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18F-FDG PET/CT是肿瘤无创性诊断和分期的重要方法[1-4]。基于全身扫描模式,PET/CT可为非小细胞肺癌(non-small cell lung cancer,NSCLC)患者提供可靠的T分期和M分期信息。然而,炎症或其他肉芽组织增生性病变也能非特异性地摄取18F-FDG,且淋巴结长径>10 mm时,葡萄糖的代谢水平也随之增高[5]。一项国际循证医学研究结果表明,18F-FDG PET/CT的诊断效能不足以对NSCLC患者进行N分期[6]。但是,有研究结果表明,ⅢA期NSCLC患者肿瘤的葡萄糖代谢参数与ⅡB及ⅢB期患者存在差异,并且肿瘤本身的异质性以及淋巴结SUVmax与纵隔血池平均标准化摄取值(mean standardized uptake value, SUVmean)的比值(称为LMV)等参数在有无淋巴结转移的患者中不同[7]。此外,Gao等[8]认为,淋巴结转移阳性的NSCLC患者的血清D-二聚体水平显著高于阴性的患者。本研究回顾性分析了NSCLC患者的临床资料和18F-FDG PET/CT的影像学信息,筛选出淋巴结转移的高危因素,为适合行超声内镜引导下的经支气管针吸活检(EBUS-TBNA)的患者提供无创性的诊断信息。
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102例NSCLC患者中,血清D-二聚体水平异常增高(>0.8 mg/L)的患者41例,血清癌胚抗原(carcinoembryonic antigen,CEA)水平异常增高(>5.0 ng/mL)的患者48例;原发肿瘤位于右肺上叶的患者46例、位于右肺中叶的患者4例、位于右肺下叶的患者13例、位于左肺上叶的患者32例、位于左肺下叶的患者7例;病理类型为腺癌的患者66例、鳞癌的患者31例、大细胞型的患者3例、腺鳞癌的患者2例;T分期为T1期的患者57例、T2期的患者25例、T3期的患者14例、T4期的患者6例;N分期为N0期的患者60例、N1期的患者25例、N2期的患者17例;纵隔淋巴结转移阳性的患者42例(转移组),阴性的患者60例(未转移组)。
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由表1可知,肺部原发肿瘤长径>30.0 mm的患者更易发生淋巴结转移(61.9%对38.1%,P<0.01);转移组患者中淋巴结短径>10.0 mm的患者明显较淋巴结短径≤10.0 mm的患者多(59.5%对40.5%,P<0.05);且转移组患者原发肿瘤葡萄糖代谢的异质性(以CV衡量)、淋巴结SUVmax和LMV亦明显高于未转移组患者(46.7±6.1对29.4±6.0、5.9±1.9对2.8±1.6、2.2±0.6对1.4±0.3,均P<0.01)。患者的年龄、性别、吸烟状态、原发肿瘤的位置、MTV、TLG、血清CEA和D-二聚体的水平在2组间的差异均无统计学意义(均P>0.05)。
参数 转移组
(n=42)未转移组
(n=60)检验值 P值 年龄(岁) 66.6±12.3 65.0±15.1 t=0.82 0.37 性别[例 (%)] χ2=0.87 0.64 男 22(52.4) 37(61.7) 女 20(47.6) 23(38.3) 吸烟状态[例(%)] χ2=0.40 0.53 吸烟或既往吸烟 18(42.9) 22(36.7) 不吸烟 24(57.1) 38(63.3) 原发肿瘤的位置[例 (%)] χ2=1.48 0.22 右肺 23(54.8) 40(66.7) 左肺 19(45.2) 20(33.3) 肿瘤长径[例(%)] χ2=9.16 <0.01 ≤30.0 mm 16(38.1) 41(68.3) >30.0 mm 26(61.9) 19(31.7) MTV(cm3) 56.5±15.8 48.7±17.6 t=0.81 0.51 TLG(g) 242.0±55.3 168.5±46.7 t=0.84 0.36 原发肿瘤CV 46.7±6.1 29.4±6.0 t=13.81 <0.01 淋巴结短径[例(%)] χ2=5.20 0.02 >10.0 mm 25(59.5) 22(36.7) ≤10.0 mm 17(40.5) 38(63.3) 淋巴结SUVmax 5.9±1.9 2.8±1.6 t=8.60 <0.01 LMV 2.2±0.6 1.4±0.3 t=3.97 <0.01 血清癌胚抗原水平[例(%)] χ2=0.81 0.37 >5.0 ng/mL 22(52.4) 26(43.3) ≤5.0 ng/mL 20(47.6) 34(56.7) 血清D-二聚体水平[例(%)] χ2=0.13 0.72 >0.8 mg/L 16(38.1) 25(41.7) ≤0.8 mg/L 26(61.9) 35(58.3) 注:MTV为肿瘤代谢体积;TLG为病灶葡萄糖酵解总量;CV为变异系数;SUVmax为最大标准化摄取值;LMV为淋巴结SUVmax与纵隔血池平均标准化摄取值的比值 表 1 102例非小细胞肺癌患者淋巴结转移影响因素的单因 素Logistic回归分析结果
Table 1. Results of univariable Logistic regression analysis of factors for lymph node metastasis in 102 patients with non-small cell lung cancer
将淋巴结短径、肿瘤长径、淋巴结SUVmax、LMV和原发肿瘤CV纳入多因素Logistic回归分析的结果表明,淋巴结SUVmax(OR=2.2,95%CI:1.30~3.80,P<0.05)以及原发肿瘤CV(OR=1.5,95%CI:1.20~1.80,P<0.01)是影响淋巴结转移的危险因素(表2)。
因素 标准差 P值 OR 95%CI 淋巴结短径(>10.0 mm) 1.22 0.50 − − 肿瘤长径(>30.0 mm) 1.22 0.10 − − 淋巴结SUVmax 0.30 0.04 2.2 1.30~3.80 LMV 1.77 0.20 − − 原发肿瘤CV 0.10 <0.01 1.5 1.20~1.80 注:SUVmax为最大标准化摄取值;LMV为淋巴结SUVmax与纵隔血池平均标准化摄取值的比值;CV为变异系数;CI为可变区间。−表示无此项数据 表 2 102例非小细胞肺癌患者淋巴结转移影响因素的多因 素Logistic回归分析结果
Table 2. Results of multivariable Logistic regression analysis of factors for lymph node metastasis in 102 patients with non- small cell lung cancer
如图1所示,ROC曲线分析结果表明,原发肿瘤CV的AUC=0.97(SD=0.02,95%CI:0.94~0.99,P<0.01),当CV>30.5时,其诊断淋巴结转移的灵敏度为97.5%、特异度为41.7%;淋巴结SUVmax的AUC=0.91(SD=0.30,95%CI:0.85~0.97,P<0.01),当淋巴结SUVmax>3.1时,其诊断淋巴结转移的灵敏度和特异度分别为95.2%和23.3%。将以上2个危险因素进行联合诊断,得出的AUC=0.98(SD=0.01,95%CI:0.96~1.00,P<0.01),高于两者独立预测淋巴结转移的AUC。
图 1 原发肿瘤CV、淋巴结SUVmax以及两者联合对102例非小细胞肺癌患者淋巴结转移的预测效能的受试者工作特征曲线
Figure 1. Receiver operator characteristic curve of the coefficient of variation of primary tumor, the maximum standardized uptake value of lymph nodes, and the combination of the two in predicting lymph node metastasis in 102 patients with non-small cell lung cancer
18F-FDG PET/CT代谢参数在预测非小细胞肺癌患者纵隔淋巴结转移中的临床价值
Clinical value of 18F-FDG PET/CT metabolic parameters in the prediction of mediastinal lymph node metastasis in patients with non-small cell lung cancer
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摘要:
目的 探讨18F-氟脱氧葡萄糖(FDG) PET/CT代谢参数在预测非小细胞肺癌(NSCLC)患者纵隔淋巴结转移中的临床价值。 方法 回顾性分析2018年1月至2021年3月于安徽省阜阳市人民医院经组织病理学检查确诊为NSCLC的102例患者的临床资料,其中男性59例、女性43例,年龄33~90(66.0±11.2)岁。所有患者术前均行18F-FDG PET/CT显像,分析并计算代谢参数,变异系数(CV)为病灶最大标准化摄取值(SUVmax)的标准差(SD)与SUVmax的比值;LMV为淋巴结SUVmax与纵隔血池平均标准化摄取值(SUVmean)的比值;病灶葡萄糖酵解总量(TLG)为肿瘤代谢体积(MTV)与SUVmean的乘积。绘制受试者工作特征(ROC)曲线,确定预测淋巴结转移的最佳临界值,并计算灵敏度和特异度。计数资料采用χ2检验或Fisher确切概率法进行比较;连续性计量资料采用独立样本t检验进行比较。采用单因素及多因素Logistic回归分析筛选淋巴结转移的预测因素。 结果 单因素Logistic回归分析结果显示,当患者肺部原发肿瘤的长径>30.0 mm或淋巴结的短径>10.0 mm时易发生淋巴结转移(61.9%对38.1%、59.5%对40.5%,χ2=9.16、5.20,均P<0.05);转移组患者的原发肿瘤CV、淋巴结SUVmax和LMV均高于未转移组患者(46.7±6.1对29.4±6.0、5.9±1.9对2.8±1.6、2.2±0.6对1.4±0.3,t=13.81、8.60、3.97,均P<0.05)。多因素Logistic回归分析结果显示,淋巴结SUVmax[OR=2.2,95%可信区间(CI):1.30~3.80,P<0.05]和原发肿瘤CV(OR=1.5,95%CI:1.20~1.80,P<0.01)是影响淋巴结转移状态的独立危险因素。ROC曲线分析结果显示,原发肿瘤CV的曲线下面积(AUC)=0.97(SD=0.02,95%CI:0.94~0.99,P<0.01),当CV>30.5时,其诊断淋巴结转移的灵敏度为97.5%、特异度为41.7%;淋巴结SUVmax的AUC=0.91(SD=0.30,95%CI:0.85~0.97,P<0.01),当淋巴结SUVmax>3.1时,其诊断淋巴结转移的灵敏度和特异度分别为95.2%和23.3%。将2种危险因素进行联合诊断,得出的AUC=0.98(SD=0.01,95%CI:0.96~1.00,P<0.01)。 结论 18F-FDG PET/CT代谢参数中原发肿瘤CV和淋巴结SUVmax是预测NSCLC患者纵隔淋巴结转移状态的独立危险因素,可为患者诊疗方案的制定提供重要参考依据。 -
关键词:
- 氟脱氧葡萄糖F18 /
- 正电子发射断层显像术 /
- 体层摄影术,X线计算机 /
- 癌,非小细胞肺 /
- 淋巴转移 /
- 最大标准化摄取值
Abstract:Objective To explore the clinical value of 18F-fluorodeoxyglucose (FDG) PET/CT metabolic parameters in the prediction of mediastinal lymph node metastasis in patients with non-small cell lung cancer (NSCLC). Methods A total of 102 patients with NSCLC histopathologically confirmed from January 2018 to March 2021 in Fuyang People's Hospital were restrospectively analyzed in this study. The patients consisted of 59 males and 43 females aged 33–90 (66.0±11.2) years. All patients underwent 18F-FDG PET/CT imaging before operation to analyze and calculate the metabolic parameters. The coefficient of variation (CV) is the ratio of the standard deviation (SD) of the maximum standardized uptake value (SUVmax) to SUVmax of the lesion; LMV is the ratio of the SUVmax of the lymph node to the mean standardized uptake value (SUVmean) of the mediastinal blood pool; the total lesion glycolysis (TLG) is the product of metabolic tumor volume (MTV) and SUVmean. The receiver operator characteristic (ROC) curve was drawn to determine the optimal cut-off value for predicting lymph node metastasis and calculate the sensitivity and specificity. Enumeration data were evaluated using χ2 test or Fisher's exact probability method, and continuous measurement data were compared using independent-sample t test. Univariate and multivariate Logistic regression analysis were used in screening the predictors of lymph node metastasis. Results The univariate Logistic regression analysis results showed that when the long diameter of the lung primary tumor was over 30.0 mm or the short diameter of the lymph nodes was over 10.0 mm, lymph node metastasis was likely to occur (61.9% vs. 38.1%, 59.5% vs. 40.5%; χ2=9.16, 5.20; both P<0.05); the CV of the primary tumor and the SUVmax and LMV of lymph nodes of patients with lymph node metastasis were higher than those of patients without lymph node metastasis (46.7±6.1 vs. 29.4±6.0, 5.9±1.9 vs. 2.8±1.6, 2.2±0.6 vs. 1.4±0.3; t=13.81, 8.60, 3.97; all P<0.05). The multivariate Logistic regression analysis results suggested that the SUVmax of lymph nodes (OR=2.2, 95% confidence interval (CI): 1.30–3.80, P<0.05) and the CV of the primary tumor (OR=1.5, 95%CI: 1.20–1.80, P<0.01) were independent risk factors affecting the status of lymph node metastasis. The ROC curve analysis results showed that the area under the CV curve of the primary tumor was 0.97 (SD=0.02, 95%CI: 0.94–0.99, P<0.01). When CV>30.5, the sensitivity of diagnosis of lymph node metastasis was 97.5%, and the specificity was 41.7%. The area under the curve of lymph node SUVmax was 0.91 (SD=0.30, 95%CI: 0.85–0.97, P<0.01). When the lymph node SUVmax>3.1, the sensitivity and specificity of the diagnosis of lymph node metastasis were 95.2% and 23.3%, respectively. The combined diagnosis of the two risk factors resulted in an area under the curve of 0.98 (SD=0.01, 95%CI: 0.96–1.00, P<0.01). Conclusion Among the metabolic parameters of 18F-FDG PET/CT, the CV of the primary tumor and the SUVmax of lymph nodes are independent risk factors for predicting mediastinal lymph node metastasis in patients with NSCLC and can provide useful information for treatment. -
图 1 原发肿瘤CV、淋巴结SUVmax以及两者联合对102例非小细胞肺癌患者淋巴结转移的预测效能的受试者工作特征曲线
Figure 1. Receiver operator characteristic curve of the coefficient of variation of primary tumor, the maximum standardized uptake value of lymph nodes, and the combination of the two in predicting lymph node metastasis in 102 patients with non-small cell lung cancer
表 1 102例非小细胞肺癌患者淋巴结转移影响因素的单因 素Logistic回归分析结果
Table 1. Results of univariable Logistic regression analysis of factors for lymph node metastasis in 102 patients with non-small cell lung cancer
参数 转移组
(n=42)未转移组
(n=60)检验值 P值 年龄(岁) 66.6±12.3 65.0±15.1 t=0.82 0.37 性别[例 (%)] χ2=0.87 0.64 男 22(52.4) 37(61.7) 女 20(47.6) 23(38.3) 吸烟状态[例(%)] χ2=0.40 0.53 吸烟或既往吸烟 18(42.9) 22(36.7) 不吸烟 24(57.1) 38(63.3) 原发肿瘤的位置[例 (%)] χ2=1.48 0.22 右肺 23(54.8) 40(66.7) 左肺 19(45.2) 20(33.3) 肿瘤长径[例(%)] χ2=9.16 <0.01 ≤30.0 mm 16(38.1) 41(68.3) >30.0 mm 26(61.9) 19(31.7) MTV(cm3) 56.5±15.8 48.7±17.6 t=0.81 0.51 TLG(g) 242.0±55.3 168.5±46.7 t=0.84 0.36 原发肿瘤CV 46.7±6.1 29.4±6.0 t=13.81 <0.01 淋巴结短径[例(%)] χ2=5.20 0.02 >10.0 mm 25(59.5) 22(36.7) ≤10.0 mm 17(40.5) 38(63.3) 淋巴结SUVmax 5.9±1.9 2.8±1.6 t=8.60 <0.01 LMV 2.2±0.6 1.4±0.3 t=3.97 <0.01 血清癌胚抗原水平[例(%)] χ2=0.81 0.37 >5.0 ng/mL 22(52.4) 26(43.3) ≤5.0 ng/mL 20(47.6) 34(56.7) 血清D-二聚体水平[例(%)] χ2=0.13 0.72 >0.8 mg/L 16(38.1) 25(41.7) ≤0.8 mg/L 26(61.9) 35(58.3) 注:MTV为肿瘤代谢体积;TLG为病灶葡萄糖酵解总量;CV为变异系数;SUVmax为最大标准化摄取值;LMV为淋巴结SUVmax与纵隔血池平均标准化摄取值的比值 表 2 102例非小细胞肺癌患者淋巴结转移影响因素的多因 素Logistic回归分析结果
Table 2. Results of multivariable Logistic regression analysis of factors for lymph node metastasis in 102 patients with non- small cell lung cancer
因素 标准差 P值 OR 95%CI 淋巴结短径(>10.0 mm) 1.22 0.50 − − 肿瘤长径(>30.0 mm) 1.22 0.10 − − 淋巴结SUVmax 0.30 0.04 2.2 1.30~3.80 LMV 1.77 0.20 − − 原发肿瘤CV 0.10 <0.01 1.5 1.20~1.80 注:SUVmax为最大标准化摄取值;LMV为淋巴结SUVmax与纵隔血池平均标准化摄取值的比值;CV为变异系数;CI为可变区间。−表示无此项数据 -
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