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近年来,乳腺癌的发病率持续上升,且发病人群年龄逐渐趋于年轻化,其已成为威胁女性健康的重大恶性疾病之一[1]。乳腺癌筛查的普及、早期发现和诊断可以指导临床及时制定合理的手术方案,是降低乳腺癌患者病死率的重要举措[2]。早期乳腺癌是指肿瘤长径<2 cm、腋窝无淋巴结转移、无远处转移的乳腺癌。目前,乳腺癌的早期筛查主要通过乳腺自检、临床触诊检查以及影像检查等方法,虽然乳腺肿块是早期乳腺癌最常见的症状,但部分早期乳腺癌可无明显症状与体征,存在临床触诊阴性的情况,因此,定期进行影像检查很有必要。常规全数字化乳腺X射线摄影(full-field digital mammography,FFDM)因具有操作简单、分辨率良好、经济及可重复操作等优势,成为目前临床乳腺癌筛查的主要影像检查手段之一,但由于其属于二维图像,存在组织重叠效应,容易出现漏诊及误诊情况,进而影响了筛查结果的准确率[3]。随着影像技术的发展,数字乳腺断层融合X射线成像(digital breast tomosynthesis,DBT)技术出现在人们的视野中,其作为一种三维成像技术,可以在不同角度获得乳腺的影像,明显降低组织重叠的影响,因此能更清晰地显示乳腺内部结构和病灶,提高乳腺病灶的检出率及筛查的准确率[4]。但因乳腺对X射线较敏感,DBT对其的辐射危害亦需要重视。有研究者报道,可通过降低X射线机球管的管电压和管电流,从而降低辐射剂量,实现低剂量X射线摄影成像[5]。而低剂量DBT是否对早期乳腺癌具有良好的诊断价值尚需进一步探讨。基于此,本研究探讨了低剂量DBT和FFDM在早期乳腺癌筛查中的应用价值,现报道如下。
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纳入本研究的246例患者中,经组织病理学检查结果确诊为早期乳腺癌192例(共计199个病灶),其中浸润性导管癌154例、导管原位癌15例、浸润性导管癌合并导管原位癌8例、浸润性小叶癌4例、导管原位癌伴局部微小浸润6例、其他5例。经组织病理学检查结果确诊为乳腺良性病变54例(共计57个病灶),其中乳腺囊性增生36例、乳腺纤维瘤18例。有112例患者行手术治疗,术后组织病理学检查结果显示:浸润性导管癌96例、导管原位癌6例、浸润性导管癌合并导管原位癌4例、导管原位癌伴局部微小浸润6例。
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由表1可知,246例患者中,经FFDM诊断为早期乳腺癌154例(其中假阳性10例)、乳腺良性病变92例(其中假阴性48例);经低剂量DBT诊断为早期乳腺癌169例(其中假阳性2例)、乳腺良性病变77例(其中假阴性25例);经FFDM联合低剂量DBT诊断为早期乳腺癌177例(其中假阳性3例)、乳腺良性病变69例(其中假阴性18例)。由表2可知,低剂量DBT单独诊断以及FFDM联合低剂量DBT诊断早期乳腺癌的灵敏度、特异度、准确率、阳性预测值和阴性预测值均高于FFDM单独诊断,差异均有统计学意义(均P<0.05);而与FFDM联合低剂量DBT相比,低剂量DBT单独诊断早期乳腺癌的灵敏度、特异度、准确率、阳性预测值和阴性预测值的差异均无统计学意义(均P>0.05)。
影像检查 组织病理学检查 合计 阳性(n=192) 阴性(n=54) FFDM 阳性 144 10 154 阴性 48 44 92 低剂量DBT 阳性 167 2 169 阴性 25 52 77 FFDM联合低剂量DBT 阳性 174 3 177 阴性 18 51 69 注:FFDM为全数字化乳腺X射线摄影;DBT为数字乳腺断层融合X射线成像 表 1 FFDM、低剂量DBT及二者联合与组织病理学检查对早期乳腺癌诊断的结果比较(例)
Table 1. Comparison between full-field digital mammography (FFDM), low-dose digital breast tomosynthesis (DBT), the combination of the two and histopathological examination in the diagnosis of early breast cancer (case)
影像检查 灵敏度 特异度 准确率 阳性预测值 阴性预测值 FFDM 75.00%(144/192) 81.48%(44/54) 76.42%(188/246) 93.51%(144/154) 47.83%(44/92) 低剂量DBT 86.98%a(167/192) 96.30%a(52/54) 89.02%a(219/246) 98.82%a(167/169) 67.53%a(52/77) FFDM联合低剂量DBT 90.63%b(174/192) 94.44%b(51/54) 91.46%b(225/246) 98.31%b(174/177) 73.91%b(51/69) χ2值 19.289 8.376 26.064 11.110 12.965 P值 <0.001 0.015 <0.001 0.003 0.001 注:FFDM为全数字化乳腺X射线摄影;DBT为数字乳腺断层融合X射线成像;a表示与FFDM比较,差异均有统计学意义(χ2=6.000~13.677,均P<0.05);b表示与FFDM比较,差异均有统计学意义(χ2=4.285~20.644,均P<0.05) 表 2 FFDM、低剂量DBT及二者联合诊断早期乳腺癌的效能比较
Table 2. Comparison of efficacy among full-field digital mammography (FFDM), low-dose digital breast tomosynthesis (DBT), and the combination of the two in the diagnosis of early breast cancer
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FFDM诊断早期乳腺癌结果与组织病理学检查结果具有良好的一致性(Kappa值=0.655),低剂量DBT诊断早期乳腺癌结果与组织病理学检查结果具有良好的一致性(Kappa值=0.722),二者联合诊断早期乳腺癌结果与组织病理学检查结果具有良好的一致性(Kappa值=0.792)。
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FFDM的腺体剂量为(1.03±0.18) mGy,低剂量DBT的腺体剂量为(1.04±0.19) mGy,二者联合检查的腺体剂量为(1.06±0.21) mGy。FFDM、低剂量DBT、二者联合检查的腺体剂量之间的差异无统计学意义(F=1.529,P=0.217)。FFDM的检查时间为(6.25±0.52) min,低剂量DBT的检查时间为(6.33±0.57) min,两者的差异无统计学意义(t=1.626,P=0.105)。
低剂量DBT成像技术和FFDM在早期乳腺癌筛查中的价值研究
Value research of low-dose DBT and FFDM in screening early breast cancer
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摘要:
目的 探讨低剂量数字乳腺断层融合X射线成像(DBT)和全数字化乳腺X射线摄影(FFDM)在早期乳腺癌筛查中的价值。 方法 前瞻性选取2020年1月至2022年4月在聊城市第二人民医院就诊的以乳腺肿块、乳腺胀痛为主要表现的246例女性患者[年龄(47.3±6.2)岁,范围28~65岁],均进行常规FFDM及低剂量DBT检查,并在超声引导下行穿刺活检。将活检组织病理学检查结果作为“金标准”,对比分析FFDM、低剂量DBT及二者联合筛查早期乳腺癌的灵敏度、特异度、准确率、阳性预测值、阴性预测值,并分析比较FFDM、低剂量DBT单独检查及二者联合检查与组织病理学检查结果的一致性。比较不同检查方法的腺体剂量和检查时间。计量资料的组间比较采用t检验或单因素方差分析,计数资料的组间比较采用χ2检验,不同检查方法与组织病理学检查结果的一致性分析采用Kappa检验。 结果 纳入研究的246例患者中,经组织病理学检查确诊为早期乳腺癌192例、乳腺良性病变54例;经FFDM诊断为早期乳腺癌154例、乳腺良性病变92例;经低剂量DBT诊断为早期乳腺癌169例、乳腺良性病变77例;经FFDM联合低剂量DBT诊断为早期乳腺癌177例、乳腺良性病变69例。低剂量DBT诊断早期乳腺癌的灵敏度(86.98%)、特异度(96.30%)、准确率(89.02%)、阳性预测值(98.82%)和阴性预测值(67.53%)均高于FFDM(75.00%、81.48%、76.42%、93.51%、47.83%),且差异均有统计学意义(χ2=6.000~13.677,均P<0.05);FFDM联合低剂量DBT诊断早期乳腺癌的灵敏度(90.63%)、特异度(94.44%)、准确率(91.46%)、阳性预测值(98.31%)和阴性预测值(73.91%)均高于FFDM,且差异均有统计学意义(χ2=4.285~20.644,均P<0.05);与FFDM联合低剂量DBT相比,低剂量DBT单独诊断早期乳腺癌的灵敏度、特异度、准确率、阳性预测值和阴性预测值的差异均无统计学意义(χ2=0.159~1.283,均P>0.05)。FFDM诊断早期乳腺癌结果与组织病理学检查结果具有良好的一致性(Kappa值=0.655),低剂量DBT诊断早期乳腺癌结果与组织病理学检查结果具有良好的一致性(Kappa值=0.722),FFDM联合低剂量DBT诊断早期乳腺癌结果与组织病理学检查结果具有良好的一致性(Kappa值=0.792)。FFDM[(1.03±0.18)mGy]、低剂量DBT[(1.04±0.19)mGy]及二者联合检查[(1.06±0.21)mGy]的腺体剂量的差异无统计学意义(F=1.529,P>0.05),FFDM检查时间[(6.25±0.52)min]与低剂量DBT检查时间[(6.33±0.57)min]的差异无统计学意义(t=1.626,P>0.05)。 结论 相较于FFDM,低剂量DBT在早期乳腺癌筛查中的应用价值更高,且与组织病理学检查结果的一致性良好,可作为临床对早期乳腺癌进行筛查的重要检查手段。 Abstract:Objective To explore the value of low-dose digital breast tomosynthesis (DBT) and full-field digital mammography (FFDM) in screening early breast cancer. Methods 246 female patients (age (47.3±6.2) years old, ranging from 28 to 65 years old) with breast lumps and breast swelling pain treated in the Second People's Hospital of Liaocheng from January 2020 to April 2022 were prospectively selected. All patients underwent routine FFDM and low-dose DBT examinations, and underwent ultrasound-guided puncture biopsy. The pathological examination results of biopsy tissue was taken as the "gold standard", and the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of FFDM, low-dose DBT and combination of the two in screening early breast cancer were compared and analyzed, and the consistency (Kappa value) between FFDM, low-dose DBT, alone and combination examination of the two and histopathological examination results were analyzed and compared. The average glandular dose and examination time of different examination methods were compared. The intergroup comparison of quantitative data adopted t test or one-way analysis of variance, while the intergroup comparison of counting data adopted χ2 test, and analysis of consistency between different examination methods and histopathological examination results adoptedKappa test. Results Of the 246 patients included in the study, 192 cases were diagnosed as early breast cancer and 54 cases were diagnosed as benign breast lesions by histopathological examination. 154 cases of early breast cancer and 92 cases of benign breast lesions were diagnosed by FFDM. 169 cases of early breast cancer and 77 cases of benign breast lesions were diagnosed by low-dose DBT. 177 cases of early breast cancer and 69 cases of benign breast lesions were diagnosed by FFDM combined with low-dose DBT. The sensitivity (86.98%), specificity (96.30%), accuracy (89.02%), positive predictive value (98.82%) and negative predictive value (67.53%) of low-dose DBT in the diagnosis of early breast cancer were higher than those of FFDM (75.00%, 81.48%, 76.42%, 93.51% and 47.83%), and the differences were statistically significant (χ2=6.000~13.677, all P<0.05). The sensitivity (90.63%), specificity (94.44%), accuracy (91.46%), positive predictive value (98.31%) and negative predictive value (73.91%) of FFDM combined with low-dose DBT in the diagnosis of early breast cancer were higher than those of FFDM, and the differences were statistically significant (χ2 =4.285~20.644, all P<0.05). There was no significant difference in the sensitivity, specificity, accuracy, positive predictive value and negative predictive value between low-dose DBT alone and FFDM combined with low-dose DBT in diagnosing early breast cancer (χ2=0.159~1.283, all P>0.05). The results of FFDM in the diagnosis of early breast cancer has good consistency with the histopathological examination results (Kappa value=0.655), and the results of low-dose DBT in the diagnosis of early breast cancer has good consistency with the histopathological examination results (Kappa value=0.722), and the combination diagnostic results of the two has good consistency with the histopathological examination results (Kappa value=0.792).. There was no statistically significant difference in the average glandular dose among FFDM [(1.03±0.18)mGy], low-dose DBT [(1.04±0.19) mGy]and combined examination of the two [(1.06±0.21) mGy] (F=1.529, P>0.05), and there was no statistically significant difference between FFDM examination time [(6.25±0.52) min] and low-dose DBT examination time [(6.33±0.57) min] (t=1.626, P>0.05). Conclusions Compared with FFDM, low-dose DBT has higher application value in screening early breast cancer, and it has good consistency with histopathological examination results, which can be used as an important examination method for clinical screening of early breast cancer. -
Key words:
- Breast neoplasms /
- Mammography /
- Early diagnosis
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表 1 FFDM、低剂量DBT及二者联合与组织病理学检查对早期乳腺癌诊断的结果比较(例)
Table 1. Comparison between full-field digital mammography (FFDM), low-dose digital breast tomosynthesis (DBT), the combination of the two and histopathological examination in the diagnosis of early breast cancer (case)
影像检查 组织病理学检查 合计 阳性(n=192) 阴性(n=54) FFDM 阳性 144 10 154 阴性 48 44 92 低剂量DBT 阳性 167 2 169 阴性 25 52 77 FFDM联合低剂量DBT 阳性 174 3 177 阴性 18 51 69 注:FFDM为全数字化乳腺X射线摄影;DBT为数字乳腺断层融合X射线成像 表 2 FFDM、低剂量DBT及二者联合诊断早期乳腺癌的效能比较
Table 2. Comparison of efficacy among full-field digital mammography (FFDM), low-dose digital breast tomosynthesis (DBT), and the combination of the two in the diagnosis of early breast cancer
影像检查 灵敏度 特异度 准确率 阳性预测值 阴性预测值 FFDM 75.00%(144/192) 81.48%(44/54) 76.42%(188/246) 93.51%(144/154) 47.83%(44/92) 低剂量DBT 86.98%a(167/192) 96.30%a(52/54) 89.02%a(219/246) 98.82%a(167/169) 67.53%a(52/77) FFDM联合低剂量DBT 90.63%b(174/192) 94.44%b(51/54) 91.46%b(225/246) 98.31%b(174/177) 73.91%b(51/69) χ2值 19.289 8.376 26.064 11.110 12.965 P值 <0.001 0.015 <0.001 0.003 0.001 注:FFDM为全数字化乳腺X射线摄影;DBT为数字乳腺断层融合X射线成像;a表示与FFDM比较,差异均有统计学意义(χ2=6.000~13.677,均P<0.05);b表示与FFDM比较,差异均有统计学意义(χ2=4.285~20.644,均P<0.05) -
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