Clinical Value Of Contrast-enhanced Ultrasound And Quantitative Analysis In Diagnosis And Treatment Of Portal Vein Tumor Thrombus

Part 1 Value of Contrast-enhanced Ultrasound and Quantitative Analysis in Diagnosis and Classification of Portal Vein Tumor ThrombusObjective:To explore the clinical application of contrast-enhanced ultrasound(CEUS)and quantitative analysis in diagnosis and classification of portal vein tumor thrombus(PVTT)by means of contrasting with Contrast-enhanced Computed Tomography(CECT),and analyzing the ability of CEUS to dynamically reflect the perfusion characteristics and hemodynamic changes of PVTT.Methods:A retrospective analysis of 196 PVTT patients confirmed by clinic and pathology was carried out,all of whom underwent routine ultrasound(US),CEUS and CECT before treatment.According to the standard of diagnosis and treatment of primary liver cancer and the classification standard of PVTT recommended by he Chinese Expert Consensus for Multidisciplinary Diagnosis and Treatment of Hepatocellular Carcinoma combined with Portal Vein Tumor Thrombosis,the diagnosis and classification efficiency of CEUS and CECT in PVTT were compared and analyzed.The arrival time(AT),time to peak(TTP),rise time(RT),peak intensity(PI),rising slope rate(RSR),washout time(WT)and area under curve(AUC)of PVTT and surrounding liver tissues were analyzed by time intensity curve(TIC).Results:(1)There was no statistical difference in PVTT classification among different diameters of hepatocellular carcinoma(HCC).(2)The CEUS of PVTT was characterized by “fast-in and fast-out”,high enhancement in arterial phase,low enhancement in portal phase and delayed phase.(3)The accuracy of CEUS and CECT in the diagnosis of PVTT was 99.5%(195/196)and 98.9%(194/196),respectively.There was no statistical difference between the two methods(?2=2.175,P>0.05).The classification accuracy of CEUS and CECT was 98.5%(193/196)and 97.4%(191/196),respectively.There was no statistical difference between the two methods(?2=2.819,P>0.05).The ROC curves of CEUS and CECT were obtained with pathology as the "gold standard".The area under the ROC curves of CEUS and CECT in the diagnosis of PVTT was 0.931 and 0.916,respectively.There was no statistical difference between the two methods(P>0.05).The area under the ROC curves of CEUS and CECT in the classification of PVTT was 0.931 and 0.916,respectively.There was no statistical difference between the two methods(P>0.05).(4)Compared with the surrounding liver tissue,the TIC showed "fast-up and fast-down" in PVTT,and the differences of AT,TTP,RT,PI,RSR,WT and AUC between PVTT and the surrounding liver tissue were statistically significant.Conclusion:CEUS and CECT have well consistency in diagnosis and classification of PVTT.CEUS can not only dynamically display the perfusion characteristics and actual infiltration range of PVTT,but also be used for TIC analysis by quantitative analysis software to provide accurate quantitative imaging information for clinicians.CEUS can be used as an important imaging method for pre-treatment evaluation of PVTT,which can help clinicians to choose treatment option.Part 2 Value of Contrast-enhanced Ultrasound in Preoperative Neoadjuvant Radiotherapy of Resectable Type I / II / III Portal Vein Tumor ThrombusObjective:A retrospective analysis of the clinical data of hepatocellular carcinoma(HCC)patients combined with portal vein tumor thrombus(PVTT)type I/II/III considered to be resectable by preliminary evaluation.A small dose of neoadjuvant radiotherapy was given before operation,the changes of contrast-enhanced ultrasound quantitative analysis perfusion parameters and PVTT classification before and after neoadjuvant radiotherapy were analyzed to explore the value of contrast-enhanced ultrasound in preoperative neoadjuvant radiotherapy of resectable type I / II / III PVTT.Methods:Seventy-six patients with HCC combined with PVTT type I/II/ III were given neoadjuvant radiotherapy before operation,and routine ultrasound,contrast-enhanced ultrasound,CEUS and Contrast-enhanced Computed Tomography(CECT)were performed before and after radiotherapy.According to the modified response evaluation criteria in solid tumors(m RECIST)and the of classification standard PVTT recommended by the Chinese Expert Consensus for Multidisciplinary Diagnosis and Treatment of Hepatocellular Carcinoma combined with Portal Vein Tumor Thrombosis,the changes of CEUS quantitative analysis perfusion parameters and PVTT classification before and after neoadjuvant radiotherapy were analyzed.Univariate analysis was carried out on the clinical data affecting the efficacy of PVTT,and the independent risk factors were obtained through logistic regression multivariate analysis.Results:(1)After neoadjuvant radiotherapy,according to m RECIST,the objective response rate of PVTT and HCC were 30.3% and 35.5%,respectively.There was no statistical difference in objective response rate between PVTT and HCC after neoadjuvant radiotherapy(?2=2.771,P>0.05);(2)With reference to Cheng's classification,PVTT classification was downgraded in 24 patients after neoadjuvant radiotherapy,with a 31.6%downgrade rate(24/76).(3)After neoadjuvant radiotherapy,the accuracy rates of CECT and CEUS were 92.1%(70/76)and 90.8%(69/76),respectively and the accuracy of CEUS combined with CECT was 98.7%(75/76).CEUS combined with CECT is more accurate in evaluating the efficacy of PVTT than CECT or CEUS alone.(4)The time-intensity curve analysis(TIC)of PVTT showed a "fast-up,fast-down" before neoadjuvant radiotherapy,and a "slow-up,slow-down" after neoadjuvant radiation.The difference of PI,RSR and AUC before and after radiotherapy was statistically significant(P<0.05).(5)The results of univariate analysis showed that there were statistically significant differences in HCC size,number of HCC lesions,PVTT classification and microvascular invasion(MVI)between patients with objective response of PVTT after neoadjuvant radiotherapy and those without objective response(P<0.05).Logistic regression analysis showed that PVTT classification and MVI were independent risk factors for the efficacy of PVTT.Conclusion:CEUS can accurately reflect the difference of perfusion characteristics in PVTT before and after neoadjuvant radiotherapy.Quantitative analysis of CEUS can provide quantitative data support for accurate evaluation of PVTT efficacy.The response evaluation of solid tumor should adhere to multiple imaging methods.The accuracy of CEUS combined with CECT is better than CEUS or CECT alone.Neoadjuvant radiotherapy downgrades the classification of PVTT in some patients,reduces the difficulty of operation and increases the chance of radical operation.For those in the undiminished stage, the microcirculation structure was destroyed after neoadjuvant radiotherapy,which reduced the chance of PVTT's further development and metastasis.PVTT classification and MVI are independent risk factors that affect the efficacy of PVTT,which are basically consistent with the factors that affect the efficacy of HCC.Part 3 Value of Contrast-enhanced Ultrasound in Multidisciplinary Treatment of Unresectable Hepatocellular Carcinoma Combined With Portal Vein Tumor ThrombusObjective:A retrospective analysis of the clinical data of hepatocellular carcinoma(HCC)patients combined with portal vein tumor thrombus(PVTT)considered to be unresectable by clinical evaluation.To explore the value of contrast-enhanced ultrasound(CEUS)in multidisciplinary team(MDT)of unresectable PVTT by analyzing the changes of CEUS and quantitative analysis parameters of patients with different therapeutic effects.Methods:Ninety-one patients with HCC combined with PVTT were given MDT according to the diagnosis and treatment of primary liver cancer.Both CEUS and Contrast-enhanced Computed Tomography(CECT)were performed before and after treatment.According to the modified response evaluation criteria in solid tumors(m RECIST)and the classification standard of PVTT recommended by he Chinese Expert Consensus for Multidisciplinary Diagnosis and Treatment of Hepatocellular Carcinoma combined with Portal Vein Tumor Thrombosis,patients were divided into effective and ineffective groups.The characteristics of CEUS,quantitative analysis of perfusion parameters(including arrival time(AT),time to peak(TTP),peak intensity(PI),washout time(WT)),area under curve(AUC))and PVTT classification were analyzed before and after MDT.Results:(1)According to m RECIST,the objective response rate of HCC was53.8% and PVTT was 56.1%.There was no statistical difference between the objective response rate of HCC and PVTT(?2=2.87,P>0.05).(2)According to Cheng's classification,after MDT,47 patients with PVTT classification downgraded,with a downgrade rate of 51.6%(47/91),40 patients with PVTT classification remained stable,with a stable rate of 44.0%(40/91),and 4 patients with PVTT classification upgraded,with a upgrade rate of 4.4%(4/91).(3)The TIC analysis of HCC and PVTT before MDT showed "fast-up and fast-down",while that of the effective group after MDT showed "slow-up and slow-down".(4)Patients were divided into effective and ineffective groups based on whether objective remissions occurred after MDT.In the effective group,the PI and AUC values of both HCC and PVTT were statistical significantly lower than those before the MDT(P<0.05),while AT,TTP and WT had no statistical difference before and after the MDT(P>0.05).In the ineffective group,there was no statistical difference in all parameters of quantitative analysis of contrast-enhanced ultrasound in both HCC and PVTT before and after MDT(P>0.05).Conclusion:MDT has a better objective response rate and downgrade rate in advanced HCC patients combined with PVTT.CEUS can accurately reflect the difference of internal perfusion characteristics of HCC patients combined with PVTT before and after MDT,make up for the influence of lipiodol deposition after TACE on the evaluation of CECT efficacy,and accurately determine the inactivation of HCC and PVTT.Quantitative analysis of CEUS can provide quantitative data support for efficacy evaluation.Quantitative analysis of CEUS can provide quantitative data support for efficacy evaluation,and the combined evaluation of CEUS and CECT will be more comprehensive and accurate.