目的：分析超声造影（CEUS）对肝细胞性肝癌（HCC）各时相的时间定义及病灶增强模式，提出CEUS诊断肝癌的参考标准。方法：分析206例253个明确诊断的HCC病灶超声造影表现,记录注射造影剂后肝动脉、门静脉及肝实质的开始增强时间、肝实质增强峰值时间、HCC病灶开始增强、开始减退时间及增强特征。结果：设置以注射造影剂肝动脉开始显影（5.8～8.4秒）作为动脉相起始时间；以门静脉开始显影（8.7～23.8秒）作为门脉相起始时间；以肝实质增强达峰值（17.6～38.1秒）为实质相起始时间；以180～360秒作为延迟期时间。253个HCC中94.1%（238灶）在动脉期增强，5.9%（15灶）在门脉期增强；84.6%（214灶）在门脉期或实质期退出，11.1%（28灶）在延迟期退出；4.3%（11灶）最终未能退出。归纳HCC的造影表现显示为“快进快出”、“快进慢出”、“快进不出”、“慢进快出”、“慢进慢出或不出”五种模式。结论：根据超声造影时相定义及HCC增强退出特征,总结HCC超声造影模式及诊断参考标准。

PURPOSE: The purposes of this study were to investigate a treatment strategy to increase liver tumor necrosis and minimize complications with ultrasound-guided percutaneous radiofrequency (RF) ablation and to evaluate its therapeutic efficacy. MATERIALS AND METHODS: A total of 332 patients with 503 liver malignancies underwent RF ablation according to a mathematical protocol with adjunctive measures. In the 332 patients, 205 had 308 hepatocellular carcinomas (HCCs) with a mean largest diameter of 4.1cm and 127 had 195 metastatic liver carcinomas (MLCs) with a mean largest diameter of 3.9cm. In patients with HCC, 60 (29.3%) had stage I/II disease and 145 (70.7%) had stage III/IV disease. Depending on tumor size, shape, and location, a defined treatment strategy was adopted that consisted of a mathematical protocol, an individualized protocol, and adjunctive measures. The mathematical protocol was followed for tumors larger than 3.5cm. The individualized protocol was used for tumors located adjacent to the diaphragm, gastrointestinal tract, or gallbladder. Some adjunctive measures such as supplementary fine needle localization, local saline solution injection, and feeding vessel ablation were used to deal with different features of these liver tumors. Patients were followed regularly to assess treatment efficiency, and the tumor was considered to have early complete necrosis if no viability was found on enhanced computed tomography 1 month after RF ablation. RESULTS: In this series, the early necrosis rates were 95.8% for HCC (295 of 308 tumors), 94.9% for MLC (185 of 195 tumors), 91.3% for tumors larger than 3.5cm (189 of 207 tumors), 90.7% for tumors near the gastrointestinal tract (49 of 54 tumors), 91.5% for tumors near the diaphragm (86 of 94 tumors), and 90.6% for tumors near the gallbladder (48 of 53 tumors). The local recurrence rates were 10.7% for HCC (33 of 308 tumors) and 14.9% for MLC (29 of 195 tumors). The 1-, 2-, and 3-year overall survival rates were 89.6%, 69.4%, and 59.6%, respectively, for HCC and 80.3%, 52.8%,and 30.9%, respectively, for MLC. The 1-, 2-, and 3-year survival rates in 60 patients with stage I/II HCC were 93.7%, 87.1%, and 76.2%, respectively. The incidence of major complications was 1.4% (eight of 574 sessions), which included of three hemorrhages, four injuries to adjacent structures, and one case of needle tract seeding. CONCLUSION: In RF ablation of hepatic tumors, application of a proper protocol and adjunctive measures play important roles in improving tumor necrosis rate and minimizing potential complications.

目的：讨经皮射频治疗近消化管肝肿瘤时肠灼伤、肠穿孔发生的原因及预防策略，评价临床应用效果。方法：有手术切除史或其他治疗等原因不宜接受再手术的邻近消化道肿瘤55例59个病灶，制定相应的附加方法及治疗后预防措施进行治疗，并进行超声、CT随访。结果：经皮射频治疗后3～72h内持续不同程度腹痛者占38.2%（21/55例），其中48例治疗后7天内行超声或CT检查，右上腹显著疼痛、肠壁增厚水肿者占25%（12/48例），12.5%（6/48例）肠壁增厚显著，并在肝肠之间有少量积液；12例有右上腹手术或邻近肠管区域肿瘤的2～3 次射频治疗病史，其中2例为胆肠吻合术后。2～3周后10例疼痛症状缓解，2例持续性右上腹不适隐痛达4～6个月。3个月后超声或CT 检查，8例（14.5%）显示肠粘连，无1例发生肠穿孔。本组病例肿瘤1次射频消融成功率达89.8%（53/59灶），治疗后复发率达15.3%（9/59灶），其后有11例（11/55，20.0%）采用手术切除或术中RF等方法再治疗。结论：上腹手术及邻近肠管区域局部反复射频治疗是RF 易发生肠壁灼伤的危险因素；重视预防策略，可有效减少肠穿孔并发症的发生。

AIM: To investigate the treatment efficacy of radiofrequency ablation (RFA) of hepatic malignant tumor and the relevant complications. METHODS: A total of 338 patients with 763 hepatic tumors underwent ultrasound-guided RFA (565 procedures). There were 204 cases of hepatic cellular carcinoma (HCC) with 430 tumors, the mean largest diameter was 4.0cm. Of them, 48 patients (23.5%) were in stages I-II (UICC Systems) and 156 (76.5%) in stages III-IV There were 134 cases of metastatic liver carcinoma (MLC), with 333 metastases in the liver, the mean diameter was 4.1cm, the liver metastases of 96 patients (71.6%) came from gastrointestinal tract. Ninety-three percent of the 338 patients were treated using the relatively standard protocol. Crucial attention must be paid to monitor the abnormal changes in ultrasound images as well as the vital signs of the patients to find the possible hemorrhage and peripheral structures injury in time. The tumors were considered as ablated completely, if no viability was found on enhanced CT within 24 h or at 1 mo after RFA. These patients were followed up for 3-57 mo. RESULTS: The ablation success rate was 93.3% (401/430 tumors) for HCC and was 96.7% (322/333 tumors) for MLC. The local recurrence rate for HCC and MLC was 7.9% (34/430 tumors) and 10.5% (35/333 tumors), respectively. A total of 137 patients (40.5%) underwent 2-11 times of repeated ablations because of tumor recurrence or metastasis. The 1st, 2nd, and 3rd year survival rate was 84.6%, 66.6%, and 63.1%, respectively; the survival rate from 48 patients of I-II stage HCC was 93.7%, 80.4%, and 80.4%, respectively. The major complication rate in this study was 2.5% (14 of 565 procedures), which consisted of 5 hemorrhages, 1 colon perforation, 5 injuries of adjacent structures, 2 bile leakages, and 1 skin burn. CONCLUSION: RFA, as a minimally invasive local treatment, has become an effective and relatively safe alternative for the patients of hepatic malignant tumor, even of advanced liver tumor, tumor recurrence, and liver metastases. Knowledge about possible complications and their control may increase the treatment efficacy and help to promote the use of RFA technique.

目的：分析≤2cm微小肝癌的超声造影增强模式，探讨超声造影新技术对微小肝癌的早期诊断价值。方法:应用新型超声造影剂SonoVue及CnTI实时灰阶超声造影匹配成像技术（CEUS）对392例肝脏局灶性病变行超声造影检查，其中经穿刺活检确认肝硬化合并≤2cm肝细胞癌（HCC），并有病理组织学分类诊断的36例38灶为本文研究对象。全部病例造影后即刻或半个月内均行穿刺活检或手术病理检查。最终确诊为中分化癌22个灶，高分化癌12个灶，透明细胞癌4个灶。结果:造影前常规超声仅对16个灶（42.1%）作出恶性诊断或可疑恶性。造影后38个HCC灶动脉期均不同程度增强；其中中分化癌22个灶均发生快速增强，并在实质期快速消退，呈典型的“快进快出”HCC增强模式;高分化癌12个灶中有9个灶（75.0%）呈“快进慢出”模式；透明细胞癌4个灶中1个灶呈“快进快出”，1个灶呈“快进慢出”模式，2个灶呈“轻度慢进慢出”模式。根据CEUS后增强表现，本组76.3%（29个灶）被确认为恶性，18.4%（7个灶）诊断为可疑恶性，另2个≤1.5cm灶（513%）造影增强不典型，未能获得定性诊断。结论:超声造影新技术对肝硬化背景下不同组织类型微小肝癌增强模式的认识为提高微小肝癌的诊断率提供依据。初步结果显示，新型超声造影可作为CT等影像学诊断的互补手段，在小肝癌的早期诊断中发挥重要作用，值得重视推广。