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肺隐球菌病(pulmonary cryptococcosis,PC)是一种侵袭性肺部真菌病,主要致病菌为新生隐球菌或格特隐球菌,呼吸道吸入是常见的致病途经[1-2]。近年来,PC的发病率呈逐年增加的趋势,据多中心回顾性调查显示,隐球菌已位居侵袭性肺真菌感染常见病原体的第3位[3],而且PC临床症状不典型,影像改变形态各异,可表现为结节肿块型、浸润实变型、弥漫性粟粒型和弥漫混合病变型,其中结节肿块型最多见且具有类似肿瘤的征象,常与肺癌、肺转移癌混淆[4]。本研究回顾性分析22例结节型PC患者的临床及18F-FDG PET/CT显像资料,现将结果报道如下。
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22例PC患者共发现235个结节,直径(0.7±0.5) cm,范围0.2~2.8 cm。其中,18F-FDG代谢增高结节130个,SUVmax=3.5±2.9(0.9~20.1),直径(0.9±0.5) cm,范围0.3~2.8 cm,二者存在正相关(r=0.702,P=0.000);无18F-FDG代谢结节105个,直径(0.3±0.1) cm,范围0.2~0.6 cm;代谢增高结节的直径大于无代谢者,差异有统计学意义(t=13.621,P=0.000)。
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以右肺(57.4%,135/235)、下叶(64.3%,151/235)多见结节,多数结节(80.0%,188/235)位于肺野外带或胸膜下,仅少数(11.5%,27/235)位于中带和内带(8.5%,20/235),其余数据见表1。
病灶位置 上叶 中叶 下叶 合计 左肺 35(14.9) 0(0.0) 65(27.7) 100(42.6) 右肺 43(18.3) 6(2.6) 86(36.6) 135(57.4) 合计 78(33.2) 6(2.6) 151(64.3) 235(100.0) 表 1 22例肺隐球菌病患者235个结节分布情况(个,%)
Table 1. The distribution of 235 nodules in 22 patients with pulmonary ryptococcosis
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单个肺叶受累者(单发结节8例、单叶散在结节3例)与多个肺叶受累者(多叶散在结节9例、多叶聚集分布结节2例)各11例;PET/CT正确诊断与误诊的患者各11例,其中误诊组中单个肺叶受累者8例。235个结节中出现分叶征、毛刺征、支气管充气征、晕征、空泡征、胸膜凹陷征和宽基底贴胸膜征的个数分别为14、8、28、51、2、5和21,具体数据见表2。典型病例的PET/CT显像见图1,此病例误诊为左侧肺癌右肺转移。
图 1 肺隐球菌感染患者(男性,35岁)的18F-FDG PET/CT 显像图 图中,A、B:左肺下叶结节CT和 PET/CT融合图像,显示高代谢,宽基底贴胸膜;C、D:右肺下叶结节CT和PET/CT融合图像,显示轻度代谢。18F-FDG:氟脱氧葡萄糖F18;PET:正电子发射断层显像术;CT:计算机体层摄影术
Figure 1. 18F-FDG PET/CT imaging of pulmonary cryptococcosis (male, 35 years old)
序号 性别 年龄 免疫功能受损 影像诊断 结节分布及数目[a+b(个)] 结节直径(cm) 结节SUVmax 结节征象及个数(个) 右肺上叶 右肺中叶 右肺下叶 左肺上叶 左肺下叶 分叶征 毛刺征 支气管充气征 晕征 空泡征 胸膜凹陷征 宽基底贴胸膜 1 男 56 否 LC 1+0 − − − − 0.6 1.1 − 1 − − − − − 2 男 54 是 LC − 1+0 − − − 2.8 9.6 1 1 1 − − − 1 3 女 53 否 LC 1+0 − − − − 1.4 7.9 1 1 − − − − 1 4 女 49 否 LC − − 1+0 − − 1.5 6.2 1 1 1 − − − − 5 男 43 否 MC − − 1+0 − − 1.6 3.1 − − 1 1 − 1 − 6 男 61 否 MC − − − 1+0 − 1.0 4.3 1 − − 1 − 1 − 7 男 53 否 LC 1+0 − − − − 1.3 5.7 1 1 1 − − − − 8 女 55 是 LC 1+0 − − − − 1.0 7.9 − 1 − − 1 1 − 9 男 54 是 LM − − − − 2+0 0.3/0.5 1.4/3.5 − − − 1 − − − 10 女 69 是 MC − − − − 4+3 0.2~1.6 2.7~13.6 1 − − − − − 1 11 男 57 是 LWM − − − 2+1 − 0.2~1.0 2.5~6.8 1 − − − − − − 12 男 63 是 LWM 4+3 − 0+1 − − 0.3~1.1 2.1~9.3 1 1 − − − 1 − 13 男 41 否 MC − − 12+22 − 20+7 0.3~2.0 1.0~3.8 5 − 17 18 − − − 14 男 35 是 LWM − − 1+0 − 1+0 0.7/2.3 2.3/20.1 − − 1 − − − 2 15 男 60 否 MC 2+1 − 9+1 5+1 − 0.2~1.4 1.8~6.5 − − − − − − 6 16 男 67 是 LWM 2+10 − 2+5 1+3 − 0.2~1.2 1.1~1.7 1 1 1 − − 1 1 17 男 50 否 MC 0+2 4+0 10+2 1+0 6+1 0.3~1.3 0.9~6.8 − − 1 7 − − 1 18 男 57 否 MC 0+6 0+1 4+4 3+10 1+2 0.2~1.2 1.0~6.0 − − 1 5 − − − 19 男 58 否 MC 0+2 − 4+2 − 3+4 0.2~1.5 1.3~6.4 − − 1 3 − − − 20 女 58 是 MC 1+1 − 2+1 − 3+2 0.2~2.3 2.2~10.5 − − 2 5 − − 5 21 男 53 否 MC 2+2 − − 1+3 4+1 0.2~1.5 1.1~7.6 − − − 6 1 − 1 22 男 59 否 MC 1+0 − 1+1 3+0 1+0 0.4~1.7 1.5~12.3 − − − 4 − − 2 注:表中,PC:肺隐球菌病;18F-FDG:氟脱氧葡萄糖F18;PET/CT:正电子发射断层显像计算机体层摄影术;LC:肺癌;MC:真菌感染;LM:肺转移癌;LWM:肺癌伴肺内转移;a:18F-FDG代谢增高结节个数;b:无18F-FDG代谢结节个数;SUVmax:最大标准化摄取值;/:结节数为2枚;~:结节数≥3枚;−:无此项数据 表 2 22例PC患者18F-FDG PET/CT显像的结节特征
Table 2. The 18F-FDG PET/CT imaging characteristics of 22 patienst with pulmonary cryptococcosis
ICH患者共发现57个结节,18F-FDG代谢增高者25个,SUVmax=5.7±4.7(1.1~20.1);NICH患者共发现178个结节,18F-FDG代谢增高者105个,SUVmax=3.0±2.0(0.9~12.3),二者SUVmax的比较差异有统计学意义(t=2.731,P=0.011)。前者出现宽基底贴胸膜征象的比例高于后者,后者晕征的比例高于前者,差异均有统计学意义。具体数据见表3。
征象 NICH
n/178(%)ICH
n/57(%)χ2值 P值 单叶受累
n/20(%)多叶受累
n/215(%)χ2值 P值 正确诊断
n/191(%)误诊
n/44(%)χ2值 P值 LS 9(5.0) 5(8.8) 1.364 0.243 7(35.0) 7(3.3) 32.911 0.000 7(3.7) 7(15.9) 9.570 0.006 SS 4(2.2) 4(7.0) 3.417 0.065 6(30.0) 2(0.9) 47.022 0.000 0(0.0) 8(18.2) 35.951 0.000 PS 23(12.9) 5(8.8) 0.471 0.492 4(20.0) 24(11.2) 1.362 0.243 23(12.0) 5(11.4) 0.016 0.900 PIS 3(1.7) 2(3.5) 0.836 0.360 3(15.0) 2(0.9) 17.395 0.005 2(1.0) 3(6.8) 5.720 0.047 HS 45(25.3) 6(10.5) 4.628 0.031 3(15.0) 48(22.3) 0.578 0.447 50(26.2) 1(2.3) 12.027 0.000 VS 1(0.6) 1(1.8) 0.832 0.362 1(5.0) 1(0.5) 4.459 0.163 1(0.5) 1(2.3) 1.297 0.340 BBPS 11(6.2) 10(17.5) 7.911 0.005 3(15.0) 18(8.4) 0.988 0.320 16(8.4) 5(11.4) 3.920 0.531 注:表中,18F-FDG:氟脱氧葡萄糖F18;PET/CT:正电子发射断层显像计算机体层摄影术;LS:分叶征;SS:毛刺征;PS:支气管充气征;PIS:胸膜凹陷征;HS:晕征;VS:空泡征;BBPS:宽基底贴胸膜征;NICH:非免疫功能受损宿主;ICH:免疫功能受损宿主 表 3 不同组别18F-FDG PET/CT显像结节征象的差异比较
Table 3. The comparison of nodular signs on 18F-FDG PET/CT imaging between different groups
单个肺叶受累者11例共发现20个结节,其中16个18F-FDG代谢增高,SUVmax=5.6±3.4(1.1~13.6);多个肺叶(多叶散在结节)受累者11例共发现215个结节,其中114个18F-FDG代谢增高,SUVmax=3.2±2.7(0.9~20.1),SUVmax差异有统计学意义(t=2.652,P=0.016)。前者出现分叶征、毛刺征、胸膜凹陷征的比例高于后者,差异有统计学意义。具体数据见表3。
18F-FDG PET/CT显像误诊的11例患者共发现44个结节,其中21个18F-FDG代谢增高,SUVmax=5.0±4.6;正确诊断真菌感染的11例患者共发现191个结节,其中109个18F-FDG代谢增高,SUVmax=3.2±2.4,二者SUVmax差异无统计学意义(t=16.825,P=0.106)。前者出现分叶征、毛刺征、胸膜凹陷征的比例高于后者,差异有统计学意义;后者出现晕征的比例高于前者,差异有统计学意义。具体数据见表3。
22例结节型肺隐球菌病18F-FDG PET/CT 显像的回顾性分析
Retrospective analysis of 18F-FDG PET/CT imaging in 22 cases of nodular type pulmonary cryptococcosis
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摘要:
目的 分析结节型肺隐球菌病(PC)患者的18F-氟脱氧葡萄糖(FDG)PET/CT显像特点。 方法 回顾性分析2011年1月至2017年1月于福建省肿瘤医院经病理确诊的PC患者22例,其中男性17例、女性5例,年龄(54.77±7.93)岁。所有患者均行18F-FDG PET/CT显像,分析结节的数目、大小、分布、最大标准摄取值(SUVmax)及结节征象。计量资料的比较采用t检验或Pearson相关性分析,不同组别结节征象的差异比较采用χ2检验、连续校正χ2检验或Fisher确切概率法。 结果 ① 22例PC患者的PET/CT显像共发现235个结节,18F-FDG代谢增高结节130个,SUVmax(3.5±2.9)与直径[(0.9±0.5) cm]呈正相关(r=0.702,P=0.000)。② 结节分布以右肺(57.4%,135/235)、下叶(64.3%,151/235)、肺野外带或胸膜下(80.0%,188/235)多见。③ 9例免疫功能受损宿主的代谢增高结节SUVmax(5.7±4.7)高于13例非免疫功能受损宿主(3.0±2.0),且差异有统计学意义(t=2.731,P=0.011);前者(17.5%,10/57)的宽基底贴胸膜征象高于后者(6.2%,11/178),而后者(25.3%,45/178)的晕征高于前者(10.5%,6/57),差异均有统计学意义(χ2=7.911、4.628,P=0.005、0.031)。④ 单个肺叶受累和多个肺叶受累的患者各为11例,前者的代谢增高结节SUVmax(5.6±3.4)高于后者(3.2±2.7),且差异有统计学意义(t=2.652,P=0.016);前者出现分叶征、毛刺征、胸膜凹陷征的比例均高于后者,差异均有统计学意义(χ2=32.911、47.022、17.395,均P<0.01)。⑤ 误诊和正确诊断的患者各为11例,前者的代谢增高结节SUVmax(5.0±4.6)高于后者(3.2±2.4),差异无统计学意义(t=16.825,P=0.106);分叶征、毛刺征、胸膜凹陷征出现的比例前者均高于后者,差异均有统计学意义(χ2=9.570、35.951、5.720,均P<0.05);后者(26.2%,50/191)晕征的比例高于前者(2.3%,1/44),且差异有统计学意义(χ2=12.027,P=0.000)。 结论 结节型PC患者PET/CT显像的SUVmax与直径呈正相关。晕征是诊断的可靠征象。对于单个肺叶受累者,类肿瘤征象及18F-FDG代谢增高的表现易造成误诊。 -
关键词:
- 隐球菌病 /
- 肺疾病,真菌性 /
- 氟脱氧葡萄糖F18 /
- 正电子发射断层显像计算机体层摄影术 /
- 最大标准化摄取值
Abstract:Objective To investigate the 18F-fluorodeoxyglucose (FDG) PET/CT imaging characteristics of pulmonary cryptococcosis (PC). Methods A retrospective study was performed in 22 patients with PC (17 male and 5 female; aged 54.77±7.93 years), confirmed through etiology or pathological examination from January 2011 to January 2017 in Fujian Provincial Cancer Hospital. 18F-FDG PET/CT was performed. The number, size, distribution, maximum standardized uptake value (SUVmax), and nodule sign of the nodules were analyzed. T test or Pearson correlation analysis was used in the comparison in measurement data. The differences in nodule signs among the different groups were determined by χ2 test, continuous correction χ2 test, or Fisher exact probability method. Results ① A total of 235 nodules were found by 18F-FDG PET/CT imaging in the 22 cases of PC patients with the diameter of (0.7±0.5) cm. Of these nodules, 130 showed high 18F-FDG metabolism with an SUVmax of (3.5±2.9) and a diameter of (0.9±0.5) cm. A positive correlation was found between the two (r=0.702, P=0.000). Meanwhile, 105 nodules showed no 18F-FDG metabolism with a diameter of (0.3±0.1) cm. The diameter in the group with high 18F-FDG metabolism was greater than that in the group without 18F-FDG metabolism, and the difference was statistically significant (t=13.621, P=0.000). ② The nodules were mainly found in the right lung (57.4%, 135/235), lower lobe (64.3%, 151/235), and outer zone or subpleura (80.0%, 188/235). ③ The SUVmax in the nine cases of immunocompromised host with high 18F-FDG metabolism was 5.7±4.7 higher than that in the 13 cases of non-immunocompromised host (SUVmax was 3.0±2.0), and the difference was statistically significant (t=2.731, P=0.011). The ratio of wide base posted to the pleural sign was 17.5 (10/57) of the former and higher the 6.2% (11/178) of the latter. The ratio of halo sign was 25.3% (45/178) in the latter and higher than the former of 10.5% (6/57). All the differences were statistically significant (χ2=7.911, 4.628; P=0.005, 0.031). ④ The nodules of the group with high 18F-FDG metabolism accounted for 80% (16/20) and 53% (114/215), respectively, in the each of 11 cases of one lobe or multiple lobar involvement patients. The former SUVmax was 5.6±3.4 and higher than the latter of 3.2±2.7. The difference was statistically significant (t=2.652, P=0.016). The lobulation sign (35%, 7/20), spicule sign (30%, 6/20), and pleural indentation sign (15%, 3/20) in the former were higher than the 3.3% (7/215), 0.9% (2/215) and 0.9% (2/215) in the latter, respectively. The difference was statistically significant (χ2=32.911, 47.022, 17.395, all P<0.01). ⑤ The SUVmax of the 21 nodules with high 18F-FDG metabolism in the 44 nodules found in the 11 misdiagnosed cases was 5.0±4.6, which was higher than 3.2±2.4 in the 11 other correctly diagnosed cases where 191 nodules were found, including 109 nodules with high 18F-FDG metabolism. The difference was not statistically significant (t=16.825, P=0.106). The lobulation sign, spicule sign and pleural indentation sign in the former were 15.9% (7/44), 18.2% (8/44), 6.8% (3/44) respectively, which are higher than the 3.7% (7/191), 0.0% (0/191), and 1.0% (2/191) in the latter. The difference was statistically significant (χ2=9.570, 35.951, 5.720; all P<0.05). The halo sign was 26.2% (50/191) in the latter, and higher than the 2.3% (1/44) in the former. The difference was statistically significant (χ2=12.027, P=0.000). Conclusions The SUVmax of the nodules is positively correlated with diameter in cases of PC by 18F-FDG PET/CT imaging. Halo sign is a reliable sign of diagnosis. The resembling tumor signs and the high 18F-FDG metabolism, caused the 18F-FDG PET/CT imaging to misdiagnose easily in patients of PC with single lobe involvment. -
表 1 22例肺隐球菌病患者235个结节分布情况(个,%)
Table 1. The distribution of 235 nodules in 22 patients with pulmonary ryptococcosis
病灶位置 上叶 中叶 下叶 合计 左肺 35(14.9) 0(0.0) 65(27.7) 100(42.6) 右肺 43(18.3) 6(2.6) 86(36.6) 135(57.4) 合计 78(33.2) 6(2.6) 151(64.3) 235(100.0) 表 2 22例PC患者18F-FDG PET/CT显像的结节特征
Table 2. The 18F-FDG PET/CT imaging characteristics of 22 patienst with pulmonary cryptococcosis
序号 性别 年龄 免疫功能受损 影像诊断 结节分布及数目[a+b(个)] 结节直径(cm) 结节SUVmax 结节征象及个数(个) 右肺上叶 右肺中叶 右肺下叶 左肺上叶 左肺下叶 分叶征 毛刺征 支气管充气征 晕征 空泡征 胸膜凹陷征 宽基底贴胸膜 1 男 56 否 LC 1+0 − − − − 0.6 1.1 − 1 − − − − − 2 男 54 是 LC − 1+0 − − − 2.8 9.6 1 1 1 − − − 1 3 女 53 否 LC 1+0 − − − − 1.4 7.9 1 1 − − − − 1 4 女 49 否 LC − − 1+0 − − 1.5 6.2 1 1 1 − − − − 5 男 43 否 MC − − 1+0 − − 1.6 3.1 − − 1 1 − 1 − 6 男 61 否 MC − − − 1+0 − 1.0 4.3 1 − − 1 − 1 − 7 男 53 否 LC 1+0 − − − − 1.3 5.7 1 1 1 − − − − 8 女 55 是 LC 1+0 − − − − 1.0 7.9 − 1 − − 1 1 − 9 男 54 是 LM − − − − 2+0 0.3/0.5 1.4/3.5 − − − 1 − − − 10 女 69 是 MC − − − − 4+3 0.2~1.6 2.7~13.6 1 − − − − − 1 11 男 57 是 LWM − − − 2+1 − 0.2~1.0 2.5~6.8 1 − − − − − − 12 男 63 是 LWM 4+3 − 0+1 − − 0.3~1.1 2.1~9.3 1 1 − − − 1 − 13 男 41 否 MC − − 12+22 − 20+7 0.3~2.0 1.0~3.8 5 − 17 18 − − − 14 男 35 是 LWM − − 1+0 − 1+0 0.7/2.3 2.3/20.1 − − 1 − − − 2 15 男 60 否 MC 2+1 − 9+1 5+1 − 0.2~1.4 1.8~6.5 − − − − − − 6 16 男 67 是 LWM 2+10 − 2+5 1+3 − 0.2~1.2 1.1~1.7 1 1 1 − − 1 1 17 男 50 否 MC 0+2 4+0 10+2 1+0 6+1 0.3~1.3 0.9~6.8 − − 1 7 − − 1 18 男 57 否 MC 0+6 0+1 4+4 3+10 1+2 0.2~1.2 1.0~6.0 − − 1 5 − − − 19 男 58 否 MC 0+2 − 4+2 − 3+4 0.2~1.5 1.3~6.4 − − 1 3 − − − 20 女 58 是 MC 1+1 − 2+1 − 3+2 0.2~2.3 2.2~10.5 − − 2 5 − − 5 21 男 53 否 MC 2+2 − − 1+3 4+1 0.2~1.5 1.1~7.6 − − − 6 1 − 1 22 男 59 否 MC 1+0 − 1+1 3+0 1+0 0.4~1.7 1.5~12.3 − − − 4 − − 2 注:表中,PC:肺隐球菌病;18F-FDG:氟脱氧葡萄糖F18;PET/CT:正电子发射断层显像计算机体层摄影术;LC:肺癌;MC:真菌感染;LM:肺转移癌;LWM:肺癌伴肺内转移;a:18F-FDG代谢增高结节个数;b:无18F-FDG代谢结节个数;SUVmax:最大标准化摄取值;/:结节数为2枚;~:结节数≥3枚;−:无此项数据 表 3 不同组别18F-FDG PET/CT显像结节征象的差异比较
Table 3. The comparison of nodular signs on 18F-FDG PET/CT imaging between different groups
征象 NICH
n/178(%)ICH
n/57(%)χ2值 P值 单叶受累
n/20(%)多叶受累
n/215(%)χ2值 P值 正确诊断
n/191(%)误诊
n/44(%)χ2值 P值 LS 9(5.0) 5(8.8) 1.364 0.243 7(35.0) 7(3.3) 32.911 0.000 7(3.7) 7(15.9) 9.570 0.006 SS 4(2.2) 4(7.0) 3.417 0.065 6(30.0) 2(0.9) 47.022 0.000 0(0.0) 8(18.2) 35.951 0.000 PS 23(12.9) 5(8.8) 0.471 0.492 4(20.0) 24(11.2) 1.362 0.243 23(12.0) 5(11.4) 0.016 0.900 PIS 3(1.7) 2(3.5) 0.836 0.360 3(15.0) 2(0.9) 17.395 0.005 2(1.0) 3(6.8) 5.720 0.047 HS 45(25.3) 6(10.5) 4.628 0.031 3(15.0) 48(22.3) 0.578 0.447 50(26.2) 1(2.3) 12.027 0.000 VS 1(0.6) 1(1.8) 0.832 0.362 1(5.0) 1(0.5) 4.459 0.163 1(0.5) 1(2.3) 1.297 0.340 BBPS 11(6.2) 10(17.5) 7.911 0.005 3(15.0) 18(8.4) 0.988 0.320 16(8.4) 5(11.4) 3.920 0.531 注:表中,18F-FDG:氟脱氧葡萄糖F18;PET/CT:正电子发射断层显像计算机体层摄影术;LS:分叶征;SS:毛刺征;PS:支气管充气征;PIS:胸膜凹陷征;HS:晕征;VS:空泡征;BBPS:宽基底贴胸膜征;NICH:非免疫功能受损宿主;ICH:免疫功能受损宿主 -
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