-
我国是胃癌高发国家,手术、化疗、放疗或联合治疗是目前胃癌的主要治疗方式。临床医师通常根据胃癌的浸润程度、转移淋巴结的数量以及有无远隔转移,制定合理的治疗方案。目前主要采用胃镜检查、内镜超声和螺旋CT来诊断原发灶和转移情况,但易漏检远处淋巴结和远隔脏器转移灶,此外,胃镜检查容易漏诊一些发生于黏膜下的胃癌,延误患者的最佳就诊时间。18F-FDG PET/CT在胃癌术前分期和评估复发、转移中具有重要的临床价值,本文主要探讨18F-FDG PET/CT在初诊胃癌患者临床分期和治疗方案制定中的应用价值。
-
46例疑诊胃癌患者术后或胃镜病理检查结果如下。病理检查结果:溃疡型改变32例、肿块型改变14例;病变位置的分布情况:胃窦部18例、胃体部10例、胃底-贲门部4例、幽门部4例、弥漫型10例。组织学病理检查结果:腺癌28例、印戒细胞癌8例、增生性息肉2例、慢性炎症改变8例。34例患者行手术治疗,按照标准[3]进行临床分期,结果:Ⅰ期9例、Ⅱ期4例、Ⅲ期6例、Ⅳ期15例。
-
46例疑诊患者中,PET/CT图像目测结果为:40例原发灶表现为阳性,6例表现为阴性。其中包括34例真阳性、6例假阳性、4例真阴性和2例假阴性。40例阳性患者中,2例患者仅表现为胃壁增厚,1例证实为印戒细胞癌,1例证实为胃息肉。另2例患者仅表现为18F-FDG高摄取,最终经病理证实均为慢性炎症。典型胃癌原发灶图像见图 1。半定量分析结果为:SUVmax为2.4~30.6,平均值为11.68±5.68;Tmax为6.1~27.8 mm,平均值为(15.08±5.92)mm。原发灶SUVmax与Tmax呈正相关(r=0.922,P=0.001)。以病理结果作为“金标准”,PET/CT诊断胃癌原发灶的灵敏度、特异度、准确率分别为94.4%(34/36)、40.0%(4/10)、82.6%(38/46)。18F-FDG PET/CT与胃镜或术后病理结果对比见表 1。
图 1 胃癌患者18F-FDG PET/CT显像图
Figure 1. Images of 18F-FDG PET/CT imaging of a 45-year-old male patient with gastric cancer
18F-FDG PET/CT诊断结果 胃镜或术后病理结果 总计 恶性病变 良性病变(含正常) 恶性病变 34 6 40 良性病变(含正常) 2 4 6 总计 36 10 46 表 1 18F-FDG PET/CT与胃镜或术后病理诊断胃癌原发病灶结果比较(例)
Table 1. Comparison of 18F-FDG PET/CT and gastroscopy/postoperative pathology in diagnosis of primary lesions of gastric carcinoma (case)
-
原发灶病理组织明确诊断为胃癌的36例患者,经手术病理或者随访证实(伴有远处转移的患者)有26例伴有区域淋巴结转移,部分患者甚至存在多个区域淋巴结转移,其中以胃周淋巴结转移最多见。这36例患者中,PET/CT显像提示有22例患者出现区域淋巴结糖代谢增高(SUVmax>2.5),部分患者伴有淋巴结肿大(短径>1.0 cm),其中2例病理证实为淋巴结炎性增生,而有6例病理证实的淋巴结转移灶在PET/CT上无阳性表现;PET/CT显像提示14例患者不伴有区域淋巴结转移,包括8例真阴性和6例假阴性患者。病理诊断为良性的10例患者,PET/CT检查均未见区域淋巴结“转移”征象。PET/CT显像诊断淋巴结转移的灵敏度为76.9%(20/26)、特异度为90.0%(18/20)、准确率为82.6%(38/46)。
-
经病理证实为胃癌的患者有36例,病理和(或)随访发现14例远处转移(部分伴有多处远处转移),其中,肺转移3例、肝转移6例、腹膜转移8例、胰转移2例、远处淋巴结转移6例。46例患者中,PET/CT检查发现14例患者有远处转移征象,32例患者表现为阴性。PET/CT检查远处转移为阳性的14例患者中,13例经手术病理和(或)随访证实;1例PET/CT检查发现胸膜下1个结节影同时伴糖代谢增高,考虑为肺转移病灶,由于病灶较局限,患者行手术切除,手术病理结果提示为非干酪性肉芽肿(结核球)。PET/CT检查远处转移为阴性的32例患者中,假阴性1例、真阴性31例。1例患者PET/CT检查未发现远处转移征象,手术过程中发现腹膜受侵,术后病理结果证实为转移病灶。PET/CT检查对胃癌远处转移的灵敏度、特异度、准确率分别为92.9%(13/14)、96.9%(31/32)、95.7%(44/46)。本研究中,经PET/CT检查发现了远处转移病灶,使得7例患者更改了原治疗方案,其中包括4例患者放弃了手术治疗,更换为化疗;2例原计划行根治术的患者改为姑息手术治疗联合化疗;1例患者伴有孤立性肝转移,为延长生存时间进行了介入治疗。有7例患者行PET/CT检查后未改变其治疗决策,但其中3例患者PET/CT检查发现了更多的病灶,使其更加全面、更加准确地评估了病情,为临床治疗方案的制定提供了准确的参考信息,同时为后续治疗及疗效评估提供了重要依据。
18F-FDG PET/CT显像在胃癌分期及治疗方案制定中的应用价值
Value of 18F-FDG PET/CT imaging on the staging of gastric carcinoma and its influence on therapeutic schedule formulation
-
摘要:
目的探讨18F-FDG PET/CT显像在胃癌分期及治疗方案制定中的应用价值。 方法回顾性分析46例临床疑诊胃癌患者的18F-FDG PET/CT图像,采用目测法和半定量法对患者PET/CT图像进行分析,即测定SUVmax与最大胃壁厚度(Tmax),以胃镜或手术后取得的病理结果作为“金标准”,评估18F-FDG PET/CT显像对病灶的诊断效能,并采用Pearson相关分析法分析SUVmax与Tmax的相关性。 结果18F-FDG PET/CT诊断原发病灶的灵敏度、特异度和准确率分别为94.4%、40.0%和82.6%;原发灶SUVmax与Tmax呈正相关(r=0.922,P=0.001);18F-FDG PET/CT诊断淋巴结转移及远处转移的灵敏度、特异度和准确率分别为76.9%、90.0%、82.6%和92.9%、96.9%、95.7%。 结论18F-FDG PET/CT在检测胃癌的原发病灶、淋巴结转移灶和远处转移灶时有较高的特异度和灵敏度,在评估临床分期、指导临床制定正确的治疗方案中具有重要的应用价值。 -
关键词:
- 胃肿瘤 /
- 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
Abstract:ObjectiveTo explore the value of the 18F-FDG PET/CT imaging on the staging of gastric carcinoma and its influence on therapeutic schedule formulation. MethodsA retrospective analysis on the 18F-FDG PET/CT images of 46 patients with suspected clinical diagnosis of gastric cancer was performed through visual and semiquantitative evaluation by detecting the SUVmax and the maximum gastric wall thickness (Tmax). Subsequently, the diagnostic efficiency of the 18F-FDG PET/CT imaging for lesions was assessed by comparing with the pathology obtained from gastroscopy or postoperative pathology. Pearson correlation analysis was used to analyze the correlation between SUVmax and Tmax. ResultsThe sensitivity, specificity, and accuracy of 18F-FDG PET/CT imaging in detecting primary lesions were 94.4%, 40.0%, and 82.6%, respectively. The SUVmax of the primary lesions was positively correlated with the Tmax (r=0.922, P=0.001). The sensitivity, specificity, and accuracy of 18F-FDG PET/CT imaging were 76.9%, 90.0%, and 82.6% in detecting lymph node metastasis and 92.9%, 96.9%, and 95.7%, respectively, in recognizing distant metastasis. Conclusions18F-FDG PET/CT imaging showed high specificity and sensitivity in detecting primary foci, lymph node metastasis, and distant metastasis of gastric cancer. This technique is also remarkably important in accurate assessment of the clinical stage and therapeutic schedule formulation. -
表 1 18F-FDG PET/CT与胃镜或术后病理诊断胃癌原发病灶结果比较(例)
Table 1. Comparison of 18F-FDG PET/CT and gastroscopy/postoperative pathology in diagnosis of primary lesions of gastric carcinoma (case)
18F-FDG PET/CT诊断结果 胃镜或术后病理结果 总计 恶性病变 良性病变(含正常) 恶性病变 34 6 40 良性病变(含正常) 2 4 6 总计 36 10 46 -
[1] 尤徐阳, 贺锋, 徐巧玲, 等. 18F-FDG PET/CT同机序贯增强CT在胃癌治疗前分期中的价值[J].中华核医学与分子影像杂志, 2016, 36(4):315-321. DOI:10.3760/cma.j.issn.2095-2848. 2016. 04.009.
You XY, He F, Xu QL, et al. Sequential 18F-FDG PET/CT and contrast-enhanced CT in the pretreatment staging of gastric cancer[J]. Chin J Nucl Med Mol Imaging, 2016, 36(4):315-321. doi: 10.3760/cma.j.issn.2095-2848.2016.04.009[2] Xu H, Guo R, Xu W, et al. 18F-fluorodeoxyglucose positron emission tomography-computed tomography scan after gastric endoscopy in those who present with non-specific symptoms, is it necessary or not?[J]. South Asian J Cancer, 2017, 6(2):59-63. DOI:10.4103/2278-330X.208853. [3] 陈凛, 卢灿荣.新版日本胃癌"处理规约"和"治疗指南"之解读[J].临床外科杂志, 2012, 20(1):10-14. DOI:10.3969/j.issn.1005-6483.2012.01.005.
Chen B, Lu CR. Interpretation of the new version of gastric cancer in Japan "Processing protoco" and "treatment guidelines"[J]. J Clin Surg, 2012, 20(1):10-14. doi: 10.3969/j.issn.1005-6483.2012.01.005[4] 金民山, 张俊, 姜一逸, 等. 18F-FDG PET/CT在不明原发灶肿瘤中的临床应用价值[J].国际放射医学核医学杂志, 2017, 41(2):94-97, 149. DOI:10.3760/cma.j.issn.1673-4114.2017.02.003.
Jin MS, Zhang J, Jiang YY, et al. Clinical value of 18F-FDG PET/CT in cancer of unknown primary[J]. Int J Radiat Med Nucl Med, 2017, 41(2):94-97, 149. doi: 10.3760/cma.j.issn.1673-4114.2017.02.003[5] Stahl A, Ott K, Weber WA, et al. FDG PET imaging of locally advanced gastric carcinomas:correlation with endoscopic and histopathological findings[J]. Eur J Nucl Med Mol Imaging, 2003, 30(2):288-295. DOI:10.1007/s00259-002-1029-5. [6] Chen R, Zhou X, Liu J, et al. Relationship between 18F-FDG PET/CT findings and HER2 expression in gastric cancer[J]. J Nucl Med, 2016, 57(7):1040-1044. DOI:10.2967/jnumed.115.171165. [7] Tian J, Chen L, Wei B, et al. The value of vesicant 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) in gastric malignancies[J]. Nucl Med Commun, 2004, 25(8):825-831. DOI:10.1097/01.mnm.0000135042.54461.f6. [8] Mochiki E, Kuwano H, Katoh H, et al. Evaluation of 18F-2-deoxy-2-fluoro-D-glucose positron emission tomography for gastric cancer[J]. World J Surg, 2004, 28(3):247-253. DOI:10.1007/s00268-003-7191-5. [9] Fonocho E, Aydin N, Reddy S, et al. Limitations in the use of 18F-FDG PET in the pre-operative staging of gastric cancer:A case series[J]. Int J Surg Case Rep, 2017, 36:147-150. DOI:10.1016/j.ijscr.2017. 05.026. [10] Yamada A, Oguchi K, Fukushima M, et al. Evaluation of 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography in gastric carcinoma:relation to histological subtypes, depth of tumor invasion, and glucose transporter-1 expression[J]. Ann Nucl Med, 2006, 20(9):597-604. doi: 10.1007/BF02984657 [11] Dassen AE, Lips DJ, Hoekstra CJ, et al. FDG-PET has no definite role in preoperative imaging in gastric cancer[J]. Eur J Surg Oncol, 2009, 35(5):449-455. DOI:10.1016/j.ejso.2008.11.010. [12] Ajani JA, Bentrem DJ, Besh S, et al. Gastric cancer, version 2.2013:featured updates to the NCCN Guidelines[J]. J Natl Compr Canc Netw, 2013, 11(5):531-546. DOI:10.6004/jnccn.2013.0070. [13] Ozkan E, Araz M, Soydal C, et al. The role of 18F-FDG-PET/CT in the preoperative staging and posttherapy follow up of gastric cancer:comparison with spiral CT[J]. World J Surg Oncol, 2011, 9:75. DOI:10.1186/1477-7819-9-75. [14] Shin JA, Park JW, An M, et al. Diagnostic accuracy of 18F-FDG positron emission tomography for evaluation of hepatocellular carcinoma[J]. Korean J Hepatol, 2006, 12(4):546-552. [15] Imamura H, Kurokawa Y, Kawada J, et al. Influence of bursectomy on operative morbidity and mortality after radical gastrectomy for gastric cancer:results of a randomized controlled trial[J]. World J Surg, 2011, 35(3):625-630. DOI:10.1007/s00268-010-0914-5. [16] Fujita J, Kurokawa Y, Sugimoto T, et al. Survival benefit of bursectomy in patients with resectable gastric cancer:interim analysis results of a randomized controlled trial[J]. Gastric Cancer, 2012, 15(1):42-48. DOI:10.1007/s10120-011-0058-9. [17] Lordick F, Ott K, Krause BJ, et al. PET to assess early metabolic response and to guide treatment of adenocarcinoma of the oesophagogastric junction:the MUNICON phase Ⅱ trial[J]. Lancet Oncol, 2007, 8(9):797-805. DOI:10.1016/S1470-2045(07)70244-9.