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I. ДИАГНОСТИКА И ЛЕЧЕНИЕ
ANALYSIS OF THE RESULTS OF MULTIPHASE COMPUTED TOMOGRAPHY IN THE DIAGNOSIS OF HEPATOCELLULAR CARCINOMA
MPHTÈ 76.29.62
Issamatov B.K.1,2, Zholdybay Zh.Zh.2, Medeubekov U.Sh.1, Tajibaev T.K.1, Kaniev Sh.A.1, Baimakhanov B.B.1
1Department of hepatopancreatobiliary surgery and liver transplantation, JSC "National scientific center of surgery named after A.N. Syzganov", Almaty, Kazakhstan
2Department of radiology, Kazakh institute of oncology and radiology, Almaty, Kazakhstan
Abstract
Hepatocellular carcinoma is one of the actual problems in the structure of oncological pathology in the world and in Kazakhstan. In the diagnosis of hepatocellular carcinoma, the use of multiphase computed tomography is generally accepted. The article describes the analysis of the results of multiphase computer tomography with the correlation of cytological and histological studies in the diagnosis of hepatocellular carcinoma. Purpose: Conduct a retrospective analysis of the results of multiphase computer tomography in patients with hepatocellular carcinoma. Material and methods: Analyzed the archival data of 50 patients with malignant liver tumors, whose received specialized treatment at the Kazakh Scientific Research Institute of Oncology and Radiology in period 2014 - 2017. All patients underwent multiphase computed tomography. The examination was carried out in 4 phases: native, arterial, port-venous and delayed. The scan was performed on the 30th, 60th and 120 second (respectively) after the administration of contrast agent. Results: The nodular form was detected in 76% of cases. If in 60% of cases the tumor was localized in the right lobe of the liver, and in 18% of cases - in the left, the lesion of both lobes was observed in 22% of cases. The sizes of the tumors were from 1 cm to 21.1 cm, and the average size of all nodes was 10.6 cm. The outlines of the tumors were uneven, but clearly defined in 92% of cases. In 94% of cases, the density of the formations was hypodense, the structure was heterogeneous with areas of increased and decreased density. The presence of central necrosis in the form of an "asterisk" was visualized in 8% of cases. The non-intensive inhomogeneous hyperenhancement in the arterial phase, with complete "washout" into the porto-venous phase, as well as in the porto-venous and delayed phases, was observed in 6% and 12% cases, respectively. In 80% of cases, hyperenhancement was observed in the arterial and venous phases. At the same time, complete erosion in the delayed phase was observed in 60% of cases, and incomplete leaching - 20%. In cytological studies, hepatocellular carcinoma was confirmed in 69.7% of cases. In 93.1% of cases, hepatocellular carcinoma was confirmed in histological studies. Conclusion: The nodes of hepatocellular carcinoma in most cases were characterized by clear, uneven contours, hypodense density, heterogeneous structure due to foci of necrosis and cystic component. When the tumor was bolus contrasted, hyperenhancement was in the arterial and port-venous phases, with "washout" in the delayed phase in most cases. According to the received data it can be said that multiphase computed tomography has high information value in the diagnosis of hepatocellular carcinoma.
ABOUT THE AUTHORS
Issamatov Bekzhan Kalibayevich -
researcher of the JSC «NSCS named after A.N. Syzganov»; doctorant of the Department «Visual diagnostics», JSC "National Medical University"
Zholdybay Zhamilya Zholdybayevna
- Doct. of Med. Sciences, Professor, Chairman of the Department «Visual diagnostics», JSC "National Medical University"
Medeubekov Ulugbek Shalkarovich -
Doct. of Med. Sciences, Professor, Deputy Chairman of the Board of JSC «NSCS named after A.N. Syzganov»
Tajibaev Talgat Kydyraliyevich - MD, Department of Hepatopancreatobiliary surgery and liver transplantation, JSC «NSCS named after A.N. Syzganov»
Kaniyev Shokan Ahmedbekovich -
Surgeon, Department of Hepatopancreatobiliary surgery and liver transplantation, JSC «NSCS named after A.N. Syzganov»
Baimakhanov Bolatbek Bimendievich
- Doct. of Med. Sciences, Professor, Chairman of the Board JSC «NSCS named after A.N. Syzganov»
Keywords
liver, hepatocellular carcinoma, multiphase computed tomography.
Гепатоцеллюлярлы карциноманы аныктауда мультифазды компьютерлш томографияньщ нэтижелерш талдау
АВТОРЛАР ТУРАЛЫ
Исаматов БекжанЦалибайулы- «А.Н.
Сызранов атындары ¥лттык рылыми хирургия орталыры» АК рылыми кызметкер\, «Улттык медицина университет\» АК «Визуалды диагностика»кафедрасынын докторанты
Жолдыбай Жамиля Жолдыбай цы/зы!
- м.р.д., профессор,«Улттыкмедицина университет\» АК «Визуалды диагностика» кафедрасынын менгеруш\с\
Медеубеков Улыщбек Шалхарулы/
- м.р.д., профессор, А.Н. Сызранов атындагы Улттык рылыми хирургия
орталыры» АК баскарма терарасынын орынбасары.
Тэжбаев Талгат Цыд^/ралиулы- «А.Н. Сызранов атындары Улттык рылыми хирургия орталыры» АК Гепатобилиарлы хирургия жэне бауыр трансплантациясы бол\м\н\н дэр/гер\.
Цаниев Шоцан Ахмедбекулы - «А.Н.
Сызранов атындары Улттык рылыми хирургия орталыры» АК Гепатобилиарлы хирургия жэне бауыр трансплантациясы бол\м\н\н хирург-дэр\гер\.
Баймаханов Болатбек Бимендеулы
- м.р.д., профессор, А.Н. Сызранов атындары Улттык рылыми хирургия
орталыры» АК баскармасынын терарасы
Туйш сездер
бауыр, гепатоцеллюлярлы карцинома, мультифазды компьютерлк томография.
Исаматов Б.К.12, Жолдыбай Ж.Ж.2, Медеубеков У.Ш.1, Таджибаев Т.К.1, Каниев Ш.А.1, Баймаханов Б.Б.1
1«А.Н. Сызганов атында™ Улттык, шлыми хирургия орталыры» АК, Алматы, Казахстан 2«Казак Улттык медицина университет!» АК, Алматы, Казакстан
Ацдатпа
Гепатоцеллюлярлы карцинома бук\л элемдеп жэне Казакстандары онкопатологиянын езект.\ мэселелер\нын б\р\ болып табылады. Гепатоцеллюлярлы карциноманын диагностикасында мультифазды компьютерл\к томо-графияны колдану кен таралран. Макалада гепатоцеллюлярлы карциномамен аурыран наукастардын мультифазды компьютерл\к томографиясынын нэтижелер\не талдау жасалран. Жумыстыц ма^саты: бауырдын катерл\ обырына шалдыккан наукастардын мультифазды компьютерл\к томография нэтижелер\н\ ретроспектива талдау. Материал мен эд 'стер: Барлыры болып 50 наукастын мурарат деректер\ зерттел\нд\. Барлык наукастарра мультифазды компьютерл\к томография етк\з\лд\. Нэтижелер!: 76% жардайда ГЦК гуй\нд\ формасын кураран. Егер 60%жардайда катерл\ \с\к бауырдын он жак бел\г\нде орналаскан болса, 18% жардайда - сол жак бел\г\нде, ал 22% жардайда - ек\ бел\кте орналаскан. 1с\кт\н келем\ 1 см-ден 21,1 см-ге дей\н болды, ал орташа келем\ 10,6 см курады. 94% жардайда \с\кт\н тырыздыры гиподенсты болды. 80% жардайда ГЦК-нын контрастт\к аген-тыны жинактауы артериялык жэне веноздык фазаларда байкалды. Сонымен катар, 60% жардайда контрастт\к агентынын толырымен шыруы кей\нге калдырылран фазада байкалды. Гепатоцеллюлярлы карцинома корытындысы 69,7% жардайда цитологиялык зерттеулер аркылыжург\з\лсе, ал 93,1%жардайда - гистологиялык эд\с аркылы дэлелденды. Цорытынды: Кеп жардайда гепатоцеллюлярлык карцинома анык, б\ркелк\ емес контурларымен, тырыздыры гиподенсты жэне гетерогенд\ к±рылымымен сипатталды. 1с\ктер контрасттык агентты артериялык жэне порто-веноздык фазалар кез\нде жинактаса, ал толырымен шыруы кей\нге калдырылран фазада байкалды. Алынран деректерге суйене отырып, мультифазды компьютерл\к томография гепатоцеллюлярлы карцинома диагностикасында жорары акпаратка ие деп айтура болады.
ОБ АВТОРАХ
Исаматов Бекжан Калибаевич - научный сотрудник АО «Национальный научный центр хирургии им. А.Н. Сызганова», докторант кафедры «Визуальная диагностика» АО «Национальный медицинский университет»
Жолдыбай Жамиля Жолдыбаевна -
д.м.н,, профессор, заведующая кафедрой «Визуальная диагностика» АО «Национальный медицинский университет»
Медеубеков Улугбек Шалкарович
- д.м.н., профессор, заместитель председателя правления АО «Национальный научный центр хирургии им. А.Н. Сызганова
Таджибаев Талгат Кыдыралиевич
- врач отделения гепатобилиарной хирургии и трансплантации печени АО «Национальный научный центр хирургии им. А.Н. Сызганова»
Каниев Шокан Ахмедбекович -
врач-хирург отделения гепатобилиарной хирургии и трансплантации печени АО «Национальный научный центр хирургии им. А.Н. Сызганова
Баймаханов Болатбек Бимендеевич
- д.м.н., профессор, председатель правления АО «Национальный научный центр хирургии им. А.Н. Сызганова
Ключевые слова
печень, гепатоцеллюлярная карцинома, многофазная компьютерная томография.
Анализ результатов мультифазной компьютерной томографии в диагностике гепатоцеллюлярной карциномы
Исаматов Б.К.12, Жолдыбай Ж.Ж.2, Медеубеков У.Ш.1, Таджибаев Т.К.1, Каниев Ш.А.1, Баймаханов Б.Б.1
1А0 «Национальный научный центр хирургии им. А.Н. Сызганова», Алматы, Казахстан 2А0 «Казахский Национальный медицинский университет», Алматы, Казахстан
Аннотация
Гепатоцеллюлярная карцинома является одним из актуальных проблем в структуре онкопатологии во всем мире и в Казахстане. В диагностике гепатоцеллюлярной карциномы общепринятым считается применение мультифазной компьютерной томографии. В статье описывается анализ результатов мультифазной компьютерной томографии у пациентов с со злокачественными образованиями печени. Цель работы: Провести ретроспективный анализ результатов мультифазной компьютерной томографии у пациентов с гепатоцеллюлярной карциномой. Материал и методы: Всего проанализированы архивные данные 50 пациентов. Всем пациентам было проведено мультифазная компьютерная томография. Результаты: Из всех образований печени узловая форма было выявлено в 76% случаях. Если в 60% случаях образование локализовалось в правой доле печени, а в 18% случаях - в левой, то поражение обеих долей наблюдалось в 22% случаях. Размеры образований были от 1 см до 21,1 см, а средний размер всех узлов составил 10,6 см. В 94% случаях плотность образований были гипо-денсными, структура гетерогенной с участками повышенной и пониженной плотности. В 80% случаях накопление контрастного вещества образованием наблюдалось в артериальной и венозной фазах. При этом, с полным вымыванием в отсроченной фазе наблюдалось в 60% случаях. в В 69,7% случаях гепатоцеллюлярная карцинома подтвердилась при цитологическом исследований, в 93,1% случаях - при гистологическом. Заключение: Узлы гепатоцеллюлярной карциномы в большинстве случаев характеризовались четкими, неровными контурами, ги-поденсной плотностью, гетерогенной структуры. Опухоли накапливали контрастное вещество в артериальную и порто-венозную фазы, с эффектом полного вымывания в отсроченную фазу в большинстве случаев. По полученным данным можно сказать, что мультифазная компьютерная томография имеет высокую информативность в диагностике гепатоцеллюлярной карциномы.
Introduction
Hepatocellular carcinoma (HCC) - a malignant liver tumor derived from hepatocytes is the most common type of primary liver cancer (95%) [1, 2].
Hepatocellular carcinoma occupies the 5th place in the structure of malignant neoplasms and is the 2nd most frequent cause of cancer death worldwide (about 800 thousand patients died in 2012) [3, 4].
Although the incidence rate of most cancers declines, the incidence of hepatocellular carcinoma increases, and more than 600,000 new cases of HCC are reported annually in the world [5, 6].
Hepatocellular carcinoma represents a serious medical and social problem in many countries of the world, including in Kazakhstan. In recent years (2013 - 2017) in Kazakhstan, there has been an increase in the incidence of HCC to 5.9 cases per 100,000 population, and the death rate remains high (about 1,000 people annually). In 2017, 82.3% of the observed patients with HCC died at the end of the year. Five-year survival was 23.7% [7].
Hepatocellular carcinoma is characterized by aggressive course, in most cases with unfavorable prognosis, the five-year survival rate does not exceed 18%. Postoperative relapse is about 50% of cases [8, 9].
In the development of hepatocellular carcinoma, persistent infection of the hepatitis B virus (HBV) and hepatitis C virus (HCV), leading to cirrhosis of the liver, with subsequent transformation into cancer, is generally recognized. And also, afla-toxin B1 (AFB1) and chronic alcohol abuse are risk factors for the development of HCC [10].
The development of HCC in the cirrhotic liver is described as a multistage progressive process: a low-differentiated dysplastic node, a highly differentiated dysplastic node, a dysplastic node with a microscopic manifestation of HCC, small foci of HCC, carcinoma. The average time for doubling the mass of the HCC is 93.5 days, which reflects the slow growth of the tumor, and therefore, on average 3 years pass from the onset of HCC to the time of its first manifestation and diagnosis [1, 11].
The wide introduction of modern highly informative radiotherapy methods (ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI)) into clinical practice, as well as their improvement, helped to improve the detection of liver formations, becoming the main methods of non-invasive diagnosis and, accordingly, determination type of subsequent treatment and prognosis of HCC [9, 12, 13, 14].
According to the recommendations of American and European associations for the study of liver pathology, in the last decade in the diagnosis of liver formations, a multiphase study is widely used in
computed tomography. The main goal of CT with the use of contrast agent (CA) is to maximize the difference in density between the normal liver parenchyma and neoplasms. The active use of bolus contrast in the study of the liver is very informative and allows not only to make a preliminary diagnosis, but also to conduct differential diagnosis. According to the guidelines, with typical radiation characteristics of the HCC, trephine-biopsy verification is not required. Due to the presence of a developed own pathological vascular network in the HCC structure, intravenous (bolus) contrasting with nonionic iodine-containing contrast preparations is used for differential diagnostics. HCC can be presented depending on the blood supply of both hypo and hypervascular tumor. The hypovascular variant is usually found in the early stages of tumor development and, with contrasting, is insignificant or does not increase at all in the arterial phase. The hyper-vascular variant has a rapid contrasting in the arterial phase and rapid «washout» in the porto-venous phase or the accumulation of CA by the pseudocapsule. The arterial phase is used to detect anomalies of arterial perfusion of the liver. Thus, the normal hepatic parenchyma surrounding the tumor may be hyperdense in the late arterial phase, which is formed due to the effect of the «draw-well», due to the fact that the neoplasm promotes a greater influx of arterial blood into the segment or the proportion of the liver to feed both itself and normal hepatic parenchyma. A typical type of arterial blood flow in a tumor is described in the literature as «sthreads and strips» [15,16,17].
HCC in the background of cirrhosis of the liver is usually surrounded by a capsule, represented by fibrous tissue and a layer of tightened liver tissue [18]. In CT, the capsule (or pseudocapsule) is defined as a thin hyperdense (hyperintense) rim around the node into the venous or delayed phase [19]. In the liver, affected by cirrhosis, the appearance of a capsule around the tumor is considered a sign of the progression of the disease [20,21,22,23].
Due to the late diagnosis of hepatocellular carcinoma, the presence of changes at the level of the micro- and macroorganism, not all patients can undergo surgery, despite the development of surgical treatment of HCC in recent years [24].
In connection with the progressive slow growth, asymptomatic course and late clinical manifestation, aggressive course and unfavorable prognosis of HCC, the value of early and refining diagnostics increases dramatically.
Purpose - Conduct a retrospective analysis of the results of multiphase computed tomography in patients with hepatocellular carcinoma.
Materials and methods
Analyzed of archival data (medical history, outpatient maps, CT studies, cytological and his-tological research) of 50 patients with malignant liver tumors, whose received specialized treatment (transarterial chemoembolization, radical surgery) in the Kazakh Scientific Research Institute of Oncology and Radiology in period 2014 - 2017.
The total number of men was 33 and women 17 patients, aged 36 to 79 years, with the average age of men being 61.3 ± 0.2 years, women - 59.7 ± 0.3 years (Table 1). All patients underwent multiphase CT. Multiphase examination of the abdominal cavity was performed on 64-slice computer tomographs «Light Speed CT» by General Electric and "So-matom Definition AS" by Siemens with the following parameters: 130 mA, 120 kV, collimation 0.75, pitch 0.9, the thickness of the cut is 1.0 mm. CT examination was carried out in 4 phases: native, arterial, port-venous and delayed. After the native scan, patients were injected intravenously (bolus) with a non-ionic contrast agent at a rate of 1 ml per 1 kg of body weight with an injector at a rate of 3.5 ml / s. The scan was performed on the 30th, 60th and 120 second (respectively) after the administration of CA.
To verify the diagnosis of malignant liver formation, 66% (33) of patients underwent a fine needle aspiration biopsy under the supervision of ultrasound. Trepan - a biopsy under the supervision of ultrasound was performed by 8% (4) patients. Patients underwent specialized treatment (trans-arterial chemoembolization from 3 to 5 courses). The next stage of treatment was surgical intervention. Extended combined hemihepatectomy was performed in 42% (21) patients, and partial liver resection (segmentectomy) 14% (7) in patients. Postoperative macro preparations were studied by histological method.
Results
In 84% (42) cases, the liver in size was enlarged, with uneven finely contoured contours in 10% (5) patients with cirrhosis. Of all liver formations, the nodular form was detected in 76% (38) cases, and the multinodular form in 24% (12). If in 60% of cases the tumor was localized in the right lobe of the liver, and in 18% of cases - in the left, the lesion of both lobes was observed in 22% of cases. At the same time, the largest number of nodes were located in the 4, 6 and 7 segments of the liver (Figure 1).
Table 1.
Features of the patients
Figure 1.
Case of a patient A.57 y.o. man with HCC on the multiphase CT. A - native - in S7 segment of the right lobe of the liver, is determined the density decrease focus, 2,1x2,0x1,8 cm, with smooth, well-defined contours, a homogeneous structure. B - arterial and C - port-venous phase - hyperenhancement of the contrast agent with a focus.
D - delay phase - "washout" of the contrast agent.
Patients: n = 50, Men Women
at the age of 36 to 79 years 33(66%) 17 (34%)
Average age 61,3±0,2years 59,7±0,3years
N=50 (100%)
Characteristics of formation
Absolute %
Uneven, clear contours
Hypodensic, with a heterogeneous structure
Hyperenhancement in arterial and venous phase
«Washout» in delayed phase
46
47
40
30
92
94
80
60
Table 2.
Computed-tomographic semiotics of HCC
Formation Multiphase Verification
CT(n=50) Cytology (n=33) Histology (n=29)
Hepatocellular carcinoma 92% (46) 69,7% (23) 93,1% (27)
Table 3.
Comparative evaluation of results multiphase CT and pathomorphological studies
The sizes of the tumors were from 1 cm to 21.1 cm, and the average size of all nodes was 10.6 cm. The contours of the formations were uneven, but distinct in 92% (46) cases. In 94% (47) cases, the formation density was hypodense, the structure was heterogeneous with areas of increased and decreased density. The presence of central necrosis in the form of an "asterisk" was visualized in 8% (4) cases. In 4% (2) cases, the nodes were represented as a cystic-solid structure. The non-intensive inho-mogeneous hyperenhancement in arterial phase, with complete "washout" into the porto-venous phase, as well as in the porto-venous and delayed phases, was observed in 6% (3) and 12% (6) cases, respectively. In 80% (40) cases, the hyperenhancement was observed in the arterial and venous phases. At the same time, complete erosion in the delayed phase was observed in 60% (30) cases, and incomplete leaching - 20% (10) (Table 2).
In 4% (2) cases, a paradoxical accumulation of CA - the effect of incomplete leaching into the delayed phase with subsequent progressive accumulation was observed. In several cases, the accumulation of CA by the pseudocapsule and along the periphery of formation (16%, 8), solid component and capsule of the cystic component (4%; 2), in the form of nodes and zones (4%; 2). In 14% (7) cases, the patient's own pathological vascular network of education in the arterial phase was visualized. Depending on the localization of the formation, involvement of hepatic vessels (central vein (14%; 7), right (10%; 5) and left (8%, 4) hepatic vessels) was observed in the process. In 24% (12) cases, intra-organ metastases in the liver were detected.
In 92% (46) cases hepatocellular carcinoma was diagnosed with multiphase CT. Of the 33 cytological studies performed, hepatocellular carcinoma was confirmed in 69.7% (23) cases. In 93.1% (27) of cases, HCC was confirmed from 29 histological studies.
In the detection of hepatocellular carcinoma, the correlation of the multiphase CT and the cytological study was 69.7%, multiphase CT and histological examination - 93.1% (Table 3).
Conclusion
When analyzing the results of the study, it was found that in most cases, the dimensions of the liver were enlarged. The nodular form of hepatocel-lular carcinoma prevailed in most cases. The largest number of tumors were located in the right lobe of the liver, namely in the 6th and 7th segments. In general, the dimensions of the nodes were more than 2 cm. The nodes of hepatocellular carcinoma in most cases were characterized by clear, uneven contours, hypodense density, heterogeneous structure due to foci of necrosis and cystic component. In bolus contrasted, nodes of HCC characterized hyperenhancement in the arterial and port-venous phases, with "washout" in the delayed phase in most cases. In several cases, there was a pronounced intrinsic vasculature of the tumor. Of all the vessels of the liver, the greatest damage was seen in the central vein. Bolus contrasting of the liver, in several cases, allowed differentiation between the main node of hepatocellular carcinoma and intra-organic secondary (mts) nodes, according to the nature of the accumulation of contrast agent.
Thus, with the help of multi-phase computed tomography, it is possible to obtain morphological characteristics of the node of hepatocellular carcinoma, such as dimensions, contours, density, structure, the presence of an intrinsic vasculature of the tumor, involvement in the process of large vessels, etc. The nature of accumulation of contrast medium in bolus contrast is of great importance in differential diagnosis between hepatocel-lular carcinoma and other liver tumors. According to the received data it can be said that multiphase computed tomography has high information value in the diagnosis of hepatocellular carcinoma. In some cases, the accumulation of contrast material by formation may not be typical of hepatocellular carcinoma. As a consequence, further study of the characteristics of liver tumors is necessary for multiphase computed tomography.
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