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恶性肿瘤是现代社会人类健康最严重的威胁之一, 早期发现肿瘤并准确对其分期是提高肿瘤治疗效果的关键。PET-CT是目前临床常采用的一种重要的全身成像技术, 通过反映病灶的葡萄糖代谢或氨基酸代谢等水平, 在肿瘤的术前评估、系统分期、放化疗效应的评价、术后病灶残余或肿瘤复发的显示中具有极高的价值[1-4]。而MRI特有的高软组织对比度、高空间分辨率和无辐射成像的优点, 加之近年来扫描速度的提高、强大多样的扫描序列及各种功能成像的应用, 使得MRI的应用备受关注。本文主要综述PET、PET-CT与磁共振弥散加权成像(diffusion-weighted imaging, DWI)的对比研究进展, 以及标准化摄取值(standarzied uptake value, SUV)与表观弥散系数(apparent diffusion coefficient, ADC)的关系, 以期为临床选择合适的医学影像检查方法提供参考。
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目前普遍认为, PET-CT全身显像最重要的临床应用是对肿瘤的系统分期[9-10], 尤其是在淋巴瘤等血液系统恶性肿瘤中的应用[11-12]。很多学者对PET、PET-CT与DWI在肿瘤良恶性的鉴别诊断、肿瘤淋巴结转移灶的检测及疗效评估方面进行了对比研究, 这些研究结果有些类似, 有些存在明显不同。以下分别介绍PET、PET-CT与DWI在肿瘤良恶性的鉴别诊断和肿瘤淋巴结转移的检测中的应用。
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肿瘤良恶性的鉴别诊断是肿瘤早期诊断的基础, 很多学者不断地努力总结肿瘤的各种特征, 包括形态学、功能代谢学以及化学元素分析等各方面, 试图寻找最佳的良、恶性鉴别点, 最大可能地提高诊断的准确率。
Ohba等[13]对110例非小细胞肺癌患者分别行18F-FDG PET和DWI, 利用显像的特征曲线对SUVcr(肿瘤SUV/对侧肺SUV)和ADCmin进行分析, 结果得出18F-FDG PET和DWI鉴别非小细胞肺癌的灵敏度和特异度的差别无统计学意义。Mori等[14]在对104例肺部结节或肿块患者的研究中使用了相同方法, 并得出了类似的结果, 不过Mori等指出, DWI在鉴别炎症时具有较低的假阳性率。Chen等[15]对56例非小细胞肺癌患者进行18F-FDG PET和全身DWI对比分析, 得出二者诊断肺部原发病灶具有相同的准确率。而Ohno等[16]和Takenaka等[17]分别对203例和115例非小细胞肺癌的18F-FDG PETCT和全身DWI研究发现, PET-CT的灵敏度、特异度及准确率均优于全身DWI, 但Takenaka等[17]指出, DWI对非小细胞肺癌的骨髓侵犯具有较高的特异度, 可能是由于Ohba等[13]、Mori等[14]和Chen等[15]使用的是18F-FDG PET而不是PET-CT, 缺乏CT形态学方面的信息。Heusner等[18]对20例乳腺癌患者的研究发现, 18F-FDGPET-CT的诊断灵敏度、特异度及准确率均高于DWI, 且后者的假阳性率较高。Ono等[19]通过对25例结直肠癌患者的回顾性分析认为, 18F-FDG PET检测原发灶的效能优于DWI, 而对淋巴结转移灶的检测则DWI优于18F-FDG PET。而对淋巴瘤研究的结果表明, 18FFDGPET-CT的诊断效能显著优于DWI[20-21]。
表 1是不同学者对PET、PET-CT和DWI在肿瘤良恶性鉴别诊断中效能的比较结果[13-29]。由表 1可以看出: 对于肺癌和淋巴瘤, PET或PET-CT的诊断效能均优于DWI; 对于前列腺癌[22-23]和甲状腺癌[24-27], DWI的诊断效能优于PET或PET-CT; 对于乳腺癌, 则与DWI相结合的其他MRI序列有关; 对于肝癌, 根据肿瘤病灶大小的不同, 18FFDGPET-CT诊断的灵敏度差异较大, 而DWI对肝癌的检出率较好, 尤其是对小于1 cm的病灶, 由于肝脏固有的葡萄糖摄取本底较高, 18F-FDG PETCT则容易出现假阴性[28-29]。需要指出的是, 上述研究中, 前列腺癌PET-CT使用的是11C-胆碱作为示踪剂, 其能提高对前列腺癌的检出率; 另外, 就甲状腺癌的病灶而言, 18F-FDGPET-CT的特异度较低, 实际工作中要注意结合超声检查及相关化验指标。
肿瘤类型 参考文献 病例数 PET或PET-CT 弥散加权成像 灵敏度 特异度 准确率 灵敏度 特异度 准确率 肺癌 [13] 110 72 82 - 73 96 - [14] 104 72 79 - 70 97 - [15] 56 - - 100 - - 100 [16] 203 62.5 94.5 88.2 57.5 87.7 81.8 [17] 115 96.0 85.6 87.8 96.0 78.9 82.6 乳腺癌 [18] 20 94 99 98 91 72 76 结直肠癌 [19] 25 30.0 76.9 85.2 80.0 100 85.2 淋巴瘤 [20] 101 97 97 - - - - [21] 31 - - - 100 30.8 71.0 前列腺癌 [22] 36 66 81 - - - - [23] 35 - - - 90~94 84~91 - 甲状腺癌 [24] 44 100 66 - - - [25] 60 - - - 93.3 96.7 - [26] 51 100 59 - - - - [27] 67 - - - 97.5 91.7 98.9 肝癌 [28] 102 27.2~92.8 - - - - - [29] 24 - - - 80~100 - - 注: “-”表示无该项数据。 表 1 PET、PET-CT与磁共振弥散加权成像在肿瘤良恶性鉴别诊断中的效能比较(%)
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确定肿瘤是否伴有淋巴结转移对于肿瘤的准确分期和临床选择治疗方案均具有重要的价值。Chen等[15]对56例非小细胞肺癌患者的研究发现, PET-CT对96处淋巴结转移灶的灵敏度、特异度和准确率均显著高于DWI, 并得出DWI对淋巴结和远处转移具有较高的灵敏度和准确率, 但是对颈部淋巴结转移的特异度较差, 对肺部小结节灶的灵敏度也较差。Nomori等[30]对88例N期非小细胞肺癌的研究得出, 18F-FDG PET-CT对淋巴结的检测比DWI具有更高的准确率(89% vs.78%), 而且发现对于长径大于1 cm的淋巴结, DWI在鉴别淋巴结炎时具有较低的假阳性率。然而, Usuda等[31]对63例肺癌患者的319处淋巴结进行的PET-CT和DWI的对比研究却得出, 18F-FDGPET-CT的灵敏度、特异度和准确率均低于DWI的结果, 作者认为原发灶表现为小的磨玻璃样的肺部病灶, 其PET-CT的检出率低于DWI, 小于20 mm淋巴结的SUVmax要比实际低, 并且DWI较18F-FDG PET-CT在淋巴结的检测中具有较低的假阳性率。Heusner等[18]和Schmidt等[32]分别对20例及33例乳腺癌患者的对比研究均得出, 对于乳腺癌淋巴结转移灶的检测, 18F-FDG PET-CT的诊断效能要显著优于全身DWI, Schmidt等还认为18F-FDG PET-CT比DWI能发现更多的淋巴结转移灶, 尤其是腋窝与纵膈的淋巴结; 而对于远处转移的病灶, 全身DWI能够显示更多的骨和肝脏上的转移灶。Ono等[19]回顾性分析25例结直肠癌患者18F-FDG PET和DWI发现, 18FFDG PET在检测原发灶方面优于DWI, 而在检测淋巴结转移灶方面则DWI优于18F-FDG PET, 但该研究的样本量较少。Nagamachi等[33]与Beer等[34]分别对36例甲状腺癌及14例前列腺癌的淋巴结转移灶的研究发现, 18F-FDG PET-CT和DWI具有近似的诊断价值, 但在后者的研究中有55个前列腺淋巴结转移灶直径均大于5 mm。
表 2是不同学者对PET-CT与DWI诊断肿瘤淋巴结转移灶的效能的比较结果[15,18-19,30-34]。由表 2可以看出, 18F-FDG PET-CT和DWI对肿瘤淋巴结转移灶的诊断价值与淋巴结的位置、大小及原发肿瘤的病理类型有密切关系, 不同学者的研究也由于样本量、统计学方法、SUV与ADC域值设定以及纳入研究的淋巴结大小不同等因素, 得出了不同的研究结果, 因此需要进一步进行大样本量且统一标准的对比研究。
肿瘤类型 参考文献 病例数 PET或PET-CT 弥散加权成像 灵敏度 特异度 准确率 灵敏度 特异度 准确率 肺癌 [15] 96 98 97 97 91 90 90 [30] 734 72.0 97.0 96.2 67.0 99.0 97.7 [31] 319 48 97 90 75 99 95 乳腺癌 [18] 140 86 100 96 86 39 52 [32] 48 96 96 96 73 77 75 结直肠癌 [19] 23 30.0 100 69.6 80.0 76.9 78.3 甲状腺癌 [33] 58 - - 61.7 - - 67.2 前列腺癌 [34] 55 85.2 85.7 85.5 96.3 78.6 83.6 注: “-”表示无该项数据。 表 2 ET、PET-CT与磁共振弥散加权成像在肿瘤淋巴结转移灶诊断中的效能比较(%)
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恶性肿瘤组织由于过度增殖, 耗能大, 在PETCT上表现为葡萄糖代谢水平升高, SUV增大; 另外, 恶性肿瘤组织由于增殖过快, 单位体积内细胞数目增多, 细胞膜表面积增大, 增加了水分子的弥散障碍, 在DWI中则表现为ADC降低。所以, SUV与ADC之间的关系值得重视。
Mori等[14]对104例肺癌患者的研究得出, SUVcr与ADCmin之间具有中度负相关性。Beer等[34]对前列腺癌淋巴结转移灶的研究得出, SUV与ADC之间存在中度负相关性, 而且良恶性淋巴结的SUV与ADC均有显著差异。Ho等[35]对33例宫颈癌患者的研究发现, 病灶在中度分化以上或病理类型为腺癌时, rADC(ADCmin/ADCmean)与rSUV(SUVmax/SUVmean)之间具有中度负相关性, 而分化较差或者病理类型为鳞癌时则两者无相关性。Gu等[36]通过对33例直肠癌患者的分析得出, SUV与ADC之间存在轻度负相关性。Nakajo等[37]对44例乳腺癌患者的研究发现, SUVmax与ADC存在轻度负相关性, 且二者分别与肿瘤病理分化级别存在正相关性和负相关性。Tanimoto等[38]对16例胰腺癌患者的研究发现, SUVmean与ADCmean、SUVbri(肿瘤SUVmax/小脑SUVmax)与ADCmean之间存在微弱的负相关性, 并指出SUV对肿瘤恶性程度的诊断具有较高的特异度, 而ADC则具有较高的灵敏度, 二者结合可以提高诊断的准确率。
Choi等[39]对47例头颈部鳞状细胞癌患者的研究得出, SUV与ADC之间无相关性, 而SUV与ADCratio(ADCb值=2000/ADCb值=1000)存在明显的相关性(b值即弥散敏感系数)。但该研究中DWI选用了高b值(b值=1000和2000 s/mm2), 虽然较高的b值所测得的ADC受血流灌注的影响小, 能较好地反映组织内水分子的弥散运动, 但也能引起较大的信号下降和图像的信噪比下降, 各向异性更加明显。而Fruehwald-Pallamar等[40]利用全身DWI背景抑制技术及平面成像技术两种DWI的成像方式, 选取b值=0和800 s/mm2, 对31例头颈部鳞状细胞癌的研究得出, SUV与ADC之间无相关性。
Wu等[41]对15例弥漫性大B细胞淋巴瘤患者进行PET-CT和DWI得出, SUV与ADC之间无相关性, 并指出弥漫性大B细胞淋巴瘤的SUV和ADC都有与炎症重叠的可能, 而且DWI图像容易受影响而形成伪影及变形, 但作者认为DWI与PET-CT能够相互补充, 提供更多的组织细胞功能信息。Punwani等[42]对16例年龄为14~18岁的霍奇金淋巴瘤患者的研究表明, 治疗前SUVmax与ADCmean存在微弱的负相关性, 治疗后SUVmax与ADCmean之间无相关性, 而ΔSUVmax((治疗前SUVmax-治疗后SUVmax)/治疗前SUVmax)与ΔADCmean((治疗前ADCmean-治疗后ADCmean)/治疗前ADCmean)之间存在微弱的负相关性。
表 3是不同学者从不同角度对SUV与ADC关系的对比研究结果[14,34-42], 由表 3可以看出, 大多数研究结果表明SUV与ADC之间, 或者是通过各种方式转换得出的SUV与ADC之间存在轻度到中度的负相关性; SUV与ADC在腺癌中的相关性程度偏高, 而在鳞癌中则稍差, 可基本明确SUVmean与ADCmean之间无相关性; 另外, SUV与ADC之间的相关性还可能与肿瘤的分化程度及治疗情况有关。
肿瘤类型 参考文献 病例数 比较对象 r值 P值 肺癌 [14] 104 ADCmin和SUVcr -0.504 < 0.001 前列腺癌 [34] 14 SUV和ADC -0.5144 < 0.001 宫颈癌 [35] 33 rADC和rSUV -0.526 0.0017 直肠癌 [36] 33 SUVmax和ADCmin -0.45 0.009 SUVmean和ADCmean -0.402 0.02 乳腺癌 [37] 44 SUVmax和ADC -0.486 0.001 头颈部肿瘤 [39] 47 ADCmean和SUVmean -0.222 0.1325 ADCratio和SUVmean 0.667 < 0.001 ADCratio和SUVmax 0.5855 < 0.001 [40] 31 SUVmax和ADC_DWIBS -0.238 0.13 SUVmax和ADC_EPI -0.113 0.561 霍奇金淋巴瘤 [42] 16 治疗前SUVmax和ADCmean -0.38 0.005 治疗后SUVmax和ADCmean -0.07 0.606 ΔSUVmax和ΔADCmean -0.41 0.002 注: 表中,SUVcr=肿瘤SUV/对侧肺SUV; rADC=ADCmin/ADCmean; rSUV=SUVmax/SUVmean; SUVbri=肿瘤SUVmax/小脑SUVmax; ADCratio=ADCb值=2000/ADCb值=1000; ADC_DWIBS表示使用弥散加权成像背景抑制技术时获得的ADC; ADC_EPI表示使用弥散加权成像平面成像技术获得的ADC; ΔSUVmax=(治疗前SUVmax-治疗后SUVmax)/治疗前SUVmax; ΔADCmean=(治疗前ADCmean-治疗后ADCmean)治疗前ADCmean。 表 3 PET或PET-CT标准化摄取值与弥散加权成像表观弥散系数关系的对比研究结果
PET、PET-CT与磁共振弥散加权成像在肿瘤诊断中的对比研究进展
Progression of comparison study between PET or PET-CT and magnetic resonance diffusion-weighted imaging in the investigation of tumor
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摘要: PET-CT和磁共振弥散加权成像是两类检测恶性肿瘤的重要成像方法,前者提供肿瘤组织的功能代谢信息,比如葡萄糖代谢、氨基酸代谢等信息,后者反映水分子的运动状况,二者各有优缺点及适应证,二者有机结合能够对病变获得尽可能多的形态学与代谢学信息,有利于病变的局部定性和系统分期,显著提高诊断的准确率,为临床选择最优化的治疗方案提供最有效的信息。
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关键词:
- 肿瘤 /
- 诊断, 鉴别 /
- 正电子发射断层显像术 /
- 体层摄影术, X线计算机 /
- 磁共振成像, 弥散
Abstract: PET-CT and magnetic resonance diffusion-weighted imaging(DWI) are two types important imaging modalities in tumor detection, the former could provide functional metabolism information, such as glucose metabolism, amino acids metabolism and so on.While the latter could offer the water molecules motion information in tissues.The two modalities both have advantages, disadvantages and indications of themselves.We will obtain more morphology and metabolism informations while the two modalities were combined favorably.The combination of the two were useful to decide the quality of local lesions and systematic stage, and to increase the diagnostic accuracy, that could provide the most effective informations for clinic to choose optimal treatment plan. -
表 1 PET、PET-CT与磁共振弥散加权成像在肿瘤良恶性鉴别诊断中的效能比较(%)
肿瘤类型 参考文献 病例数 PET或PET-CT 弥散加权成像 灵敏度 特异度 准确率 灵敏度 特异度 准确率 肺癌 [13] 110 72 82 - 73 96 - [14] 104 72 79 - 70 97 - [15] 56 - - 100 - - 100 [16] 203 62.5 94.5 88.2 57.5 87.7 81.8 [17] 115 96.0 85.6 87.8 96.0 78.9 82.6 乳腺癌 [18] 20 94 99 98 91 72 76 结直肠癌 [19] 25 30.0 76.9 85.2 80.0 100 85.2 淋巴瘤 [20] 101 97 97 - - - - [21] 31 - - - 100 30.8 71.0 前列腺癌 [22] 36 66 81 - - - - [23] 35 - - - 90~94 84~91 - 甲状腺癌 [24] 44 100 66 - - - [25] 60 - - - 93.3 96.7 - [26] 51 100 59 - - - - [27] 67 - - - 97.5 91.7 98.9 肝癌 [28] 102 27.2~92.8 - - - - - [29] 24 - - - 80~100 - - 注: “-”表示无该项数据。 表 2 ET、PET-CT与磁共振弥散加权成像在肿瘤淋巴结转移灶诊断中的效能比较(%)
肿瘤类型 参考文献 病例数 PET或PET-CT 弥散加权成像 灵敏度 特异度 准确率 灵敏度 特异度 准确率 肺癌 [15] 96 98 97 97 91 90 90 [30] 734 72.0 97.0 96.2 67.0 99.0 97.7 [31] 319 48 97 90 75 99 95 乳腺癌 [18] 140 86 100 96 86 39 52 [32] 48 96 96 96 73 77 75 结直肠癌 [19] 23 30.0 100 69.6 80.0 76.9 78.3 甲状腺癌 [33] 58 - - 61.7 - - 67.2 前列腺癌 [34] 55 85.2 85.7 85.5 96.3 78.6 83.6 注: “-”表示无该项数据。 表 3 PET或PET-CT标准化摄取值与弥散加权成像表观弥散系数关系的对比研究结果
肿瘤类型 参考文献 病例数 比较对象 r值 P值 肺癌 [14] 104 ADCmin和SUVcr -0.504 < 0.001 前列腺癌 [34] 14 SUV和ADC -0.5144 < 0.001 宫颈癌 [35] 33 rADC和rSUV -0.526 0.0017 直肠癌 [36] 33 SUVmax和ADCmin -0.45 0.009 SUVmean和ADCmean -0.402 0.02 乳腺癌 [37] 44 SUVmax和ADC -0.486 0.001 头颈部肿瘤 [39] 47 ADCmean和SUVmean -0.222 0.1325 ADCratio和SUVmean 0.667 < 0.001 ADCratio和SUVmax 0.5855 < 0.001 [40] 31 SUVmax和ADC_DWIBS -0.238 0.13 SUVmax和ADC_EPI -0.113 0.561 霍奇金淋巴瘤 [42] 16 治疗前SUVmax和ADCmean -0.38 0.005 治疗后SUVmax和ADCmean -0.07 0.606 ΔSUVmax和ΔADCmean -0.41 0.002 注: 表中,SUVcr=肿瘤SUV/对侧肺SUV; rADC=ADCmin/ADCmean; rSUV=SUVmax/SUVmean; SUVbri=肿瘤SUVmax/小脑SUVmax; ADCratio=ADCb值=2000/ADCb值=1000; ADC_DWIBS表示使用弥散加权成像背景抑制技术时获得的ADC; ADC_EPI表示使用弥散加权成像平面成像技术获得的ADC; ΔSUVmax=(治疗前SUVmax-治疗后SUVmax)/治疗前SUVmax; ΔADCmean=(治疗前ADCmean-治疗后ADCmean)治疗前ADCmean。 -
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