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宫颈癌是女性常见的恶性肿瘤之一,在全球女性恶性肿瘤中居第4位,仅次于乳腺癌、结直肠癌和肺癌[1]。转移性淋巴结是影响宫颈癌患者预后的独立危险因素之一[2]。因此,对伴有转移性淋巴结的中晚期宫颈癌患者治疗方案的制定尤为重要。目前,美国国立综合癌症网络指南2020年第1版将同步放化疗(concurrent chemoradiotherapy,CCRT)作为伴有转移性淋巴结的中晚期宫颈癌患者的标准治疗方法[3]。宫颈癌的病理类型主要包括鳞状细胞癌(简称鳞癌)、腺癌、腺鳞癌以及其他特殊类型,其中鳞癌最常见,占80%~85%[4]。近年来,18F-FDG PET/CT代谢参数在宫颈癌的早期诊断、分期、疗效评估和预后预测中成为研究热点[5-8],但其在中晚期宫颈鳞癌转移性淋巴结CCRT疗效中的预测价值鲜有报道。本研究旨在分析18F-FDG PET/CT代谢参数SUVmax、肿瘤代谢体积(metabolic tumor volume,MTV)、糖酵解总量(total lesion glycolysis,TLG)以及其他相关临床特征(如患者年龄、临床分期)对中晚期宫颈鳞癌转移性淋巴结CCRT疗效的预测价值。
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由表1可知,有效组与无效组患者的年龄和临床分期的差异均无统计学意义(t=0.464、Fisher确切概率法,均P>0.05)。
组别 年龄( ,岁)$ \bar x \pm s $ 临床分期(例,%) ⅢC期 ⅣA期 ⅣB期 有效组(n=36) 51.06±9.26 16(72.7) 4(100) 16(66.7) 无效组(n=14) 49.79±6.93 6(27.3) 0 8(33.3) 检验值 t=0.464 − P值 0.645 0.582 注:−表示采用Fisher确切概率法,无检验值 表 1 2组行同步放化疗的中晚期宫颈鳞癌转移性淋巴结患 者临床特征比较
Table 1. Comparison of clinical characteristics between two groups of cervical squamous cell carcinoma patients with metastatic lymph nodes undergoing concurrent chemoradiotherapy
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由表2可知,有效组与无效组SUVmax的差异无统计学意义(Z=0.864,P=0.387);有效组的MTV和TLG均明显小于无效组,且差异均有统计学意义(Z=3.457,P=0.001;Z=3.630,P<0.001)。有效组和无效组宫颈鳞癌转移性淋巴结ⅢC期患者CCRT前的18F-FDG PET/CT和治疗前后的增强CT典型图见图1、2。
组别 SUVmax MTV(cm3) TLG(g) 有效组(n=36) 8.72(4.99,13.11) 1.89(1.00,4.33) 10.98(2.45,29.54) 无效组(n=14) 9.59(7.48,12.27) 7.11(3.34,17.17) 56.03(26.76,91.08) Z值 0.864 3.457 3.630 P值 0.387 0.001 <0.001 注:FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CT为计算机体层摄影术;SUVmax为最大标准化摄取值;MTV为肿瘤代谢体积;TLG为糖酵解总量 表 2 2组中晚期宫颈鳞癌转移性淋巴结患者18F-FDG PET/CT代谢参数与同步放化疗疗效的关系[M(Q1, Q3)]
Table 2. The relationship between 18F-FDG PET/CT metabolic parameters and the efficacy of concurrent chemoradiotherapy in two groups of cervical squamous cell carcinoma patients with metastatic lymph nodes[M(Q1, Q3)]
图 1 有效组和无效组宫颈鳞癌转移性淋巴结ⅢC期患者(女性,41岁、54岁)CCRT前的18F-FDG PET/CT图
Figure 1. 18F-FDG PET/CT images of cervical squamous cell carcinoma patients (female, 41 years old, 54 years old) with metastatic lymph nodes stage ⅢC in effective group and ineffective group before concurrent chemoradiotherapy
图 2 有效组和无效组宫颈鳞癌转移性淋巴结ⅢC期患者(女性,41岁、54岁)CCRT前、后的增强CT图
Figure 2. Enhanced CT images of cervical squamous cell carcinoma patients (female, 41 years old, 54 years old) with metastatic lymph nodes stage ⅢC in effective group and ineffective group before and after concurrent chemoradiotherapy
根据ROC曲线获得18F-FDG PET/CT代谢参数预测宫颈鳞癌转移性淋巴结患者疗效的最佳临界值,结果显示,SUVmax、MTV、TLG的最佳临界值分别为6.475、3.140 cm3、26.265 g;灵敏度分别为0.361、0.786、0.857;特异度分别为0.929(AUC=0.579,95%CI:0.414~0.744,P=0.387) 、0.722(AUC=0.817,95%CI:0.685~0.950,P=0.001) 、0.722(AUC=0.833,95%CI:0.718~0.949,P<0.001)(图3)。
图 3 18F-FDG PET/CT代谢参数预测中晚期宫颈鳞癌患者转移性淋巴结CCRT疗效的受试者工作特征曲线 FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CT为计算机体层摄影术;CCRT为同步放化疗;SUVmax为最大标准化摄取值;MTV为肿瘤代谢体积;TLG为糖酵解总量
Figure 3. Receiver operating characteristic curves of 18F-FDG PET/CT metabolic parameters for predicting concurrent chemoradiotherapy efficacy of intermediate-advanced cervical squamous cell carcinoma patients with metastatic lymph nodes
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由表3单因素Logistic回归分析结果可知,年龄、临床分期以及SUVmax均与转移性淋巴结CCRT疗效无明显相关性(OR=1.193、1.067、7.348,均P>0.05);而MTV和TLG均与转移性淋巴结CCRT疗效存在相关性(OR=7.333、15.600,均P<0.05)。
因素 例(%) 单因素分析 多因素分析 OR(95%CI) χ2值 P值 OR(95%CI) χ2值 P值 年龄(岁) 1.193(0.344~4.141) 0.077 0.781 0.546(0.096~3.097) 0.467 0.495 <50 23(46) ≥50 27(54) 临床分期 1.067(0.307~3.708) 0.010 0.919 0.627(0.116~3.393) 0.294 0.587 ⅢC期 22(44) ⅣA期+ⅣB期 28(56) SUVmax 7.348(0.861~62.743) 3.322 0.068 2.085(0.169~25.791) 0.328 0.567 <6.475 14(28) ≥6.475 36(72) MTV(cm3) 7.333(1.716~31.343) 7.228 0.007 2.551(0.376~17.285) 0.920 0.337 <3.140 27(54) ≥3.140 23(46) TLG(g) 15.60(2.951~82.469) 10.457 0.001 8.335(1.040~66.817) 3.987 0.046 <26.265 28(56) ≥26.265 22(44) 注:FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CT为计算机体层摄影术;SUVmax为最大标准化摄取值;MTV为肿瘤代谢体积;TLG为糖酵解总量;CI为置信区间 表 3 宫颈鳞癌转移性淋巴结患者临床特征和18F-FDG PET/CT代谢参数的Logistic回归分析
Table 3. Logistic regression analysis of clinical characteristics and 18F-FDG PET/CT metabolic parameters in patients with metastatic lymph nodes of cervical squamous cell carcinoma
由表3多因素Logistic回归分析结果可知,TLG<26.265 g(OR=8.335,95%CI:1.040~66.817,χ2=3.987,P=0.046)是中晚期宫颈鳞癌转移性淋巴结疗效的独立预测因子。
18F-FDG PET/CT代谢参数对中晚期宫颈鳞癌转移性淋巴结同步放化疗疗效的预测价值
Prognostic value of 18F-FDG PET/CT metabolic parameters on the efficacy of concurrent chemoradiotherapy for metastatic lymph nodes of intermediate-advanced cervical squamous cell carcinoma
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摘要:
目的 探讨18F-氟脱氧葡萄糖(FDG)PET/CT代谢参数对中晚期宫颈鳞癌转移性淋巴结同步放化疗(CCRT)疗效的预测价值。 方法 回顾性分析2016年12月至2020年12月于川北医学院附属医院行CCRT的50例中晚期宫颈鳞癌患者(ⅢC期22例、ⅣA期4例、ⅣB期24例)的临床资料,年龄(50.7±8.6)岁。根据CCRT前后转移性淋巴结的变化情况,将患者分为有效组(36例)和无效组(14例),分析18F-FDG PET/CT代谢参数最大标准化摄取值(SUVmax)、肿瘤代谢体积(MTV)、糖酵解总量(TLG)以及其他相关临床特征(如患者年龄、临床分期)对中晚期宫颈鳞癌转移性淋巴结CCRT疗效的预测价值。符合正态分布的计量资料以 $\bar x\pm s $ 表示,组间比较采用两独立样本t检验(方差齐);不符合正态分布的计量资料以M(Q1, Q3)表示, 组间比较采用Mann-Whitney U 检验;分类变量以例(%)表示,组间比较采用 χ2检验或 Fisher 确切概率法。根据受试者工作特征(ROC)曲线获得18F-FDG PET/CT代谢参数预测转移性淋巴结CCRT疗效的最佳临界值,并根据最佳临界值进行分类,对分类后的变量进行单因素Logistic回归分析,并采用多因素Logistic回归分析确定中晚期宫颈鳞癌转移性淋巴结CCRT疗效潜在的独立预测因子和预测效能。结果 2组间患者的年龄、临床分期和SUVmax差异均无统计学意义(t=0.464、Fisher确切概率法、Z=0.864,均P>0.05);2组间MTV和TLG的差异有统计学意义(Z=3.457、3.630,均P<0.05)。单因素Logistic回归分析结果显示,MTV和TLG均与中晚期宫颈鳞癌转移性淋巴结CCRT疗效存在相关性(OR=7.333、15.600,均P<0.05)。多因素Logistic回归分析结果显示,TLG<26.265 g(OR=8.335,95% CI:1.040~66.817,χ2=3.987,P=0.046)是中晚期宫颈鳞癌转移性淋巴结CCRT疗效潜在的独立预测因子。ROC曲线评估TLG对中晚期宫颈鳞癌转移性淋巴结CCRT疗效的结果显示,曲线下面积为0.833(95%CI:0.718~0.949,P<0.001)。 结论 MTV和TLG与中晚期宫颈鳞癌转移性淋巴结CCRT疗效存在相关性,其中TLG<26.265 g对其预测价值较高。 -
关键词:
- 宫颈肿瘤 /
- 癌,鳞状细胞 /
- 化放疗 /
- 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 /
- 转移性淋巴结
Abstract:Objective To explore the value of 18F-fluorodeoxyglucose (FDG) PET/CT metabolic parameters in predicting the efficacy of concurrent chemoradiotherapy (CCRT) in metastatic lymph nodes of intermediate–advanced cervical squamous cell carcinoma. Methods The clinical data of 50 patients with intermediate–advanced cervical squamous cell carcinoma (stage ⅢC, 22 cases; stage ⅣA, 4 cases; and stage ⅣB, 24 cases) who underwent CCRT in the Affiliated Hospital of North Sichuan Medical College from December 2016 to December 2020 were analyzed retrospectively. The patients aged (50.7±8.6) years. In accordance with the changes in metastatic lymph nodes before and after CCRT, the patients were divided into effective group (36 cases) and ineffective group (14 cases). The 18F-FDG PET/CT metabolic parameters maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), total lesion glycolysis (TLG) and other related clinical features, such as age and clinical stage, were analyzed to predict the efficacy of CCRT in metastatic lymph nodes of intermediate-advanced cervical squamous cell carcinoma. In accordance with normal distribution, the measurement data were expressed by $\bar x\pm s $ , and comparison between groups was conducted by two independent sample t-test (uniform variance). The measurement data that did not conform to the normal distribution were represented by M(Q1, Q3), and Mann-Whitney U test was used for comparison between groups. The classification variables were expressed as an cases (%), and χ2 test or Fisher's exact test was used for comparison between groups. In accordance with the receiver operating characteristic (ROC) curves, the best critical value of 18F-FDG PET/CT metabolic parameters for predicting the efficacy of CCRT in metastatic lymph nodes was obtained, and the classified variables were classified on the basis of the optimal critical value. Univariate Logistic regression analysis was used to determine the potential independent predictors and predictive efficacy of CCRT in metastatic lymph nodes of intermediate-advanced cervical squamous cell carcinoma.Results No significant difference was found in the age, clinical stage, and SUVmax between the two groups (t=0.464, Fisher's exact test, Z=0.864; all P>0.05). Significant differences were found in the MTV and TLG between the two groups (Z=3.457, 3.630; both P<0.05). The univariate Logistic regression analysis showed that MTV and TLG were correlated with the efficacy of CCRT in metastatic lymph nodes of intermediate-advanced cervical squamous cell carcinoma (OR=7.333, 15.600; both P<0.05). The multivariate Logistic regression analysis showed that TLG<26.265 g (OR=8.335, 95%CI: 1.040–66.817, χ2=3.987; P=0.046) was a potential independent predictor of CCRT efficacy in metastatic lymph nodes of intermediate-advanced cervical squamous cell carcinoma. The ROC curves to evaluate the efficacy of TLG in the CCRT treatment of metastatic lymph nodes showed that the area under curve was 0.833 (95%CI: 0.718–0.949, P<0.001). Conclusions Correlation exists among MTV, TLG, and the efficacy of CCRT in the metastatic lymph nodes of intermediate–advanced cervical squamous cell carcinoma, and TLG<26.265 g was found to be the highest predictive value. -
图 3 18F-FDG PET/CT代谢参数预测中晚期宫颈鳞癌患者转移性淋巴结CCRT疗效的受试者工作特征曲线 FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CT为计算机体层摄影术;CCRT为同步放化疗;SUVmax为最大标准化摄取值;MTV为肿瘤代谢体积;TLG为糖酵解总量
Figure 3. Receiver operating characteristic curves of 18F-FDG PET/CT metabolic parameters for predicting concurrent chemoradiotherapy efficacy of intermediate-advanced cervical squamous cell carcinoma patients with metastatic lymph nodes
表 1 2组行同步放化疗的中晚期宫颈鳞癌转移性淋巴结患 者临床特征比较
Table 1. Comparison of clinical characteristics between two groups of cervical squamous cell carcinoma patients with metastatic lymph nodes undergoing concurrent chemoradiotherapy
组别 年龄( ,岁)$ \bar x \pm s $ 临床分期(例,%) ⅢC期 ⅣA期 ⅣB期 有效组(n=36) 51.06±9.26 16(72.7) 4(100) 16(66.7) 无效组(n=14) 49.79±6.93 6(27.3) 0 8(33.3) 检验值 t=0.464 − P值 0.645 0.582 注:−表示采用Fisher确切概率法,无检验值 表 2 2组中晚期宫颈鳞癌转移性淋巴结患者18F-FDG PET/CT代谢参数与同步放化疗疗效的关系[M(Q1, Q3)]
Table 2. The relationship between 18F-FDG PET/CT metabolic parameters and the efficacy of concurrent chemoradiotherapy in two groups of cervical squamous cell carcinoma patients with metastatic lymph nodes[M(Q1, Q3)]
组别 SUVmax MTV(cm3) TLG(g) 有效组(n=36) 8.72(4.99,13.11) 1.89(1.00,4.33) 10.98(2.45,29.54) 无效组(n=14) 9.59(7.48,12.27) 7.11(3.34,17.17) 56.03(26.76,91.08) Z值 0.864 3.457 3.630 P值 0.387 0.001 <0.001 注:FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CT为计算机体层摄影术;SUVmax为最大标准化摄取值;MTV为肿瘤代谢体积;TLG为糖酵解总量 表 3 宫颈鳞癌转移性淋巴结患者临床特征和18F-FDG PET/CT代谢参数的Logistic回归分析
Table 3. Logistic regression analysis of clinical characteristics and 18F-FDG PET/CT metabolic parameters in patients with metastatic lymph nodes of cervical squamous cell carcinoma
因素 例(%) 单因素分析 多因素分析 OR(95%CI) χ2值 P值 OR(95%CI) χ2值 P值 年龄(岁) 1.193(0.344~4.141) 0.077 0.781 0.546(0.096~3.097) 0.467 0.495 <50 23(46) ≥50 27(54) 临床分期 1.067(0.307~3.708) 0.010 0.919 0.627(0.116~3.393) 0.294 0.587 ⅢC期 22(44) ⅣA期+ⅣB期 28(56) SUVmax 7.348(0.861~62.743) 3.322 0.068 2.085(0.169~25.791) 0.328 0.567 <6.475 14(28) ≥6.475 36(72) MTV(cm3) 7.333(1.716~31.343) 7.228 0.007 2.551(0.376~17.285) 0.920 0.337 <3.140 27(54) ≥3.140 23(46) TLG(g) 15.60(2.951~82.469) 10.457 0.001 8.335(1.040~66.817) 3.987 0.046 <26.265 28(56) ≥26.265 22(44) 注:FDG为氟脱氧葡萄糖;PET为正电子发射断层显像术;CT为计算机体层摄影术;SUVmax为最大标准化摄取值;MTV为肿瘤代谢体积;TLG为糖酵解总量;CI为置信区间 -
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