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放射性核素显像是术前甲状旁腺诊断的主要检查方法,1989年自99Tcm-MIBI作为显像剂应用以来,围绕其所开展的扫描技术主要有单核素双时相技术和双核素(99Tcm-MIBI/ 99TcmO4-)减影技术。2009年版欧洲核医学指南[1]指出,双核素减影技术和SPECT/CT融合技术在检出甲状旁腺功能亢进症(简称甲旁亢)的灵敏度优于单核素双时相技术。因不同显像技术的单独或联合应用,有关甲状旁腺放射性核素显像灵敏度(34%~100%)的各类报道存在很大差异[2-3]。另外,患者纳入或排除标准的不同也是其原因之一[4-5]。本研究的目的是在常规双时相平面显像的基础上联合减影平面显像和(或)SPECT/CT融合显像,评价联合显像对于甲旁亢患者术前病灶诊断的增益价值。
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原发性和继发性甲旁亢患者的术前PTH水平均高于正常值(0.6~12 pmol/L),两者血清PTH水平差异无统计学意义。由表 1可知,术前原发性甲旁亢患者符合高钙血症的临床生化表现,而继发性甲旁亢患者由于肾衰导致的低钙血症也与表 1统计的数据相符,术后随访甲旁亢患者的血清PTH、血钙水平均在正常范围内。
组别 血清甲状旁腺素(pmol/L) 血钙(mmol/L) 术前 术后 术前 术后 原发性甲旁亢患者(n=21) 102.4±88.8 6.8±3.1 2.9±0.3 2.9±0.3 继发性甲旁亢患者(n=7) 98.2±53.6 8.8±5.1 1.9±0.2 2.1±0.3 注:表中,血清甲状旁腺激素、血钙值均为术前2耀3 d及术后6个月的随访值。甲旁亢:甲状腺功能亢进症。 表 1 28例甲状旁腺功能亢进症患者术前和术后血清甲状旁腺素和血钙水平
Table 1. Serum levels of parathyroid hormone and blood calcium in 28 patients with hyperparathyroidism before and after operation
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28例患者中发现可疑性结节55处,其中40处甲旁亢病灶组织(19处腺瘤、20处增生、1处腺癌),15处非甲旁亢病灶组织(1处甲状腺腺瘤样增生、7处结节性甲状腺肿、3处结节性甲状腺肿合并桥本甲状腺炎、2处甲状腺腺瘤、2处桥本甲状腺炎伴重度异型增生)。术后测量腺瘤病灶的平均最大直径为(2.2±1.2)cm,最大直径范围0.6~5.0 cm;增生病灶的平均最大直径为(1.3±0.6)cm,最大直径范围为0.5~2.7 cm。腺瘤病灶的最大直径明显大于增生病灶,且差异有统计学意义(T=234,P=0.01)。
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不同显像技术对28例甲旁亢患者的诊断效能见表 2。在40处甲旁亢病灶组织和15处非甲旁亢病灶组织中,双时相分别检出19处病灶和2处阳性浓聚灶,其灵敏度、特异度分别为47.5%(19/40)、86.7%(13/15)。双时相诊断甲旁亢病灶为阴性结果的患者中,减影相检出其他5处病灶,提高了病灶检出的灵敏度(60.0% vs. 47.5%),差异有统计学意义(χ2=2.716,P=0.125)。在15处非甲旁亢病灶中,减影相检出4处阳性浓聚灶,由于假阳性浓聚灶的增多,减影相的特异度降低为73.3%(11/15),与双时相相比,多检出2处假阳性浓聚灶(桥本甲状腺炎伴重度异型增生)。SPECT/CT融合相检出甲旁亢病灶组织26处、非甲旁亢浓聚灶1处,SPECT/CT融合相检出的1处假阳性浓聚灶(甲状腺腺瘤样增生)在双时相和减影相上也均表现为阳性浓聚灶。
显像技术 甲旁亢患者(n=28) 原发性甲旁亢患者(n=21) 继发性甲旁亢患者(n=7) 灵敏度 特异度 准确率 灵敏度 特异度 准确率 灵敏度 特异度 准确率 双时相 47.5(19/40) 86.7(13/15) 58.2(32/55) 57.1(13/23) 81.8(9/11) 64.7(22/34) 36.8(6/17) 100.0(4/4) 47.6(10/21) 减影相 60.0(24/40) 73.3(11/15) 63.6(35/55) 76.2(17/23) 63.6(7/11) 70.5(24/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) SPECT/CT融合相 65.0(26/40)a 93.3(14/15)b 72.7(40/55) 85.7(20/23) 90.9(10/11) 88.2(30/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 双时相+减影相 62.5(25/40)a 73.3(11/15) 65.4(36/55) 80.9(19/23) 63.6(7/11) 76.4(26/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 双时相+SPECT/CT融合相 65.0(26/40)a 93.3(14/15) 72.7(40/55) 85.7(20/23) 90.9(10/11) 88.2(30/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 减影相+SPECT/CT融合相 67.5(27/40)a 93.3(14/15) 74.8(41/55) 90.4(21/23) 90.9(10/11) 91.2(31/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 联合显像 67.5(27/40)a 93.3(14/15) 74.8(41/55) 90.4(21/23) 90.9(10/11) 91.2(31/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 注:双时相:双时相平面显像;减影相:减影平面显像;SPECT/CT融合相:SPECT/CT融合显像;双时相+减影相:双时相平面显像联合减影平面显像;双时相+SPECT/CT:双时相平面显像联合SPECT/CT融合显像;减影相+SPECT/CT:减影平面显像联合SPECT/CT融合显像;联合显像:双时相平面显像联合减影平面显像及SPECT/CT融合显像。a:与双时相平面显像比较,灵敏度的差异均有统计学意义(χ2=5.024、2.716、5.024、6.635、6.635,均P < 0.05);b:与双时相平面显像比较,特异度的差异有统计学意义(χ2=4.432,P= 0.04)。甲旁亢:甲状旁腺功能亢进症;SPECT/CT:单光子发射计算机体层摄影术。 表 2 不同显像技术对28例甲旁亢患者的诊断效能(%)
Table 2. Diagnostic efficiency of different imaging techniques in 28 patients with hyperparathyroidism(%)
将双时相联合减影相分析,检出甲旁亢病灶25处、非甲旁亢病灶4处;将双时相联合SPECT/CT融合相分析,检出甲旁亢病灶26处、非甲旁亢病灶1处;双时相联合SPECT/CT融合相较双时相联合减影相多检出1处甲旁亢病灶,该腺瘤病灶位于近左叶下极处,直径<1 cm,在平面显像上表现为阴性病灶,而在SPECT/CT断层融合显像上表现为阳性病灶。
减影相联合SPECT/CT融合相与全部联合相诊断效能相同,检出甲旁亢病灶27处、非甲旁亢病灶1处,减影相联合SPECT/CT融合相与双时相联合SPECT/CT融合相比较,同样多检出1处甲旁亢病灶,主要是由于该患者2年前行甲状腺腺瘤切除术,因颈部解剖结构显像不清晰,在SPECT/CT相上表现为阴性病灶,而在减影相上表现为阳性病灶。减影相联合SPECT/CT融合相与双时相的灵敏度和特异度比较均有提高(67.5% vs. 47.5%;93.3% vs. 86.7%),差异均有统计学意义(χ2=6.635,P=0.02;χ2=4.432,P=0.04),
本研究中,4例原发性甲旁亢患者在注射99Tcm-MIBI 5 min时扫描,病灶处出现显像剂的快速浓聚,120 min时该浓聚灶显影减淡,术后病理证实为非典型甲状旁腺腺瘤(图 1)。典型病例见图 2、图 3。
图 1 原发性甲状旁腺功能亢进症患者(女性,58岁)术后病理图(×40,苏木精-伊红染色) 图中,镜下组织见异型细胞增生,腺瘤样排列,细胞核深染,间质血管丰富,诊断结果为非典型甲状旁腺腺瘤。
Figure 1. Postoperative pathological image of a patient with primary hyperthyroidism (×40, hematoxylin-eosin staining)
图 2 原发性甲状旁腺功能亢进患者(女性,58岁)99Tcm-MIBI平面显像图 图中,A:注射99Tcm-MIBI后5 min时(早期相)示甲状腺左叶下极见显像剂聚集(黑色箭头);B:注射99Tcm-MIBI后120 min时(延迟相)示甲状腺左叶下极显像剂聚集区减淡(黑色箭头);C:注射99TcmO4- 20 min时,正常甲状腺显像;D:将图A与图C进行数字化减影(减影相),显示甲状腺左叶下极见显像剂聚集,为甲状旁腺功能亢进病灶。MIBI:甲氧基异丁基异腈;99TcmO4-:99m锝高锝酸钠。
Figure 2. 99Tcm-MIBI planar images of a patient with primary hyperparathyroidism
SPECT/CT双时相联合减影技术诊断甲状旁腺功能亢进症的增益价值
Incremental value of SPECT/CT fusion imaging with dual-phase and dual-tracer technique in the diagnostic localization of parathyroid lesions in patients with hyperparathyroidism
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摘要:
目的探讨在99Tcm-MIBI双时相平面显像的基础上联合减影平面显像及SPECT/CT融合显像对甲状旁腺功能亢进症(以下简称甲旁亢)患者术前诊断的增益价值。 方法2015年3月至2016年3月序贯纳入本院甲旁亢患者28例。所有患者行放射性核素显像前1~2周检测血清甲状腺旁腺激素(PTH)及血钙值。静脉注射99TcmO4-40~60 MBq后行甲状腺99TcmO4-显像;待采集结束后,再次静脉注射99Tcm-MIBI 600 MBq,行早期99Tcm-MIBI平面显像,后行SPECT/CT融合显像。在行99Tcm-MIBI延迟平面显像后,获得减影平面显像。以病理诊断结果为金标准,计算各显像技术的诊断效能。显像技术检出病灶数据的比较采用配对卡方检验,其他数值型变量采用Wilcoxon秩和检验。 结果原发性和继发性甲旁亢患者术前检测PTH水平分别为(102.4±88.8)、(98.2±53.6)pmol/L,血钙水平分别为(2.9±0.3)、(1.9±0.2)mmol/L。28例甲旁亢患者共发现可疑性结节55处,其中40处甲旁亢病灶,15处非甲旁亢病灶。双时相检出19处病灶和2处阳性浓聚灶,其灵敏度为47.5%(19/40)。在双时相诊断甲旁亢病灶为阴性结果的患者中,减影相检出其他5处病灶,提高了病灶检出的灵敏度(60.0%),差异有统计学意义(χ2=2.716,P=0.125)。SPECT/CT融合显像检出甲旁亢病灶26处,将双时相和减影相联合分析,检出甲旁亢病灶25处、非甲旁亢病灶4处;将双时相联合SPECT/CT融合显像分析,检出甲旁亢病灶26处、非甲旁亢病灶1处。减影相联合SPECT/CT融合显像与全部联合显像诊断效能相同,检出甲旁亢病灶27处、非甲旁亢病灶1处,其灵敏度和特异度较双时相(67.5% vs.47.5%和93.3% vs.86.7%)提高,差异均有统计学意义(χ2=6.635,P=0.02;χ2=4.432,P=0.04)。 结论甲旁亢患者在行常规双时相平面显像的基础上联合减影平面显像及SPECT/CT融合显像,较单纯行双时相平面显像可以提高患者病灶的检出率。 -
关键词:
- 甲状旁腺功能亢进症 /
- 放射性核素显像 /
- 单光子发射计算机体层摄影术 /
- 甲状旁腺腺瘤
Abstract:ObjectiveTo investigate the increasing value of SPECT/CT fusion imaging with a dual-phase and dual-tracer technique for localizing parathyroid lesions in an unselected patient cohort with hyperparathyroidism. MethodsPatients with biochemically confirmed hyperparathyroidism were included in a prospective trial. The baseline values of all laboratory parameters were determined 1-2 weeks before 99Tcm-MIBI parathyroid scintigraphy was performed. Afterward, 40-60 MBq 99TcmO4- was injected with static thyroid image acquisition, followed by 600 MBq 99Tcm-MIBI injection. SPECT/CT was acquired immediately. With 99Tcm-MIBI additional delayed imaging were acquired. Patients were subjected to a subtraction protocol. Surgical and histological findings were used as the standard of comparison, sensitivity and specificity were calculated, and McNemar test and Wilcoton test were conducted to compare them at a significant level of 0.05. ResultsThe preoperative parathyroid hormone(PTH) levels of primary and secondary hyperparathyroidism were (102.4±88.8), (98.2±53.6) pmol/L, and the serum calcium level was (2.9±0.3), (1.9±0.2) mmol/L respectively. After surgical examination was completed, 40 enlarged parathyroid glands were found in 28 patients. Of these patients, 21 had single adenoma, and 7 had a multi-gland disease. The dual-phase technique could be used to accurately detect and diagnose parathyroid disease in 19 of 40 histological samples. The sensitivity and specificity for parathyroid disease localization were 47.5%(19/40). For those who yielded negative results and underwent the subtraction phase, five other lesions were detected, indicating an increased detection sensitivity(60.0%), the difference was significant(χ2=2.761, P=0.125). Furthermore, 26 of 40 histological samples were diagnosed with SPECT/CT fusion imaging, 25 hyperparathyroidism lesions were detected with dual-phase and subtraction-combined analysis, and 26 of 40 histological samples were accurately diagnosed with dual-phase combined with SPECT/CT fusion imaging. Subtraction-combined SPECT/CT fusion imaging and all combined scintigraphy diagnostic values exhibited the same performance. The sensitivity and specificity of the proposed method significantly improved compared with those of the dual-phase technique(67.5% vs. 47.5%, χ2=6.635, P=0.02; 93.3% vs. 86.7%, χ2=4.432, P=0.04). ConclusionFor patients with hyperparathyroidism, the detection rate of lesions by conventional dual-phase plane imaging combined with subtraction plane imaging and SPECT/CT fusion imaging was improved compared with that by single-and dual-phase plane imaging. -
图 2 原发性甲状旁腺功能亢进患者(女性,58岁)99Tcm-MIBI平面显像图 图中,A:注射99Tcm-MIBI后5 min时(早期相)示甲状腺左叶下极见显像剂聚集(黑色箭头);B:注射99Tcm-MIBI后120 min时(延迟相)示甲状腺左叶下极显像剂聚集区减淡(黑色箭头);C:注射99TcmO4- 20 min时,正常甲状腺显像;D:将图A与图C进行数字化减影(减影相),显示甲状腺左叶下极见显像剂聚集,为甲状旁腺功能亢进病灶。MIBI:甲氧基异丁基异腈;99TcmO4-:99m锝高锝酸钠。
Figure 2. 99Tcm-MIBI planar images of a patient with primary hyperparathyroidism
表 1 28例甲状旁腺功能亢进症患者术前和术后血清甲状旁腺素和血钙水平
Table 1. Serum levels of parathyroid hormone and blood calcium in 28 patients with hyperparathyroidism before and after operation
组别 血清甲状旁腺素(pmol/L) 血钙(mmol/L) 术前 术后 术前 术后 原发性甲旁亢患者(n=21) 102.4±88.8 6.8±3.1 2.9±0.3 2.9±0.3 继发性甲旁亢患者(n=7) 98.2±53.6 8.8±5.1 1.9±0.2 2.1±0.3 注:表中,血清甲状旁腺激素、血钙值均为术前2耀3 d及术后6个月的随访值。甲旁亢:甲状腺功能亢进症。 表 2 不同显像技术对28例甲旁亢患者的诊断效能(%)
Table 2. Diagnostic efficiency of different imaging techniques in 28 patients with hyperparathyroidism(%)
显像技术 甲旁亢患者(n=28) 原发性甲旁亢患者(n=21) 继发性甲旁亢患者(n=7) 灵敏度 特异度 准确率 灵敏度 特异度 准确率 灵敏度 特异度 准确率 双时相 47.5(19/40) 86.7(13/15) 58.2(32/55) 57.1(13/23) 81.8(9/11) 64.7(22/34) 36.8(6/17) 100.0(4/4) 47.6(10/21) 减影相 60.0(24/40) 73.3(11/15) 63.6(35/55) 76.2(17/23) 63.6(7/11) 70.5(24/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) SPECT/CT融合相 65.0(26/40)a 93.3(14/15)b 72.7(40/55) 85.7(20/23) 90.9(10/11) 88.2(30/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 双时相+减影相 62.5(25/40)a 73.3(11/15) 65.4(36/55) 80.9(19/23) 63.6(7/11) 76.4(26/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 双时相+SPECT/CT融合相 65.0(26/40)a 93.3(14/15) 72.7(40/55) 85.7(20/23) 90.9(10/11) 88.2(30/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 减影相+SPECT/CT融合相 67.5(27/40)a 93.3(14/15) 74.8(41/55) 90.4(21/23) 90.9(10/11) 91.2(31/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 联合显像 67.5(27/40)a 93.3(14/15) 74.8(41/55) 90.4(21/23) 90.9(10/11) 91.2(31/34) 42.1(7/17) 100.0(4/4) 52.4(11/21) 注:双时相:双时相平面显像;减影相:减影平面显像;SPECT/CT融合相:SPECT/CT融合显像;双时相+减影相:双时相平面显像联合减影平面显像;双时相+SPECT/CT:双时相平面显像联合SPECT/CT融合显像;减影相+SPECT/CT:减影平面显像联合SPECT/CT融合显像;联合显像:双时相平面显像联合减影平面显像及SPECT/CT融合显像。a:与双时相平面显像比较,灵敏度的差异均有统计学意义(χ2=5.024、2.716、5.024、6.635、6.635,均P < 0.05);b:与双时相平面显像比较,特异度的差异有统计学意义(χ2=4.432,P= 0.04)。甲旁亢:甲状旁腺功能亢进症;SPECT/CT:单光子发射计算机体层摄影术。 -
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