{"id":5094,"date":"2015-12-18T09:52:25","date_gmt":"2015-12-18T09:52:25","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=5094"},"modified":"2016-01-15T13:04:07","modified_gmt":"2016-01-15T13:04:07","slug":"rolul-imagisticii-prin-rezonanta-magnetica-in-diagnosticarea-leziunilor-focale-hepatice-descoperite-incidental","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/rolul-imagisticii-prin-rezonanta-magnetica-in-diagnosticarea-leziunilor-focale-hepatice-descoperite-incidental\/","title":{"rendered":"Rolul imagisticii prin Rezonan\u0163\u0103 Magnetic\u0103 \u00een diagnosticarea leziunilor focale hepatice descoperite incidental"},"content":{"rendered":"

Inciden\u0163a leziunilor focale hepatice descoperite accidental a crescut \u00een ultimii ani \u00een paralel cu folosirea din ce \u00een ce mai des a metodelor imagistice de diagnosticare (ecografie cu sau f\u0103r\u0103 substan\u0163\u0103 de contrast, computer tomograf, rezonan\u0163\u0103 magnetic\u0103 nuclear\u0103). Majoritatea acestor leziuni sunt benigne la pacien\u0163ii f\u0103r\u0103 istoric de ciroz\u0103 hepatic\u0103. Hemangioame, hiperplazia nodular\u0103 focal\u0103 \u015fi adenoamele sunt leziunile solide focale \u00eent\u00e2lnite cel mai frecvent. Cele mai frecvente leziuni maligne pe ficatul noncirotic sunt reprezentate de metastaze. Carcinomul hepatocelular \u015fi colangiocarcinomul intrahepatic apar de obicei pe fondul unei boli hepatice cronice.<\/p>\n

Este necesar\u0103 cre\u015fterea acurate\u021bei \u015fi specificit\u0103\u021bii de diagnosticare prin metode imagistice a leziunilor focale hepatice pentru a reduce num\u0103rul de biopsii inutile, asociate la r\u00e2ndul lor cu risc de morbiditate \u015fi mortalitate postprocedural\u0103 (2.0% p\u00e2n\u0103 la\u00a0 4.8% , respectiv 0.05%).<\/p>\n

Av\u00e2nd \u00een vedere absenta radia\u021biei ionizante \u015fi accesul relativ limitat la ecografia cu substan\u0163\u0103 de contrast, IRM e considerat\u0103 metoda de elec\u0163ie pentru diagnosticul leziunilor focale hepatice.<\/p>\n

IRM HEPATIC<\/strong><\/p>\n

Protocol IRM<\/em><\/strong><\/p>\n

Un protocol complet IRM evalueaz\u0103 parenchimul hepatic, vasculariza\u0163ia \u015fi sistemul biliar. Acest scop este atins prin folosirea unei combina\u0163ii complexe de secven\u0163e (T2 ponderate single shot fast spin echo<\/em>, T1 ponderate gradient echo<\/em> \u00een \u015fi opposed phase<\/em>, T2 ponderate cu supresie gr\u0103soas\u0103, difuzie,T1 ponderate pre \u015fi postcontrast dinamic cu achizi\u0163ii \u00een faz\u0103 arterial\u0103, venoas\u0103 \u015fi tardiv\u0103 \u015fi, dac\u0103 exist\u0103 posibilitatea, cu substrac\u0163ia setului de imagini postcontrast din setul de imagini precontrast). Imaginile de calitate bun\u0103 necesit\u0103 un compromis \u00eentre o rezolu\u0163ie \u00eenalt\u0103 \u015fi necesitatea men\u0163inerii apneei, ceea ce limiteaz\u0103 durata secven\u0163elor la 20 secunde sau mai pu\u0163in. Mentinerea apneei nu e totdeauna posibil\u0103 la pacien\u0163ii \u00een stare grav\u0103. \u00cen consecin\u0163\u0103, modificarea protocolului de baz\u0103 poate include secven\u0163e cu respira\u0163ie liber\u0103, cu gating respirator sau cu tehnici de corec\u0163ie a mi\u015fc\u0103rii (ex BLADE sau PROPELLER sau achizi\u0163ia radial\u0103 a spa\u0163iului K).<\/p>\n

Diffusion Weighted Imaging (DWI)<\/em><\/strong><\/p>\n

Difuzia m\u0103soar\u0103 abilitatea protonilor moleculelor de ap\u0103 de a se mi\u015fca liber \u00een mediul intra- \u015fi extracelular. \u00cen consecin\u0163\u0103, secven\u0163a de difuzie pentru leziunile focale hepatice reflect\u0103 densitatea celular\u0103 a masei. Se poate calcula coeficientul aparent de difuzie (ADC) prin suprapunerea valorilor b multiple (de obicei cel putin 3 valori de la b0 la b800), acesta fiind un parametru cuantificabil ce reflecta at\u00e2t difuzia, c\u00e2t \u015fi perfuzia pe unitatea de \u0163esut dat\u0103. B0 reprezint\u0103 o secven\u0163a T2 ponderat\u0103 cu rezolu\u0163ie joas\u0103, folosit\u0103 pentru detec\u0163ia leziunilor \u015fi orientare anatomic\u0103. Valorile B \u00eenalte reflect\u0103 adev\u0103rata restric\u0163ie de difuzie. Leziunile cu ADC sc\u0103zut (grad mare de restric\u0163ie de difuzie) au probabilitate mai mare de a fi maligne, de\u015fi exist\u0103 un grad de superpozabilitate cu leziunile benigne.<\/p>\n

Mai mul\u0163i autori sugereaz\u0103 un prag minim al ADC de 1.2-1.6 x10-3 mm2\/s, sub care leziunea este cel mai probabil malign\u0103, cu specificitate 80-90%.<\/p>\n

\u00cen consecin\u0163\u0103, combinarea secven\u0163ei de difuzie cu secven\u0163ele RM cu contrast dinamic cre\u015fte acurate\u0163ea diagnostic\u0103.<\/p>\n

Agen\u0163ii de contrast<\/em><\/strong><\/p>\n

Substan\u0163ele de contrast RM administrate intravenos se clasific\u0103 \u00een extracelulare \u015fi specifice hepatocitare. Cele extracelulare se echilibreaz\u0103 cu spa\u0163iul lichidian extracelular dup\u0103 injectare\u00a0 intravenoas\u0103 \u015fi sunt excretate prin filtrare glomerular\u0103, similar substan\u0163elor de contrast administrate la CT. Aceasta permite ob\u0163inerea de imagini multifazice postcontrast, dinamice \u015fi evaluarea pattern-ului de \u00eenc\u0103rcare cu contrast, ce reflect\u0103 at\u00e2t vasculariza\u0163ia, c\u00e2t \u015fi permeabilitatea leziunii. Agen\u0163ii de contrast specifici hepatocitari au eliminare dual\u0103, o parte fiind distribuit\u0103 extracelular \u015fi eliminat\u0103 prin rinichi, o alt\u0103 parte fiind preluat\u0103 de hepatocite \u015fi excretat\u0103 biliar. Imaginile \u00een faza hepatobiliar\u0103 se achizi\u0163ioneaz\u0103 tardiv (ex 1-2 ore postinjectare pentru Multihance).<\/p>\n

CARACTERIZAREA LEZIUNILOR FOCALE HEPATICE<\/strong><\/p>\n

HEMANGIOAMELE<\/em><\/strong><\/p>\n

Hemangioamele sunt cele mai frecvente leziuni focale hepatice, cu o inciden\u0163\u0103 de 2-20%. Caracteristicile clasice descrise IRM includ contur net,\u00a0 rotund sau lobulat, hiperintensitate marcat\u0103 pe secven\u0163ele T2 ponderate (\u201csemnul becului\u201d) \u015fi pattern caracteristic de \u00eenc\u0103rcare cu contrast. Se disting trei tipuri de \u00eenc\u0103rcare cu substan\u0163a de contrast extracelular\u0103. Leziunile mici (diametru <1,5 cm) pot demonstra \u00eenc\u0103rcare omogen\u0103 intens\u0103 \u00een faza arterial\u0103 (\u201cflash-filling\u201d). Hemangioamele cu dimensiuni mai mari, cavernoase, demonstreaz\u0103 fie \u00eenc\u0103rcare periferic\u0103 nodular\u0103 \u00eentrerupt\u0103, ce avanseaz\u0103 progresiv centripet cu aspect uniform pe secven\u0163ele tardive, fie \u00eenc\u0103rcare periferic\u0103 nodulara \u00eentrerupt\u0103 cu persisten\u0163a unei arii hipocaptante central tardiv. Hemangioamele gigante pot con\u0163ine arii de fibroz\u0103\/tromboz\u0103.<\/p>\n

Dificult\u0103\u0163i pot ap\u0103rea \u00een diagnosticul diferen\u0163ial al hemangioamelor \u015fi metastazelor hepatice hipervasculare (ex. tumori neuroendocrine), ce pot fi marcat hiperintense pe secven\u0163ele T2 ponderate, cu \u00eenc\u0103rcare cu contrast \u00een faza arteriala. Hemangioamele mici cu \u00eenc\u0103rcare de tip \u201dflash filling\u201d pot necesita urm\u0103rire IRM dac\u0103 diagnosticul diferen\u0163ial este dificil. Metastazele pot demonstra lizereu continuu de \u00eenc\u0103rcare cu contrast, comparativ cu lizereul discontinuu caracteristic hemangioamelor. Lizereul de priz\u0103 de contrast din faza arterial\u0103 se poate sp\u0103la \u00een cazul metastazelor sau poate deveni hipointens fa\u0163\u0103 de restul parenchimului hepatic \u00een faza venoas\u0103 parenchimatoas\u0103.<\/p>\n

\u00cen cazul contrastului specific hepatocitar, hemangioamele demonstreaz\u0103 pattern-urile de\u00a0 \u00eenc\u0103rcare cunoscute \u00een timpul dinamic \u015fi r\u0103m\u00e2n hipointense fa\u0163\u0103 de restul parenchimului \u00een faza hepatocitar\u0103 (pseudo \u201cwash-out\u201d), av\u00e2nd \u00een vedere absen\u0163a hepatocitelor din compozi\u0163ia lor.<\/p>\n

Hiperplazia nodulara focal\u0103 (HNF)<\/em><\/strong><\/p>\n

HNF este descoperita frecvent la pacien\u0163i asimptomatici \u015fi este format\u0103 din hepatocite non-neoplazice dezorganizate ce \u00eenconjoar\u0103 o cicatrice central\u0103 cu vase anormale incluse. Fiind formate din hepatocite, HNF sunt dificil de distins pe imaginile native, f\u0103r\u0103 substan\u0163\u0103 de contrast, \u015fi prezint\u0103 un pattern tipic de \u00eenc\u0103rcare postcontrast, cu enhancement precoce arterial nodular \u015fi omogenizare cu restul parenchimului \u00een faz\u0103 portal\u0103. Unele leziuni con\u0163in o cicatrice central\u0103 hiperintens\u0103 T2. Aceasta poate fi hipointens\u0103 postcontrast \u00een faza arteriala, demonstr\u00e2nd \u00eenc\u0103rcare tardiv\u0103 cu contrast extracelular.<\/p>\n

IRM cu administrare de contrast specific hepatocitar este testul de elec\u0163ie pentru diagnosticul HNF. \u00cen faza hepatobiliar\u0103, acestea sunt izo- sau hiperintense fa\u0163\u0103 de parenchimul hepatic normal de vecin\u0103tate, reflect\u00e2nd con\u0163inutul bogat \u00een hepatocite.<\/p>\n

Totu\u015fi modific\u0103rile trebuie interpretate cu grij\u0103, exist\u00e2nd situa\u0163ii rare de enhancement paradoxal \u00een faza hepatobiliar\u0103 pentru carcinomul hepatocelular \u015fi adenom. Uneori hiperintensitatea leziunii \u00een faza hepatobiliar\u0103 poate fi explicat\u0103 prin persisten\u0163a intralezional\u0103 a contrastului prin mecanism extracelular \u00een cazul metastazelor necrotice sau fibrotice.<\/p>\n

Adenomul hepatocelular (AHC)<\/em><\/strong><\/p>\n

AHC este o leziune hepatic\u0103 focal\u0103 benign\u0103 rar\u0103, legata str\u00e2ns de expunerea hormonal\u0103 exogen\u0103. Se identific\u0103 trei subtipuri distincte cu comportament biologic \u015fi pattern-uri de \u00eenc\u0103rcare cu contrast diferite. Acestea includ: muta\u0163ia factorului 1 alfa hepatocitar, beta-catenina \u015fi AHC inflamator.<\/p>\n

Majoritatea AHC sunt subtipuri HNF1 alfa \u015fi inflamator. AHC inflamator este hiperintens pe secven\u0163ele T2 ponderate cu enhancement intens \u00een faza arteriala, persistent \u00een faza portal\u0103. AHC subtipul HNF1 alfa poate demonstra enhancement intens \u00een faza arterial\u0103 non-persistent \u015fi prezint\u0103 deseori lipide intralezionale eviden\u0163iabile pe secven\u0163ele in-oppossed phase. Datorit\u0103 con\u0163inutului difuz de lipide, subtipul HNF1 alfa se mai nume\u015fte \u015fi AHC steatozic.<\/p>\n

Imaginile \u00een faza hepatobiliar\u0103 cu contrast specific hepatocitar sunt utile \u00een diagnosticul diferen\u021bial AHC versus HNF, frecvent necesar la femeile tinere asimptomatice. Spre deosebire de HNF, AHC re\u0163in rareori contrast \u00een faza hepatobiliar\u0103.<\/p>\n

Carcinomul hepatocelular (CHC)<\/em><\/strong><\/p>\n

CHC apare aproape exclusiv pe fondul unei afec\u021biuni hepatice cronice. Aspectul clasic pe imaginile IRM cu contrast extracelular pe fondul modific\u0103rilor\u00a0 de ciroz\u0103 hepatic\u0103 este priza de contrast tumoral\u0103 \u00een faza arterial\u0103, cu \u201dwash-out \u201d \u00een faza portal\u0103 \u015fi de echilibru; \u00een plus, se noteaz\u0103 priz\u0103 de contrast tardiv\u0103 a pseudocapsulei. Se crede c\u0103 pierderea aportului venos portal prin procesul multifazic de carcinogenez\u0103 poate explica fenomenul de \u201dwash out\u201d. Caracterele de \u201dwash out\u201d \u015fi priza de contrast tardiv\u0103 a pseudocapsulei sunt \u00eenalt specifice pentru diagnosticul de CHC. Totu\u015fi, trebuie analizate cu grij\u0103 leziunile tratate anterior, ce pot prezenta \u0163esut de granula\u0163ie marginal cu caractere de \u00eenc\u0103rcare cu contrast similare pseudocapsulei.<\/p>\n

Alte modific\u0103ri ce sus\u0163in diagnosticul de CHC includ: invazia vascular\u0103, restric\u0163ia de difuzie \u015fi aspectul hiperintens pe secven\u0163ele T2 ponderate.<\/p>\n

Studiile pentru \u00eenc\u0103rcarea postcontrast specific hepatocitar r\u0103m\u00e2n controversate, cu situa\u021bii citate de enhancement paradoxal al CHC, non-reten\u021bie \u00een cazul nodulilor displazici sau fibrotici \u015fi o poten\u0163ial\u0103 dilem\u0103 diagnostic\u0103 pentru leziunile mici (sub 1-2 cm) vizualizabile doar \u00een faza hepatobiliar\u0103.<\/p>\n

Enhancement-ul arterial, de\u015fi nespecific, este o caracteristic\u0103 esen\u021bial\u0103 a CHC \u015fi singurul criteriu cerut de UNOS la pacien\u021bii cu ciroz\u0103 hepatic\u0103.<\/p>\n

Odat\u0103 cu cre\u0219terea inciden\u0163ei \u015fi a cererii de transplant hepatic, AASLD\/UNOS\/OPTN \u015fi separat The American College of Radiology au propus ghiduri revizuite pentru optimizarea diagnosticului CHC ce se bazeaz\u0103 pe caracteristici multiple (enhancement arterial, wash out, cre\u015ftere \u00een dimensiuni \u00een timp). Totu\u015fi, nodulii sub 1 cm r\u0103m\u00e2n insuficient caracteriza\u021bi, iar rolul contrastului specific hepatocitar neclar.<\/p>\n

Colangiocarcinomul (CC)<\/em><\/strong><\/p>\n

Colangiocarcinomul reprezint\u0103 10% din tumorile maligne hepatice primare \u015fi tinde s\u0103 ap\u0103r\u0103 pe fondul unei afec\u0163iuni hepatice cronice: colangita, hepatita, boli hepatice cronice non alcoolice, obezitate. Caracteristice IRM sunt reprezentate de: mas\u0103 neregulat conturat\u0103 hipointens\u0103 T1, hiperintens\u0103 T2, heterogen\u0103, cu enhancement periferic precoce urmat de enhancement progresiv centripet, heterogen. Lizereul marginal de enhancement ini\u0163ial este de obicei continuu \u015fi nu ar trebui confundat cu lizereul \u00eentrerupt caracteristic hemangioamelor. Enhancement-ul arterial periferic poate demonstra \u201dwash-out\u201d la colangiocarcinom, aspect ce nu se \u00eent\u00e2lne\u0219te \u00een cazul hemangioamelor.<\/p>\n

Caracteristici mai specifice, de\u015fi nu frecvent \u00eent\u00e2lnite \u00een cazul colangiocarcinoamelor, sunt reprezentate de cicatricea central\u0103 hipointens\u0103 T2, retrac\u021bia capsulara \u015fi dilata\u021bia periferic\u0103 a c\u0103ilor biliare.<\/p>\n

De\u015fi enhancementul tardiv se descrie frecvent, aceast\u0103 caracteristic\u0103 se poate suprapune izolat cu boala metastatic\u0103, astfel \u00eenc\u00e2t biopsia este frecvent necesar\u0103.<\/p>\n

Metastazele<\/em><\/strong><\/p>\n

Metastazele hepatice au aspect variabil \u00een func\u0163ie de tumora primar\u0103 \u015fi pot fi hiper- sau hipovasculare, cu \u00eenc\u0103rcare superioar\u0103 sau inferioar\u0103 parenchimului hepatic normal de vecin\u0103tate.<\/p>\n

Metastaze hipervasculare se pot \u00eent\u00e2lni \u00een cazul tumorilor neuroendocrine, carcinomului cu celule renale, carcinomului tiroidian, melanomului \u015fi sarcomului. Restul metastazelor tind sa fie hipovasculare.<\/p>\n

Pot ap\u0103rea arii de hemoragie intern\u0103 \u00een cazul metastazelor carcinomului cu celule renale, melanomului sau carcinomului pulmonar, cu hiperintensitate caracteristic\u0103 pe secven\u0163ele T1 ponderate.<\/p>\n

Imagistica cu contrast specific hepatocitar \u015fi secven\u0163a de difuzie pot cre\u015fte semnificativ rata de detec\u0163ie a metastazelor hepatice de mici dimensiuni, comparativ cu examenele CT sau IRM clasice.<\/p>\n

Concluzie<\/em><\/strong><\/p>\n

De\u015fi multe leziuni hepatice au caractere imagistice tipice, considerarea contextului clinic, \u00een special prezen\u0163a sau absen\u0163a unei afec\u0163iuni hepatice cronice atunci c\u00e2nd avem \u00een vedere CHC sau CC, este esen\u0163ial\u0103 pentru un diagnostic corect \u015fi pentru stabilirea managementului acestor pacien\u021bi.<\/p>\n

\n

Cristina MAIER
\nMEDINST Diagnostic
\nRom\u00e2no-German<\/p>\n

\"MADinst\"<\/p>\n

Medinst Diagnostic Rom\u00e2no-German func\u021bioneaz\u0103 din anul 1997 \u00een cadrul Institutului Na\u021bional de Neurologie \u0219i Boli Neurovasculare Bucure\u0219ti.<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"

Inciden\u0163a leziunilor focale hepatice descoperite accidental a crescut \u00een ultimii ani \u00een paralel cu folosirea din ce \u00een ce mai des a metodelor imagistice de diagnosticare (ecografie cu sau f\u0103r\u0103 […]<\/p>\n","protected":false},"author":6,"featured_media":5150,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_exactmetrics_skip_tracking":false,"_exactmetrics_sitenote_active":false,"_exactmetrics_sitenote_note":"","_exactmetrics_sitenote_category":0,"footnotes":""},"categories":[33,439],"tags":[442],"class_list":["post-5094","post","type-post","status-publish","format-standard","has-post-thumbnail","category-articole","category-gastroenterologie","tag-medinst"],"yoast_head":"\nRolul imagisticii prin Rezonan\u0163\u0103 Magnetic\u0103 \u00een diagnosticarea leziunilor focale hepatice descoperite incidental - Jurmed - Medici<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/jurmed.ro\/medici\/rolul-imagisticii-prin-rezonanta-magnetica-in-diagnosticarea-leziunilor-focale-hepatice-descoperite-incidental\/\" \/>\n<meta property=\"og:locale\" content=\"ro_RO\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Rolul imagisticii prin Rezonan\u0163\u0103 Magnetic\u0103 \u00een diagnosticarea leziunilor focale hepatice descoperite incidental - 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