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在我国乃至世界范围,乳腺癌都是女性发病率及病死率最高的恶性肿瘤之一。近年来我国乳腺癌发病率迅速上升,2000年我国女性的乳腺癌年龄标化发病率为19.9/10万,已经跃居我国女性恶性肿瘤的第一位[1]。对于复发转移性乳腺癌,目前认为是不可治愈性疾病,中位生存期仅2~3年,5年生存率仅15%~25%[2]。目前,乳腺癌治疗后复发和转移的概率高达20%~35%[3]。因此,尽早及准确地诊断出乳腺癌复发及转移,提供个体化的治疗方案以延长患者的生存期及提高生活质量,是非常有意义的。随着分子生物学技术的应用和医疗水平的不断提高,以肿瘤形态学结合基因表达特征的分子分型概念已被大家认同,对乳腺癌进行分型,有助于正确诊断乳腺癌并对治疗方法的选择和疾病的预后起指导作用。我们通过回顾性分析59例行18F-FDG PET/CT检查的女性乳腺癌术后患者,探讨18F-FDG PET/CT在乳腺癌术后复发转移以及治疗决策改变和预后中的价值。
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59例乳腺癌术后患者,其中35例经组织病理学或临床随访确诊存在复发转移,24例未发现复发转移。59例患者中,PET/CT检查真阳性35例、真阴性21例、假阳性3例(图 1)、假阴性0例。18F-FDG PET/CT诊断乳腺癌术后复发转移的灵敏度、特异度、准确率、阳性预测值和阴性预测值分别为100%、87.5%、94.9%、92.1%、100%。PET/CT共发现复发转移病灶72个,SUVmax为1.63~16.22(6.03±3.58),复发转移病灶分布情况见表 1。
图 1 乳腺癌术后PET/CT检查假阳性患者的PET/CT显像图。患者女性, 44岁, 行右乳肿块切除术, 病理示右乳浸润性导管癌Ⅲ级。CT随访42个月未见明显异常病灶, 考虑术后改变。图中, A:CT示右侧腋窝稍低密度灶, PET/CT见18F-FDG葡萄糖高代谢灶SUVmax为3.2;B:右乳局部, PET/CT见18F-FDG葡萄糖高代谢灶SUVmax为2.5。
Figure 1. PET/CT images of a false-positive patient
复发转移部位 病灶数 SUVmax(x±s) 乳腺 06 8.93±6.15 胸壁 11 5.15±3.95 淋巴结 30 5.62±2.75 骨 11 6.57±3.46 肺 08 4.10±2.89 肝 06 8.24±2.76 表 1 72个乳腺癌术后复发转移病灶分布情况及SUVmax
Table 1. Distribution and SUVmax of 72 recurrence and metastasis lesions in patients with postoperative breast cancer
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乳腺癌术后复发转移灶的SUVmax在年龄、ER、PR、HER2及乳腺癌亚型分组间的差异无统计学意义(t=0.808、0.225、0.355、-0.426和-1.076,均P>0.05)(表 2)。
参数 分组 病灶数(%) SUVmax t值 P值 年龄 ≤50岁 26(36.11) 7.58±5.03 -0.808 0.815 >50岁 46(63.88) 6.50±3.14 ER 阴性 47(65.27) 7.20±3.89 -0.225 0.677 阳性 25(34.72) 6.76±4.29 PR 阴性 49(68.06) 6.47±3.43 -0.355 0.851 阳性 23(31.94) 8.19±3.30 HER2 阴性 33(45.83) 6.24±3.61 -0.426 0.737 阳性 39(54.17) 7.27±3.61 乳腺癌亚型 三阴型 28(38.89) 6.14±4.07 -1.076 0.998 非三阴型 44(61.11) 6.93±3.59 注:表中,ER:雌激素受体;PR:孕激素受体;HER2:人表皮生长因子受体2。 表 2 72个乳腺癌术后复发转移病灶按不同临床病理学参数分组后的SUVmax比较
Table 2. Comparison of SUVmax of 72 recurrence and metastasis lesions according to different clinical pathologic parameters
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35例PET/CT检查真阳性的患者中,25例分期上调,10例分期未变(表 3)。
PET/CT检查前 PET/CT检查后 分期 例数 分期 例数 Ⅰ 1 Ⅰ 0 Ⅱ 9 Ⅱ 0 Ⅲ 22 Ⅲ 12 Ⅳ 3 Ⅳ 23 表 3 35例18F-FDG PET/CT检查真阳性患者临床再分期改变情况
Table 3. Clinical restaging of 35 cases of true-positve patients under 18F-FDG PET/CT examination
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在行PET/CT检查前,有7例患者(11.86%)未接受过任何辅助治疗;40例患者(67.80%)仅接受过化疗;12例患者(20.34%)接受过化疗及内分泌治疗。35例PET/CT检查真阳性患者中,30例PET/CT检查后治疗策略改变(21例PET/CT检查后诊断多发转移,治疗策略由随访改为化疗和(或)放疗(图 2);5例PET/CT检查后诊断淋巴结转移3例、对侧乳腺阳性病灶2例,治疗策略由随访改为手术及化疗;2例为术后化疗前评估;1例发现淋巴结转移,治疗策略改变了放疗的部位;1例发现疾病进展,改变了化疗方案)。另外5例PET/CT检查后治疗策略未改变,3例按原方案继续化疗,2例检查后继续随访或对症治疗(图 3)。21例PET/CT检查真阴性患者中,4例行PET/CT术后评估全身情况后制定治疗方案,9例维持原化疗方案,8例继续随访。
图 2 PET/CT检查后治疗策略改变的乳腺癌患者的PET/CT显像图。患者女性, 59岁, 行左乳改良根治术, 病理示左乳浸润性导管癌Ⅲ级。术后20个月行PET/CT检查示病情进展多处转移, 左胸壁结节SUVmax为2.11, 淋巴结多处SUVmax为3.58, 骨盆骨及脊柱多处SUVmax为5.3。临床分期由Ⅱ级上调至Ⅳ级, 改变化疗方案。图中, A:左侧胸壁结节, PET/CT见18F-FDG葡萄糖高代谢灶SUVmax为2.11;B:纵隔淋巴结, PET/CT见18F-FDG葡萄糖高代谢灶SUVmax为3.58。
Figure 2. PET/CT images of a patient with a change in therapeutic strategy
图 3 PET/CT检查后治疗决策未改变的乳腺癌患者的PET/CT显像图。患者女性, 52岁, 行左乳改良根治术, 术后病理示左乳浸润性导管癌Ⅱ级。术后14个月行PET/CT检查示病情进展多处转移, 左乳手术区尧右乳尧甲状腺尧肝脏尧左侧膈肌局部尧全身淋巴结多处葡萄糖代谢增高, 最高处SUVmax为8.28。临床分期由Ⅲ级上调至Ⅳ级, 患者放弃治疗。图中, A:肝脏多处18F-FDG葡萄糖高代谢灶;B:右乳局部见18F-FDG葡萄糖高代谢灶。
Figure 3. PET/CT images of a patient without a change in therapeutic strategy
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18F-FDG PET/CT真阳性组和真阴性组患者的中位数生存时间分别为3.58年和4.16年。PET/CT真阳性组患者的1年、2年、3年及4年生存率分别是100%、97.14%、77.14%、57.14%;PET/CT真阴性组患者的1年、2年、3年及4年生存率分别是100%、100%、100%、95%。两组患者OS及PFS的差异有统计学意义(χ2=10.274和17.187,均P<0.01),从生存曲线可以看出,PET/CT真阳性患者的OS及PFS短于真阴性患者(图 4)。
18F-FDG PET/CT在乳腺癌术后随访中的价值
Clinical value of 18F-FDG PET/CT in follow-up of postoperative breast cancer
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摘要:
目的研究18F-FDG PET/CT在乳腺癌术后复发转移中的诊断价值以及在治疗决策改变和预后中的价值。 方法回顾性分析2007年7月至2016年9月行18F-FDG PET/CT检查的59例女性乳腺癌术后患者,分析PET/CT对真阳性患者临床治疗策略的影响,并对真阳性组和真阴性组患者进行Kaplan-Meier生存分析。在PET/CT显像真阳性组中,按照患者年龄、雌激素受体(ER)、孕激素受体(PR)、人类表皮生长因子受体2(HER2)及乳腺癌亚型进行分组,组间SUVmax的比较采用t检验。 结果在59例乳腺癌术后患者中,18F-FDG PET/CT诊断乳腺癌术后复发转移的灵敏度、特异度、准确率、阳性预测值和阴性预测值分别为100%、87.5%、94.9%、92.1%、100%。PET/CT真阳性组与真阴性组患者平均随访时间分别为(58.33±37.69)个月和(47.40±25.99)个月,中位数生存时间分别为3.58年和4.16年,PET/CT真阴性患者的总生存时间(OS)和无进展生存时间(PFS)长于真阳性患者,且差异有统计学意义(χ2=10.274和17.187,均P < 0.01)。35例PET/CT真阳性患者中,25例分期上调,30例检查后治疗策略改变。乳腺癌复发转移灶的SUVmax在年龄、ER、PR、HER2及亚型分组间的差异无统计学意义(t=0.808、0.225、0.355、-0.426和-1.076,均P>0.05)。 结论 18F-FDG PET/CT显像在诊断乳腺癌术后复发转移中有较高的灵敏度和准确率,能及时修正乳腺癌术后复发转移患者的临床再分期,以及指导临床治疗策略的改变,在乳腺癌的术后随访中具有较高的临床应用价值。 -
关键词:
- 乳腺肿瘤 /
- 正电子发射断层显像术 /
- 体层摄影术,X线计算机 /
- 预后 /
- 肿瘤转移 /
- 肿瘤复发
Abstract:Objective To evaluate the clinical value of 18F-FDG PET/CT imaging in detecting the recurrence and metastasis, therapeutic strategy, and prognosis of postoperative breast cancer patients. Methods From July 2007 to September 2016, 59 patients with postoperative breast cancer were retrospectively studied. The influence of PET/CT imaging results on the choice of therapeutic strategy was analyzed. Kaplan-Meier survival analysis was conducted based on the true-positive and true-negative groups of patients. Comparison of SUVmax according to the age, estrogen receptor(ER), progesterone receptor (PR), human epidermal growth factor receptor-2(HER2), and subtypes of the patients in the PET/CT imaging true-positive group was performed using t-test. Results The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 18F-FDG PET/CT were 100%, 87.5%, 94.9%, 92.1%, and 100%, respectively. No statistically significant difference in the SUVmax for breast cancer recurrence and metastasis was observed between the two groups of patients according to age, ER, PR, HER2, and subtypes of breast cancer(t=0.808, 0.225, 0.355, -0.426 and -1.076, all P>0.05). The true-positive and true-negative groups were followed for a median period of 58.33±37.69 and 47.40±25.99 months, and their median survival times were 3.58 and 4.16 years, respectively. The two groups significantly differed in the overall survival and progression-free survival times (Kaplan-Meier survival analysis, χ2=10.274, P < 0.01; χ2=17.187, P < 0.01). Clinical restaging was raised in 25 true-positive patients after PET/CT imaging, and the therapeutic strategy was changed in 30 true-positive patients. Conclusions PET/CT imaging is highly sensitive and accurate in diagnosing the recurrence and metastasis of postoperative breast cancer and allows clinical restaging in a timely manner. It helps in choosing the appropriate clinical therapeutic strategy, thereby improving the prognosis of patients. Compared with the true-positive patients, the true-negative patients who underwent PET/CT imaging had a better prognosis. Therefore, PET/CT imaging has a high clinical value in the follow-up of postoperative breast cancer patients. -
图 2 PET/CT检查后治疗策略改变的乳腺癌患者的PET/CT显像图。患者女性, 59岁, 行左乳改良根治术, 病理示左乳浸润性导管癌Ⅲ级。术后20个月行PET/CT检查示病情进展多处转移, 左胸壁结节SUVmax为2.11, 淋巴结多处SUVmax为3.58, 骨盆骨及脊柱多处SUVmax为5.3。临床分期由Ⅱ级上调至Ⅳ级, 改变化疗方案。图中, A:左侧胸壁结节, PET/CT见18F-FDG葡萄糖高代谢灶SUVmax为2.11;B:纵隔淋巴结, PET/CT见18F-FDG葡萄糖高代谢灶SUVmax为3.58。
Figure 2. PET/CT images of a patient with a change in therapeutic strategy
图 3 PET/CT检查后治疗决策未改变的乳腺癌患者的PET/CT显像图。患者女性, 52岁, 行左乳改良根治术, 术后病理示左乳浸润性导管癌Ⅱ级。术后14个月行PET/CT检查示病情进展多处转移, 左乳手术区尧右乳尧甲状腺尧肝脏尧左侧膈肌局部尧全身淋巴结多处葡萄糖代谢增高, 最高处SUVmax为8.28。临床分期由Ⅲ级上调至Ⅳ级, 患者放弃治疗。图中, A:肝脏多处18F-FDG葡萄糖高代谢灶;B:右乳局部见18F-FDG葡萄糖高代谢灶。
Figure 3. PET/CT images of a patient without a change in therapeutic strategy
表 1 72个乳腺癌术后复发转移病灶分布情况及SUVmax
Table 1. Distribution and SUVmax of 72 recurrence and metastasis lesions in patients with postoperative breast cancer
复发转移部位 病灶数 SUVmax(x±s) 乳腺 06 8.93±6.15 胸壁 11 5.15±3.95 淋巴结 30 5.62±2.75 骨 11 6.57±3.46 肺 08 4.10±2.89 肝 06 8.24±2.76 表 2 72个乳腺癌术后复发转移病灶按不同临床病理学参数分组后的SUVmax比较
Table 2. Comparison of SUVmax of 72 recurrence and metastasis lesions according to different clinical pathologic parameters
参数 分组 病灶数(%) SUVmax t值 P值 年龄 ≤50岁 26(36.11) 7.58±5.03 -0.808 0.815 >50岁 46(63.88) 6.50±3.14 ER 阴性 47(65.27) 7.20±3.89 -0.225 0.677 阳性 25(34.72) 6.76±4.29 PR 阴性 49(68.06) 6.47±3.43 -0.355 0.851 阳性 23(31.94) 8.19±3.30 HER2 阴性 33(45.83) 6.24±3.61 -0.426 0.737 阳性 39(54.17) 7.27±3.61 乳腺癌亚型 三阴型 28(38.89) 6.14±4.07 -1.076 0.998 非三阴型 44(61.11) 6.93±3.59 注:表中,ER:雌激素受体;PR:孕激素受体;HER2:人表皮生长因子受体2。 表 3 35例18F-FDG PET/CT检查真阳性患者临床再分期改变情况
Table 3. Clinical restaging of 35 cases of true-positve patients under 18F-FDG PET/CT examination
PET/CT检查前 PET/CT检查后 分期 例数 分期 例数 Ⅰ 1 Ⅰ 0 Ⅱ 9 Ⅱ 0 Ⅲ 22 Ⅲ 12 Ⅳ 3 Ⅳ 23 -
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