简化和标准肝脏MRI方案在结直肠癌肝转移患者随访中的临床应用

doi:10.3877/cma.j.issn.1674-3946.2024.04.022

目的

比较简化肝脏核磁共振成像（MRI）方案和标准肝脏MRI方案在评估疾病的存在、节段受累和对化疗的反应及手术计划方面对比，用于结直肠癌肝转移的治疗后随访。

方法

回顾性分析2020年1月至2023年1月连续接受化疗的113例结直肠癌肝转移患者的临床资料，化疗前和化疗后8~12周分别进行简化和标准肝脏MRI方案。治疗后获得的图像，根据RECIST 1.1记录治疗反应。使用加权Cohen kappa统计量确定图像集之间的一致性水平，采用Friedman检验比较不同MRI评估疾病情况。P<0.05被认为差异有统计学意义。

结果

标准方案和简化方案的总转移数具有很高的一致性（组内相关系数=0.97）。各节段受累的加权κ为0.73-0.85，各节段的加权kappa值为0.82。节段受累的差异并没有改变潜在的手术计划。使用简化方案与标准方案对RECIST 1.1治疗反应进行分类显示出很好的一致性（加权κ=0.92）。

结论

简化肝脏MRI方案允许在化疗后进行评估，类似于标准肝脏MRI方案。使用简化的方案可以减少成像时间，而不会牺牲对结直肠癌肝转移的后续诊断性能。

关键词: 结直肠肿瘤, 肝转移, 磁共振成像, 疗效比较研究

Objective

The simplified hepatic magnetic resonance imaging (MRI) protocol was compared with the standard hepatic MRI protocol in assessing the presence of disease, segmental involvement, and response to chemotherapy, as well as surgical planning, for post-treatment follow-up of colorectal metastases.

Methods

Clinical data of 113 patients with liver metastases from colorectal cancer who received continuous chemotherapy from January 2020 to January 2023 were retrospectively analyzed. Simplified and standard liver MRI regimens were performed before chemotherapy and 8 to 12 weeks after chemotherapy. For images obtained after treatment, treatment responses were recorded according to RECIST 1.1. Weighted Cohen kappa statistics were used to determine the consistency level between image sets, and Friedman test was used to compare the disease assessment of different MRI. P<0.05 was considered statistically significant.

Results

The total transfer numbers of the standard scheme and the simplified scheme were highly consistent (intra-group correlation coefficient =0.97). The weighted κ of each segment was 0.73 to 0.85, and the weighted kappa of each segment was 0.82. The difference in segmental involvement did not alter the underlying surgical plan. Classification of response to RECIST 1.1 using simplified versus standard regiments showed good agreement (weighted κ=0.92).

Conclusion

The simplified liver MRI protocol allows evaluation after chemotherapy and is similar to the standard liver MRI protocol. Using a simplified protocol can reduce imaging time without sacrificing subsequent diagnostic performance for liver metastases in colorectal cancer.

Key words: Colorectal Neoplasms, Liver Metastases, Magnetic Resonance Imaging, Comparative Effectiveness Research

表1 两组患者MRI方案和反应类别的治疗反应[例（%）]

AMRI方案	SMRI方案
AMRI方案	PD	SD	PR	CR	合计
PD	24(10.6)	1(0.4)	0(0.0)	0(0.0)	25(11.1)
SD	1(0.4)	22(9.7)	4(1.8)	0(0.0)	27(11.9)
PR	0(0.0)	1(0.4)	172(76.1)	0(0.0)	173(76.6)
CR	0(0.0)	0(0.0)	0(0.0)	1(0.4)	1(0.4)
合计	25(11.1)	24(10.6)	176(77.9)	1(0.4)	226(100)

表1 两组患者MRI方案和反应类别的治疗反应[例（%）]

AMRI方案	SMRI方案
AMRI方案	PD	SD	PR	CR	合计
PD	24(10.6)	1(0.4)	0(0.0)	0(0.0)	25(11.1)
SD	1(0.4)	22(9.7)	4(1.8)	0(0.0)	27(11.9)
PR	0(0.0)	1(0.4)	172(76.1)	0(0.0)	173(76.6)
CR	0(0.0)	0(0.0)	0(0.0)	1(0.4)	1(0.4)
合计	25(11.1)	24(10.6)	176(77.9)	1(0.4)	226(100)

表2 两种方案判断肝段有无转移癌的结局对比（加权κ）

肝段	SMRI方案	AMRI方案	肝段	SMRI方案	AMRI方案
Ⅰ	0.73	0.82	Ⅶ	0.76	0.85
Ⅱ	0.83	0.87	Ⅷ	0.76	0.85
Ⅲ	0.85	0.85	组合段
Ⅳa	0.84	0.86	Ⅱ和Ⅲ	0.96
Ⅳb	0.85	0.81	Ⅳa和Ⅳb	0.94
V	0.78	0.90	Ⅴ和Ⅷ	0.95
Ⅵ	0.80	0.88	Ⅵ和Ⅶ	0.91

表2 两种方案判断肝段有无转移癌的结局对比（加权κ）

肝段	SMRI方案	AMRI方案	肝段	SMRI方案	AMRI方案
Ⅰ	0.73	0.82	Ⅶ	0.76	0.85
Ⅱ	0.83	0.87	Ⅷ	0.76	0.85
Ⅲ	0.85	0.85	组合段
Ⅳa	0.84	0.86	Ⅱ和Ⅲ	0.96
Ⅳb	0.85	0.81	Ⅳa和Ⅳb	0.94
V	0.78	0.90	Ⅴ和Ⅷ	0.95
Ⅵ	0.80	0.88	Ⅵ和Ⅶ	0.91

图1 肝窦梗阻综合征可降低MRI上病变显著性（74岁的结直肠癌肝转移患者，奥沙利铂治疗）注：A和B=MR图像的前处理，B值为750 s/mm²的DW像（A）和肝胆相（HBP）增强T1加权像（B）显示肝右静脉附近的小转移灶（箭头示）；C和D=化疗后MR图像。DW图像，b值为750 s/mm²（C），HBP加多西二钠增强T1加权像（D）。T1加权像上可见肝实质网状结构改变，转移不再表现为限制性扩散，由于背景肝脏的异质性，残余转移被漏诊。

图2 模拟血管转移瘤（71岁男性结直肠癌肝转移患者）注：A=MR图像的前处理。在基线T2加权像上，在II和Ⅷ节段（箭头示）可见两个转移癌；B-D=化疗后MR图像。B值为750 s/mm²（B）的DW图像显示，Ⅷ期转移灶对治疗有反应，不再显示限制扩散。在门静脉期T1加权像（C）上，作为标准MRI方案的一部分，两个转移癌都显示为低信号。在门静脉期，静脉返回高信号，这使静脉与转移癌区分开来。在肝胆期MR图像（D）中，转移癌和肝内静脉均返回低信号，导致读者在使用简化的肝脏MRI方案时将Ⅷ段转移癌误解为血管。

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Clinical application of simplified and standard liver MRI protocols in follow-up of patients with liver metastases from colorectal cancer

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Clinical application of simplified and standard liver MRI protocols in follow-up of patients with liver metastases from colorectal cancer