PET-CT在淋巴瘤中的应用

PET/CT在淋巴瘤中的应用复旦大学附属肿瘤医院肿瘤内科郭晔指南更新JCO2007;25:579-586JCO2014;32:3048-3058新的淋巴瘤分期JCO2014;32:3059-3067内容背景介绍PET/CT用于淋巴瘤的分期评估PET/CT用于淋巴瘤治疗后评估PET/CT用于淋巴瘤治疗中期评估背景知识PET：正电子发射型计算机断层显象，是以人体解剖结构为基础，利用正电子核素标记药物的示踪作用，显示人体内物质代谢，细胞增殖，血流灌注及脏器功能状态。缺点是不能准确测量肿瘤大小CT：显示人体解剖结构及形态学改变，有较强的空间分辨率PET/CT：PET和CT图像同机融合，一次成象获得全身PET和CT的图象，将功能影象与解剖形态学优化组合，两者结合取长补短18FDG在肿瘤细胞中的摄取FDG在常见淋巴瘤中的摄取进行FDG-PET的要求JuweidME,etal.JClinOncol2007;25:571-578.PET图像的解读标准(视觉判断法)JuweidME,etal.JClinOncol2007;25:571-578.5分类法(Deauville标准)BarringtonS,etal.JClinOncol2014;32:3048举例：治疗前治疗后：1分Exampleofscore1:completemetabolicresponsewithnouptakeinnormal-sizelymphnodesatsiteofinitialdiseaseinleftneck(arrow).举例：治疗前治疗后：2分Exampleofscore2:residualuptakeofintensitymediastinalbloodpoolinlymphnodesinleftaxilla(arrow).Maximumstandardizeduptakevalue(SUVmax)inlymphnodeswas1.2;SUVmaxinmediastinalbloodpoolwas1.7.举例：治疗前治疗后：3分Exampleofscore3:residualuptakeofintensitymediastinalbloodpoolbutliverinresidualmediastinalmass(arrow).Maximumstandardizeduptakevalue(SUVmax)inmasswas1.7;SUVmaxinliverwas2.2.举例：治疗前治疗后：4分Exampleofscore4:residualuptakeofintensityliverinresidualmediastinalmass(arrow).Maximumstandardizeduptakevalue(SUVmax)inmasswas4.5;SUVmaxinliverwas3.2.举例：治疗前治疗后：5分Exampleofscore5:residualuptakeinmediastinumwithintensitymarkedlyhigherthannormalliver.Maximumstandardizeduptakevalue(SUVmax)inmasswas13.0;SUVmaxinliverwas2.3.新的指南推荐级别Expertsinnuclearmedicineandradiologyappliedtolymphomaundertookaliteraturereviewandsharedknowledgeaboutresearchinprogress.Recommendationswereformulatedasfollows:﹣Basedonestablishedcurrentknowledge(type1)﹣Toidentifyemergingapplications(type2)﹣Tohighlightkeyareasrequiringfurtherresearch(type3)BarringtonS,etal.JClinOncol2014;32:3048肿瘤缓解术语CT–CR：completeresponse–CRu：completeresponseunconfirmed–PR：partialresponse–SD：stabledisease–PD：progressivediseasePET/CT–CMR：completemetabolicresponse–PMR：partialmetabolicresponse–NMR：nometabolicresponse–PMR：progressivemetabolicdiseaseChesonBD,etal.JClinOncol1999;17:1244.ChesonBD,etal.JClinOncol2014;32:3059InterpretationofPET-CTscans1.StagingofFDG-avidlymphomasisrecommendedusingvisualassessment,withPET-CTimagesscaledtofixedSUVdisplayandcolortable;focaluptakeinHLandaggressiveNHLissensitiveforbonemarrowinvolvementandmayobviateneedforbiopsy;MRIismodalityofchoiceforsuspectedCNSlymphoma(type1)2.Five-pointscaleisrecommendedforreportingPET-CT;resultsshouldbeinterpretedincontextofanticipatedprognosis,clinicalfindings,andothermarkersofresponse;scores1and2representCMR;score3alsoprobablyrepresentsCMRinpatientsreceivingstandardtreatment(type1)3.Score4or5withreduceduptakefrombaselinelikelyrepresentspartialmetabolicresponse,butatendoftreatmentrepresentsresidualmetabolicdisease;increaseinFDGuptaketoscore5,score5withnodecreaseinuptake,andnewFDG-avidfociconsistentwithlymphomarepresenttreatmentfailureand/orprogression(type2)BarringtonS,etal.JClinOncol2014;32:3048PET结果假阳性产生的原因化疗/放疗后的坏死/炎症反应–化疗间隔：至少3周（最佳6-8周）–放疗间隔：8-12周造血因子的骨髓刺激增生的胸腺组织某些摄取FDG的良性疾病免疫细胞的影响不规范的操作和图像的解读内容背景介绍PET/CT用于淋巴瘤的分期评估PET/CT用于淋巴瘤治疗后评估PET/CT用于淋巴瘤治疗中期评估传统CT分期评估的缺点仅根据病变/淋巴结的形态和大小决定临床意义对于结外病变的判断能力不足评估能力受扫描区域或部位的限制需要增强扫描，无法用于碘过敏的患者PET与CT用于分期评估的比较PET分期评估的结果RoleofPET-CTforstaging1.PET-CTshouldbeusedforstaginginclinicalpracticeandclinicaltrialsbutisnotroutinelyrecommendedinlymphomaswithlowFDGavidity;PET-CTmaybeusedtoselectbestsitetobiopsy(type1)2.Contrast-enhancedCTwhenusedatstagingorrestagingshouldideallyoccurduringsinglevisitcombinedwithPET-CT,ifnotalreadyperformed;baselinefindingswilldeterminewhethercontrast-enhancedPET-CTorlower-doseunenhancedPET-CTwillsufficeforadditionalimagingexaminations(type2)3.Bulkremainsanimportantprognosticfactorinsomelymphomas;volumetricmeasurementoftumorbulkandtotaltumorburden,includingmethodscombiningmetabolicactivityandanatomicalsizeorvolume,shouldbeexploredaspotentialprognosticators(type3)BarringtonS,etal.JClinOncol2014;32:3048内容背景介绍PET/CT用于淋巴瘤的分期评估PET/CT用于淋巴瘤治疗后评估PET/CT用于淋巴瘤治疗中期评估基于CT的IWG标准1999年IWG制定了淋巴瘤疗效评价和预后评估指南IWG指南统一了原本各异的疗效评估标准该指南得到了临床医生和监管机构的广泛认可，并用于大量新药的审批程序ChesonBD,etal.JClinOncol1999;17:1244.疗效评估标准1999年，IWG国际工作小组发布了《NHL疗效评估标准》疗效体格检查淋巴结淋巴结肿块骨髓CR正常正常正常正常CRu正常正常正常不确定正常正常缩小75%正常或不确定PR正常正常正常阳性正常缩小≥50%缩小≥50%无关肝/脾缩小缩小≥50%缩小≥50%无关Relapse/PD肝/脾增大新病变新病变或增大新病变或增大再发ChesonBD,etal.JClinOncol1999;17:1244.IWG标准的缺点无法区分肿瘤残留抑或纤维化CRu的解读容易发生歧义没有针对骨髓以外结外病变的评价PET疗效评估的阳性和阴性预测值基于PET的IHP标准ChesonBD,etal.JClinOncol2007;25:5792007年IHP制定了新的淋巴瘤疗效评价标准IHP标准是对于IWG标准的改进和补充IHP标准适用于以治愈为目的的淋巴瘤类型，特别是DLBCL和HLIHP标准的淋巴瘤类型推荐ChesonBD,etal.JClinOncol2007;25:579临床试验中的疗效定义ChesonBD,etal.JClinOncol2007;25:579新的PET疗效定义CMR:completemetabolicresponse﹣Score1,2,or3withorwithoutaresidualmasson5PSPMR:partialmetabolicresponse﹣Score4or5withreduceduptakecomparedwithbaselineandresidualmass(es)ofanysize﹣Atinterim,thesefindingssuggestrespondingdisease﹣Atendoftreatment,thesefindingsindicateresidualdiseaseNMR:nometabolicresponse﹣Score4or5withnosignificantchangeinFDGuptakefrombaselineatinterimorendoftreatmentPMR:progressivemetabolicdisease﹣Score4or5withanincreasein