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肺磨玻璃结节(ground-glass nodule,GGN)是肺部常见的影像征象,在CT肺窗下表现为局灶性云雾状密度增高影、阴影内血管和支气管清晰可辨[1]。按其成分不同分为纯磨玻璃结节(pure ground-glass nodule,pGGN)和伴有实性成分的混合磨玻璃结节(mixed ground-glass nodule,mGGN)。肺GGN可是良性病变(如炎症、局灶性出血或纤维化等),也可为不同级别的肺腺癌[2]。由于其缺乏特异性,对其良恶性的鉴别一直是临床中的难题。PET/CT作为目前最先进的影像诊断技术之一,它既可以利用同机高分辨率CT(high resolution CT,HRCT)精确地显示病变的解剖学特点,又能提供病灶的18F-FDG代谢特征。但关于PET/CT对肺GGN的诊断价值仍存在较大争议,笔者回顾性分析了72例肺GGN的18F-FDG PET/CT联合同机HRCT影像学特点及代谢情况,旨在探讨18F-FDG PET/CT联合同机HRCT对肺GGN良恶性鉴别的临床应用价值。
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32例良性结节(pGGN 22例、mGGN 10例)中可见分叶征2例、毛刺征1例、空泡征1例、空气支气管征1例、胸膜凹陷征3例及血管集束征1例,余良性结节无上述征象(图 1)。40例恶性结节(pGGN 3例、mGGN 37例)中可见分叶征15例、毛刺征11例、空泡征8例、空气支气管征6例、胸膜凹陷征12例及血管集束征11例(图 2)。
图 1 良性肺磨玻璃结节的18F-FDG PET/CT联合同机高分辨率CT图患者男性,76岁,临床随访结节缩小且未新增实性成分归纳为良性病变。图中,A:高分辨率CT于右肺中叶内侧段见直径为9 mm,边界清晰的纯磨玻璃结节(红色箭头示);B:CT横断面图像;C:PET/CT融合图像,结节代谢低于本底,通过ROI技术在CT断层图上勾画病灶边界,对应PET得出SUVmax约为0.328;D:半年后行CT复查示结节直径缩小(红色箭头所示),约5 mm。
Figure 1. 18F-FDG PET/CT combined with the same scanner high resolution CT images of benign ground-glass nodule
图 2 恶性肺磨玻璃结节的18F-FDG PET/CT联合同机高分辨率CT图患者女性,56岁,病理证实为浸润性肺癌。图中,A~B:高分辨率CT断层图上于右肺下叶见直径约16 mm、有分叶征、毛刺征、空泡征及胸膜凹陷征的混合磨玻璃结节;C~D:18F-FDG PET/CT融合横断图像,结节呈高代谢,SUVmax约为5.110。
Figure 2. 18F-FDG PET/CT combined with the same scanner high resolution CT images of malignant ground-glass nodule
单因素分析结果显示,HRCT上良恶性肺GGN直径、密度类型、分叶征、毛刺征、胸膜凹陷征及血管集束征在两组间差异均有统计学意义,而空泡征及空气支气管征在两组之间的差异无统计学意义(表 1)。多因素logistic回归分析结果显示,混合型密度是恶性肺GGN的显著预测因子(χ2=10.261,OR=23.515,P < 0.05)。将良恶性结节的直径绘制成ROC,通过曲线分析得出,以结节直径≥11 mm为评判标准的约登指数最高,曲线下面积为0.798(图 3)。HRCT对肺GGN诊断的灵敏度、特异度、准确率分别为75.0%、81.3%、77.8%(表 2)。
指标 良性组
(n=32)恶性组
(n=40)χ2值 t值 P值 肺GGN的直径/mm 9.53±4.98 16.55±6.79 4.932 < 0.001 肺GGN密度 29.425 < 0.001 单纯型 22 3 混合型 10 37 分叶征 2 15 9.626 0.002 毛刺征 1 11 7.605 0.006 空泡征 1 8 3.214 0.073 空气支气管征 1 6 1.664 0.197 胸膜凹陷征 3 12 4.585 0.032 血管集束征 1 11 7.605 0.006 SUVmax 0.88±0.91 2.38±2.24 3.884 < 0.001 注:表中,GGN:肺磨玻璃结节。 表 1 良恶性肺磨玻璃结节在高分辨率CT征象及SUVmax中的比较
Table 1. Comparison of benign and malignant ground-glass in high resolution CT signs and SUVmax
图 3 肺磨玻璃结节直径及SUVmax的受试者工作特征曲线
Figure 3. Receiver operating characteristic curve of diameter and SUVmax of pulmonary ground-glass nodules
扫描方法 灵敏度 特异度 准确率 PET/CT 82.5(33/40) 78.1(25/32) 80.6(58/72) HRCT 75.0(30/40) 81.3(26/32) 77.8(56/72) PET/CT联合HRCT 90.0(36/40) 68.8(22/32) 80.6(58/72) 注:表中,HRCT:高分辨率CT。 表 2 PET/CT、HRCT、PET/CT联合HRCT对GGN的诊断效能分析(%)
Table 2. Diagnostic efficacy analysis of PET/CT, HRCT and PET/CT combined with the same scanner HRCT for GGN (%)
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良、恶性组肺GGNs的SUVmax分别为0.88±0.91,2.38±2.24;恶性组SUVmax明显高于良性组,差异有统计学意义(表 1)。将两组的SUVmax绘制成ROC,以约登指数最大时所对应的值为最佳临界值,当SUVmax≥0.9时,其评估肺GGN为恶性的灵敏度、特异度及曲线下面积分别为82.5%、78.1%、0.821(图 3)。18F-FDG PET/CT对肺GGN诊断的灵敏度、特异度、准确率分别为82.5%、78.1%、80.6%。18F-FDG PET/CT联合HRCT对肺GGN诊断的灵敏度、特异度、准确率分别为90.0%、68.8%、80.6%(表 2)。
18F-FDG PET/CT联合同机HRCT对肺磨玻璃结节的诊断价值
Value of 18F-FDG PET/CT combined with the same scanner HRCT in the diagnosis of pulmonary ground-glass nodules
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摘要:
目的探讨18F-FDG PET/CT联合同机高分辨率CT(HRCT)对肺磨玻璃结节的诊断价值。 方法回顾性分析经手术病理或临床随访证实的72例肺磨玻璃结节患者(恶性40例、良性32例)资料,对其临床资料、影像特征、SUVmax等参数进行统计学分析。 结果单因素分析结果显示,HRCT下肺磨玻璃结节的直径(t=4.932,P < 0.001)、密度(χ2=29.425,P < 0.001)、分叶征(χ2=9.626,P=0.002)、毛刺征(χ2=7.605,P=0.006)、胸膜凹陷征(χ2=4.585,P=0.032)、血管集束征(χ2=7.605,P=0.006)及SUVmax(t=3.884,P < 0.001)在良、恶性两组间差异均有统计学意义。而性别(χ2=0.026,P=0.873)、年龄(t=1.417,P=0.161)、空泡征(χ2=3.214,P=0.073)及空气支气管征(χ2=1.664,P=0.197)在两组间差异均无统计学意义。多因素分析结果显示,混合型密度是鉴别良恶性病变的显著预测因子(χ2=10.261,OR=23.515,P < 0.05)。受试者工作特征曲线分析结果显示,以结节直径≥11 mm、SUVmax≥0.9为评判指标具有较好的鉴别精度。HRCT、PET/CT及PET/CT联合HRCT对肺磨玻璃结节诊断的灵敏度分别为75.0%、82.5%、90.0%,特异度分别为81.3%、78.1%、68.8%,准确率分别为77.8%、80.6%、80.6%。 结论18F-FDG PET/CT联合HRCT通过对肺磨玻璃结节的代谢情况及影像学分析,对其鉴别诊断有一定的临床价值,两者联合使用可以提高诊断的灵敏度。 -
关键词:
- 氟脱氧葡萄糖F18 /
- 正电子发射断层显像术 /
- 高分辨率CT /
- 磨玻璃结节 /
- 标准化摄取值
Abstract:ObjectiveTo investigate the value of 18F-FDG PET/CT combined with the same scanner high resolution CT (HRCT) in the diagnosis of pulmonary ground-glass nodules (GGNs). MethodsA total of 72 patients with pulmonary GGNs (40 cases were malignant, 32 presented benign lesions) were retrospectively analyzed and confirmed by surgical pathology or clinical follow-up.The clinical data, imaging features, maximum standardized uptake value (SUVmax) were analyzed statistically. ResultsUnivariate analysis showed significant differences in diameter (t=4.932, P < 0.001), density type (χ2=29.425, P < 0.001), lobular sign (χ2=9.626, P=0.002), spiculation sign (χ2=7.605, P=0.006), pleural indentation (χ2=4.585, P=0.032), vascular convergence (χ2=7.605, P=0.006), and SUVmax(t=3.884, P < 0.001).By contrast, no differences in gender (χ2=0.026, P=0.873), age (t=1.417, P=0.161), vacuole sign (χ2=3.214, P=0.073), and air bronchus sign (χ2=1.664, P=0.197) were observed between the two groups in HRCT.Multivariate analysis showed that mixed density was a notable predictor of malignancy (χ2=10.261, OR=23.515, P < 0.05).The receiver operating characteristic curve showed the diameter ≥ 11 mm and SUVmax ≥ 0.9 as the standard reference indexes that yielded good identification accuracy.The sensitivity of HRCT, PET/CT, and PET/CT combined with the same scanner HRCT in the diagnosis of GGNs were 75.0%, 82.5%, and 90.0%, with specificity values of 81.3%, 78.1%, and 68.8% and accuracy of 77.8%, 80.6%, and 80.6%, respectively. Conclusions18F-FDG PET/CT combined with the same scanner HRCT present certain clinical value in the differential diagnosis of GGNs by analyzing the metabolic condition and imaging characteristics.This approach can improve diagnostic sensitivity. -
图 1 良性肺磨玻璃结节的18F-FDG PET/CT联合同机高分辨率CT图患者男性,76岁,临床随访结节缩小且未新增实性成分归纳为良性病变。图中,A:高分辨率CT于右肺中叶内侧段见直径为9 mm,边界清晰的纯磨玻璃结节(红色箭头示);B:CT横断面图像;C:PET/CT融合图像,结节代谢低于本底,通过ROI技术在CT断层图上勾画病灶边界,对应PET得出SUVmax约为0.328;D:半年后行CT复查示结节直径缩小(红色箭头所示),约5 mm。
Figure 1. 18F-FDG PET/CT combined with the same scanner high resolution CT images of benign ground-glass nodule
表 1 良恶性肺磨玻璃结节在高分辨率CT征象及SUVmax中的比较
Table 1. Comparison of benign and malignant ground-glass in high resolution CT signs and SUVmax
指标 良性组
(n=32)恶性组
(n=40)χ2值 t值 P值 肺GGN的直径/mm 9.53±4.98 16.55±6.79 4.932 < 0.001 肺GGN密度 29.425 < 0.001 单纯型 22 3 混合型 10 37 分叶征 2 15 9.626 0.002 毛刺征 1 11 7.605 0.006 空泡征 1 8 3.214 0.073 空气支气管征 1 6 1.664 0.197 胸膜凹陷征 3 12 4.585 0.032 血管集束征 1 11 7.605 0.006 SUVmax 0.88±0.91 2.38±2.24 3.884 < 0.001 注:表中,GGN:肺磨玻璃结节。 表 2 PET/CT、HRCT、PET/CT联合HRCT对GGN的诊断效能分析(%)
Table 2. Diagnostic efficacy analysis of PET/CT, HRCT and PET/CT combined with the same scanner HRCT for GGN (%)
扫描方法 灵敏度 特异度 准确率 PET/CT 82.5(33/40) 78.1(25/32) 80.6(58/72) HRCT 75.0(30/40) 81.3(26/32) 77.8(56/72) PET/CT联合HRCT 90.0(36/40) 68.8(22/32) 80.6(58/72) 注:表中,HRCT:高分辨率CT。 -
[1] Lee HY, Lee KS. Ground-glass opacity nodules:histopathology, imaging evaluation, and clinical implications[J]. J Thorac Imaging, 2011, 26(2):106-118. DOI:10.1097/RTI.0b013e3181fbaa64. [2] Goo JM, Park CM, Lee HJ. Ground-glass nodules on chest CT as imaging biomarkers in the management of lung adenocarcinoma[J].AJR Am J Roentgenol, 2011, 196(3):533-543. DOI:10.2214/AJR.10.5813. [3] Travis WD, Brambilla E, Noguchi M, et al. International association for the study of lung cancer/American thoracic society/European respiratory society:international multidisciplinary classification of lung adenocarcinoma:executive summary[J]. Proc Am Thorac Soc, 2011, 8(5):381-385. DOI:10.1513/pats.201107-042ST. [4] Zhang L, Yankelevitz DF, Carter D, et al. Internal growth of nonsolid lung nodules:radiologic-pathologic correlation[J]. Radiology, 2012263(1):279-286. DOI:10.1148/radiol.11101372. [5] Saito H, Kameda Y, Masui K, et al. Correlations between thin-section CT findings, histopathological and clinical findings of small pulmonary adenocarcinomas[J]. Lung Cancer, 2011, 71(2):137-143. DOI:10.1016/j.lungcan.2010.04.018. [6] Tsushima Y, Tateishi U, Uno H, et al. Diagnostic performance of PET/CT in differentiation of malignant and benign non-solid solitary pulmonary nodules[J]. Ann Nucl Med, 2008, 22(7):571-577. DOI:10.1007/s12149-008-0160-1. [7] Naidich DP, Bankier AA, Macmahon H, et al. Recommendations for the management of subsolid pulmonary nodules detected at CT:a statement from the Fleischner Society[J]. Radiology, 2013, 266(1):304-317. DOI:10.1148/radiol.12120628. [8] Hu H, Wang Q, Tang H, et al. Multi-slice computed tomography characteristics of solitary pulmonary ground-glass nodules:Differences between malignant and benign[J]. Thorac Cancer, 2016, 7(1):80-87. DOI:10.1111/1759-7714.12280. [9] Eguchi T, Yoshizawa A, Kawakami S, et al. Tumor size and computed tomography attenuation of pulmonary pure ground-glass nodules are useful for predicting pathological invasiveness[J/OL]. PLoS One, 2014, 9(5):e97867[2017-03-06]. http://www.ncbi.nlm.nih.gov/pubmed/24846292. DOI:10.1371/journal.pone.0097867. [10] Yanagawa M, Tanaka Y, Kusumoto M, et al. Automated assessment of malignant degree of small peripheral adenocarcinomas using volumetric CT data:Correlation with pathologic prognostic factors[J]. Lung Cancer, 2010, 70(3):286-294. DOI:10.1016/j.lungcan.2010. 03.009. [11] 张善华, 王和平, 王善军, 等.肺部局灶性磨玻璃影的CT诊断[J].医学影像学杂志, 2012, 22(8):1329-1332. DOI:10.3969/j.issn.1006-9011.2012.08.027.
Zhang SH, Wang HP, Wang SJ, et al. CT diagnosis of pulmonary focal ground glass opacity[J]. J Med Imaging, 2012, 22(8):1329-1332. doi: 10.3969/j.issn.1006-9011.2012.08.027[12] Fan L, Liu SY, Li QC, et al. Multidetector CT features of pulmonary focal ground-glass opacity:differences between benign and malignant[J]. Br J Radiol, 2012, 85(115):897-904. DOI:10.1259/bjr/33150223. [13] Inoue D, Gobara H, Hiraki T, et al. CT fluoroscopy-guided cutting needle biopsy of focal pure ground-glass opacity lung lesions:diagnostic yield in 83 lesions[J]. Eur J Radiol, 2012, 81(2):354-359. DOI:10.1016/j.ejrad.2010.11.025. [14] Nam KB, Kim TJ, Park JS, et al. Long-Term Follow-Up results from PET/CT surveillance after surgical resection of lung adenocarcinoma manifesting as Ground-Glass opacity[J/OL]. Medicine(Baltimore), 2016, 95(4):e2634[2017-03-06]. DOI:10.1097/MD.0000000000002634. [15] Chiu CF, Lin YY, Hsu WH, et al. Shorter-time dual-phase FDG PET/CT in characterizing solid or ground-glass nodules based on surgical results[J]. Clin Imaging, 2012, 36(5):509-514. DOI:10. 1016/j.clinimag.2011.11.032. [16] Song SH, Ahn JH, Lee HY, et al. Prognostic impact of nomogram based on whole tumour size, tumour disappearance ratio on CT and SUVmax on PET in lung adenocarcinoma[J]. Eur Radiol, 2016, 26(6):1538-1546. DOI:10.1007/s00330-015-4029-0. [17] 王艳丽, 房娜, 曾磊, 等. 18F-FDG PET-CT联合同机HRCT对肺孤立性单纯性磨玻璃结节的诊断价值研究[J].临床放射学杂志, 2015, 34(2):212-218. DOI:10.13437/j.cnki.jcr.2015.02.012.
Wang YL, Fang N, Zeng L, et al. Evaluation of 18F-FDG PET-CT Double-Phase imaging combined with HRCT performed on the same scanner in diagnosing solitary pulmonary ground glass nodules[J]. J Clin Radiol, 2015, 34(2):212-218. doi: 10.13437/j.cnki.jcr.2015.02.012