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Article(id=1207416371223306597, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1207416365246419268, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2022.09.0908, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1641830400000, receivedDateStr=2022-01-11, revisedDate=null, revisedDateStr=null, acceptedDate=1644681600000, acceptedDateStr=2022-02-13, onlineDate=1765800095611, onlineDateStr=2025-12-15, pubDate=1664294400000, pubDateStr=2022-09-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1765800095611, onlineIssueDateStr=2025-12-15, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1765800095611, creator=13701087609, updateTime=1765800095611, updator=13701087609, issue=Issue{id=1207416365246419268, tenantId=1146029695717560320, journalId=1189873630562394117, year='2022', volume='47', issue='9', pageStart='851', pageEnd='956', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1765800094186, creator=13701087609, updateTime=1765800167087, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1207416671069904914, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1207416365246419268, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1207416671069904915, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1207416365246419268, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=908, endPage=914, ext={EN=ArticleExt(id=1207416371579822455, articleId=1207416371223306597, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Comparison of mutidetector CT features between gastroduodenal heterotopic pancreas and gastrointestinal stromal tumors smaller than 3 cm in diameter, columnId=1190310109000602400, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Clinical Research, runingTitle=null, highlight=null, articleAbstract=

Objective To compare the clinical and multidetector computed tomography (MDCT) features of gastroduodenal heterotopic pancreas (HP) and gastrointestinal stromal tumors (GIST) smaller than 3 cm in diameter. Methods A total of 61 patients pathologically confirmed as gastroduodenal HP (n=28) and GIST (diameter <3 cm, n=33) in Daping Hospital during 2012-2021 were included. Their clinical and MDCT features (including lesion location, growth mode, morphology, contour,size and MDCT multi-phase enhancements) were retrospectively reviewed and compared. The characteristics with significant difference between the two were searched as the index of differential diagnosis, and receiver operating characteristic (ROC) curves were used to evaluate the diagnostic efficiency of each parameter. Results No significant difference existed in gender, body mass index (BMI), clinical symptoms and signs between the patients with gastroduodenal HP and GIST (P>0.05), while statistically significant differences existed in age, MDCT morphological features (location, growth pattern, lobulation sign) and CT values (plain CT value, portal venous phase CT value and enhancement value) between the two groups (P<0.05, P<0.01). Among them, age,location, and portal venous phase CT value had better efficiency, and the areas under ROC curves (AUC) were all greater than 0.700.When the 3 MDCT morphological features (location, growth pattern, lobulation sign) were combined in use, the AUC was improved to 0.954 (95%CI 0.867-0.991). The plain scan CT value, portal venous phase CT value and enhancement value can be separately used to distinguish HP and GIST respectively, and the portal venous phase CT value has the best efficiency. The optimal cut-offs of age, plain scan CT value, portal venous phase CT value and enhancement value were 50 years, 40.33 HU, 72.53 HU and 37.33 HU,respectively, which could be used as reference indicators to differentiate HP from GIST. Conclusion By comprehensively analyze the patient's age, lesion MDCT morphological features and multi-phase enhanced quantitative parameters, a preliminary differential diagnosis can be made between gastroduodenal HP and GIST smaller than 3 cm in diameter.

, correspAuthors=Yi Wang, authorNote=null, correspAuthorsNote=
*E-mail:
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目的 比较胃十二指肠异位胰腺(HP)与直径<3 cm胃肠道间质瘤(GIST)的临床及多排螺旋CT(MDCT)影像特征。方法 收集大坪医院 2012年5月－2021年5月收治并经病理证实的胃十二指肠HP 28例和直径<3 cm GIST 33例，回顾性分析、比较其临床与MDCT特征，包括病变位置、生长方式、形态、轮廓、大小及MDCT多期增强表现等；寻找两者间差异显著的特征作为鉴别诊断的指标，采用ROC曲线评价各指标的诊断效能。结果 胃十二指肠HP与GIST患者的性别、体重指数(BMI)、临床症状及体征比较差异无统计学意义(P>0.05)。两组患者的年龄、病变MDCT形态学特征(位置、生长方式、分叶征)及CT值(平扫CT值、门静脉期CT值及强化值)比较，差异有统计学意义(P<0.05，P<0.01)；其中年龄、位置、门静脉期CT值鉴别效能较好，ROC曲线下面积(AUC)均>0.7。当3个MDCT形态学特征(位置、生长方式、分叶征)联合使用时，AUC可提高至0.954(95%CI 0.867~0.991)。平扫CT值、门静脉期CT值及强化值均可用于鉴别HP与GIST，以门静脉期CT值效能最好。年龄、平扫CT值、门静脉期CT值及强化值的最佳阈值分别为50岁、40.33 HU、72.53 HU及37.33 HU，可作为鉴别HP及GIST的参考值。结论 通过综合分析患者年龄、MDCT病变形态学特征及多期增强定量指标，可对胃十二指肠HP与<3 cm GIST作出初步鉴别诊断。

, correspAuthors=王毅, authorNote=null, correspAuthorsNote=
王毅，E-mail：
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张春来，硕士研究生，主治医师，主要从事肿瘤影像学方面的研究

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张春来，硕士研究生，主治医师，主要从事肿瘤影像学方面的研究

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J Comput Assist Tomogr, 2017, 41(5): 675-678., articleTitle=Gastric heterotopic pancreas:computed tomography with clinicopathologic correlation, refAbstract=null), Reference(id=1207416381759398793, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207416371223306597, doi=null, pmid=null, pmcid=null, year=2011, volume=17, issue=33, pageStart=3850, pageEnd=3855, url=null, language=null, rfNumber=[17], rfOrder=20, authorNames=Wang D, Wei XE, Yan L, journalName=World J Gastroenterol, refType=null, unstructuredReference=Wang D, Wei XE, Yan L, et al. Enhanced CT and CT virtual endoscopy in diagnosis of heterotopic pancreas[J]. 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HP. 异位胰腺；GIST. 胃肠道间质瘤；A－D. 胃十二指肠HP的MDCT特征；A. MDCT平扫示胃体远段卵圆形软组织结节(箭头)，大小约22.9 mm×14.8 mm×25.7 mm，边界清楚，呈腔内外生长，密度均匀，平扫CT值为49.00 HU；B. 动脉期明显强化(箭头)，CT值为126.67 HU，强化值77.67 HU；C. 门静脉期病变进一步强化(箭头)，CT值为133.33 HU，强化值84.33 HU；D. 平衡期强化程度有所下降(箭头)，CT值为105.00 HU，强化值56.00 HU；E－H. 胃十二指肠GIST的MDCT特征；E. MDCT平扫示胃底圆形软组织结节(箭头)，大小约19.1 mm×16.4 mm×19.1 mm，边界清楚，呈腔外生长，密度均匀，平扫CT值为23.67 HU；F. 动脉期病变强化较明显(箭头)，CT值为59.67 HU，强化值36.00 HU；G. 门静脉期持续强化(箭头)，CT值为69.00 HU，强化值45.33 HU；H. 平衡期强化程度略下降(箭头)，CT值为66.67 HU，强化值43.00 HU

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HP. 异位胰腺；GIST. 胃肠道间质瘤；A. 术后病理学证实为HP(HE ×100)；B. 术后病理学证实为GIST(HE ×100)

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MDCT. 多排螺旋CT；HP. 异位胰腺；GIST. 胃肠道间质瘤；A. 联合指标1(联合病变位置、生长方式和分叶征3个指标)的AUC最大，显示出最佳的鉴别诊断效能，更有助于鉴别HP与GIST；B. 联合指标2(联合平扫CT值、门静脉期CT值及强化值3个指标)的AUC与单个指标比较没有明显差异，不能提高HP与GIST的鉴别诊断效能

, figureFileSmall=Vk21/gJS4E/E1Zc44KysWA==, figureFileBig=Bmq2f/gcHLTfADtZAh/log==, tableContent=null), ArticleFig(id=1207416378982769408, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207416371223306597, language=EN, label=Tab. 1, caption=

Clinical and MDCT features of gastroduodenal HP and GIST

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特征HP(n=28)GIST(n=33)P
临床特征
 年龄(岁，$\bar{x}±s$)40.1±12.060.7±9.0<0.001
 性别[例(%)]  0.554
  男14(50.0%)14(42.4%)
  女14(50.0%)19(57.6%)
 BMI(kg/m2, $\bar{x}±s$)23.5±2.922.4±2.70.129
 临床症状和体征[例(%)]
  腹部疼痛或不适20(71.4)18(54.5)0.197
  腹部压痛10(35.7)7(21.2)0.258
  恶心、呕吐或腹胀8(28.6)15(45.5)0.197
  反酸、嗳气或呃逆12(42.9)12(36.4)0.793
  黑便2(7.1)6(18.2)0.203
  其他9(32.1)9(27.3)0.781
  体检发现占位2(7.1)5(15.2)0.328
MDCT特征
 病变位置[例(%)]  <0.001
  胃底021(63.6)
  胃体14(50.0)5(15.2)
  胃窦10(35.7)2(6.1)
  十二指肠4(14.3)5(15.2)
 生长方式[例(%)]  0.032
  腔内生长10(35.7)20(60.6)
  腔外生长3(10.7)6(18.2)
  腔内外生长15(53.6)7(21.2)
 病变形态[例(%)]  0.094
  圆形4(14.3)13(39.4)
  卵圆形17(60.7)17(51.5)
  扁丘状6(21.4)3(9.09)
  不规则形1(3.57)0
 病变轮廓[例(%)]
  分叶征9(32.1)2(6.1)0.016
  中央凹陷征2(7.1)1(3.0)0.459
 病变大小($\bar{x}±s$)
  最大直径(mm)20.3±6.319.4±5.80.546
  体积(mm3)2662.1±2273.12881.0±2310.40.438
), ArticleFig(id=1207416379079238405, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207416371223306597, language=CN, label=表1, caption=

胃十二指肠HP与GIST的临床及MDCT特征比较

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特征HP(n=28)GIST(n=33)P
临床特征
 年龄(岁，$\bar{x}±s$)40.1±12.060.7±9.0<0.001
 性别[例(%)]  0.554
  男14(50.0%)14(42.4%)
  女14(50.0%)19(57.6%)
 BMI(kg/m2, $\bar{x}±s$)23.5±2.922.4±2.70.129
 临床症状和体征[例(%)]
  腹部疼痛或不适20(71.4)18(54.5)0.197
  腹部压痛10(35.7)7(21.2)0.258
  恶心、呕吐或腹胀8(28.6)15(45.5)0.197
  反酸、嗳气或呃逆12(42.9)12(36.4)0.793
  黑便2(7.1)6(18.2)0.203
  其他9(32.1)9(27.3)0.781
  体检发现占位2(7.1)5(15.2)0.328
MDCT特征
 病变位置[例(%)]  <0.001
  胃底021(63.6)
  胃体14(50.0)5(15.2)
  胃窦10(35.7)2(6.1)
  十二指肠4(14.3)5(15.2)
 生长方式[例(%)]  0.032
  腔内生长10(35.7)20(60.6)
  腔外生长3(10.7)6(18.2)
  腔内外生长15(53.6)7(21.2)
 病变形态[例(%)]  0.094
  圆形4(14.3)13(39.4)
  卵圆形17(60.7)17(51.5)
  扁丘状6(21.4)3(9.09)
  不规则形1(3.57)0
 病变轮廓[例(%)]
  分叶征9(32.1)2(6.1)0.016
  中央凹陷征2(7.1)1(3.0)0.459
 病变大小($\bar{x}±s$)
  最大直径(mm)20.3±6.319.4±5.80.546
  体积(mm3)2662.1±2273.12881.0±2310.40.438
), ArticleFig(id=1207416379226039053, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207416371223306597, language=EN, label=Tab. 2, caption=

Multi-phase enhanced CT values of MDCT in gastroduodenal HP and GIST (HU, $\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
扫描时相HP(n=28)GIST(n=33)P*
HP正常胰腺PGIST正常胰腺P
平扫38.40±12.2346.75±5.130.00131.66±9.9341.46±6.66<0.001<0.001
动脉期
 实测值75.02±28.73106.94±16.91<0.00167.89±35.2297.42±19.75<0.0010.396
 强化值36.62±21.8660.19±17.31<0.00136.23±35.2955.96±17.770.0040.960
门静脉期
 实测值85.74±25.4896.26±14.780.05270.25±21.4688.60±12.16<0.0010.012
 强化值47.35±17.7049.52±11.740.49338.59±22.4447.14±10.840.0370.024
平衡期
 实测值78.23±19.4381.09±10.890.41070.55±16.8677.38±9.870.0540.104
 强化值39.83±14.0634.34±8.390.04138.89±17.1135.92±8.050.3130.817
), ArticleFig(id=1207416379368645399, tenantId=1146029695717560320, journalId=1189873630562394117, articleId=1207416371223306597, language=CN, label=表2, caption=

胃十二指肠HP与GIST的MDCT多期增强CT值比较(HU, $\bar{x}±s$)

, figureFileSmall=null, figureFileBig=null, tableContent=
扫描时相HP(n=28)GIST(n=33)P*
HP正常胰腺PGIST正常胰腺P
平扫38.40±12.2346.75±5.130.00131.66±9.9341.46±6.66<0.001<0.001
动脉期
 实测值75.02±28.73106.94±16.91<0.00167.89±35.2297.42±19.75<0.0010.396
 强化值36.62±21.8660.19±17.31<0.00136.23±35.2955.96±17.770.0040.960
门静脉期
 实测值85.74±25.4896.26±14.780.05270.25±21.4688.60±12.16<0.0010.012
 强化值47.35±17.7049.52±11.740.49338.59±22.4447.14±10.840.0370.024
平衡期
 实测值78.23±19.4381.09±10.890.41070.55±16.8677.38±9.870.0540.104
 强化值39.83±14.0634.34±8.390.04138.89±17.1135.92±8.050.3130.817
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胃十二指肠异位胰腺与小于3 cm胃肠道间质瘤的多排螺旋CT特征比较
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张春来 1 , 张静 1 , 董秋杰 1 , 李晓光 1 , 王毅 2, 3, *
解放军医学杂志 | 临床研究 2022,47(9): 908-914
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解放军医学杂志 | 临床研究 2022, 47(9): 908-914
胃十二指肠异位胰腺与小于3 cm胃肠道间质瘤的多排螺旋CT特征比较
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张春来1, 张静1, 董秋杰1, 李晓光1, 王毅2, 3, *
作者信息
  • 1陆军军医大学大坪医院放射科，重庆 400042
  • 2陆军军医大学大坪医院核医学科，重庆 400042
  • 3重庆市影像医学与核医学临床研究中心，重庆 400042

    • 张春来，硕士研究生，主治医师，主要从事肿瘤影像学方面的研究

通讯作者:

王毅，E-mail：
Comparison of mutidetector CT features between gastroduodenal heterotopic pancreas and gastrointestinal stromal tumors smaller than 3 cm in diameter
Chun-Lai Zhang1, Jing Zhang1, Qiu-Jie Dong1, Xiao-Guang Li1, Yi Wang2, 3, *
Affiliations
  • 1Deptartment of Radiology, Daping Hospital, Army Medical University, Chongqing 400042, China
  • 2Deptartment of Nuclear Medicine, Daping Hospital, Army Medical University, Chongqing 400042, China
  • 3Chongqing Clinical Research Centre of Imaging and Nuclear Medicine, Chongqing 400042, China
出版时间: 2022-09-28 doi: 10.11855/j.issn.0577-7402.2022.09.0908
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摘要
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目的 比较胃十二指肠异位胰腺(HP)与直径<3 cm胃肠道间质瘤(GIST)的临床及多排螺旋CT(MDCT)影像特征。方法 收集大坪医院 2012年5月－2021年5月收治并经病理证实的胃十二指肠HP 28例和直径<3 cm GIST 33例，回顾性分析、比较其临床与MDCT特征，包括病变位置、生长方式、形态、轮廓、大小及MDCT多期增强表现等；寻找两者间差异显著的特征作为鉴别诊断的指标，采用ROC曲线评价各指标的诊断效能。结果 胃十二指肠HP与GIST患者的性别、体重指数(BMI)、临床症状及体征比较差异无统计学意义(P>0.05)。两组患者的年龄、病变MDCT形态学特征(位置、生长方式、分叶征)及CT值(平扫CT值、门静脉期CT值及强化值)比较，差异有统计学意义(P<0.05，P<0.01)；其中年龄、位置、门静脉期CT值鉴别效能较好，ROC曲线下面积(AUC)均>0.7。当3个MDCT形态学特征(位置、生长方式、分叶征)联合使用时，AUC可提高至0.954(95%CI 0.867~0.991)。平扫CT值、门静脉期CT值及强化值均可用于鉴别HP与GIST，以门静脉期CT值效能最好。年龄、平扫CT值、门静脉期CT值及强化值的最佳阈值分别为50岁、40.33 HU、72.53 HU及37.33 HU，可作为鉴别HP及GIST的参考值。结论 通过综合分析患者年龄、MDCT病变形态学特征及多期增强定量指标，可对胃十二指肠HP与<3 cm GIST作出初步鉴别诊断。

胃十二指肠  /  异位胰腺  /  胃肠道间质瘤  /  多排螺旋CT  /  鉴别诊断

Objective To compare the clinical and multidetector computed tomography (MDCT) features of gastroduodenal heterotopic pancreas (HP) and gastrointestinal stromal tumors (GIST) smaller than 3 cm in diameter. Methods A total of 61 patients pathologically confirmed as gastroduodenal HP (n=28) and GIST (diameter <3 cm, n=33) in Daping Hospital during 2012-2021 were included. Their clinical and MDCT features (including lesion location, growth mode, morphology, contour,size and MDCT multi-phase enhancements) were retrospectively reviewed and compared. The characteristics with significant difference between the two were searched as the index of differential diagnosis, and receiver operating characteristic (ROC) curves were used to evaluate the diagnostic efficiency of each parameter. Results No significant difference existed in gender, body mass index (BMI), clinical symptoms and signs between the patients with gastroduodenal HP and GIST (P>0.05), while statistically significant differences existed in age, MDCT morphological features (location, growth pattern, lobulation sign) and CT values (plain CT value, portal venous phase CT value and enhancement value) between the two groups (P<0.05, P<0.01). Among them, age,location, and portal venous phase CT value had better efficiency, and the areas under ROC curves (AUC) were all greater than 0.700.When the 3 MDCT morphological features (location, growth pattern, lobulation sign) were combined in use, the AUC was improved to 0.954 (95%CI 0.867-0.991). The plain scan CT value, portal venous phase CT value and enhancement value can be separately used to distinguish HP and GIST respectively, and the portal venous phase CT value has the best efficiency. The optimal cut-offs of age, plain scan CT value, portal venous phase CT value and enhancement value were 50 years, 40.33 HU, 72.53 HU and 37.33 HU,respectively, which could be used as reference indicators to differentiate HP from GIST. Conclusion By comprehensively analyze the patient's age, lesion MDCT morphological features and multi-phase enhanced quantitative parameters, a preliminary differential diagnosis can be made between gastroduodenal HP and GIST smaller than 3 cm in diameter.

gastroduodenum  /  heterotopic pancreas  /  gastrointestinal stromal tumors  /  multidetector computed tomography  /  differential diagnosis
张春来, 张静, 董秋杰, 李晓光, 王毅. 胃十二指肠异位胰腺与小于3 cm胃肠道间质瘤的多排螺旋CT特征比较. 解放军医学杂志, 2022 , 47 (9) : 908 -914 . DOI: 10.11855/j.issn.0577-7402.2022.09.0908
Chun-Lai Zhang, Jing Zhang, Qiu-Jie Dong, Xiao-Guang Li, Yi Wang. Comparison of mutidetector CT features between gastroduodenal heterotopic pancreas and gastrointestinal stromal tumors smaller than 3 cm in diameter[J]. Medical Journal of Chinese People’s Liberation Army, 2022 , 47 (9) : 908 -914 . DOI: 10.11855/j.issn.0577-7402.2022.09.0908
正文
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异位胰腺(heterotopic pancreas，HP)通常在手术或尸检中偶然发现[1-2]，约占剖腹手术病变的0.2%~0.9%[3-5]。HP一般表现为胃肠道黏膜下肿块，在影像学或内镜检查中易被误诊为其他黏膜下肿瘤尤其是胃肠道间质瘤(gastrointestinal stromal tumors，GIST)，后者约占胃黏膜下肿瘤的90%[1, 3]。HP与GIST的治疗及预后存在较大差异。GIST是一种侵袭性肿瘤，具有潜在恶性倾向，通常需要手术切除[5]，偶尔还需术后化疗；而HP是一种先天发育异常[6-7]，类似于错构瘤，对于无症状HP患者，因其恶性转化或转移的风险非常低[5, 7]，通常无须任何治疗，只需随访观察，仅极少数患者由于并发症需要手术切除[1, 4, 8-9]。因此，胃肠道黏膜下病变的鉴别诊断对指导治疗具有重要的临床意义。临床上HP与较小的GIST之间鉴别十分困难，而多排螺旋CT(multidetector computed tomography,MDCT)能显示胃肠道细微解剖及评价病变的血供，可用于胃肠道黏膜下病变的治疗前评估。本研究收集经手术和病理证实为胃十二指肠HP和直径<3 cm的GIST病例，比较两者的临床和MDCT特征，以期为两种病变的鉴别诊断提供影像学依据。
1 资料与方法
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1.1 研究对象
收集陆军军医大学大坪医院2012年5月－2021年5月收治并经病理学证实的胃十二指肠HP患者28例和直径<3 cm 的GIST患者33例。28例HP患者中，男14例，女14例；年龄17~66(40.1±12.0)岁。33例GIST患者中，男14例，女19例；年龄43~74(60.7±9.0)岁。纳入标准：(1)经手术或病理学证实为胃十二指肠HP或GIST；(2)GIST病变直径<3 cm。排除标准：(1)临床及影像学资料不完整；(2)MDCT未行多期增强扫描；(3)MDCT影像有严重伪影等技术缺陷。收集患者的人口统计学特征、临床症状和体征、手术记录、病理学结果及MDCT特征等。本研究获得医院医学伦理委员会批准，由于是回顾性研究，患者知情同意获得豁免。
1.2 MDCT扫描
采用Philips Brilliance iCT 256层或GE LightSpeed 64排MDCT机，扫描范围为膈顶至中腹部。检查前口服300 ml温开水，患者取仰卧位先行平扫，再行动脉期、门静脉期及平衡期多期增强扫描。增强扫描采用高压注射器经肘静脉注射碘佛醇(350 mgI/ml)90 ml，速率3.5 ml/s，延迟时间分别为动脉期25 s，门静脉期55 s，平衡期90 s。扫描条件：120 kVp，智能mA，螺距0.984，容积数据采集。采用ADW 4.3后处理工作站常规行轴位(层厚5 mm)及冠状位(层厚3 mm)重建，并将图像传入影像归档和通信系统(Picture Archiving and Communication Systems，PACS)用于影像分析。同一患者行多次MDCT检查仅纳入首次检查结果。
1.3 影像分析
由两名经验丰富的腹部放射学医师行影像分析，意见不一致时经讨论达成共识。观测指标：(1)病变位置，包括胃底、胃体、胃窦或十二指肠。(2)病变形态，包括类圆形、椭圆形、扁平丘状或不规则形。(3)边缘是否清楚。(4)轮廓是否具有中央凹陷征或小分叶征。(5)生长方式，包括腔内生长、腔外生长或腔内外生长。腔内生长是指病变附着于胃肠壁内缘，并完全局限于胃肠腔内，而没有向胃肠腔外生长；腔外生长是指病变向胃肠壁外生长而不突向腔内；腔内外生长是指上述两种情况兼有。(6)病变平扫CT值及增强各期CT值，并计算增强各期的强化值(强化值＝增强扫描CT值－平扫CT值)。
CT值测量方法：先选择5例患者用于影像观测训练，感兴趣区(region of interest，ROI)的面积固定为0.2 cm2，于横轴位影像病变最大层面避开坏死、囊变、钙化及邻近结构选取ROI，尽可能覆盖肿瘤最大强化部分，每个位置测量3次，取其平均值。于横轴位影像分别测量病变最大长径及与之垂直的最大短径，冠状位影像测量其高径，计算病变体积(V)。V＝0.5233×长径×短径×高径。
1.4 统计学处理
采用SPSS 22.0软件进行统计分析。Shapiro-Wilk法检验计量资料的正态性，符合正态分布的资料以$\bar{x}±s$表示，两组间比较采用独立样本t检验。不符合正态分布的计量资料以M(Q1，Q3)表示，两组间比较采用U检验。计数资料以频数和百分比表示，组间比较采用χ2检验或Fisher精确检验。采用受试者工作特征(ROC)曲线评估具有统计学意义指标的诊断效能。P<0.05为差异有统计学意义。
2 结果
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2.1 临床特征比较
HP与GIST的临床特征包括年龄、性别、体重指数(BMI)、临床症状和体征等，其中临床症状和体征包括腹部疼痛或不适、腹部压痛、恶心、呕吐或腹胀、反酸、嗳气或呃逆、黑便及体检报告胃十二指肠占位性病变等。28例HP和33例GIST患者的性别、BMI、临床症状及体征差异均无统计学意义(P>0.05)；GIST组年龄明显大于HP组，差异有统计学意义(P<0.01)(表1)。
2.2 MDCT形态学特征比较
HP与GIST的位置分布差异有统计学意义(P<0.01)，HP多见于胃体(50.0%，14/28)和胃窦(35.7%，10/28)，而GIST多见于胃底(63.6%，21/33)，其次是胃窦和十二指肠，各占15.2%(5/33)。HP与GIST的生长方式差异也有统计学意义(P<0.05)，HP多呈腔内外生长(53.6%)或腔内生长(35.7%)，很少单独出现腔外生长，而大多数GIST呈腔内生长(60.6%)。HP与GIST的形态均以卵圆形多见，分别占60.7%和51.5%，HP其次为扁丘状(21.4%)，GIST其次为圆形(39.4%)，但两组病变形态占比比较差异无统计学意义(P>0.05)(表1)。病变轮廓，HP出现分叶征比例较高(32.1%，9/28)，而GIST仅见2例(6.1%)，二者比较差异有统计学意义(P<0.05)。中央凹陷征在两种病变中出现的比例均很低，差异无统计学意义(P>0.05)。其他MDCT征象，HP中1例见中央坏死样低密度影，1例边缘有环形脂肪影，1例平衡期见导管状结构，另1例见点状钙化影；GIST中2例见囊变，1例见钙化影。对于病变大小，本研究GIST组均为直径<3 cm，故两者之间差异无统计学意义(P>0.05)。
2.3 MDCT多期增强特征比较
正常胰腺与HP及GIST、HP与GIST之间平扫CT值比较，差异均有统计学意义(P<0.01)；正常胰腺平扫CT值明显高于HP及GIST(P<0.01)。正常胰腺增强扫描动脉期CT值及绝对强化值均明显高于HP及GIST(P<0.01)，而HP与GIST之间比较差异无统计学意义(P>0.05)。HP与正常胰腺的门静脉期CT值及绝对强化值比较，差异均无统计学意义(P>0.05)；但GIST的门静脉期CT值及绝对强化值均明显低于正常胰腺(P<0.05，P<0.01)，HP的门静脉期CT值及绝对强化值均明显高于GIST(P<0.05)。增强扫描平衡期，仅HP与正常胰腺之间绝对强化值的差异有统计学意义(P<0.05)，其他各组参数比较差异均无统计学意义(P>0.05)(表2、图1、图2)。
2.4 ROC曲线分析
两组患者的年龄、病变MDCT形态学特征(位置、生长方式和分叶征)及CT值(平扫CT值、门静脉期CT值及强化值)差异均有统计学意义(P<0.05，P<0.01)。ROC曲线分析显示，年龄、病变位置和门静脉期CT值的AUC均>0.7，具有较好的鉴别诊断效能。当病变位置、生长方式和分叶征3个指标联合应用(联合指标1)时，其AUC可提高至0.954(95%CI 0.867~0.991)，敏感度为0.893，特异度为0.909(图3)，显示出较好的鉴别诊断效能。在CT值指标中，当平扫CT值、门静脉期CT值及强化值3个指标联合应用(联合指标2)时，其AUC与各指标单独应用差异无统计学意义(P>0.05)(图3)。从SPSS输出的表中查得各指标的诊断点：年龄<50岁、病变平扫CT值>40.33 HU、门静脉期CT值>72.53 HU及强化值>37.33 HU用于HP诊断的敏感度分别为0.786、0.464、0.750和0.750，特异度分别为0.879、0.879、0.667和0.636。
3 讨论
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本研究的病例中，HP多见于胃体(50.0%)，其次是胃窦(35.7%)，与文献[4]报道略有差异；GIST多见于胃底(63.6%)，而HP未见位于胃底的病例。因此，病变位置可作为两者鉴别的重要指标之一，进一步经ROC曲线分析获得了AUC为0.780、敏感度1.000和特异度0.636的鉴别诊断效能。病变形态在HP与GIST之间总体差异不明显，两种病变均以卵圆形多见，HP其次为扁丘状，而GIST其次为圆形；尽管圆形病变更大可能性是GIST，扁丘状病变更大可能性是HP[9]，但这一形态特征在两者之间总体差异无统计学意义，还需进一步的大样本研究来验证其临床意义。
Jang等[10]报道，上消化道其他黏膜下肿瘤较HP更多呈圆形(46.2% vs. 6.7%)，其6.7%的HP呈圆形占比低于本研究结果(14.3%)。从组织学观点看，HP不是真正的肿瘤，而是扁平腺体组织错构瘤，有胰腺腺泡形成和导管发育[1, 3]，因此更可能呈扁平状。GIST是真性肿瘤，由梭形细胞、上皮样细胞或混合型细胞组成，具有明显的垂直生长趋势[8]。本研究结果也印证了此点，HP呈扁丘状形态较GIST更多(21.4% vs. 9.1%)。也有研究报道，HP只有当腺内囊肿形成后，才可能表现为一个较大突起的黏膜下肿块，从而表现为椭圆形或圆形[3]。
本研究结果显示，HP多表现为腔内外生长(53.6%)，而GIST多呈腔内生长(60.6%)，两种病变呈腔外生长的病例均较少，且两者生长方式差异明显。因此，生长方式可作为HP与GIST鉴别的一个指标。进一步经ROC曲线分析获得AUC为0.662、敏感度0.536和特异度0.788的鉴别诊断效能。Kim等[3]报道86%的HP病变呈腔内生长，与本研究结果存在差异，可能与腔内、腔外和腔内外3种生长方式的定义或观测者间的差异有关。Jang等[10]描述了上消化道HP的MRI特征，仅1个(7%)病变呈腔内生长模式。他们认为HP这种生长模式上的特点可能与成像时胃或十二指肠扩张程度不同有关。
本研究发现，分叶征在HP和GIST之间差异明显，用于鉴别HP与GIST具有很高的特异度(0.939)，但敏感度(0.321)较低。Zhang等[11]对184例HP进行临床病理学研究发现，HP多表现为明显的腺泡特征伴有小叶结构，当该成分位于周边部分时，可引起病变边缘不整，从而呈现小分叶状形态。有研究报道中央凹陷征是HP的特征性影像学征象，对HP的诊断具有高度的特异度[5, 12-14]，但本研究中HP患者此征象的出现率(7.1%)较低，与GIST组比较差异不明显。本研究1例HP有多发点状钙化，有研究报道钙化不是HP的特异性征象[8]；1例边缘见环形脂肪密度影，需注意与脂肪瘤进行鉴别；另1例平衡期影像可见导管状结构，沿着肿块长轴中心生长。文献报道，导管样结构是HP的重要影像学征象之一，有助于鉴别HP与GIST[4-6, 14-15]。虽然导管样结构较小，直径1~5 mm，深度5~10 mm，但在MDCT矢状面或冠状面影像上较易观察到，称之为“异位胰管”征。
与以往研究结果类似，本研究中HP和GIST的多数临床特征，包括性别、BMI、临床症状和体征等差异均不明显，这些特征不能用于两种病变之间的鉴别诊断。本研究中仅患者年龄HP组[(40.1±12.0)岁]明显小于GIST组[(60.7±9.0)岁]，ROC曲线分析显示其用于鉴别HP与GIST的AUC为0.909，敏感度为0.786，特异度为0.879，效能优于上述各单个MDCT特征。然而，如果将MDCT病变位置、生长方式和分叶征3个指标联合用于鉴别HP与GIST，AUC为0.954，敏感度为0.893、特异度为0.909，其鉴别诊断效能优于年龄。
MDCT平扫CT值及多期增强扫描定量指标用于胃肠道HP与其他黏膜下肿瘤鉴别诊断的相关研究未见文献报道。本研究结果显示，HP与GIST之间平扫CT值、门静脉期CT值及强化值差异明显，可用于HP与GIST的鉴别诊断；进一步采用ROC曲线分析显示，上述3个指标的AUC分别为0.671、0.703和0.669，敏感度分别为0.464、0.750和0.750，特异度分别为0.879、0.667和0.636，鉴别诊断的阈值分别为40.33 HU、72.53 HU和37.33 HU，但3个指标联合应用并不能提高鉴别诊断的准确性。推测HP与GIST之间平扫CT值的差异与两种病变的组织学成分占比及细胞密集程度有关，而门静脉期CT值及强化值的差异则反映了二者之间毛细血管构筑、血流灌注和血管通透性的差异。
本研究结果还显示，HP与正常胰腺的平扫CT值、多期增强定量参数均存在明显差异，提示HP的组织学成分占比、细胞密集程度和血供均与正常胰腺存在较大不同，这与以往部分研究结果不完全一致。也有部分研究得出了相似的结果，他们认为这种差异与HP的组织学成分相关：以腺泡为主的HP，平扫CT值接近正常胰腺，表现为更明显的强化，接近正常胰腺的强化方式；而以导管为主的HP表现为不明显或不均匀的强化方式，低于正常胰腺的强化[1, 6-8, 14, 16-17]。
本研究的临床意义在于初步发现临床(患者年龄)及MDCT特征(病变位置、生长方式、分叶征、平扫CT值、门静脉期CT值、强化值)共7个指标可用于鉴别胃十二指肠HP与直径<3 cm的GIST。这些特征有助于临床进行初步定性诊断，从而避免对无症状HP患者实施不必要的外科手术或内镜等侵入性操作，也有助于避免因把GIST误诊为HP而延误治疗。对于无症状的胃肠道黏膜下扁丘状或椭圆形病变，通过分析上述临床及MDCT特征，一旦诊断更趋向于HP，可以选择让患者定期复查，而不是立即实施外科手术。
本研究存在一定的局限性。首先，由于是回顾性研究，一定程度的选择偏差和不同MDCT设备的使用不可避免。其次，本研究中所有的HP直径均<3 cm，为避免病变大小差异造成的潜在偏倚，GIST也仅选择了直径<3 cm的病例。采用这一纳入标准，且需有MDCT多期增强扫描并获得病理学证实，故符合条件的样本量较小，可能出现一定的偏倚。尽管如此，对于上消化道黏膜下小病变，本研究仍具有一定的临床意义，GIST是常见的黏膜下肿瘤，一般建议尽早切除，而大多数HP却无需治疗，本研究通过临床及MDCT特征对胃十二指肠黏膜下较小的GIST与HP进行鉴别，有助于临床选择更为合适的处理方式。
综上所述，GIST是常见的胃肠道黏膜下肿瘤，在直径<3 cm时需与其他黏膜下良性病变进行鉴别，以决定治疗方式，尤其是对于HP，仅根据临床和内镜特征难以与小的GIST进行鉴别。本研究综合对比分析了胃十二指肠黏膜下HP与直径<3 cm GIST的临床和MDCT特征，发现患者年龄及MDCT病变位置、生长方式、分叶征、平扫CT值、门静脉期CT值、强化值共7个指标可用于二者的鉴别，且其中3个形态学指标的联合应用具有更高的鉴别诊断效能，能够对胃十二指肠黏膜下HP与直径<3 cm GIST作出初步鉴别诊断，为临床治疗方式的选择提供重要的影像学依据。
基金
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  • 重庆市影像医学与核医学临床研究中心基金(CSTC2015YFPT-gcjsyjzx0175)
文献
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参考文献 引证文献
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2022年第47卷第9期
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doi: 10.11855/j.issn.0577-7402.2022.09.0908
  • 接收时间：2022-01-11
  • 首发时间：2025-12-15
  • 出版时间：2022-09-28
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  • 收稿日期：2022-01-11
  • 录用日期：2022-02-13
基金
Fund of Chongqing Clinical Research Centre of Imaging and Nuclear Medicine(CSTC2015YFPT-gcjsyjzx0175)
重庆市影像医学与核医学临床研究中心基金(CSTC2015YFPT-gcjsyjzx0175)
作者信息
    1陆军军医大学大坪医院放射科，重庆 400042
    2陆军军医大学大坪医院核医学科，重庆 400042
    3重庆市影像医学与核医学临床研究中心，重庆 400042

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