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摘要：
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摘要：目的 探讨钆塞酸二钠磁共振成像（magnetic resonance imaging，MRI）表观弥散系数（apparent
diffusion coefficient，ADC）联合增强血管期病灶最大强化率（maximum enhancement rate，ER max ）
鉴别诊断肝硬化背景下不典型增生结节（dysplastic nodule，DN）与小肝癌（small hepatocellular
carcinoma，sHCC）的价值。方法 回顾性分析2016年1月至2019年9月在南京市第二医院就诊、具有
肝硬化背景并经术后病理或肝组织活检确诊的33例sHCC和24例DN患者的MRI平扫+扩散加权成像
（diffusion weighted imaging，DWI）+钆塞酸二钠增强图像。对患者图像进行编号，采用两种方法
盲法阅片。首先使用方法一（MRI平扫+ DWI +增强血管期）进行诊断，打乱顺序后相隔2周再使用
方法二（方法一+增强肝胆期）进行诊断，计算两种方法的敏感性、特异度和正确率。测量两组患
者病灶ADC值和ER max ，采用受试者工作特征（receiver operator characteristic，ROC）曲线分析ADC
值、ER max 及ADC + ER max 的鉴别诊断效能。结果 方法二的敏感性（90.9% vs 69.7%）和正确率（89.5%
vs 71.9%）均显著高于方法一（χ 2 = 4.694，P = 0.030；χ 2 = 5.632，P = 0.018），特异度（87.5% vs
75.0%）差异无统计学意义（χ 2 = 1.231，P = 0.267）。sHCC患者病灶ADC值显著低于DN患者[（1.24 ±
0.21）× 10 -3 mm 2 /s vs （1.54 ± 0.19）× 10 -3 mm 2 /s]，ER max 显著高于DN患者[（79.03 ± 18.22）% vs
（49.52 ± 15.16）%]，差异均有统计学意义（t = -5.835，P ＜ 0.001；t = 6.620，P ＜ 0.001）。病灶
ADC值、ER max 及ADC + ER max 鉴别sHCC和DN的曲线下面积分别为0.851、0.895和0.950，约登指数
分别为0.543、0.657和0.771。ADC + ER max 联合鉴别诊断sHCC的特异度（97.1% vs 75.0%）显著高于
方法一（χ 2 = 13.917，P ＜ 0.001），敏感性（80.0% vs 69.7%）差异无统计学意义（χ 2 = 1.508，P =
0.219）；与方法二相比，敏感性（80.0% vs 90.9%）和特异度（97.1% vs 87.5%）差异均无统计学意
义（χ 2 = 2.065，P = 0.151；χ 2 = 3.794，P = 0.051）。结论 MRI钆塞酸二钠增强肝胆期图像有利于提高
sHCC的诊断效能。对于无肝细胞特异性对比剂的医疗单位，采用ADC值联合血管期强化的ER max 可达
到与之相近的鉴别诊断效能。
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Abstract: Objective To evaluate the value of apparent diffusion coefficient (ADC) values combined
with maximum enhancement rate (ER max ) in gadoxetate disodiummagnetic resonance imaging (MRI) on
identifying dysplastic nodule (DN) and small hepatocellular carcinoma (sHCC) in the context of liver
cirrhosis. Methods The MRI + diffusion weighted imaging (DWI) + gadoxetate disodiumenhanced images of
patients with sHCC (33 cases) and patients with DN (24 cases) who were confirmed by pathology or biopsy
in the Second Hospital of Nanjing from January 2016 to September 2019 were retrospectively analyzed. The
patients were all in the context of liver cirrhosis. The images of patients were numbered and read blindly
by two methods. Firstly, method 1 (non-enhanced MRI + DWI + enhanced vascular phases images) was
used to diagnose, secondly, the order of the images were shuffled and after two weeks method 2 (method
1 + enhanced hepatobiliary phase images) was used to diagnose. The sensitivity, specificity and accuracy
of the two methods were calculated. ADC value and ER max of lesions in the two groups were measured.
The receiver operating characteristic (ROC) curve was used to analyze the differential diagnostic efficacy
of ADC value, ER max and ADC + ER max . Results The sensitivity (90.9% vs 69.7%) and accuracy (89.5% vs
71.9%) of method 2 were significantly higher than those of method 1 (χ 2 = 4.694, P = 0.030; χ 2 = 5.632, P =
0.018), the differences of specificity (87.5% vs 75.0%) was not statistically significant (χ 2 = 1.231, P = 0.267).
ADC value [(1.24 ± 0.21) × 10 -3 mm 2 /s vs (1.54 ± 0.19) × 10 -3 mm 2 /s] of lesions in patients with sHCC was
lower and ER max [(79.03 ± 18.22)% vs (49.52 ± 15.16)%] was higher than those with DN, and the differences
were statistically significant (t = -5.835, P ＜ 0.001; t = 6.620, P ＜ 0.001). The area under the curve of ADC
value, ER max and ADC + ER max in the identification of sHCC and DN were 0.851, 0.895 and 0.950, and the
Youden index were 0.543, 0.657 and 0.771, respectively. The specificity of ADC + ER max in the identification
of sHCC was significantly higher than that of method 1 (97.1% vs 75.0%, χ 2 = 13.917, P ＜ 0.001), and the
difference of sensitivity was not statistically significant (80.0% vs 69.7%, χ 2 = 1.508, P = 0.219). There were
no significant differences in sensitivity (80.0% vs 90.9%) and specificity (97.1% vs 87.5%) compared with
method 2 (χ 2 = 2.065, P = 0.151; χ 2 = 3.794, P = 0.051). Conclusions The gadoxetate disodium hepatobiliary
phase images of enhanced MRI is beneficial to increase the diagnostic efficiency of sHCC. ADC combined
ER max of enhanced vascular phases MRI can achieve the similar diagnostic efficacy for hospitals without
hepatocellular specific contrast agents.
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