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在我国,食管鳞癌占所有食管癌的95%以上,且绝大多数发生于胸段食管,而淋巴结转移是食管癌最常见的转移途径,淋巴结转移枚数是食管癌患者重要的独立负性预后因子,与患者的生存时间呈负相关[1-4]。第7版美国癌症联合委员会食管癌分期中规定,从锁骨上区到腹腔干均为区域淋巴结,1~2枚区域淋巴结转移为N1,3~6枚转移为N2,≥7枚转移为N3[5]。因此术前准确判断淋巴结是否转移至关重要。本研究对18F-FDG PET/CT显像与增强CT在术前胸段食管鳞癌淋巴结转移诊断中的准确率进行评价,现报道如下。
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54例患者共切取并分离淋巴结186枚,均经病理证实,其中转移淋巴结77枚,非转移淋巴结109枚。
18F-FDG PET/CT诊断淋巴结转移65枚(典型病例见图 1中A),其中假阳性5枚(5组、11L组、17组各1枚,7组2枚,典型病例见图 1中B),PET/CT图像显示淋巴结边界清晰,SUV均>2.6,但病理证实纤维组织内见钙化,为良性;诊断良性淋巴结121枚,其中假阴性17枚(1R组、2L组、4R组、8M组各1枚,2R组3枚,8L组4枚,16组6枚,典型病例见图 1中C),除16组1枚(短径12 mm,伴囊变,SUV=2.2,病理证实为转移淋巴结,见图 1中D)和8M组1枚(短径10 mm,位于中段食管旁,与食管病灶融合,见图 1中E)外,其余淋巴结短径均≤5 mm,SUV均<2.5,病理证实均为转移淋巴结。增强CT诊断淋巴结转移58枚,其中假阳性27枚(10R组9枚,10L组6枚,11L组3枚,5组、6组、7组各2枚,11R组、4R组、8M组各1枚),短径均≥10 mm,病理证实为良性;诊断良性淋巴结128枚,其中假阴性46枚(1R组、3P组、4L组、11L组和10L组各1枚,17组、8M组和7组各2枚,1L组、2L组和10R组各3枚,16组5枚,4R组6枚,8L组7枚,2R组8枚),短径均<10 mm,病理证实为转移淋巴结(表 1)。由表 1可见,胸段食管鳞癌淋巴结转移主要位于2R组、4R组、8M组、8L组、16组和17组;18F-FDG PET/CT显像假阴性主要位于2R组(3枚)、8L组(4枚)和16组(6枚)。
图 1 胸段食管鳞癌患者18F-FDG PET/CT与增强CT显像图图中,A:2R组淋巴结(箭头所示),直径5 mm,PET/CT融合图像放射性异常摄取,SUVmax=3.4,增强CT图像相应部位淋巴结为假阴性;B:5组淋巴结(箭头所示),短径5 mm,SUVmax=3.2,PET/CT显示为假阳性,增强CT为真阴性,病理证实为良性;C:16组淋巴结(箭头所示),直径5 mm,PET/CT融合图像无放射性摄取,增强CT图像相应部位淋巴结边界欠清晰,病理证实为转移淋巴结;D:16组淋巴结伴囊变(箭头所示),短径12 mm,PET/CT融合图像无放射性摄取,显示为假阴性,而增强CT呈环形轻度强化,显示为真阳性淋巴结;E:原发灶旁8M组淋巴结(箭头所示),由于原发灶对显像剂的摄取掩盖了淋巴结的放射性摄取,故PET/CT未发现病灶,而增强CT该部位淋巴结为真阳性,短径10 mm。
Figure 1. Representative images of 18F-FDG PET/CT and enhanced CT in detecting metastatic lymph nodes of thoracic esophageal squamous cell carcinoma
组别 18F-FDG PET/CT 增强CT 合计 转移淋巴结占比[(n/77)/%] 真阳性 假阳性 真阴性 假阴性 真阳性 假阳性 真阴性 假阴性 1R组 1 0 2 1 1 0 2 1 4 2.6 1L组 3 0 6 0 0 0 6 3 9 3.9 2R组 15 0 12 3 10 0 12 8 30 23.4 2L组 3 0 6 1 1 0 6 3 10 5.2 3P组 1 0 2 0 0 0 2 1 3 1.3 4R组 6 0 7 1 1 1 6 6 14 9.1 4L组 2 0 0 0 1 0 0 1 2 2.6 5组 1 1 10 0 1 2 9 0 12 1.3 6组 0 0 7 0 0 2 5 0 7 0 7组 4 2 5 0 2 2 5 2 11 5.2 8M组 4 0 3 1 3 1 2 2 8 6.5 8L组 3 0 1 4 0 0 1 7 8 9.1 9组 0 0 1 0 0 0 1 0 1 0 10R组 4 0 12 0 1 9 3 3 16 5.2 10L组 1 0 11 0 0 6 5 1 12 1.3 11R组 0 0 6 0 0 1 5 0 6 0 11L组 1 1 8 0 0 3 6 1 10 1.2 15组 0 0 0 0 0 0 0 0 0 0 16组 1 0 1 6 2 0 1 5 8 9.1 17组 8 1 2 0 6 0 3 2 11 10.4 18组 2 0 0 0 2 0 0 0 2 2.6 19组 0 0 1 0 0 0 1 0 1 0 20组 0 0 1 0 0 0 1 0 1 0 合计 60 5 104 17 31 27 82 46 186 100 表 1 18F-FDG PET/CT与增强CT诊断不同组别胸段食管鳞癌肿大淋巴结及病理检查结果(例)
Table 1. Results of 18F-FDG PET/CT and enhanced CT in diagnosing different groups of lymph nodes of thoracic esophageal squamous cell carcinoma compared with the histopathological results
18F-FDG PET/CT诊断淋巴结转移的灵敏度、特异度和准确率分别为77.9%(60/77)、95.4%(104/109)和88.2%(164/186),均高于增强CT的40.3%(31/77)、75.2%(82/109)和60.8%(113/186),且二者差异有统计学意义(χ2=24.04、15.77和36.77,P均 < 0.01)。
短径≤5 mm的淋巴结47枚,18F-FDG PET/CT正确诊断35枚,准确率为74.5%,增强CT正确诊断37枚,准确率为78.7%,二者差异无统计学意义(χ2=0.24,P>0.05);短径5~10 mm和≥10 mm淋巴结分别为81枚、58枚,18F-FDG PET/CT正确诊断分别为75枚、54枚,准确率分别为92.6%、93.1%,增强CT正确诊断分别为47枚、29枚,准确率分别为58.0%、50.0%,18F-FDG PET/CT和增强CT的诊断差异均有统计学意义(χ2=26.03和26.47,P均 < 0.01)。
从整体上看,18F-FDG PET/CT诊断胸段食管鳞癌淋巴结分期正确42例(77.8%)、错误12例(22.2%);增强CT正确29例(53.7%)、错误25例(46.3%)(表 2)。18F-FDG PET/CT联合增强CT诊断可修正3例N分期,准确率提高至83.3%(45/54)。
分期 18F-FDG PET/CT 增强CT 正确分期 N0 21 15 N1 16 10 N2 4 4 N3 1 0 提高分期 N0→N1 1 4 N0→N2 0 3 N1→N2 2 3 降低分期 N1→N0 6 11 N2→N0 2 1 N2→N1 1 2 N3→N2 0 1 表 2 18F-FDG PET/CT与增强CT诊断胸段食管鳞癌N分期及病理对照结果(例)
Table 2. Results of 18F-FDG PET/CT and enhanced CT in diagnosing the N stage of thoracic esophageal squamous cell carcinoma
18F-FDG PET/CT在胸段食管鳞癌淋巴结转移中的诊断价值
Value of 18F-FDG PET/CT in detecting metastatic lymph nodes of thoracic esophageal squamous cell carcinoma
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摘要:
目的 探讨18F-FDG PET/CT在胸段食管鳞癌淋巴结转移中的诊断价值,并与增强CT及术后病理结果进行对比。 方法 胸段食管鳞癌患者54例,术前一周内行18F-FDG PET/CT和增强CT扫描,术后以病理学诊断为“金标准”,比较两种显像方法对胸段食管鳞癌淋巴结转移的灵敏度、特异度、准确率及不同短径范围的诊断准确率。应用SPSS13.0软件进行四格表χ2检验。 结果 手术共切取肿大淋巴结186枚,均经病理证实,其中淋巴结转移77枚,18F-FDG PET/CT诊断淋巴结转移的灵敏度、特异度及准确率分别为77.9%(60/77)、95.4%(104/109)和88.2%(164/186),增强CT分别为40.3%(31/77)、75.2%(82/109)和60.8%(113/186),二者诊断效能差异有统计学意义(χ2=24.04、15.77和36.77,P均 < 0.01)。对于短径>5 mm(5~10 mm及≥10 mm)的淋巴结,18F-FDG PET/CT诊断的准确率高于增强CT,且差异有统计学意义(χ2=26.03和26.47,P均 < 0.01);对于短径≤5 mm的淋巴结,二者间诊断的准确率差异无统计学意义(χ2=0.24,P>0.05)。 结论 18F-FDG PET/CT在胸段食管鳞癌淋巴结转移中具有较高的诊断价值,对于短径>5 mm的淋巴结优势明显。 -
关键词:
- 食管肿瘤 /
- 正电子发射断层显像术 /
- 体层摄影术, X线计算机 /
- 氟脱氧葡萄糖F18 /
- 淋巴结转移 /
- 短径
Abstract:Objective To analyze the diagnostic value of 18F-FDG PET/CT and enhanced CT in detecting metastatic lymph nodes of thoracic esophageal squamous cell carcinoma. Methods Fifty-four patients with thoracic esophageal squamous cell carcinoma underwent both 18F-FDG PET/CT and enhanced CT before surgery within a week. All lesions were confirmed histopathologically as the golden standard. The sensitivity, specificity, and accuracy of the two imaging modalities were compared. In addition, the diagnostic accuracy of the two methods in detecting metastatic lymph nodes having different diameters in patients with thoracic esophageal squamous cell carcinoma was evaluated. Theχ2-test was used with SPSS 13.0. Results A total of 186 lymph node specimens, including 77 specimens of metastases, were extracted and confirmed by pathology. The sensitivity, specificity, and accuracy of 18F-FDG PET/CT were 77.9%(60/77), 95.4%(104/109), 88.2%(164/186), respectively, whereas those of enhanced CT were 40.3%(31/77), 75.2%(82/109), and 60.8%(113/186), respectively. All values were statistically significant(χ2=24.04, 15.77, and 36.77, all P < 0.01). The diagnostic accuracy of 18F-FDG PET/CT is significantly better than that of enhanced CT in the group of R>5 mm (χ2=26.03 and 26.47, both P < 0.01) without the group of R≤5 mm(χ2=0.24, P>0.05). Conclusion 18F-FDG PET/CT has a great value in detecting metastatic lymph nodes of thoracic esophageal squamous cell carcinoma, especially lymph nodes that are R>5 mm. -
图 1 胸段食管鳞癌患者18F-FDG PET/CT与增强CT显像图图中,A:2R组淋巴结(箭头所示),直径5 mm,PET/CT融合图像放射性异常摄取,SUVmax=3.4,增强CT图像相应部位淋巴结为假阴性;B:5组淋巴结(箭头所示),短径5 mm,SUVmax=3.2,PET/CT显示为假阳性,增强CT为真阴性,病理证实为良性;C:16组淋巴结(箭头所示),直径5 mm,PET/CT融合图像无放射性摄取,增强CT图像相应部位淋巴结边界欠清晰,病理证实为转移淋巴结;D:16组淋巴结伴囊变(箭头所示),短径12 mm,PET/CT融合图像无放射性摄取,显示为假阴性,而增强CT呈环形轻度强化,显示为真阳性淋巴结;E:原发灶旁8M组淋巴结(箭头所示),由于原发灶对显像剂的摄取掩盖了淋巴结的放射性摄取,故PET/CT未发现病灶,而增强CT该部位淋巴结为真阳性,短径10 mm。
Figure 1. Representative images of 18F-FDG PET/CT and enhanced CT in detecting metastatic lymph nodes of thoracic esophageal squamous cell carcinoma
表 1 18F-FDG PET/CT与增强CT诊断不同组别胸段食管鳞癌肿大淋巴结及病理检查结果(例)
Table 1. Results of 18F-FDG PET/CT and enhanced CT in diagnosing different groups of lymph nodes of thoracic esophageal squamous cell carcinoma compared with the histopathological results
组别 18F-FDG PET/CT 增强CT 合计 转移淋巴结占比[(n/77)/%] 真阳性 假阳性 真阴性 假阴性 真阳性 假阳性 真阴性 假阴性 1R组 1 0 2 1 1 0 2 1 4 2.6 1L组 3 0 6 0 0 0 6 3 9 3.9 2R组 15 0 12 3 10 0 12 8 30 23.4 2L组 3 0 6 1 1 0 6 3 10 5.2 3P组 1 0 2 0 0 0 2 1 3 1.3 4R组 6 0 7 1 1 1 6 6 14 9.1 4L组 2 0 0 0 1 0 0 1 2 2.6 5组 1 1 10 0 1 2 9 0 12 1.3 6组 0 0 7 0 0 2 5 0 7 0 7组 4 2 5 0 2 2 5 2 11 5.2 8M组 4 0 3 1 3 1 2 2 8 6.5 8L组 3 0 1 4 0 0 1 7 8 9.1 9组 0 0 1 0 0 0 1 0 1 0 10R组 4 0 12 0 1 9 3 3 16 5.2 10L组 1 0 11 0 0 6 5 1 12 1.3 11R组 0 0 6 0 0 1 5 0 6 0 11L组 1 1 8 0 0 3 6 1 10 1.2 15组 0 0 0 0 0 0 0 0 0 0 16组 1 0 1 6 2 0 1 5 8 9.1 17组 8 1 2 0 6 0 3 2 11 10.4 18组 2 0 0 0 2 0 0 0 2 2.6 19组 0 0 1 0 0 0 1 0 1 0 20组 0 0 1 0 0 0 1 0 1 0 合计 60 5 104 17 31 27 82 46 186 100 表 2 18F-FDG PET/CT与增强CT诊断胸段食管鳞癌N分期及病理对照结果(例)
Table 2. Results of 18F-FDG PET/CT and enhanced CT in diagnosing the N stage of thoracic esophageal squamous cell carcinoma
分期 18F-FDG PET/CT 增强CT 正确分期 N0 21 15 N1 16 10 N2 4 4 N3 1 0 提高分期 N0→N1 1 4 N0→N2 0 3 N1→N2 2 3 降低分期 N1→N0 6 11 N2→N0 2 1 N2→N1 1 2 N3→N2 0 1 -
[1] Wijnhoven BP, Tran KT, Esterman AA, et al.An evaluation of prognostic factors and tumor staging of resected carcinoma of the esophagus[J].Ann Surg, 2007, 245(5):717-725. DOI:10.1097/01.sla.0000251703.35919.02. [2] Chen J, Zhu J, Pan J, et al.Postoperative radiotherapy improved survival of poor prognostic squamous cell carcinoma esophagus[J].Ann Thorac Surg, 2010, 90(2):435-442. DOI:10.1016/j.athoracsur.2010.04.002. [3] 陈元美, 陈俊强, 朱坤寿, 等.淋巴结转移数目与胸段食管鳞癌根治术预后关系[J].中华胸心血管外科杂志, 2014, 30(2):76-78. DOI:10.3760/cma.j.issn.1001-4497.2014.02.004.
Chen YM, Chen JQ, Zhu KS, et al.The relationship between number of metastatic lymph node and prognosis of thoracic-esophageal cancer patients treated with radical resection[J].Chin J Thorac Cardiovasc Surg, 2014, 30(2):76-78. doi: 10.3760/cma.j.issn.1001-4497.2014.02.004[4] 李菲, 黄俊星, 张俊.18F-FDG PET/CT在食管癌中的临床应用[J].国际放射医学核医学杂志, 2016, 40(4):282-286. DOI:10.3760/cma.j.issn.1673-4114.2016.04.009.
Li F, Huang JX, Zhang J.The clinical application of 18F-FDG PET/CT in esophageal cancer[J].Int J Radiat Med Nucl Med, 2016, 40(4):282-286. doi: 10.3760/cma.j.issn.1673-4114.2016.04.009[5] Rice TW, Blackstone EH, Rusch VW.7th edition of the AJCC Cancer Staging Manual:esophagus and esophagogastric junction[J].Ann Surg Oncol, 2010, 17(7):1721-1724.DOI10.1245/s10434-010-1024-1. doi: 10.1245/s10434-010-1024-1 [6] Rusch VW, Asamura H, Watanabe H, et al.The IASLC lung cancer staging project:a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer[J].J Thorac Oncol, 2009, 4(5):568-577. DOI:10.1097/JTO.0b013e3181a0d82e. [7] 黄伟鹏, 许建生, 陈洁容, 等.胸段食管癌淋巴结转移分布特征的螺旋CT表现[J].中国临床医学影像杂志, 2009, 20(4):236-239. DOI:10.3969/j.issn.1008-1062.2009.04.003.
Huang WP, Xu JS, Chen JR, et al.CT features of lymph node metastases of thoracic esophageal carcinoma[J].J Chin Clin Med Imaging, 2009, 20(4):236-239. doi: 10.3969/j.issn.1008-1062.2009.04.003[8] Pennathur A, Gibson MK, Jobe BA, et al.Oesophageal carcinoma[J].Lancet, 2013, 381(9864):400-412. DOI:10.1016/S0140-6736(12)60643-6. [9] 王秀芳, 郑玄中, 靳宏星.食管癌淋巴结转移影像诊断方法及进展[J].肿瘤研究与临床, 2009, 21(5):356-358. DOI:10.3760/cma.j.issn.1006-9801.2009.05.027.
Wang XF, Zheng XZ, Jin HX.Imaging diagnosis methods and progress for lymph node metastasis in esophageal carcinoma[J].Cancer Res Clin, 2009, 21(5):356-358. doi: 10.3760/cma.j.issn.1006-9801.2009.05.027[10] Ohashi S, Miyamoto S, Kikuchi O, et al.Recent advances from basic and clinical studies of esophageal squamous cell carcinoma[J].Gastroenterology, 2015, 149(7):1700-1715. DOI:10.1053/j.gastro.2015.08.054. [11] 姚沛旭, 许建生, 黄伟鹏, 等.容积CT和重建技术对食管癌术前评分法N分期的研究[J].中国CT和MRI杂志, 2007, 5(2):22-24. DOI:10.3969/j.issn.1672-5131.2007.02.008.
Yao PX, Xu JS, Huang WP, et al.A study of integrated scoring system by spiral CT volume scan and reconstruction on preoperative N staging of esophageal carcinoma[J].Chin J CT MRI, 2007, 5(2):22-24. doi: 10.3969/j.issn.1672-5131.2007.02.008[12] Yoon YC, Lee KS, Shim YM, et al.Metastasis to regional lymph nodes in patients with esophageal squamous cell carcinoma:CT versus FDG PET for presurgical detection-prospective study[J].Radiology, 2003, 227(3):764-770. DOI:10.1148/radiol.2281020423. [13] Kato H, Kuwano H, Nakajima M, et al.Comparison between positron emission tomography and computed tomography in the use of the assessment of esophageal carcinoma[J].Cancer, 2002, 94(4):921-928. DOI:10.1002/cncr.10330. [14] Tan R, Yao SZ, Huang ZQ, et al.Combination of FDG PET/CT and contrast-enhanced MSCT in detecting lymph node metastasis of esophageal cancer[J].Asian Pac J Cancer Prev, 2014, 15(18):7719-7724. DOI:10.7314/APJCP.2014.15.18.7719. [15] 姚树展, 刘松涛, 韩广秀, 等.PET/CT在胸段食管癌诊断与淋巴分期中的应用价值[J].医学影像学杂志, 2009, 19(7):835-838. DOI:10.3969/j.issn.1006-9011.2009.07.015.
Yao SZ, Liu ST, Han GX, et al.The applicable value of PET/CT in diagnosing and lymphatic staging for thoracic esophageal cancer[J].J Med Imaging, 2009, 19(7):835-838. doi: 10.3969/j.issn.1006-9011.2009.07.015[16] 谭茹, 朱仁娟, 葛全序, 等.18F-FDG PET/CT和增强MSCT评价食管癌淋巴结转移[J].中华核医学杂志, 2007, 27(6):356-359. DOI:10.3760/cma.j.issn.2095-2848.2007.06.012.
Tan R, Zhu RJ, Ge QX, et al.The application of 18F-FDG PET/CT and contrast enhanced MSCT in detecting metastatic lymph nodes in esophageal cancer[J].Chin J Nucl Med, 2007, 27(6):356-359. doi: 10.3760/cma.j.issn.2095-2848.2007.06.012