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甲状腺相关性眼病(thyroid-associated ophthalmopathy, TAO)是眼眶的自身免疫性疾病,与自身免疫性甲状腺疾病密切相关[1],也是Graves甲亢最常见的甲状腺外表现。TAO可引起眼睑及眼眶的一系列临床症状,甚至可造成失明,严重影响患者的生活质量[2],早期诊断及治疗对于改善患者的视力及生活质量大有裨益。
激素、免疫抑制或眼眶局部放疗是活动期TAO的有效治疗方案,而对于非活动期患者可考虑手术治疗[2]。准确判断TAO的活动性是选择恰当治疗方案的关键。2016年欧洲甲状腺学会及欧洲格雷夫斯眼病学组制定的TAO诊治指南[3]中推荐根据临床症状、采用临床活动性评分(clinical activity score,CAS)评价TAO活动性,≥3分为活动期TAO。该方法简便易行,但依赖医患双方的主观性。MRI及99Tcm-奥曲肽生长抑素受体显像已经是临床上判断TAO活动性比较成熟的方法[4-5],但MRI主要评估眼外肌的活动性,对眼眶后部脂肪组织等诊断价值有限;而奥曲肽显像虽然特异度高,但操作较为复杂,在我国尚未进入临床,限制了其应用。
有研究者利用99Tcm-DTPA炎症显像剂的功能,行DTPA眼眶扫描判断TAO活动性[6-11],但是相关研究较少,且由于眼眶内结构精细,99Tcm-DTPA眼眶平面显像、甚至断层显像虽然能定性却无法精确定位受累眼肌、脂肪,不利于局部注射治疗方案的制定。本研究利用SPECT/CT精确解剖定位的优势,行99Tcm-DTPA SPECT/CT眼眶显像以探讨其诊断TAO活动性的价值,并与CAS评分及MRI图像进行比较。
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33例TAO患者的66个眼眶的CAS评分中位数为3.00,四分位数间距为1.25;UR为1.41±0.60,两者呈中度相关,差异有统计学意义(r=0.441,P=0.000);CAS评分<3的非活动期TAO组有27个眼眶(27/66,40.91%),≥3的活动期TAO组有39个眼眶(39/66,59.09%),非活动期TAO组的UR(1.20±0.58)低于活动期组的UR(1.56±0.57),且差异有统计学意义(t=−2.476,P=0.016)。ROC曲线的曲线下面积为0.679,区分活动期与非活动期的UR阈值为1.20,灵敏度为79.5%,特异度为55.6%(图1)。
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21例行MRI检查的患者,42个眼眶的MRI评分中位数为1.00,四分位数间距为3.00,UR为1.39±0.63,两者呈显著相关,差异有统计学意义(r=0.515,P=0.000)。按MRI评分进行分组,非活动期TAO组(19/42, 45.24%)的UR(1.00±0.60)明显低于活动期TAO组(23/42,54.76)的UR(1.72±0.45),且差异有统计学意义(t=−4.438,P=0.000)。
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SPECT/CT与MRI(图2)判定眼外肌活动性的一致性分析见表1。由表1可知,42个眼眶共168条眼外肌,两者对眼外肌活动性的判断中度一致(kappa=0.569,P=0.000),符合率为80.4%(135/168)。
图 2 活动期甲状腺相关性眼病患者(男性,44岁)眼眶99Tcm-DTPA SPECT/CT和MRI图
Figure 2. The 99Tcm-DTPA SPECT/CT and MRI images of a patient with active thyroid-associated ophthalmopathy(male, 44 years old)
SPECT/CT 合计 活动期 非活动期 MRI 活动期 42 11 53 非活动期 22 93 115 合计 64 104 168 注:表中,TAO:甲状腺相关性眼病;SPECT/CT:单光子发射计算机体层摄影术;MRI:磁共振成像。 表 1 21例TAO患者行SPECT/CT与MRI判定眼外肌活动性的一致性分析(眼外肌数,条)
Table 1. The consistency of evaluation of the extraocular muscleactivity between SPECT/CT and MRI of 21 thyroid- associated ophthalmopathy patients
99Tcm-DTPA SPECT/CT眼眶显像评价甲状腺相关性眼病活动性:与临床活动性评分及MRI的对比分析
The activity of thyroid-associated ophthalmopathy assessed by 99Tcm-DTPA orbit SPECT/CT: comparison with clinical activity score and MRI
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摘要:
目的 探讨99Tcm-二亚乙基三胺五乙酸(DTPA)SPECT/CT眼眶显像对甲状腺相关性眼病(TAO)活动性判断的价值。 方法 回顾性分析2016年2月至2017年1月临床诊断为TAO的33例患者[男性13例、女性20例,年龄(45.36±13.44)岁]的66个眼眶的99Tcm-DTPA SPECT/CT图像、临床活动性评分(CAS)及其中21例患者(42个眼眶)的MRI图像。用感兴趣区(ROI)技术进行半定量分析,计算眼眶与枕部区域的摄取比值(UR);用肉眼观察法分别判定SPECT/CT及MRI图像的每条眼外肌的活动性,并根据MRI处于活动期眼外肌的数量给每个眼眶进行CAS评分,≥3分判定为活动期,<3分为非活动期。活动期与非活动期TAO之间的UR比较采用t检验;UR与CAS评分、MRI评分之间的相关性采用Spearman相关性分析;SPECT/CT与MRI判断眼外肌活动性的一致性比较采用Kappa分析。绘制受试者工作特征(ROC)曲线,评价SPECT/CT诊断效能。 结果 ① 66个眼眶的CAS评分与UR呈中度相关(r=0.441,P=0.000);非活动期TAO的UR(1.20±0.58)低于活动期的UR(1.56±0.57),且差异有统计学意义(t=−2.476,P=0.016)。ROC曲线下面积为0.679,区分活动期与非活动期的UR阈值为1.20,灵敏度为79.5%,特异度为55.6%。② 42个眼眶的MRI评分与UR呈显著相关(r=0.515,P=0.000),非活动期TAO的UR(1.00±0.60)低于活动期的UR(1.72±0.45),且差异有统计学意义(t=−4.438,P=0.000)。③ 99Tcm-DTPA SPECT/CT与MRI对42个眼眶共168条眼外肌的活动性判断呈中度一致性(kappa=0.569,P=0.000)。 结论 99Tcm-DTPA SPECT/CT眼眶显像是判断TAO活动性较为可靠及客观的影像学方法,值得在临床推广应用。 -
关键词:
- 甲状腺相关性眼病 /
- 活动性 /
- 单光子发射计算机体层摄影术 /
- 二亚乙基三胺五乙酸
Abstract:Objective To determine the value of 99Tcm-DTPA orbit SPECT/CT in evaluating the activity of thyroid-associated ophthalmopathy (TAO). Methods The 99Tcm-DTPA orbit SPECT/CT imaging data of 66 orbits of 33 patients [13 men and 20 women, age (45.36±13.44) years old] were retrospectively analyzed, along with the clinical activity score (CAS) and MRI of the 21 patients (42 orbits) . The orbit/occipital area's uptake ratio (UR) was calculated by the ROI. The activity of each extraocular muscle (EOM) on the SPECT/ CT and MRI images was assessed by visual analysis. MRI score of every orbit was obtained according to the number of active EOM, the range of which was 0−4 . As for the CAS, ≥3 represented the active stage, and the others denote the inactive stage. The UR between the active TAO and inactive TAO was compared using t test, the correlation between the UR and CAS/MRI score was calculated by Spearman analysis, and the consistency of the activity of every EOM assessed by SPECT/CT and MRI was evaluated by Kappa test. The receiver operating characteristic (ROC) curve was depicted to determine the diagnostic efficiency of SPECT/CT using CAS as the gold standard. Results ① CAS was moderately correlated with the UR of all the 66 orbits (r=0.441, P=0.000). The UR of the inactive group (1.20±0.58) was significantly lower than that of the active group (1.56±0.57) (t=−2.476, P=0.016). The area under the curve of the ROC was 0.679. The threshold differentiating the inactive phase from the active one was 1.20, with the sensitivity of 79.5% and with the specificity being 55.6%. ② The MRI score of the 42 orbits was significantly correlated with UR (r=0.515, P=0.000). The UR of the inactive group (1.00±0.60) was significantly lower than that of the active group (1.72±0.45) according to the MRI score (t=−4.438, P=0.000). ③The activity of the 168 muscles assessed by 99Tcm-DTPA SPECT/CT was moderately consistent with that assessed by MRI (kappa=0.569, P=0.000). Conclusions 99Tcm-DTPA orbit SPECT/CT is a reliable and objective method to evaluate the activity of TAO, and it will be helpful in clinical practice. -
表 1 21例TAO患者行SPECT/CT与MRI判定眼外肌活动性的一致性分析(眼外肌数,条)
Table 1. The consistency of evaluation of the extraocular muscleactivity between SPECT/CT and MRI of 21 thyroid- associated ophthalmopathy patients
SPECT/CT 合计 活动期 非活动期 MRI 活动期 42 11 53 非活动期 22 93 115 合计 64 104 168 注:表中,TAO:甲状腺相关性眼病;SPECT/CT:单光子发射计算机体层摄影术;MRI:磁共振成像。 -
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