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磁共振成像胆道评分和肝肌比值对肝占位患者术前肝储备功能的评估价值
DOI: 10.12449/JCH250920
伦理学声明： 本研究方案于2023年10月27日经由广西医科大学附属武鸣医院伦理委员会审批，批号：伦理WM-2023（248），患者均签署知情同意书。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：叶彦宏负责收集数据，资料分析，起草论文；陆力坚负责论文修改，拟定写作思路，指导撰写文章并最后定稿。
Application value of preoperative assessment of liver reserve function based on magnetic resonance cholangiopancreatography-related parameters and liver-to-muscle ratio in patients with hepatic space-occupying lesion
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摘要:
目的 本研究通过构建基于磁共振胆道相关参数和肝肌比的Nomogram预测模型，探讨该预测模型在肝占位患者术前肝储备功能评估中的应用价值。 方法 收集2022年4月—2024年4月在广西医科大学附属武鸣医院住院并拟行手术的112例肝占位患者的临床资料和钆塞酸二钠增强MRI的影像资料。根据肝损伤程度，将患者分为肝功能代偿良好组（Child-Pugh A级65例）、肝功能失代偿组（Child-Pugh B级42例，C级5例）。测量两组患者不同增强扫描时期的肝肌比、胆总管相对强化程度及胆道评分，并运用单因素和多因素Logistic回归分析筛选独立的预测因素，进而构建Nomogram模型。同时绘制受试者操作特征曲线（ROC曲线）、校正曲线、决策曲线，以评估模型的区分度、准确性和临床应用价值。计量资料符合正态分布的数据两组间比较采用成组t检验；符合偏态分布的数据两组间比较采用Mann-Whitney U检验。计数资料两组间比较采用χ2检验。 结果 两组间肝胆期5 min肝肌比（Z=-3.99）、肝胆期10 min肝肌比（Z=-4.39）、肝胆期15 min肝肌比（Z=-4.23）、肝胆期20 min肝肌比（Z=-5.40）、胆总管相对强化程度（Z=-4.85）及胆道评分（t=7.99）比较差异均有统计学意义（P值均<0.001）。多因素Logistic回归分析显示，肝胆期10 min肝肌比（OR=0.63，95%CI：0.44～0.90）、肝胆期20 min肝肌比（OR=0.38，95%CI：0.17～0.82）及胆道评分（OR=0.17，95%CI：0.07～0.39）是术前诊断肝功能失代偿的独立影响因素（P值均<0.05）。基于肝胆期10 min肝肌比、肝胆期20 min肝肌比及胆道评分建立的Nomogram模型术前诊断肝功能失代偿的ROC曲线下面积为0.905（95%CI：0.849～0.960），敏感度为78.7%，特异度为89.2%。 结论 基于肝胆期10 min肝肌比、肝胆期20 min肝肌比及胆道评分构建的列线图模型，在术前能有效评估拟接受手术治疗的肝占位患者的肝储备功能状态。 Abstract:Objective To establish a nomogram predictive model based on magnetic resonance cholangiopancreatography-related parameters and liver-to-muscle ratio， and to investigate the application value of this model in preoperative assessment of liver reserve function in patients with hepatic space-occupying lesion. Methods Clinical data and Gd-EOB-DTPA MRI imaging data were collected from 112 patients with hepatic space-occupying lesion who were hospitalized and scheduled for surgery in Wuming Hospital of Guangxi Medical University from April 2022 to April 2024. According to the degree of liver injury， the patients were divided into Child-Pugh class A group （65 patients with compensated liver function） and Child-Pugh class B+C group （47 patients with decompensated liver function， including 42 patients with Child-Pugh class B liver function and 5 patients with Child-Pugh class C liver function）. The two groups of patients were measured in terms of liver-to-muscle ratio， relative signal intensity of the common bile duct， and bile duct score in different phases of contrast-enhanced CT scan， and univariate and multivariate Logistic regression analyses were used to identify independent predictive factors and establish a nomogram model. In addition， the receiver operating characteristic （ROC） curve， the calibration curve， and the decision curve were plotted to assess the discriminatory ability， accuracy， and clinical application value of the model. The independent-samples t test was used for comparison of normally distributed continuous data between two groups， and the Mann-Whitney U test was used for comparison of data with skewed distribution between two groups； the chi-square test was used for comparison of categorical data between two groups. Results There were significant differences between the two groups in liver-to-muscle ratio at 5 minutes （Z=-3.99， P<0.001）， 10 minutes （Z=-4.39， P<0.001）， 15 minutes （Z=-4.23， P<0.001）， and 20 minutes （Z=-5.40， P<0.001） during the hepatobiliary phase， the relative enhancement degree of the common bile duct （Z=-4.85， P<0.001）， and bile duct score （t=7.99， P<0.001）. The multivariate Logistic regression analysis showed that liver-to-muscle ratio at 10 minutes during the hepatobiliary phase （odds ratio ［OR］=0.63， 95% confidence interval ［CI］： 0.44 — 0.90， P<0.05）， liver-to-muscle ratio at 20 minutes during the hepatobiliary phase （OR=0.38， 95%CI： 0.17 — 0.82， P<0.05）， and bile duct score （OR=0.17， 95%CI： 0.07 — 0.39， P<0.05） were independent influencing factors for the preoperative diagnosis of liver function decompensation. The nomogram model established based on liver-to-muscle ratio at 10 minutes during the hepatobiliary phase， liver-to-muscle ratio at 20 minutes during the hepatobiliary phase， and bile duct score had an area under the ROC curve of 0.905 （95%CI： 0.849 — 0.960）， with a sensitivity of 78.7% with a specificity of 89.2%. Conclusion The nomogram model established based on the liver-to-muscle ratio at 10 and 20 minutes during the hepatobiliary phase and bile duct score can effectively assess the status of liver reserve function in patients with hepatic space-occupying lesion before surgery. -
Key words:
- Liver Neoplasms /
- Magnetic Resonance Imaging /
- Nomograms
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注： a，胆道评分1分：胆道各区均未显示；b，胆道评分2分：胆道各区模糊可见；c，胆道评分3分：胆道各区均可见，但部分胆管或汇合处未见显示；d，胆道评分4分：各区胆管从近端至远端均清晰可见。
图 1 胆道评分
Figure 1. Biliary tract score
图 4 胆道评分、胆总管相对强化程度、增强扫描各期肝肌比区分Child-Pugh A级与Child-Pugh B+C级的ROC曲线
Figure 4. The ROC curves of biliary score 、relative signal intensity of Common bile duct and HMR at each stage of contrast scan distinguish Child-Pugh A grade and Child-Pugh B+C grade
表 1 肝功能代偿良好组与肝功能失代偿组一般资料比较
Table 1. Comparison of general data between the well-compensated and decompensated groups
项目 合计（n=112） 肝功能代偿
良好组（n=65）肝功能失代偿组
（n=47）统计值 P值 年龄（岁） 56.58±11.51 55.95±13.02 57.45±9.08 t=-0.72 0.476 动脉期肝肌比 1.62（1.45～1.85） 1.63（1.46～1.81） 1.61（1.44～1.87） Z=-0.40 0.693 门静脉期肝肌比 2.10（1.95～2.35） 2.12（1.96～2.34） 2.06（1.86～2.35） Z=-0.79 0.431 移行期肝肌比 2.15（1.93～2.36） 2.19（2.01～2.40） 2.09（1.87～2.28） Z=-1.83 0.068 肝胆期5 min肝肌比 2.33（2.03～2.61） 2.48（2.21～2.62） 2.03（1.88～2.38） Z=-3.99 <0.001 肝胆期10 min肝肌比 3.23（2.56～5.67） 4.40（2.91～7.04） 2.70（2.26～3.71） Z=-4.39 <0.001 肝胆期15 min肝肌比 3.13（2.45～4.93） 3.65（2.90～6.00） 2.60（2.10～3.41） Z=-4.23 <0.001 肝胆期20 min肝肌比 2.69（2.16～3.29） 2.92（2.63～3.63） 2.14（1.83～2.66） Z=-5.40 <0.001 胆总管相对强化程度 3.69（2.62～5.92） 4.60（3.42～8.29） 2.67（2.21～3.65） Z=-4.85 <0.001 性别［例（%）］ χ2=1.58 0.209 男 89（79.46） 49（75.38） 40（85.11） 女 23（20.54） 16（24.62） 7（14.89） 胆道评分（分） 2.76±0.08 3.18±0.66 2.17±0.67 t=7.99 <0.001 
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表 2 单因素Logistic回归分析
Table 2. Univariate logistic regression analyses
因素 β值 SE Wald值 P值 OR（95%CI） 动脉期肝肌比 0.07 0.53 0.02 0.891 1.08（0.38～3.03） 门静脉期肝肌比 -0.46 0.54 0.74 0.390 0.63（0.22～1.80） 移行期肝肌比 -0.84 0.56 2.23 0.136 0.43（0.14～1.30） 肝胆期5 min肝肌比 -1.24 0.47 6.90 0.009 0.29（0.12～0.73） 肝胆期10 min肝肌比 -0.59 0.15 16.38 <0.001 0.55（0.42～0.74） 肝胆期15 min肝肌比 -0.45 0.13 11.91 <0.001 0.64（0.49～0.82） 肝胆期20 min肝肌比 -1.27 0.36 12.25 <0.001 0.28（0.14～0.57） 胆总管相对强化程度 -0.25 0.08 9.35 0.002 0.78（0.67～0.91） 胆道评分 -2.22 0.41 28.79 <0.001 0.11（0.05～0.25）
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表 3 多因素Logistic 回归分析
Table 3. Multivariate logistic regression analyses
因素 β值 SE Z值 P值 OR（95%CI） 肝胆期10 min肝肌比 -0.46 0.18 -2.50 0.012 0.63（0.44～0.90） 肝胆期20 min肝肌比 -0.98 0.40 -2.46 0.014 0.38（0.17～0.82） 胆道评分 -1.78 0.43 -4.19 <0.001 0.17（0.07～0.39）
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表 4 MRI指标及Nomogram模型区分肝功能代偿良好与肝功能失代偿的诊断效能
Table 4. MRI indicators and the Nomogram model distinguish the diagnostic performance of well-compensated liver function from decompensated hepatic function
项目 AUC P值 95%CI 敏感度 特异度 截断值 Z值 P值1） 动脉期肝肌比 0.522 0.691 0.411～0.633 0.769 0.362 1.455 5.979 <0.001 门静脉期肝肌比 0.544 0.430 0.433～0.655 0.846 0.298 1.905 5.894 <0.001 移行期肝肌比 0.601 0.068 0.494～0.709 0.754 0.447 2.000 5.185 <0.001 肝胆期5 min肝肌比 0.722 <0.001 0.617～0.827 0.923 0.553 2.055 3.521 <0.001 肝胆期10 min肝肌比 0.743 <0.001 0.654～0.833 0.462 0.957 4.985 3.903 <0.001 肝胆期15 min肝肌比 0.735 <0.001 0.641～0.829 0.769 0.681 2.865 3.570 <0.001 肝胆期20 min肝肌比 0.730 <0.001 0.631～0.828 0.877 0.533 2.475 3.864 <0.001 胆总管相对强化程度 0.770 <0.001 0.678～0.861 0.662 0.809 3.880 3.097 0.002 胆道评分 0.846 <0.001 0.769～0.923 0.892 0.766 2.500 2.626 0.009 Nomogram模型 0.905 <0.001 0.849～0.960 0.787 0.892 0.545 注：1）与Nomogram模型AUC比较。
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