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临床研究
压缩感知磁共振胰胆管成像对胆总管良恶性梗阻的诊断价值
黄梦月 张勇 高雪梅 程敬亮 刘静静 黄梦娜

Cite this article as: HUANG M Y, ZHANG Y, GAO X M, et al. The value of compression-sensing magnetic resonance cholangiopancreatography in diagnosing benign and malignant obstruction of common bile duct[J]. Chin J Magn Reson Imaging, 2023, 14(3): 100-104, 110.本文引用格式:黄梦月, 张勇, 高雪梅, 等. 压缩感知磁共振胰胆管成像对胆总管良恶性梗阻的诊断价值[J]. 磁共振成像, 2023, 14(3): 100-104, 110. DOI:10.12015/issn.1674-8034.2023.03.017.


[摘要] 目的 探讨屏气压缩感知磁共振胰胆管成像(breath-hold magnetic resonance cholangiopancreatography with compressed sensing, BH-CS-MRCP)鉴别诊断胆总管良恶性梗阻的价值。材料与方法 招募临床确诊的胆总管梗阻患者,所有患者均行BH-CS-MRCP、呼吸导航的压缩感知磁共振胰胆管成像(navigator-triggered magnetic resonance cholangiopancreatography with compressed sensing, NT-CS-MRCP)和常规磁共振胰胆管成像(traditional magnetic resonance cholangiopancreatography, T-MRCP)序列扫描,并记录扫描时间。由两位影像诊断医师对三组MRCP的图像质量、胆管及胰管的显示度、梗阻病变的可视度和锐度、梗阻病变的良恶性判断进行评估。采取单因素方差分析比较三种序列图像评价指标的差异,分别计算其敏感度、特异度、准确度。结果 68例胆总管梗阻患者,年龄(59.97±15.75)岁,男42例,女26例,良性梗阻49例,恶性梗阻19例。BH-CS-MRCP、NT-CS-MRCP、T-MRCP扫描时间分别为17 s、(210.61±38.52)s、(443.65±78.45)s。BH-CS-MRCP、NT-CS-MRCP、T-MRCP对图像总体质量、胆管(胆总管、一级胆管、二级胆管)、胰管的显示差异无统计学意义(P>0.05)。三种序列对梗阻部位病变的锐度及可视度的评分差异无统计学意义(P>0.05)。胆总管恶性梗阻诊断中,BH-CS-MRCP、NT-CS-MRCP的敏感度均为84.21%、特异度均为91.84%、准确度均为89.71%,T-MRCP的敏感度为84.21%、特异度为89.58%、准确度为86.76%。结论 和T-MRCP相比,BH-CS-MRCP和NT-CS-MRCP可以利用较短的时间获得相当质量的图像及较好的胆总管良恶性梗阻的鉴别诊断效能。
[Abstract] Objective To investigate the diagnostic efficacy of breath-hold magnetic resonance cholangiopancreatography with compressed sensing (BH-CS-MRCP) in the differential diagnosis of benign and malignant common bile duct obstruction.Materials and Methods The patients with common bile duct were selected, and subjected to BH-CS-MRCP, navigator-triggered magnetic resonance cholangiopancreatography with compressed sensing (NT-CS-MRCP) and traditional MRCP (T-MRCP) scans, and the scanning time was recorded. The image quality, the visibility of the bile duct and pancreatic duct, the visibility and sharpness of obstructive lesions, and the benign and malignant judgment of obstructive lesions were independently evaluated by two radiologists. One-way ANOVA was used to compare the differences in the evaluation indexes of the three sequences, and the sensitivity, specificity, and accuracy were calculated.Results Sixty-eight patients with common bile duct obstruction [age (59.97±15.75) years] were included in the study, including 42 males, 26 females, 49 benign obstructions, and 19 malignant obstructions. The mean acquisition time of BH-CS-MRCP (17 s), NT-CS-MRCP (210.61±38.52) s and T-MRCP (443.65±78.45) s were obtained, respectively. BH-CS-MRCP, NT-CS-MRCP, and T-MRCP showed no significant differences in the total quality, bile duct (common bile duct, primary bile duct, secondary bile duct), and main pancreatic duct (P>0.05). There were no significant differences in the sharpness and visibility of the obstruction lesions among the three sequences (P>0.05). The sensitivity, specificity, and accuracy of both BH-CS-MRCP and NT-CS-MRCP in the diagnosis of benign and malignant common bile duct obstruction were 84.21%, 91.84%, and 89.71%, respectively. The sensitivity, specificity, and accuracy of T-MRCP were 84.21%, 89.58%, and 86.76%.Conclusions Compared with T-MRCP, BH-CS-MRCP and NT-CS-MRCP can acquire comparable image quality and better differential diagnostic efficiency of benign and malignant of common bile duct obstruction in a shorter time.
[关键词] 胆管梗阻;压缩感知;磁共振胰胆管成像;磁共振成像;诊断效能;鉴别诊断
[Keywords] bile duct obstruction;compressed sensing;magnetic resonance cholangiopancreatography;magnetic resonance imaging;diagnostic performan;differential diagnosis

黄梦月    张勇    高雪梅    程敬亮    刘静静 *   黄梦娜   

郑州大学第一附属医院磁共振科,郑州 450052

通信作者:刘静静,E-mail:liujingjing198631@126.com

作者贡献声明:刘静静设计本研究的方案,对稿件重要的智力内容进行了修改;黄梦月起草和撰写稿件,获取、分析或解释本研究的数据;张勇,高雪梅,程敬亮,黄梦娜获取、分析或解释本研究的数据,对稿件重要的智力内容进行了修改;刘静静获得了2021年度河南省医学科技攻关计划项目基金资助;全体作者都同意发表最后的修改稿,同意对本研究的所有方面负责,确保本研究的准确性和诚信。


基金项目: 2021年度河南省医学科技攻关计划项目 SBGJ202102111
收稿日期:2022-10-13
接受日期:2023-03-03
中图分类号:R445.2  R575.7  R735.8 
文献标识码:A
DOI: 10.12015/issn.1674-8034.2023.03.017
本文引用格式:黄梦月, 张勇, 高雪梅, 等. 压缩感知磁共振胰胆管成像对胆总管良恶性梗阻的诊断价值[J]. 磁共振成像, 2023, 14(3): 100-104, 110. DOI:10.12015/issn.1674-8034.2023.03.017.

0 前言

       胆总管梗阻是由多原因引起的胆管内胆汁流通受阻,其常见病因有炎症、结石和肿瘤等[1]。常用的临床检查方法包括磁共振胰胆管成像(magnetic resonance cholangiopancreatography, MRCP)、经皮肝穿刺胆管造影术(percutaneous transhepatic cholangiography, PTC)和内镜逆行胰胆管造影术(endoscopic retrograde cholangiopancreatography, ERCP)[2]。PTC和ERCP均为有创性,患者不易接受,MRCP作为无创的检查方法可有效诊断胆管梗阻病变。但是常规MRCP(traditional MRCP, T-MRCP)扫描时间长,图像质量易受呼吸均匀性的影响[3]。为解决这一问题,压缩感知MRCP(MRCP with compressed sensing, CS-MRCP)被提出并应用于临床。压缩感知(compressed sensing, CS)技术是通过k空间欠采样和非线性优化迭代重构将CS技术应用于加速MRI采集的一项技术[4, 5]。其中屏气CS-MRCP(breath-hold CS-MRCP, BH-CS-MRCP)只需患者单次屏气就可以完成检查,摆脱了呼吸不均匀性的影响,关于CS-MRCP的图像质量、胰胆管及相关病变显示的研究已有文献报道。然而,目前关于BH-CS-MRCP对胆总管良恶性评估的研究尚未见报道[6, 7],本研究主要探讨BH-CS-MRCP用于胆总管梗阻患者中的图像质量及其鉴别胆总管良恶性梗阻的效能,为指导临床诊治胆总管梗阻提供参考。

1 材料与方法

1.1 一般资料

       招募2018年12月至2022年6月郑州大学第一附属医院行MRCP检查的胆总管梗阻患者79例。入组标准:(1)患者均可配合屏气,具有17 s以上的屏气能力;(2)肝外胆管梗阻扩张,扩张标准:无胆囊切除史的患者,胆总管的宽度超过8 mm视为胆总管扩张;胆囊切除的患者,胆总管宽度超过10 mm视为胆总管扩张[8, 9]。排除标准:(1)肝内胆管梗阻患者;(2)幽闭恐惧症、孕妇、精神异常、听力障碍患者;(3)有严重心血管疾病患者。其中11例患者排除(不能配合屏气17 s患者4例、幽闭恐惧症3例、肝内胆管梗阻患者2例、听力障碍1例、精神异常1例),最后68例纳入本研究,年龄(59.97±15.75)岁,其中经病理证实的恶性梗阻19例(胰头癌7例、肝外胆总管癌8例、十二指肠乳头癌4例),良性梗阻49例,其中病理活检17例(十二指肠炎症12例、外科术后瘢痕形成梗阻5例)、术中诊断19例(胆总管结石19例),临床诊断13例(胰腺炎13例)。本研究遵守《赫尔辛基宣言》,并经过郑州大学第一附属医院科研项目伦理委员会批准,其批准文号为:2018-KY-89,所有受试者均签署了知情同意书。

1.2 MRI检查方法

       所有患者检查前禁食禁水6~8 h,没有使用抗蠕动药物。采用德国西门子公司Prisma 3.0 T MR扫描仪及8通道体部专用相控线圈。检查前患者进行呼吸训练,扫描时仰卧位头先进,扫描定位以患者剑突为中心,主要扫描序列包括BH-CS-MRCP、呼吸导航的CS-MRCP(navigator-triggered CS-MRCP, NT-CS-MRCP)、T-MRCP,详细参数见表1

表1  BH-CS-MRCP、NT-CS-MRCP和T-MRCP的序列参数
Tab. 1  The sequence parameters for BH-CS-MRCP, NT-CS-MRCP and T-MRCP

1.3 图像分析

       所有图像均由两位经验丰富的腹部影像诊断医师(1名主治医师,工作经验7年;1名副主任医师,工作经验10年)进行评估,分别对图像质量、胆管及胰管的显示度、梗阻病变的可视度和锐度、梗阻病变的良恶性进行分析,当良恶性评估结果出现差异时,由两位医师协商统一后给出最终诊断。评级标准如下:图像质量(1=不能诊断,2=图像质量较差,3=一般可接受,4=良好,5=完美);胆总管、第一级胆管、二级胆管、胰管的可视度[1=不显示,2=显示差诊断价值有限,3=部分显示(显示部分不超过一半)或虽然完全显示但模糊不清,4=显示清晰但显示不完全(显示部分超过一半)或虽完全显示但有轻度伪影,5=能清晰地完全显示];病变可视度(1=完全不显示,2=显示很差,3=显示尚可,4=显示好,5=显示很好);病变的锐度(1=不能诊断,2=边缘模糊,3=形态和边缘中度模糊,4=形态和边缘轻度模糊,5=病变形态和边缘清晰);胆总管良恶性梗阻诊断信心[1=良性(具有典型的良性梗阻MRCP征象),2=可能良性(良性梗阻MRCP征象不典型或典型良性梗阻征象伴有不典型恶性梗阻征象),3=不确定(同时具有或者同时不具有典型的良恶梗阻性征象,良恶性梗阻征象均不典型,图像质量较差无法诊断),4=可能恶性(恶性梗阻MRCP征象不典型或典型恶行性梗阻征象伴有不典型良性梗阻征象),5=恶性(具有典型的恶性梗阻MRCP征象)]。胆总管良性梗阻MRCP征象:枯枝征、杯口征、鼠尾征、充盈缺损、狭窄处规则、平滑、对称;恶性梗阻MRCP征象:软藤征、空虚征、截断征、双管征、四管征、鸟嘴状、胆管呈残根状[10, 11, 12, 13]。当恶性征象较良性典型或恶性征象较良性多的情况下诊断为恶性;反之诊断为良性;图像质量较差无法诊断时,判定良恶性诊断错误。

1.4 统计学分析

       采用SPSS 26.0统计学分析软件。利用Kolmogorov-Smirnov检验分析数据是否符合正态分布,若符合正态分布以均值±标准差(x¯±s)表示,采用组内相关系数(intra-class correlation coefficient, ICC)分析两位医师测量数据的一致性。应用单因素方差分析比较BH-CS-MRCP、NT-CS-MRCP和T-MRCP的采集时间、图像质量、胆管及胰管的显示度、梗阻病变的可视度和锐度之间的差异。统计BH-CS-MRCP、NT-CS-MRCP和T-MRCP对良恶性胆管梗阻的真阳性、假阳性、真阴性、假阴性、误诊、漏诊的例数,并计算诊断良恶性的敏感度、特异度、准确度、阳性预测值、阴性预测值。P<0.05为差异有统计学意义。

2 结果

2.1 临床基线资料

       共68例胆总管梗阻患者入组,年龄(59.97±15.75)岁,男42例、女26例,其中良性梗阻49例、恶性梗阻19例。

2.2 两位医师测量MRI参数的一致性分析

       两位放射科医师之间的图像总体质量、胆总管、一级胆管、二级胆管、胰管、病变的锐度及可视度评分都具有高度一致性或几乎完全一致(ICC>0.75)(表2)。

表2  两位评分者一致性分析(n=68)
Tab. 2  Two-rater agreement analysis (n=68)

2.3 扫描时间结果

       BH-CS-MRCP(17 s)扫描时间小于NT-CS-MRCP[(210.61±38.52)s]及T-MRCP[(443.65±78.45)s],NT-CS-MRCP扫描时间小于T-MRCP,差异均具有统计学意义(P<0.001)。

2.4 图像质量比较分析

       BH-CS-MRCP、NT-CS-MRCP、T-MRCP的总体质量、胆管(胆总管、一级胆管、二级胆管)胰管的显示差异无统计学意义(P>0.05)。三种序列胆管梗阻平面病变可视度差异无统计学意义(P>0.05;表3图1~3)。

图1  男,54岁,胆总管结石。BH-CS-MRCP(1A)、NT-CS-MRCP(1B)和T-MRCP(1C)的MIP图像,肝内外胆管显示清晰,胆总管中下段可见充盈缺损,呈“杯口征”(白箭),病变上方胆管明显扩张。
图2  女,47岁,十二指肠乳头腺癌。BH-CS-MRCP(2A)、NT-CS-MRCP(2B)和T-MRCP(2C)的MIP图像,可见胆总管末端突然截断(蓝箭),胰管扩张(绿箭),呈双管征。图3 男,54岁,胰腺炎,呼吸不均匀。BH-CS-MRCP(3A)、NT-CS-MRCP(3B)和T-MRCP(3C)的MIP图像,BH-CS-MRCP、NT-CS-MRCP的MIP图像肝内外胆管均可清晰地显示,胆管梗阻界面显示清晰(红箭),T-MRCP的MIP图像可见运动伪影,肝内胆管局部可见重影,胆管梗阻界面稍模糊(红箭)。BH-CS-MRCP:屏气压缩感知磁共振胰胆管成像,NT-CS-MRCP:呼吸导航的压缩感知磁共振胰胆管成像,T-MRCP:常规磁共振胰胆管成像,MIP:最大密度投影。
Fig. 1  A 54 years old male patient with choledocholithiasis. The MIP images of BH-CS-MRCP (1A), NT-CS-MRCP (1B), and T-MRCP (1C) show clear intrahepatic and extrahepatic bile ducts. Filling defects and the "cup mouth sign" (white arrow) are seen in the middle and lower segments of the common bile duct, and the bile duct above the lesion is significantly dilated.
Fig. 2  A 47 years old female patient with duodenal papillary adenocarcinoma. The MIP images of BH-CS-MRCP (2A), NT-CS-MRCP (2B), and T-MRCP (2C) show that the end of the common bile duct is suddenly cut off (blue arrow), and the pancreatic duct is dilated (green arrow) with a double duct sign.
Fig. 3  A 54 years old male patient with pancreatitis, and with uneven breathing. The MIP images of patients BH-CS-MRCP (3A) and NT-CS-MRCP (3B) show clear intrahepatic and extrahepatic bile ducts, and the interface of bile duct obstruction is displayed clearly (red arrow). The motion artifacts are seen on the MIP image of T-MRCP (3C), double shadows are seen in the local intrahepatic bile ducts, and the interface of bile duct obstruction is slightly blurred (red arrow). BH-CS-MRCP: breath-hold magnetic resonance cholangiopancreatography with compressed sensing; NT-CS-MRCP: navigator-triggered magnetic resonance cholangiopancreatography with compressed sensing; T-MRCP: traditional magnetic resonance cholangiopancreatography; MIP: maximumintensity projection.
表3  BH-CS-MRCP、NT-CS-MRCP、T-MRCP三种序列各个参数的比较
Tab. 3  The comparison of parameters of BH-CS-MRCP, NT-CS-MRCP, T-MRCP and T-MRCP

2.5 MRCP对胆总管良恶性的诊断学分析

       BH-CS-MRCP、NT-CS-MRCP诊断胆总管良恶性梗阻的真阳性16例、假阳性4例、真阴性45例、假阴性3例、恶性梗阻误诊4例(良恶性表现不典型误诊3例,图像质量较差误诊1例)、漏诊3例(良恶性表现不典型),诊断敏感度84.21%、特异度91.84%、准确度89.71%、阳性预测值80.00%、阴性预测值93.65%;T-MRCP诊断胆总管良恶性梗阻的真阳性16例、假阳性6例、真阴性43例、假阴性3例、恶性梗阻误诊6例(良恶性表现不典型误诊3例,图像质量较差误诊3例),漏诊3例(良恶性表现不典型),诊断敏感度84.21%、特异度89.58%、准确度86.76%、阳性预测值72.73%、阴性预测值93.48%。

3 讨论

       本研究通过对CS-MRCP与T-MRCP的图像质量及对胆总管良恶性梗阻鉴别诊断效能的对比分析显示,与T-MRCP相比,BH-CS-MRCP与NT-CS-MRCP可以较短时间获得质量相当的图像并具有较好的胆总管良恶性梗阻的鉴别诊断效能。本研究首次应用BH-CS-MRCP评估其在胆总管良恶性梗阻的诊断价值,为临床提供一种快速、可靠的MRCP检查方法,为胆总管梗阻的治疗提供诊断依据。

3.1 扫描时间

       T-MRCP扫描时间长,且需要患者规律呼吸,否则扫描时间会更长,病情严重者往往不能坚持完成MRCP检查[14, 15]。而本研究中仅需要患者一次屏气即可完成BH-CS-MRCP序列扫描检查,扫描时间仅需17 s,为NT-CS-MRCP序列扫描时间的1/12,为T-MRCP序列扫描时间的1/26,NT-CS-MRCP是在患者自由呼吸下采集,不需要屏气配合,其扫描时间比T-MRCP扫描时间缩短约50%,与文献报道一致[16, 17]。CS技术提高采集速度缩短扫描时间是基于以下几点:(1)稀疏性信号采集;(2)非相干采样;(3)重建算法[18, 19]。并且CS使用稀疏性采集来减少所需的相位编码步骤,但不依赖于扫描线圈[20]

3.2 图像质量分析

       关于CS图像质量的评估以往文献报道存在部分争议,YOON等[21, 22]研究报道,与NT-CS-MRCP和T-MRCP相比,BH-CS-MRCP对二级胆管及胰管显示稍差,这与BH-CS-MRCP的稀疏采集的模式有关。另外,部分学者报道,呼吸规律患者中BH-CS-MRCP与T-MRCP的整体图像质量无显著差异,呼吸不规则患者中BH-CS-MRCP图像质量明显优于T-MRCP。这种研究结果的差异可能是研究对象(呼吸配合情况)或机器不同造成的[23, 24]。本研究中三种序列的图像总体质量、胆总管及一级胆管的显示差异无统计学意义,这与以往部分文献报道的结果相吻合[25, 26]。然而,本研究中BH-CS-MRCP、NT-CS-MRCP和T-MRCP对二级胆管及胰管的显示差异无统计学意义,可能因为胆总管梗阻的患者常伴有肝内外胆管及胰管的扩张,且研究对象均为有屏气能力患者。

3.3 胆总管良恶性的诊断效能

       CS技术在临床的应用已有相关文献报道,KWON等[27]曾报道,与T-MRCP相比,NT-CS-MRCP可以提供较高的病变可视度和胆总管良恶性梗阻的诊断效能。然而,该研究并未探讨BH-CS-MRCP对胆总管良恶性梗阻的诊断效能。而本研究中进一步探讨BH-CS-MRCP、NT-CS-MRCP和T-MRCP对胆道梗阻的应用价值,发现三种序列对胆总管病变的显示及良恶性梗阻的诊断信心差异无统计学意义,这与文献报道略有不同,可能因为本研究中仅纳入屏气配合的患者,而且由于BH-CS-MRCP扫描时间较短仅17 s,因此出现运动伪影的概率相对较小[22]。虽然文献报道BH-CS-MRCP在小胆管及细节方面显示不如NT-CS-MRCP[28, 29],但NT-CS-MRCP及T-MRCP扫描时间相对较长,其扫描图像出现伪影的概率就会有所增加,特别当患者呼吸不均匀时运动伪影会更明显,甚至会影响对病变的显示。此外本研究中BH-CS-MRCP、NT-CS-MRCP与T-MRCP对胆总管恶性的诊断敏感度相同,但是BH-CS-MRCP、NT-CS-MRCP扫描时间明显缩短,特异度、准确度、阳性预测值、阴性预测值高于T-MRCP,因此对于具有较好屏气能力的患者,BH-CS-MRCP可作为胆总管梗阻患者首选序列,其可节约检查的时间成本,能够有效减轻患者因长时间的检查带来的不适,且不受患者呼吸均匀性的影响,为不能规律呼吸的患者提供另一种可能;当患者屏气能力差时,BH-CS-MRCP显然不具备优势,而在本研究中发现NT-CS-MRCP在比T-MRCP扫描时间明显缩短的情况下,仍可提供较好的胆总管良恶性梗阻的诊断效能。

3.4 本研究的局限性

       本项研究尚存在局限性:首先,本研究病例来自单中心研究机构,可能会出现选择偏差;其次,本研究中仅对屏气配合好的患者进行分析,可能出现选择偏差;第三,本研究因病例数目有限,未进行屏气好、屏气差、呼吸均匀、呼吸不均匀的进一步分组对比研究;第四,本研究未进行不同机器及不同场强间的对比分析;第五,本组研究中仅对3D-MRCP进行对比研究,未与2D-MRCP进行对比分析。

4 结论

       综上所述,本研究分析了CS-MRCP与T-MRCP的图像质量及对胆总管良恶性梗阻鉴别诊断效能的差异,结果显示CS-MRCP可以利用较短的时间提供相当质量的图像及较好的胆道良恶性梗阻的诊断效能,有效提高了临床检查效率,减轻患者检查的不适。特别是当患者具有17 s以上的屏气能力时,BH-CS-MRCP可以大大缩短检查时间,且不会受到呼吸均匀性的影响,并能够很好地显示胆道梗阻病变并提供较好的胆道良恶性梗阻的诊断效能,此时BH-CS-MRCP可作为首选检查。

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