pancreas with altered echotexture in 13 patients and focal mass in the head in six. ERCP showed stricture of distal common bile duct in 12 patients, irregular narrowing of intrahepatic ducts in six, diffuse irregular narrowing of pancreatic duct in nine, and focal stricture of proximal pancreatic duct in six. Serologic markers showed increased IgG and antinuclear antibody levels in seven of 12 patients. At follow-up, CT abnormalities and common bile duct strictures resolved after steroid therapy in three patients. CONCLUSION: Features that suggest autoimmune pancreatitis include focal or diffuse pancreatic enlargement, with minimal peripancreatic inflammation and absence of vascular encasement or calcification at CT and endoscopic US, and diffuse irregular narrowing of main pancreatic duct, with associated multiple biliary strictures at ERCP.     

Radiologic diagnosis and staging of pancreatic ductal adenocarcinoma

IBD CT is the single best modality for diagnosis and staging of patients with suspected pancreatic carcinoma. While carefully performed real-time US is an excellent technique for determining the level and etiology of bile duct obstruction, it is of more limited value for diagnosis of tumors in the body and tail of the gland, and is less accurate than IBD CT for assessment of tumor resectability. Thus, most patients require IBD CT for accurate, nonoperative staging. ERCP and angiography continue to be useful adjunctive procedures for evaluation of patients with suspected pancreatic carcinoma, particularly for evaluation of equivocal CT or US findings. An isolated pancreatic mass, that is, a mass with no ancillary CT or US findings of carcinoma (local extension, distant metastases), is a non-specific finding and requires further evaluation with either ERCP or angiography, and perhaps most importantly, with FNAB. Other neoplasms may mimic pancreatic ductal carcinoma, particularly islet cell carcinoma and lymphoma. Pancreatitis also can result in a focal pancreatic mass, simulating a neoplasm. These diseases usually respond to therapy and thus it is essential to confirm the radiologic diagnosis of pancreatic carcinoma with biopsy, particularly if surgery is not planned or if chemoradiation therapy is anticipated.     

早期壶腹区肿瘤的CT分析

目的探讨早期胰头一壶腹恶性肿瘤的CT及临床表现。方法分析52例胰头一壶腹区恶性肿瘤的CT表现,其中21例胰内段胆总管癌,18例胰头癌,13例壶腹癌。结果临床上以上腹痛及进行性黄疸为主要表现。CT表现为软组织肿块,胆管及胰管扩张,血管侵犯,胰头外形改变。结论熟悉胰头壶腹区恶性肿瘤早期临床与CT表现,对于此区肿瘤诊治极为重要。     

Abdominal US for diagnosis of pancreatic tumor: prospective cohort analysis.

PURPOSE: To elucidate the accuracy of abdominal ultrasonography (US) in the diagnosis of pancreatic tumors. MATERIALS AND METHODS: In all patients referred for pancreatic US during 1988-1990, data on malignant disease and survival were analyzed by using the Swedish Death and Cancer Registries. Nine hundred nineteen patients were entered into the analysis. In 140 of them, a clinical diagnosis of tumor in the pancreatic area was confirmed within 1 year after US. These tumors were primary pancreatic tumors (n = 102), common bile duct and duodenal cancers (n = 17), and metastases in the pancreatic area (n = 21). RESULTS: The sensitivity of US in the detection of all tumors in the pancreatic area was 88.6% (124 of 140 patients), which was similar to that for the detection of exocrine pancreatic cancer, 90% (79 of 88 patients). There were nine false-positive US examinations, for a specificity of 98.8% (770 of 779 patients). Systematic sampling of 94 investigations confirmed an association between US accuracy and presence of clinical symptoms of pancreatic cancer. Significant differences in the sensitivity (P < .05) and accuracy (P < .01) of diagnosis were observed between three experienced investigators. CONCLUSION: Study results support the use of US as a first-line diagnostic examination in patients suspected of having pancreatic tumor. Dependency on the investigator's experience with US mandates continuous evaluation of its performance.     

MRCP和US对肝外胆管病变诊断价值的对照研究

目的 :比较磁共振胆胰管水成像 (MRCP)和超声 (US)对胆总管病变的诊断价值 ;方法 :分析MRCP和US对 2 4例胆总管病变 (12例胆总管结石 ;12例胆总管肿瘤或肿瘤性病变 )诊断的敏感性和特异性。结果 :MRCP和US对 12例胆总管结石的诊断敏感性和特异性分别为 10 0 % (12 /12 )和 92 7% (11/12 ) ;对胆总管肿瘤或肿瘤性病变 ,MRCP诊断的敏感性和特异性为 10 0 % (12 /12 ) ;US的敏感性和特异性分别为 75 % (9/12 )和 75 % (9/12 )。结论 :MRCP和US诊断胆总管结石的敏感性和特异性差异无显著性意义 ;对胆总管下段肿瘤或肿瘤性病变MRCP优于US。     

Complications of orthotopic liver transplantation: spectrum of findings with helical CT.

Orthotopic liver transplantation has become the treatment of choice for patients with end-stage nonmalignant liver disease. The surgical techniques and immunosuppressive therapy for this procedure have improved considerably. Nevertheless, there are still significant complications, particularly those of vascular origin, which can lead to graft failure and require retransplantation unless prompt treatment is instituted. These complications include arterial and venous thrombosis and stenosis; arterial pseudoaneurysm; biliary leakage, stricture, and obstruction; liver ischemia, infarction, and abscess; fluid collections and hematomas; lymphoproliferative disorders; recurrent tumors; hepatitis C virus infection; and splenic infarction. Since the clinical presentation of posttransplantation complications is frequently nonspecific and varies widely, imaging studies are critical for early diagnosis. Helical computed tomography (CT) is a valuable complement to ultrasonography (US) in the postoperative period and is a safe, accurate, and noninvasive method of demonstrating hepatic vessels (hepatic artery, portal vein, hepatic veins, and inferior vena cava) and evaluating nonvascular complications (in the hepatic parenchyma and bile duct abnormalities) and extrahepatic tissues. Knowledge and early recognition of these complications is essential for graft salvage, and CT can provide valuable information, particularly for patients with indeterminate US results or in whom US examination is difficult.     

Contrast-enhanced ultrasound in the biliary system: Potential uses and indications

Conventional ultrasound (US) is the first-line imaging investigation for biliary diseases. However, it is lack of the ability to depict the microcirculation of some lesions which may lead to failure in diagnosis for some biliary diseases. The use of contrast-enhanced US (CEUS) has reached the field of bile duct disease in recent years and promising results have been achieved. In this review, the methodology, image interpretation, enhancement pattern, clinical usefulness, and indications for CEUS in the biliary system are summarized. CEUS may be indicated in the biliary system under the following circumstances: (1) Where there is a need to make a characterization of intrahepatic cholangiocarcinoma (ICC); (2) For differentiation diagnosis between ICC and other tumors (i.e. hepatocellular carcinoma or liver metastasis) or infectious diseases; (3) For differentiation diagnosis between biliary cystadenoma and biliary cystadenocarcinoma; (4) To detect malignant change in Caroli's disease; (5) To depict the extent of Klatskin's tumor with greater clarity; (6) To make a distinction between gallbladder cholesterol polyp, adenoma and polypoid cancer; (7) To make a distinction between chronic cholecystitis with thickened wall and gallbladder cancer; (8) For differentiation diagnosis between motionless sludge and gallbladder cancer; (9) For differentiation diagnosis between common bile duct cancer and sludge or stone without acoustic shadowing; and (10) In patients who are suspected of having a drop of their percutaneous transhepatic cholangiodrainage tube, US contrast agent can be administered to through the tube detect the site of the tube.     

Congenital neuroblastoma: evaluation with multimodality imaging

The authors retrospectively evaluated 12 patients with congenital (neonatal) neuroblastoma to assess the utility of newer imaging modalities. Findings at prenatal ultrasound (US), performed in four patients, were nonspecific (hydramnios and hydrops fetalis) in two and consistent with a suprarenal mass (one solid, one cystic) in the other two. Postnatal US helped accurately detect adrenal tumors (solid or complex, with one exception) but was less accurate in the diagnosis of metastatic disease to the liver. Computed tomography accurately depicted all primary tumors and liver metastases. Magnetic resonance (MR) imaging helped establish the correct diagnosis in three patients. This study again confirmed the benign course of neonatal neuroblastoma, with 50% of the patients classified with stage IV-S disease and two deaths occurring in the series, both due to complications. Therefore, aggressive diagnostic imaging is less desirable, and US is therefore very useful, despite its limitations. The prenatal detection and solid appearance of a suprarenal mass makes the diagnosis of neuroblastoma very likely, as does the presence of liver lesions. In the absence of these characteristic findings, US should be repeated to exclude adrenal hemorrhage. MR imaging seems to be a good alternative in some instances.     

Diagnostic imaging of renal tumors of small dimensions

The incidence of small renal tumors (less than cm 3) has increased in the past few years. Reasons for the increased number of reports are related to the contribution of Sonography and Computed Tomography--which enable a greater number of kidneys to be examined and allow a more detailed study of renal parenchyma. In order to assess the diagnostic value and role of the various imaging techniques in this pathology, the authors reviewed all renal tumors observed between 1982 and 1987. Nineteen cases presented with the characteristics of small renal tumors with "solid" findings on both US and CT. Sixteen cases were histologically proven (15 adenocarcinomas, 1 oncocytoma). Three recent, unoperated, cases are included since their features are the same as in the other cases. Metastases and other kinds of tumors (i.e. angiomyolipomas) are not included in this series. Ivp was performed in 14/19 cases; US and CT were always performed. CT proved to be the most sensitive technique, being positive in all cases. Ivp was positive in 9/14 cases (64%) and US in 14/19 (73%). A significant increase in the number of small renal tumors detected was observed, mainly in 1985-1987. This increase is correlated with the increase in the total number of abdominal examinations which US and CT have made possible. Most patients were asymptomatic; in fact, 15/19 cases were incidentally discovered with US and CT of the upper abdomen. US and CT appear to give a substantial contribution to an early diagnosis of small renal tumors, which may have a significant impact on both surgery and prognosis.     

肝外胆管癌X线和超声诊断的探讨

本文归纳了30例肝外胆管癌用PTC、ERCP、术中或术后“T”形管造影的X线征象:完全性阻塞端形态有杯口、截断、钝圆、尖削、不规则等;不完全阻塞端有菜花状、不规则、局限性狭窄等。低张钡餐检查对远段胆道病变,仍不失为简易有效的手段。US对肝内胆管扩张和结石的准确率很高,但胆总管下段病变受到限制。为了合理利用各种检查方法,设计了以US为第一步的筛选程序,在CT尚不普及的情况下是切实可行的。     

Biliary dilatation: defining the level and cause by real-time US

In a 15-month period, 110 patients with subsequently proved biliary dilatation were evaluated with ultrasound (US). The level of dilatation was defined as pancreatic, suprapancreatic, or at the level of the porta hepatis. Causes of dilatation included pancreatitis, choledocholithiasis, neoplasm, and stricture. The distal duct was examined initially on transverse scans obtained with the patient in a semierect right posterior oblique position; the proximal duct was then examined on longitudinal scans obtained with the patient in a supine left posterior oblique position. When this scanning technique was used, US indicated the level of dilatation in 91.8% of cases and suggested the correct cause in 70.9%. Because this approach markedly improves US visualization of the intrapancreatic bile duct, distal obstructing lesions, which are the most common, can be optimally examined.     

壶腹周围癌的CT和MRI征象分析

目的：探讨ＣＴ和ＭＲ在壶腹周围癌检测中的应用价值。方法：对３７例经手术病理证实的壶腹周围癌进行回顾性分析,并就其ＣＴ和ＭＲ表现为２５例正常腹部ＣＴ资料作对照分析。结果：壶腹部肿块为壶腹周围癌的主要征象,肿块远端胰腺不同程度萎缩、稀疏,胰后脂肪间隙模糊,胆总管远端和胰管近端间距增宽,ＭＲＣＰ显示扩张胆总管远端呈“鼠尾”状改变等征象,部分壶腹癌不能明确显示肿块,但胆总管远端和胰管近端间距缩小,ＭＲＣＰ     

Radiologic assessment of metastases to the thyroid gland

PURPOSE: We reviewed the radiologic and clinical data in patients with metastatic disease to the thyroid gland and assessed the role of radiologic techniques in this disorder. METHOD: The findings on US (n = 11), CT (n = 7), MRI (n = 6), palpation or US-guided fine needle aspiration (FNA) biopsy, and clinical records were reviewed in 11 cases of pathologically verified metastatic tumors of the thyroid gland. RESULTS: Five patients had palpable thyroid nodules and six had nonpalpable nodules discovered incidentally with imaging procedures. Three patients had no known malignancies at the time of diagnosis of thyroid tumors. Correct diagnosis was obtained in 10 of the 11 cases with FNA biopsy. Thyroid metastases were detected in all of the cases with US and MRI and six of the seven cases with CT. Thyroid metastases were solitary (n = 5) or multiple (n = 6), and about half of them measured <2 cm in diameter. These tumors typically had well defined margins and no calcification and sometimes had cystic portions. Multiple nodules within the same patient were radiologically quite similar to each other. On US, metastases appeared as hypoechoic or markedly hypoechoic areas without halo, on CT as low density areas, and on MRI as areas of varying signal intensities. Half of the metastases showed hypointensity on either T2-weighted images or gadolinium-enhanced T1-weighted images. The tumors involved lymph nodes in 10 cases and other remote organs in 5. Level I or II or parotid nodes were involved in six cases. CONCLUSION: These radiologic features may alert clinicians to a possibility of metastatic thyroid cancer. US combined with US-guided FNA biopsy is suitable for early diagnosis of metastases to the thyroid gland.