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磁共振成像胆道评分和肝肌比值评估肝纤维化病理分级的价值
DOI: 10.12449/JCH240413
Value of MRI biliary score and liver/muscle ratio in evaluating the pathological grade of liver fibrosis
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摘要:
目的 探讨钆塞酸二钠多期增强MRI扫描所得胆道评分和肝肌比值在评估肝纤维化病理分级中的应用价值。 方法 回顾性分析2020年1月—2023年5月广西医科大学附属武鸣医院51例慢性乙型肝炎肝纤维化患者的MRI和临床资料。将51例肝纤维化患者分为两组，其中S1、S2期为低级别组（n=30），S3、S4期为高级别组（n=21）。扫描采用GE Architact 3.0T磁共振扫描仪，包括常规肝脏平扫，动脉期、门静脉期、延迟期、肝胆期、排泄期的增强扫描。对不同级别肝纤维化患者进行胆道评分和测量肝肌比值。计量资料组间比较采用成组t检验，计数资料组间比较采用χ2检验或Fisher确切检验法。绘制受试者工作特征曲线（ROC曲线）评价MRI指标对肝纤维化病理分级的诊断价值。 结果 低级别组胆道评分（3.67±0.55）大于高级别组（2.57±0.75）（t=6.05，P<0.001）；低级别组门静脉期、延迟期、肝胆期的肝肌比值（2.38±0.76，2.48±0.70，4.10±0.63）均大于高级别组（1.97±0.18，1.99±0.27，3.16±0.47）（t值分别为2.41、3.09、5.81，P值分别为0.020、0.003、<0.001）。上述指标区分低、高级别肝纤维化的ROC曲线下面积分别为0.86、0.79、0.82、0.88，诊断高级别肝纤维化的敏感度分别为70%、63.3%、83.3%、96.7%，特异度分别为90%、95.2%、74.1%、100%。胆道评分联合肝胆期肝肌比值的ROC曲线下面积达0.95，敏感度85.7%，特异度96.7%。 结论 MRI钆塞酸二钠多期增强扫描所得胆道评分和肝胆期肝肌比值在区分低、高级别肝纤维化方面具有较高的诊断效能，对临床肝纤维化的诊治有一定的指导价值。 Abstract:Objective To investigate the value of biliary score and hepatic signal intensity-to-muscle signal intensity ratio （HMR） obtained by multiphase contrast-enhanced MRI scan using Gd-EOB-DTPA in evaluating the pathological grade of liver fibrosis. Methods A retrospective analysis was performed for the MRI and clinical data of 51 patients with chronic hepatitis B liver fibrosis in Wuming Hospital Affiliated to Guangxi Medical University from January 2020 to May 2023. The 51 patients with liver fibrosis were divided into low-grade group （S1-S2） and high-grade group （S3-S4）. GE Architact 3.0T MR scanner was used to perform MRI scans， including routine plain scan and contrast-enhanced scan at arterial phase， portal venous phase， delayed phase， hepatobiliary phase， and excretory phase， and biliary score and HMR were measured for the patients with different grades of liver fibrosis. The t-test was used for comparison of continuous data between groups， and the chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups. The receiver operating characteristic （ROC） curve was plotted to evaluate the value of MRI indicators in determining the pathological grade of liver fibrosis. Results Among the 51 patients with liver fibrosis， there were 30 patients in the low-grade group and 21 in the high-grade group. Compared with the high-grade group， the low-grade group had significantly higher biliary score （3.67±0.55 vs 2.57±0.75， t=6.05， P<0.001） and HMR at portal venous phase （2.38±0.76 vs 1.97±0.18， t=2.41， P=0.020）， delayed phase （2.48±0.70 vs 1.99±0.27， t=3.09， P=0.003）， and hepatobiliary phase （4.10±0.63 vs 3.16±0.47， t=5.81， P<0.001）. The above indicators had an area under the ROC curve （AUC） of 0.86， 0.79， 0.82， and 0.88， respectively， in distinguishing low- and high-grade liver fibrosis， with a positive rate of 70%， 63.3%， 83.3%， and 96.7%， respectively， and a negative rate of 90%， 95.2%， 74.1%， and 100%， respectively， in the diagnosis of high-grade liver fibrosis. Biliary score combined HMR had an AUC of 0.95， with a positive rate of 85.7% and a negative rate of 96.7%. Conclusion Biliary score and HMR at hepatobiliary phase obtained by multiphase contrast-enhanced MRI scan using Gd-EOB-DTPA has a relatively high diagnostic efficacy in distinguishing between low- and high-grade liver fibrosis and a certain guiding value for the diagnosis and treatment of liver fibrosis in clinical practice. -
图 1 肝纤维化S4期MRI增强扫描及肝活检病理结果
注： a，男，68岁，胆汁排泄期示，胆道各区均未见显影，胆道评分1分；b，肝穿活检病理（HE染色，×200），镜下见类圆形肝细胞团内的肝细胞排列稍紊乱，可见较多肝细胞水肿，部分细胞气球样变，小范围的点状坏死，汇管区扩大，淋巴细胞浸润，纤维组织增生并分割包绕肝细胞团。免疫组化：Hepar-1（+），HBsAg（+），CK7（+），符合慢性乙型肝炎改变（G2S4）。
Figure 1. MRI enhanced scan image of the bile excretion phase of the S4 stage of liver fibrosis + Pathological image of liver biopsy
图 2 肝纤维化S2期MRI增强扫描及肝活检病理结果
注： a，女，52岁，胆汁排泄期示，胆道各区模糊可见，胆道评分2分；b，肝活检病理（HE染色，×200），镜下见肝小叶结构存在，部分肝细胞排列稍紊乱，小灶见碎片状坏死；汇管区扩大，可见淋巴细胞浸润及纤维组织增生。免疫组化：Hepar-1（+），HBsAg（+），CK7（+），符合慢性乙型肝炎改变（G2S2）。
Figure 2. MRI enhanced scan image of the bile excretion phase of the S2 stage of liver fibrosis + Pathological image of liver biopsy
图 3 肝纤维化S3期MRI增强扫描及肝活检病理结果
注： a，男，36岁，胆汁排泄期示，各区均可见，但部分胆管或汇合处未见显示，胆道评分3分；b，肝活检病理（HE染色，×200），镜下见肝细胞排列紊乱，可见点灶状坏死及碎片状坏死；汇管区扩大，淋巴细胞浸润及纤维组织增生。免疫组化：Hepar-1（+），HBsAg（+），CK7（+），符合慢性乙型肝炎改变（G2S3）。
Figure 3. MRI enhanced scan image of the bile excretion phase of the S3 stage of liver fibrosis + Pathological image of liver biopsy
图 4 肝纤维化S1期MRI增强扫描及肝活检病理结果
注： a，男，71岁，胆汁排泄期示，各区胆管从近端至远端均清晰可见，胆道评分4分；b，肝活检病理（HE染色，×200），镜下见肝小叶结构存在，肝细胞排列整齐，部分区域水肿变性，可见点灶状坏死；汇管区纤维组织增生，少量淋巴细胞浸润。免疫组化：Hepar-1（+），HBsAg（+），CK7（+），符合慢性乙型肝炎改变（G1S1）。
Figure 4. MRI enhanced scan image of the bile excretion phase of the S1 stage of liver fibrosis + Pathological image of liver biopsy
图 5 肝穿活检组织免疫组化结果（×40）
注： a，Hepar-1（+）呈棕色粗颗粒状弥漫分布，HBsAg（+）呈棕黄色，CK7（+）；b，HBsAg（+）呈棕黄色弥漫性、强阳性表达。
Figure 5. Immunohistochemical results of liver biopsy（×40）
图 6 胆道评分、增强扫描各期HMR区分低级别、高级别肝纤维化的ROC曲线
Figure 6. ROC curve of biliary score and hepatic muscle ratio of enhancement scan distinguishing low-grade and high-grade liver fibrosis
图 7 胆道评分联合肝胆期HMR区分低、高级别肝纤维化的ROC曲线
Figure 7. ROC curve of the biliary score combined with hepatobiliary period hepatic muscle ratio distinguishing low and high grade hepatic fibrosis
表 1 低级别组和高级别组之间一般情况比较
Table 1. General comparison between low-grade group and high-grade group
指标 低级别组（n=30） 高级别组（n=21） 男/女（例） 27/3 17/4 年龄（岁） 51.74±9.02 44.14±7.26 体质量（kg） 51.44±7.28 50.58±10.8 身高（cm） 165.01±5.31 162.92±7.56 BMI（kg/m2） 20.55±2.72 21.31±3.17 对比剂用量（mL） 7.88±2.01 7.01±1.35 
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表 2 低级别与高级别组肝纤维化胆道评分和各期HMR比较
Table 2. Comparison of biliary scores between the low-grade and high-grade liver fibrosis groups， and that of hepatic muscle ratios of each stage
项目 低级别组（n=30） 高级别组（n=21） t值 P值 胆道评分 3.67±0.55 2.57±0.75 6.05 <0.001 动脉期HMR 1.64±0.28 1.58±0.13 0.85 0.400 门静脉期HMR 2.38±0.76 1.97±0.18 2.41 0.020 延迟期HMR 2.48±0.70 1.99±0.27 3.09 0.003 肝胆期HMR 4.10±0.63 3.16±0.47 5.81 <0.001
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