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鼻咽是头颈部结外淋巴瘤累及Waldeyer淋巴环时常受累部位之一,研究证实鼻咽部非霍奇金淋巴瘤(non-Hodgkin's lymphoma,NHL)占Waldeyer环淋巴瘤的10%~28%[1-2]。鼻咽部最常见恶性肿瘤是鼻咽癌(nasopharyngeal carcinoma,NPC),在影像学检查中发现鼻咽肿块而缺乏特异性征象时,原发鼻咽淋巴瘤(primary nasopharyngeal lymphoma,PNL)常易被误诊为NPC,而二者在治疗及预后上均有明显差别。18F-FDG PET/CT能同时从解剖及功能代谢方面对病变进行评价,在肿瘤诊断、疗效评价、监测复发等方面应用广泛,在怀疑为鼻咽部肿瘤的患者中,PET/CT常用于病变的定性及分期诊断。目前国内外关于PET/CT对PNL与NPC鉴别诊断方面的研究较少,我们通过分析对比两者PET/CT影像学表现,以期提高二者诊断的准确率,减少误诊。
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33例PNL患者中20例病变呈弥漫性浸润鼻咽全壁(双侧对称14例、双侧不对称6例),未完全浸润全壁13例(单侧7例、双侧6例);71例NPC患者中10例呈弥漫性浸润鼻咽全壁(双侧对称4例、双侧不对称6例),未完全浸润全壁61例(单侧39例、双侧22例);PNL与NPC累及全壁与不全、单侧与双侧、对称与不对称间差异均有统计学意义(表 1)。
参数 PNL NPC 检验值 P值 体积/×104 mm3 3.70±5.53 2.06±2.31 t=1.63 0.111 SUVmax 12.00±6.34 10.09±4.41 t=1.55 0.128 全壁/不全浸润 20/13 10/61 χ2=23.75 <0.001 双侧/单侧 26/7 32/39 χ2=10.38 <0.001 对称/不对称 14/19 6/65 χ2=16.74 <0.001 深部结构浸润 7/33(21.2%) 54/71(76.1%) χ2=27.94 <0.001 凸入鼻后孔 21/33(63.6%) 24/71(33.8%) χ2=8.17 0.004 淋巴结浸润或转移 26/33(78.8%) 51/71(71.8%) t=0.57 0.309 淋巴结SUVmax 11.24±6.28 10.09±5.52 t=0.79 0.433 淋巴结最大者长径/mm 27.15±16.41 22.58±6.61 t=1.37 0.128 淋巴结最大者短径/mm 22.35±12.07 17.29±5.6 t=2.03 0.052 淋巴结最大者平均直径/mm 24.75±14.15 19.82±5.67 t=1.71 0.099 淋巴结坏死 3/26(11.5%) 31/51(60.8%) χ2=16.94 <0.001 淋巴结融合 5/26(19.2%) 6/51(11.8%) χ2=0.78 0.376 注:表中,PNL:原发鼻咽淋巴瘤;NPC:鼻咽癌;SUVmax:最大标准化摄取值。 表 1 PNL与NPC患者PET/CT显像各参数的比较
Table 1. Parameters of PNL and NPC in PET/CT imaging
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33例PNL患者中26例病变局限于鼻咽壁,7例累及深部结构(4例浸润颅底骨质、2例累及椎前肌、4例累及咽旁间隙),71例NPC患者中17例局限于鼻咽壁,54例累及深部结构(33例累及颅底骨质、29例累及椎前肌、21例累及咽旁间隙),两者间差异有统计学意义(χ2=27.94,P<0.001);33例PNL患者中21例病变凸入鼻后孔(21/33,63.6%),71例NPC患者中24例凸入鼻后孔(24/71,33.8%),差异有统计学意义(χ2=8.17,P<0.05)(表 1)。PNL及NPC典型PET/CT表现见图 1。
图 1 鼻咽淋巴瘤和鼻咽癌患者的典型PET/CT表现图中, A、C为淋巴瘤病例, B、D为鼻咽癌病例, 左侧为PET/CT融合图像, 右侧为对应病例颅底CT骨窗图像。A:男性, 53岁, 弥漫性大B细胞淋巴瘤患者, 病变凸入鼻后孔, 与翼内肌、椎前肌分界清楚, 邻近颅底未见明确骨质改变;B:男性, 62岁, 非角化性未分化癌患者, 病变累及鼻咽壁范围, 与A病例大致相仿, 但颅底可见明显骨质破坏;C:男性, 66岁, 弥漫性大B细胞淋巴瘤患者, 病变累及全鼻咽壁, 凸入鼻后孔, 呈大致对称性生长, 与椎前肌分界清楚, 虽紧贴颅底, 但骨质无明显破坏;D:男性, 59岁, 非角化性未分化癌患者, 病变呈弥漫性生长, 凸入鼻后孔, 双侧不对称, 累及椎前肌及双侧咽旁间隙, 颅底见明显骨质破坏。
Figure 1. Typical PET/CT imaging features of primary nasopharyngeal lymphoma and nasopharyngeal carcinoma paients
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PNL患者的鼻咽肿块体积为(0.18~27.53)×104 mm3,平均(3.70±5.53)×104 mm3;DLBCL患者的鼻咽肿块体积为(0.18~27.53)×104 mm3,平均(5.05±6.89)×104 mm3;NPC患者的鼻咽肿块体积为(0.14~10.74)×104 mm3,平均(2.06±2.31)×104 mm3,PNL、DLBCL组与NPC组间的差异均无统计学意义(t=1.63、1.85,均P>0.05)。PNL、DLBCL、NPC组肿块SUVmax分别为2.8~29.0(12.00±6.34)、5.0~29.0(14.26±6.42)、3.1~28.2(10.09±4.41),PNL组与NPC组间差异无统计学意义(t=1.55,P>0.05),DLBCL组与NPC组间差异有统计学意义(t=2.67,P<0.05)。
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33例PNL患者中有26例同时伴有咽旁或颈部淋巴结浸润,71例NPC中有51例伴有咽旁或颈部淋巴结转移,不同患者淋巴结SUVmax、最大者长径、短径及平均直径间的差异均无统计学意义(t=0.79、1.37、2.03、1.71,均P>0.05)(表 1);26例伴有咽旁或是颈部淋巴结浸润的PNL患者中3例可见轻度坏死(3/26,11.5%),51例伴有咽旁或颈部淋巴结轻移的NPC患者中31例可见坏死(31/51,60.8%),两者间的差异有统计学意义(χ2=16.94,P<0.001);26例伴有咽旁或颈部淋巴结浸润的PNL患者中淋巴结融合5例(5/26,19.2%),51例伴有咽旁或颈部淋巴结转移的NPC患者中淋巴结融合6例(6/51,11.8%),两者间的差异无统计学意义(χ2=0.78,P>0.05)(表 1)。PNL及NPC淋巴结浸润或转移典型PET/CT表现见图 2。
图 2 鼻咽淋巴瘤和鼻咽癌淋巴结浸润或转移患者的典型PET/CT表现图中, 左侧为平扫CT图像, 右侧为PET/CT融合图像;A:男性, 66岁, 弥漫性大B细胞淋巴瘤患者, 为淋巴结颈部淋巴瘤浸润病例, 该病例淋巴结较大, 密度较均匀, 放射性摄取较均匀;B:女性, 53岁, 非角化性未分化鼻咽癌患者, 为鼻咽癌颈部淋巴结转移病例, 该病例中有2枚淋巴结未见坏死, 呈高代谢, 1枚淋巴结平扫见明显低密度坏死, 代谢较未坏死淋巴结明显减低。白色箭头所示为受肿瘤浸润或转移的淋巴结。
Figure 2. Typical PET/CT imaging features of lymphatic involvement or metastasis in primary nasopharyngeal lymphoma and nasopharyngeal carcinoma paients
原发鼻咽淋巴瘤与鼻咽癌的18F-FDG PET/CT诊断与鉴别
Value of 18F-FDG PET/CT examination in the differential diagnosis of primary nasopharyngeal lymphoma and nasopharyngeal carcinoma
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摘要:
目的探讨18F-FDG PET/CT在鉴别诊断原发鼻咽淋巴瘤(PNL)与鼻咽癌(NPC)中的价值。 方法回顾性分析经病理证实、检查前未经过肿瘤治疗的33例PNL和71例NPC患者的PET/CT资料,对鼻咽部病变形态、范围、周围浸润、体积、SUVmax及淋巴结浸润或转移情况进行对比分析,另单独选取PNL中的弥漫性大B细胞淋巴瘤(DLBCL)与NPC患者的鼻咽肿块体积、SUVmax进行比较。应用SPSS13.0软件进行独立样本t检验及四格表χ2检验。 结果33例PNL患者中20例病变呈弥漫性浸润鼻咽全壁(双侧对称14例、双侧不对称6例),未完全浸润全壁13例(单侧7例、双侧6例);71例NPC患者中10例呈弥漫性浸润鼻咽全壁(双侧对称4例、双侧不对称6例),未完全浸润全壁61例(单侧39例、双侧22例);PNL、NPC组累及全壁与不全、单侧与双侧、对称与不对称间差异均有统计学意义(χ2=23.75、10.38、16.74,均P < 0.001)。PNL、NPC病变患者局限于鼻咽壁者分别有26、17例,累及深部结构者分别有7、54例,两者间差异有统计学意义(χ2=27.94,P < 0.001)。PNL、NPC患者中,病变凸入鼻后孔的分别有21、24例,两者之间的差异有统计学意义(χ2=8.17,P < 0.05)。PNL、DLBCL和NPC患者鼻咽肿块体积分别为(3.70±5.53)×104、(5.05±6.89)×104、(2.06±2.31)×104 mm3,PNL、DLBCL患者与NPC患者鼻咽肿块体积之间的差异均无统计学意义(t=1.63、1.85,均P>0.05)。PNL、DLBCL、NPC患者肿块SUVmax分别为12.00±6.34、14.26±6.42、10.09±4.41,PNL患者与NPC患者间差异无统计学意义(t=1.55,P>0.05),DLBCL患者与NPC患者间差异有统计学意义(t=2.67,P < 0.05)。PNL患者中26例伴有咽旁或颈部淋巴结浸润,NPC患者中51例伴有咽旁或颈部淋巴结转移,淋巴结SUVmax、最大者长径、短径及平均直径间差异均无统计学意义(t=0.79、1.37、2.03、1.71,均P>0.05)。26例伴有咽旁或颈部淋巴结浸润的PNL患者中3例可见轻度坏死,51例伴有咽旁或颈部淋巴结转移的NPC患者中31例可见坏死,两者差异有统计学意义(χ2=16.94,P < 0.001)。26例伴有咽旁或颈部淋巴结浸润的PNL患者中淋巴结融合5例,51例伴有咽旁或颈部淋巴结转移的NPC患者中淋巴结融合6例,两者间的差异无统计学意义(χ2=0.78,P>0.05)。 结论18F-FDG PET/CT在PNL及NPC鉴别诊断中具有一定价值。PET/CT主要通过病变形态、范围、深部结构浸润、淋巴结坏死等方面进行鉴别;不同病理亚型淋巴瘤可高于或低于NPC代谢,DLBCL代谢活性高于NPC;病变体积不能作为主要的鉴别诊断依据。 -
关键词:
- 鼻咽肿瘤 /
- 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 /
- 鼻咽淋巴瘤
Abstract:ObjectiveTo explore the value of 18F-FDG PET/CT examination in the differential diagnosis of primary nasopharyngeal lymphoma (PNL) and nasopharyngeal carcinoma (NPC). MethodsPET/CT data of 33 patients with PNL and 71 patients with NPC who were confirmed histopathologically and had not undergone oncotherapy before examination were retrospectively analyzed. The form, range, invasion, volume, SUVmax of nasopharyngeal lesion, and lymphadenopathy involvement were analyzed comparatively. The SUVmax and volume of lesions that confirmed diffuse large B cell lymphoma(DLBCL) were compared with NPC. t-text and χ2-text with SPSS 13.0. ResultsDiffuse infiltration of all nasopharyngeal walls was detected in 20 of 33 patients with PNL(bilateral symmetry in 14 patients and asymmetry in 6) and 10 of 71 patients with NPC(bilateral symmetry in 4 patients and asymmetry in 6). Partial infiltration of nasopharyngeal walls was observed in 13 of 33 patients with PNL(unilateral invasion in 7 patients and bilateral invasion in 6) and 61 of 71 patients with NPC(unilateral invasion in 39 patients and bilateral invasion in 22). Statistical significances were found between diffuse and partial infiltration, unilateral and bilateral invasion, and symmetry and asymmetry of nasopharyngeal walls of PNL and NPC(χ2=23.75, 10.38, and 16.74, respectively; all P < 0.001). Tumor limited to the nasopharyngeal wall was found in 26 patients with PNL and 17 patients with NPC. Meanwhile, deep-structure invasion was detected in 7 patients with PNL and 54 patients with NPC. Significant difference was found in tumor invasion between PNL and NPC(χ2=27.94; P < 0.001). Tumor volumes of PNL, DLBCL, and NPC were 3.70±5.53×104, 5.05±6.89×104, and 2.06±2.31×104 mm3, respectively. No significant difference was found between tumor volume of PNL and DLBCL compared with NPC(t=1.63 and 1.85 respectively; both P>0.05). The SUVmax's of PNL and NPC were 12.00±6.34, 14.26±6.42, and 10.09±4.41, respectively. No significant difference was found between the SUVmax's of PNL and NPC(t=1.55; P>0.05). Significant difference was found between DLBCL and NPC(t=2.67; P < 0.05). Lesions in 21 patients with PNL and 24 patients with NPC protruded into posterior nasal apertures, and significant difference was found between the two groups(χ2=8.17; P < 0.05). A total of 26 patients with PNL had retropharyngeal or cervical lymphatic involvement. A total of 51 patients with NPC had retropharyngeal or cervical lymphatic metastasis. SUVmax, major diameter, minor diameter, and average diameter did not significantly differ from largest lymphatic involvement or metastasis in PNL and NPC(t=0.79, 1.37, 2.03, and 1.71, respectively; all P>0.05). Through CT imaging, lymphatic necrosis was detected in 3 of 26 patients with lymphatic involvement of PNL and 31 of 51 patients with lymphatic metastasis of NPC. Significant difference was found between the two groups(χ2=16.94; P < 0.001). Lymphatic blend was detected in 5 patients with PNL and in 6 patients with NPC. No significant difference was found between the two groups(χ2=0.78; P>0.05). ConclusionsPET/CT examination has a definite diagnosis value in patients with PNL and NPC. The differential diagnosis between PNL and NPC was mainly according to form, range, and invasion of nasopharyngeal lesion. The metabolic level of different pathological subtypes may be higher or lower than that of NPC. The metabolic activity of DLBCL was higher than that of NPC. The volume of nasopharyngeal lesion cannot be considered as a main basis to distinguish between PNL and NPC. -
图 1 鼻咽淋巴瘤和鼻咽癌患者的典型PET/CT表现图中, A、C为淋巴瘤病例, B、D为鼻咽癌病例, 左侧为PET/CT融合图像, 右侧为对应病例颅底CT骨窗图像。A:男性, 53岁, 弥漫性大B细胞淋巴瘤患者, 病变凸入鼻后孔, 与翼内肌、椎前肌分界清楚, 邻近颅底未见明确骨质改变;B:男性, 62岁, 非角化性未分化癌患者, 病变累及鼻咽壁范围, 与A病例大致相仿, 但颅底可见明显骨质破坏;C:男性, 66岁, 弥漫性大B细胞淋巴瘤患者, 病变累及全鼻咽壁, 凸入鼻后孔, 呈大致对称性生长, 与椎前肌分界清楚, 虽紧贴颅底, 但骨质无明显破坏;D:男性, 59岁, 非角化性未分化癌患者, 病变呈弥漫性生长, 凸入鼻后孔, 双侧不对称, 累及椎前肌及双侧咽旁间隙, 颅底见明显骨质破坏。
Figure 1. Typical PET/CT imaging features of primary nasopharyngeal lymphoma and nasopharyngeal carcinoma paients
图 2 鼻咽淋巴瘤和鼻咽癌淋巴结浸润或转移患者的典型PET/CT表现图中, 左侧为平扫CT图像, 右侧为PET/CT融合图像;A:男性, 66岁, 弥漫性大B细胞淋巴瘤患者, 为淋巴结颈部淋巴瘤浸润病例, 该病例淋巴结较大, 密度较均匀, 放射性摄取较均匀;B:女性, 53岁, 非角化性未分化鼻咽癌患者, 为鼻咽癌颈部淋巴结转移病例, 该病例中有2枚淋巴结未见坏死, 呈高代谢, 1枚淋巴结平扫见明显低密度坏死, 代谢较未坏死淋巴结明显减低。白色箭头所示为受肿瘤浸润或转移的淋巴结。
Figure 2. Typical PET/CT imaging features of lymphatic involvement or metastasis in primary nasopharyngeal lymphoma and nasopharyngeal carcinoma paients
表 1 PNL与NPC患者PET/CT显像各参数的比较
Table 1. Parameters of PNL and NPC in PET/CT imaging
参数 PNL NPC 检验值 P值 体积/×104 mm3 3.70±5.53 2.06±2.31 t=1.63 0.111 SUVmax 12.00±6.34 10.09±4.41 t=1.55 0.128 全壁/不全浸润 20/13 10/61 χ2=23.75 <0.001 双侧/单侧 26/7 32/39 χ2=10.38 <0.001 对称/不对称 14/19 6/65 χ2=16.74 <0.001 深部结构浸润 7/33(21.2%) 54/71(76.1%) χ2=27.94 <0.001 凸入鼻后孔 21/33(63.6%) 24/71(33.8%) χ2=8.17 0.004 淋巴结浸润或转移 26/33(78.8%) 51/71(71.8%) t=0.57 0.309 淋巴结SUVmax 11.24±6.28 10.09±5.52 t=0.79 0.433 淋巴结最大者长径/mm 27.15±16.41 22.58±6.61 t=1.37 0.128 淋巴结最大者短径/mm 22.35±12.07 17.29±5.6 t=2.03 0.052 淋巴结最大者平均直径/mm 24.75±14.15 19.82±5.67 t=1.71 0.099 淋巴结坏死 3/26(11.5%) 31/51(60.8%) χ2=16.94 <0.001 淋巴结融合 5/26(19.2%) 6/51(11.8%) χ2=0.78 0.376 注:表中,PNL:原发鼻咽淋巴瘤;NPC:鼻咽癌;SUVmax:最大标准化摄取值。 -
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