超声在肝细胞癌早期诊断与鉴别诊断中的应用策略

摘要: 肝细胞癌起病隐匿，早期诊断和准确鉴别对改善患者预后具有重要意义。超声因便捷、实时、可重复及适于动态随访，仍是肝细胞癌高危人群筛查和初步评估的重要影像学方法。近年来，随着相关超声技术的发展，超声在肝细胞癌中的应用已由单纯病灶检出逐步拓展至病灶定性、鉴别诊断和预后评估等。本文将结合肝细胞癌早期诊断与鉴别诊断的临床需求，对灰阶超声、多普勒超声及超声造影在肝细胞癌中的应用价值、临床定位及局限进行综述，重点讨论其在小肝细胞癌中的评估和常见鉴别诊断中的作用，强调应结合背景肝状态、病灶形态、血流特征、增强方式及随访动态变化进行综合判断，以提高肝细胞癌的早期诊断和鉴别诊断水平。
- 癌，肝细胞 /
- 超声检查 /
- 诊断
Abstract: Hepatocellular carcinoma （HCC） often has an insidious onset， and early diagnosis and accurate differential diagnosis are critical for improving the prognosis of patients. Ultrasound remains an important radiological examination for the screening and initial assessment of high-risk populations due to its advantages of convenience， real-time monitoring， repeatability， and suitability for dynamic follow-up. With the development of ultrasound technologies in recent years， the application of ultrasound in HCC has gradually expanded from lesion detection to lesion characterization， differential diagnosis， and prognostic evaluation. With reference to the clinical needs for the early and differential diagnosis of HCC， this article reviews the application value， clinical localization， and limitations of gray-scale ultrasound， Doppler ultrasound， and contrast-enhanced ultrasound in HCC， with a focus on their application in the evaluation and differential diagnosis of small HCC. It highlights that comprehensive evaluation should be performed based on liver background， lesion morphology， blood flow features， enhancement patterns， and dynamic changes during follow-up， so as to improve the early and differential diagnosis of HCC.
- Carcinoma， Hepatocellular /
- Ultrasonography /
- Diagnosis

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表 1 超声造影LI-RADS分类及其主要影像表现^［26］

Table 1. Contrast-enhanced ultrasound LI-RADS classification and its main imaging findings^［26］

分类	含义	超声造影影像表现
LR-1	明确良性	囊肿（无增强）；血管瘤（周边不连续球状强化并向中心填充）；典型脂肪沉积/缺失（非肿块样且各期等增强）
LR-2	可能良性	直径<10 mm等增强实性结节；非肿块样等增强区域；长期稳定（≥2年）的LR-3结节
LR-3	中间可能性	无明确APHE和晚期轻度廓清；直径<20 mm病灶存在晚期轻度廓清但无APHE；直径<10 mm病灶存在APHE但无晚期轻度廓清
LR-4	可能HCC	直径≥20 mm病灶存在晚期轻度廓清但无APHE；直径≥10 mm病灶存在APHE但无晚期轻度廓清；直径<10 mm病灶存在APHE并伴晚期轻度廓清
LR-5	明确HCC	直径≥10 mm病灶，存在APHE，并伴晚期轻度廓清
LR-M	恶性但非HCC特异	出现提示恶性但非HCC特异的超声造影表现，包括：环形APHE、早期廓清、明显廓清
LR-TIV	肿瘤侵犯静脉	静脉内出现增强软组织成分，表现为血管内异常强化
LR-NC	无法分类	因图像质量不足、技术因素或关键增强信息缺失，无法完成可靠分类
注：LI-RADS，肝脏影像报告与数据系统；APHE，动脉期高增强；HCC，肝细胞癌。

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表 2 HCC鉴别诊断的临床特征和超声表现

Table 2. The clinical features and ultrasonic manifestations of HCC differential diagnosis

鉴别诊断	临床特征	超声表现
增生结节	多见于肝硬化	多较小、较稳定，回声较均一；新发、短期增大或灌注异常需警惕
血管瘤	非高危肝背景更常见	灰阶多为高回声；CEUS典型特征为周边结节样强化并向心填充
局灶性结节性增生	多见于非肝硬化背景	可见中央供血动脉或轮辐样血流；CEUS动脉期较均匀快速增强，多无明显廓清
肝细胞腺瘤	常见于年轻女性、有激素暴露史或代谢异常	可为富血供病灶，部分表现与HCC相似
肝内胆管癌	可无典型HCC高危背景，也可伴慢性肝病	低回声或不均匀结节，可伴胆管扩张；CEUS常早期且明显廓清
混合型肝癌	临床背景可与HCC相似	可兼具HCC与肝内胆管癌部分增强特征
转移瘤	常有肝外原发肿瘤病史，非肝病高危背景	常为多发病灶，可见牛眼征；CEUS多呈早期明显廓清
注：CEUS，超声造影；HCC，肝细胞癌。

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参考文献(38)

[1]	Wang W Y, Wei C. Advances in the early diagnosis of hepatocellular carcinoma[J]. Genes Dis, 2020, 7( 3): 308- 319. DOI: 10.1016/j.gendis.2020.01.014.
[2]	Singal A G, Zhang E, Narasimman M, et al. HCC surveillance improves early detection, curative treatment receipt, and survival in patients with cirrhosis: A meta-analysis[J]. J Hepatol, 2022, 77( 1): 128- 139. DOI: 10.1016/j.jhep.2022.01.023.
[3]	National Health Commission of the People’s Republic of China. Guideline for diagnosis and treatment of primary liver cancer(2026 edition)[J]. J Clin Hepatol, 2026, 42( 4): 794- 827. DOI: 10.12449/JCH260409. 中华人民共和国国家卫生健康委员会. 原发性肝癌诊疗指南(2026年版)[J]. 临床肝胆病杂志, 2026, 42( 4): 794- 827. DOI: 10.12449/JCH260409.
[4]	European Association for the Study of the Liver. EASL clinical practice guidelines on the management of hepatocellular carcinoma[J]. J Hepatol, 2025, 82( 2): 315- 374. DOI: 10.1016/j.jhep.2024.08.028.
[5]	Singal A G, Llovet J M, Yarchoan M, et al. AASLD practice guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma[J]. Hepatology, 2023, 78( 6): 1922- 1965. DOI: 10.1097/HEP.0000000000000466.
[6]	Lau G, Obi S, Zhou J, et al. APASL clinical practice guidelines on systemic therapy for hepatocellular carcinoma-2024[J]. Hepatol Int, 2024, 18( 6): 1661- 1683. DOI: 10.1007/s12072-024-10732-z.
[7]	Tzartzeva K, Obi J, Rich N E, et al. Surveillance imaging and alpha fetoprotein for early detection of hepatocellular carcinoma in patients with cirrhosis: A meta-analysis[J]. Gastroenterology, 2018, 154( 6): 1706- 1718.e1. DOI: 10.1053/j.gastro.2018.01.064.
[8]	Kim D H, Hong S B, Choi S H, et al. Surveillance failure in ultrasound for hepatocellular carcinoma: A systematic review and meta-analysis[J]. Gut, 2022, 71( 1): 212- 213. DOI: 10.1136/gutjnl-2020-323615.
[9]	Barnard Giustini A, Ioannou G N, Sirlin C, et al. Review article: Available modalities for screening and imaging diagnosis of hepatocellular carcinoma-Current gaps and challenges[J]. Aliment Pharmacol Ther, 2023, 57( 10): 1056- 1065. DOI: 10.1111/apt.17506.
[10]	Huang D Q, Singal A G, Kanwal F, et al. Hepatocellular carcinoma surveillance: Utilization, barriers and the impact of changing aetiology[J]. Nat Rev Gastroenterol Hepatol, 2023, 20( 12): 797- 809. DOI: 10.1038/s41575-023-00818-8.
[11]	Schoenberger H, Chong N, Fetzer D T, et al. Dynamic changes in ultrasound quality for hepatocellular carcinoma screening in patients with cirrhosis[J]. Clin Gastroenterol Hepatol, 2022, 20( 7): 1561- 1569.e4. DOI: 10.1016/j.cgh.2021.06.012.
[12]	Park J, Lee J M, Kim T H, et al. Imaging diagnosis of hepatocellular carcinoma: Future directions with special emphasis on hepatobiliary magnetic resonance imaging and contrast-enhanced ultrasound[J]. Clin Mol Hepatol, 2022, 28( 3): 362- 379. DOI: 10.3350/cmh.2021.0361.
[13]	Koo E, Seif El Dahan K, Daher D, et al. Risk of hepatocellular carcinoma in subcentimeter liver nodules identified on surveillance ultrasound: A systematic review[J]. Clin Gastroenterol Hepatol, 2025, 23( 8): 1320- 1327.e2. DOI: 10.1016/j.cgh.2024.08.051.
[14]	Choi S J, Choi S H, Kim D W, et al. Value of threshold growth as a major diagnostic feature of hepatocellular carcinoma in LI-RADS[J]. J Hepatol, 2023, 78( 3): 596- 603. DOI: 10.1016/j.jhep.2022.11.006.
[15]	Vogel A, Meyer T, Sapisochin G, et al. Hepatocellular carcinoma[J]. Lancet, 2022, 400( 10360): 1345- 1362. DOI: 10.1016/S0140-6736(22)01200-4.
[16]	Tanaka H. Current role of ultrasound in the diagnosis of hepatocellular carcinoma[J]. J Med Ultrason(2001), 2020, 47( 2): 239- 255. DOI: 10.1007/s10396-020-01012-y.
[17]	Lencioni R, Piscaglia F, Bolondi L. Contrast-enhanced ultrasound in the diagnosis of hepatocellular carcinoma[J]. J Hepatol, 2008, 48( 5): 848- 857. DOI: 10.1016/j.jhep.2008.02.005.
[18]	Wilson A, Lim A K P. Microvascular imaging: New Doppler technology for assessing focal liver lesions. Is it useful?[J]. Clin Radiol, 2022, 77( 12): e807- e820. DOI: 10.1016/j.crad.2022.05.032.
[19]	Park M K, Lee D H, Hur B Y, et al. Effectiveness of US surveillance of hepatocellular carcinoma in chronic hepatitis B: US LI-RADS visualization score[J]. Radiology, 2023, 307( 5): e222106. DOI: 10.1148/radiol.222106.
[20]	Frinking P, Segers T, Luan Y, et al. Three decades of ultrasound contrast agents: A review of the past, present and future improvements[J]. Ultrasound Med Biol, 2020, 46( 4): 892- 908. DOI: 10.1016/j.ultrasmedbio.2019.12.008.
[21]	Zhou J H, Li L L, Yan K, et al. Expert consensus regarding the clinical application of liver contrast-enhanced US with Sonazoid(Sonazoid CEUS)[J]. Int J Surg, 2026, 112( 1): 55- 70. DOI: 10.1097/JS9.0000000000003510.
[22]	Terzi E, Iavarone M, Pompili M, et al. Contrast ultrasound LI-RADS LR-5 identifies hepatocellular carcinoma in cirrhosis in a multicenter restropective study of 1, 006 nodules[J]. J Hepatol, 2018, 68( 3): 485- 492. DOI: 10.1016/j.jhep.2017.11.007.
[23]	Li L L, Dioguardi Burgio M, Fetzer D T, et al. Contrast-enhanced ultrasound for hepatocellular carcinoma diagnosis-AJR expert panel narrative review[J]. AJR Am J Roentgenol, 2026, 226( 2): e2532813. DOI: 10.2214/AJR.25.32813.
[24]	Korean Liver Cancer Association KLCA and National Cancer Center NCC Korea. 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma[J]. Clin Mol Hepatol, 2022, 28( 4): 583- 705. DOI: 10.3350/cmh.2022.0294.
[25]	Kudo M. Defect reperfusion imaging with sonazoid®: A breakthrough in hepatocellular carcinoma[J]. Liver Cancer, 2016, 5( 1): 1- 7. DOI: 10.1159/000367760.
[26]	American College of Radiology. CEUS LI-RADS 2017 Core[EB/OL]. https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS. https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/LI-RADS
[27]	Huang J Y, Li J W, Lu Q, et al. Diagnostic accuracy of CEUS LI-RADS for the characterization of liver nodules 20 mm or smaller in patients at risk for hepatocellular carcinoma[J]. Radiology, 2020, 294( 2): 329- 339. DOI: 10.1148/radiol.2019191086.
[28]	Pan J M, Chen W, Zheng Y L, et al. Tumor size-based validation of contrast-enhanced ultrasound liver imaging reporting and data system(CEUS LI-RADS) 2017 for hepatocellular carcinoma characterizing[J]. Br J Radiol, 2021, 94( 1126): 20201359. DOI: 10.1259/bjr.20201359.
[29]	Li Jiawu, Ling Wenwu, Chen Shuang, et al. Influence of liver lesion size and differentiation degree of hepatocellular carcinoma on classification of contrast-enhanced ultrasound liver imaging reporting and data management system[J]. Chin J Med Imaging Technol, 2022, 38( 9): 1356- 1360. DOI: 10.13929/j.issn.1003-3289.2022.09.017. 李加伍, 凌文武, 陈爽, 等. 肝脏病灶大小及肝细胞癌分化程度对超声造影肝脏影像报告与数据管理系统分类诊断的影响[J]. 中国医学影像技术, 2022, 38( 9): 1356- 1360. DOI: 10.13929/j.issn.1003-3289.2022.09.017.
[30]	Yang D H, Chen X J, Huang L J, et al. Correlation between CEUS LI-RADS categorization of HCC < 20 mm and clinic-pathological features[J]. Insights Imaging, 2024, 15( 1): 110. DOI: 10.1186/s13244-024-01688-7.
[31]	Wu J P, Zhao Q X, Wang Y L, et al. Feeding artery: A valuable feature for differentiation of regenerative nodule, dysplastic nodules and small hepatocellular carcinoma in CEUS LI-RADS[J]. Eur Radiol, 2024, 34( 2): 745- 754. DOI: 10.1007/s00330-023-10006-6.
[32]	Li Y, Lu S L, Mao S Y, et al. Contrast-enhanced US using perfluorobutane for diagnosing small HCC in high-risk patients: Comparison with MRI LI-RADS version 2018[J]. Radiology, 2026, 318( 3): e252271. DOI: 10.1148/radiol.252271.
[33]	Lin M X, Lu D S, Duan Y, et al. Cirrhotic nodule transformation to hepatocellular carcinoma: Natural history and predictive biomarkers on contrast-enhanced ultrasound[J]. AJR Am J Roentgenol, 2020, 214( 1): 96- 104. DOI: 10.2214/AJR.19.21739.
[34]	D’Onofrio M, Crosara S, de Robertis R, et al. Contrast-enhanced ultrasound of focal liver lesions[J]. AJR Am J Roentgenol, 2015, 205( 1): W56- W66. DOI: 10.2214/AJR.14.14203.
[35]	Reizine E, Mulé S, Luciani A. Focal benign liver lesions and their diagnostic pitfalls[J]. Radiol Clin North Am, 2022, 60( 5): 755- 773. DOI: 10.1016/j.rcl.2022.05.005.
[36]	Liu G J, Wang W, Lu M D, et al. Contrast-enhanced ultrasound for the characterization of hepatocellular carcinoma and intrahepatic cholangiocarcinoma[J]. Liver Cancer, 2015, 4( 4): 241- 252. DOI: 10.1159/000367738.
[37]	Dong Y, Teufel A, Trojan J, et al. Contrast enhanced ultrasound in mixed hepatocellular cholangiocarcinoma: Case series and review of the literature[J]. Dig Liver Dis, 2018, 50( 4): 401- 407. DOI: 10.1016/j.dld.2017.11.003.
[38]	Dong Y, Zhang X L, Mao F, et al. Contrast-enhanced ultrasound features of histologically proven small(≤20 mm) liver metastases[J]. Scand J Gastroenterol, 2017, 52( 1): 23- 28. DOI: 10.1080/00365521.2016.1224380.