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肺癌性淋巴管病(pulmonary lymphangitic carcinomatosis, PLC)是一种肺内或肺外恶性肿瘤转移并在肺淋巴管内弥漫性广泛生长的肺内转移癌,是肺内外肿瘤肺内转移的一种特殊类型。PLC的预后极差,50%~85%的患者生存期仅为3~6个月,且临床诊断较困难,常与肺炎、充血性心衰、肺栓塞、哮喘、结节病等间质性肺病变相混淆[1]。目前主要依靠患者的临床表现、恶性肿瘤病史、高分辨率CT和(或)薄层CT的影像学特点及随访结果进行综合确诊。我们通过回顾性分析确诊的PLC的18F-FDG PET/CT影像学特点,总结其特征性表现,探讨PET/CT对PLC的诊断价值。
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选取2016年8月至2017年9月在我院我科行PET/CT检查并经病理结果确诊的PLC患者53例。其中男性34例、女性19例,年龄39~84岁,平均年龄(62.67±10.28)岁。53例PLC患者包括肺腺癌39例、肺鳞癌5例、肺小细胞癌5例、食管癌3例和纵隔鳞癌1例。纳入标准:①明确的恶性肿瘤病史并经病理结果证实;②肺门及纵隔高代谢淋巴结经病理证实为转移性病灶。③PLC病灶经病理证实(5例)或经高分辨率CT和(或)薄层CT检查并且结合多次随访(正规抗炎无效、肿瘤综合治疗后病灶未进展或好转等)综合证实(48例)。排除标准:疑似PLC但不符合纳入标准的病例均被排除在外。本研究获得我院伦理委员会批准,批准号:KS(Y)1779,所有患者均于检查前签署了知情同意书。
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患者均行PET/CT+薄层屏气CT扫描。仪器为西门子Biograph mCT-S PET/CT(64排螺旋CT)。18F-FDG由上海原子科兴药业有限公司生产提供,PH值约为7.0,放化纯度>95%。受检患者检查前禁食6 h以上,血糖控制在正常水平(< 7.8 mmol/L),注射18F-FDG 3.7~5.55 MBq/kg(0.10~0.15 mCi/kg),平静休息45~60 min,扫描前排空膀胱尿液并除去身上所有影响图像质量的异物。受检患者采用仰卧位,双臂交叉环抱于头顶,先行CT定位扫描,扫描范围从颅底至股骨上1/3处,选择检查范围后进行螺旋CT扫描,扫描条件:管电压120 kV,根据管电流调节技术(CARE Dose 4D)自动调节,层厚5 mm。再行全身PET图像采集5~6个床位,采集时间为2 min/床位。利用CT扫描数据对PET图像进行衰减校正,采用TrueX+飞行时间(TOF)法重建图像,获得横断面、矢状面及冠状面的PET图像、CT图像及PET/CT融合图像。所有患者扫描后均加做胸部薄层屏气CT平扫,层厚1.0 mm,管电压120 kV,管电流110 mA,扫描时间0.5 s/圈,肺窗,重建函数为B50f medium sharp。
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测量方法:采集好的图像传输至PACS图像后处理工作站。由1名主治及主治以上职称医师进行PLC病灶确认及CT ROI的勾画,另1名主任医师进行复核诊断及数据审核。应用西门子公司后处理软件在CT图像上勾画ROI,工作站根据以下公式计算出平均标准化摄取值(mean standardized uptake value,SUVmean)。
${\rm{SU}}{{\rm{V}}_{{\rm{mean}}}} = \frac{{{\rm{感兴趣区域活性(MBq/mL)}}}}{{{\rm{注射计量[MBq/单位体重(g)]}}}} $ SUV易受到患者体重、肺组织摄取放射性能力等因素影响,为了克服SUV测定的缺点,使病例间去除个体本底的差异,我们选择肺动脉干水平计算纵隔血池活性,然后计算ROI与纵隔血池标准化比值(standardized uptake ratios, SUR)。
${\rm{SUV}} = \frac{{{\rm{感兴趣区域活性(MBq/mL)}}}}{{{\rm{纵膈血池活性(MBq/mL)}}}} $ 测定指标:测定增厚小叶间隔肺野、对侧正常小叶间隔肺野、受累支气管血管束、对侧同节段正常支气管血管束、肿大的淋巴结以及纵隔血池的SUVmean;测定并计算增厚小叶间隔肺野、对侧正常小叶间隔肺野、受累支气管血管束及对侧同节段正常支气管血管束与纵隔血池的SUR。
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应用SPSS19.0软件对数据进行统计学分析。计量资料采用均数±标准差(x±s)表示。当计量资料呈正态分布且方差齐时,两组数据的比较采用独立样本t检验,P < 0.05表示差异有统计学意义。
18F-FDG PET/CT在肺癌性淋巴管病的影像学特征及诊断价值
Imaging features and diagnostic value of 18F-FDG PET/CT in pulmonary lymphangitic carcinomatosis
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摘要:
目的探讨肺癌性淋巴管病(PLC)18F-FDG PET/CT的影像学特征及其诊断价值。 方法回顾性分析我院2016年8月至2017年9月临床确诊的53例PLC患者,均行PET/CT+薄层屏气CT扫描。利用CT扫描数据对PET图像进行衰减校正,采用TrueX+飞行时间法重建图像并进行分析、总结。测定各感兴趣区的平均标准化摄取值(SUVmean)并计算标准化比值(SUR),比较不同区域的SUVmean和SUR的差异。 结果53例PLC患者中,51例(96%,51/53)可见增厚小叶间隔伴放射性摄取,增厚小叶间隔所在肺野SUVmean明显高于正常肺野,差异有统计学意义(1.46±0.92 vs.0.58±0.18,t=19.85,P < 0.01);增厚小叶间隔肺野/纵隔血池的SUR高于正常小叶间隔肺野/纵隔血池的SUR,差异有统计学学意义(0.84±0.38 vs.0.40±0.21,t=12.77,P < 0.01)。51例(96%,51/53)可见支气管血管束放射性摄取增强。PLC累及支气管血管束SUVmean明显高于正常支气管血管束,差异有统计学意义(3.85±1.67 vs.0.90±0.19,t=15.45,P < 0.01)。增粗支气管血管束/纵隔血池的SUR高于正常支气管血管束/纵隔血池的SUR(2.89±0.94 vs.0.59±0.19,t=12.62,P < 0.01)。51例(96%,51/53)可见肺门及纵隔淋巴结肿大伴放射性摄取增强。 结论典型PLC患者的PET/CT融合显像特征为支气管血管束增粗伴放射性浓聚;PLC累及小叶间隔结节样增厚伴放射性摄取增高;肺门和纵隔淋巴结肿大或显示伴放射性异常浓聚。PET/CT融合显像结合局部SUVmean和SUR的测定,不但可以更早地诊断PLC病灶,而且可以提高对PCL病灶诊断的准确率。 -
关键词:
- 肺肿瘤 /
- 正电子发射断层显像计算机体层摄影术 /
- 癌性淋巴管炎
Abstract:ObjectiveTo explore the imaging features and diagnostic value of 18F-FDG PET/CT in pulmonary lymphangitic carcinomatosis(PLC). MethodsRetrospective analysis on 53 PLC cases was performed. The patients underwent PET/CT+ thin breath hold CT scanning. The PET images were attenuated by CT scanning data and reconstructed by TrueX+time of flight method. The mean standardized uptake value(SUVmean) of each region of interest was measured, and the standardized uptake ratios(SUR) value was calculated. The difference of the SUVmean and SUR values in different regions was compared. ResultsAmong the 53 patients with PLC, 51(96%, 51/53) displayed interlobular septal thickening of the interlobular septa with radioactive uptake, and the lung SUVmean was significantly higher than that of the normal lung field(1.46±0.92 vs. 0.58±0.18, t=19.85, P < 0.01). The interlobular septal thickening lung/mediastinal blood pool SUR was higher than that of the normal septal lung/mediastinal blood pool SUR(0.84±0.38 vs. 0.40±0.21, t=12.77, P < 0.01), and 51 cases(96%, 51/53) manifested bronchovascular bundle uptake enhancement. The SUVmean of PLC involving bronchovascular bundle was significantly higher than that of normal bronchovascular bundle(3.85±1.67 vs. 0.90±0.19, t=15.45, P < 0.01). The SUR of the thickened bronchi vascular bundle/mediastinal blood pool was higher than that of the normal bronchovascular bundle/mediastinal blood pool SUR(2.89±0.94 vs. 0.59±0.19, t=12.62, P < 0.01). In 51 cases(96%, 51/53), the swelling of the hilum and mediastinal lymph nodes was enhanced with radioactivity. ConclusionsPET/CT fusion imaging of typical patients with PLC is characterized by the thickening of bronchial vascular bundles with radioactive concentration and thickening of the interlobular septal nodules with increased uptake of radioactivity. Moreover, the hilar and mediastinal lymph nodes were enlarged or normal with abnormal concentration of radioactivity. PET/CT fusion imaging combined with local SUVmean and SUR can measurements not only enables the early and accurate diagnosis of PLC lesions. -
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[1] Charest M, Armanious S. Prognostic implication of the lymphangitic carcinomatosis pattern on perfusion lung scan[J]. Can Assoc Radiol J, 2012, 63(4):294-303. DOI:10.1016/j.carj.2011.04.004. [2] Bhattacharya PK, Jamil M, Khonglah Y, et al. A Rare Case of Pulmonary Lymphangitic Carcinomatosis in a Young Adult with Carcinoma Stomach[J]. J Clin Diagn Res, 2017, 11(8):OD07-OD09. DOI:10.7860/JCDR/2017/27352.10397. [3] Lee SJ, Lee J, Yu SJ, et al. Timely diagnosis of pulmonary artery tumor embolism by ultrasound-guided transbronchial needle aspiration[J]. Thorac Cancer, 2014, 5(2):184-187. DOI:10.1111/1759-7714.12062. [4] Gorshein E, Burger R, Ferrari A, et al. Dramatic mixed response of lymphangitic pulmonary metastases in newly diagnosed prostate cancer[J]. Urol Ann, 2017, 9(3):278-280.DOI:10.4103/UA.UA_21_17. [5] Moubax K, Wuyts W, Vandecaveye V, et al. Pulmonary lymphangitic carcinomatosis as a primary manifestation of gastric carcinoma in a young adult: a case report and review of the literature[J/OL]. BMC Res Notes, 2012, 5: 638[2018-01-01]. https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC3519516. DOI: 10.1186/1756-0500-5-638. [6] Vattimo AV, Burroni L, Bertelli P, et al. The 'fragmented' scintigraphic lung pattern in pulmonary lymphangitic carcinomatosis secondary to breast cancer[J]. Respiration, 1998, 65(5):406-410. DOI:10.1159/000029304. [7] Kashitani N, Eda R, Masayoshi T, et al. Lobar extent of pulmonary lymphangitic carcinomatosis. Tl-201 chloride and Tc-99m MIBI scintigraphic findings[J]. Clin Nucl Med, 1996, 21(9):726-729. doi: 10.1097/00003072-199609000-00011 [8] 王宏伟, 陆江阳, 王晓虹, 等.肺淋巴管癌病8例尸检临床病理学观察[J].诊断病理学杂志, 2005, 12(3):174-177. DOI:10.3969/j.issn.1007-8096.2005.03.005.
Wang HW, Lu JY, Wang XH, et al. Clinicopathological features of pulmonary lymphangitic carcinomatosis:a report of 8 autopsied cases[J]. Chin J Diagn Pathol, 2005, 12(3):174-177. doi: 10.3969/j.issn.1007-8096.2005.03.005[9] 肖燕, 王海燕, 王宏伟, 等.肺淋巴管癌病误诊病例回顾性分析[J].中国肺癌杂志, 2007, 10(1):54-57.
Xiao Y, Wang HY, Wang HW, et al. Misdiagnosis analysis of pulmonary lymphomatosis carcinomatous[J]. Chin J Lung Cancer, 2007, 10(1):54-57.[10] Oikonomou A, Prassopoulos P. Mimics in chest disease:interstitial opacities[J]. Insights Imaging, 2013, 4(1):9-27. DOI:10.1007/s13244-012-0207-7. [11] Godbole R, Ghatol A, Betancourt J, et al. Pulmonary Tumor Thrombotic Microangiopathy:Clinical, Radiologic, and Histologic Correlation[J]. J Clin Imaging Sci, 2015, 5:44. DOI:10.4103/2156-7514.161978. [12] Park SB, Choi JY, Moon SH, et al. Prognostic value of volumetric metabolic parameters measured by[18F]fluorodeoxyglucose-positron emission tomography/computed tomography in patients with small cell lung cancer[J]. Cancer Imaging, 2014, 14:2. DOI:10.1186/1470-7330-14-2. [13] Chung HW, Lee KY, Kim HJ, et al. FDG PET/CT metabolic tumor volume and total lesion glycolysis predict prognosis in patients with advanced lung adenocarcinoma[J]. J Cancer Res Clin Oncol, 2014, 140(1):89-98. DOI:10.1007/s00432-013-1545-7. [14] Ooi H, Chen CY, Hsiao YC, et al. Fluorodeoxyglucose Uptake in Advanced Non-small Cell Lung Cancer With and Without Pulmonary Lymphangitic Carcinomatosis[J]. Anticancer Res, 2016, 36(8):4313-4320. [15] Digumarthy SR, Fischman AJ, Kwek BH, et al. Fluorodeoxyglucose positron emission tomography pattern of pulmonary lymphangitic carcinomatosis[J]. J Comput Assist Tomogr, 2005, 29(3):346-349. doi: 10.1097/01.rct.0000163952.03192.ef [16] Acikgoz G, Kim SM, Houseni M, et al. Pulmonary lymphangitic carcinomatosis(PLC):spectrum of FDG-PET findings[J]. Clin Nucl Med, 2006, 31(11):673-678. DOI:10.1097/01.rlu.0000242210. 99022.fd. [17] Prakash P, Kalra MK, Sharma A, et al. FDG PET/CT in assessment of pulmonary lymphangitic carcinomatosis[J]. AJR Am J Roentgenol, 2010, 194(1):231-236. DOI:10.2214/AJR.09.3059. [18] Oikonomou A, Prassopoulos P. Mimics in chest disease:interstitial opacities[J]. Insights Imaging, 2013, 4(1):9-27. DOI:10.1007/s13244-012-0207-7.