核医学 肿瘤与炎症-20151012课件

18F-FDGPET/CTinoncology吴志坚华中科技大学同济医学院协和医院PET中心何为PET/CTPET/CT的基本原理18F-FDGPET/CT的临床应用价值PET（PositronEmissionTomography）正电子发射型计算机断层应用正电子放射性核素示踪技术原理，以解剖形态学为基础，显示活体组织代谢、细胞增殖、受体分布、血流灌注及脏器功能状态，用于提供分子水平信息来诊断疾病、研究生物机体生命活动本质及其活动规律，又称为生化显像或分子显像。CT提供的解剖信息能够准确地与PET功能图像融合，弥补PET空间分辨率的不足，对病灶进行精确的空间定位CT为PET代谢图像提供了一种快速而精确的衰减校正方法，明显缩短检查时间，由PET检查的1h缩短至PET/CT的16min进一步提高了诊断的准确性PET/CT优势Glucose2-deoxy-2-fluoro-glucoseFDG最常用正电子核素显像剂－18F－FDG18F-FDG肿瘤显像原理Quantitativeparameterof

18F-FDGPET/CTStandardizeduptakevalue(SUV)-Accumulationinaregionofinterest,normalizadfortheinjecteddoseandpatientbodyweight.SUV=MeanROIactivity(mCi/ml)Injecteddose(mCi)/bodyweight(g)了解病史、身体状况、精神状况：肿瘤病人有无放化疗、能否耐受检查、是否需应用镇静剂。介绍检查过程、采集时间及保持体位不动的重要性。有无怀孕、哺乳。测定身高、体重、血糖水平。取走病人身体上的金属物品。AcquisitionProtocolWholebodyorregionalFDGimagingBrainFDGimagingPreDistributionTransmissionEmissionRecon15min45-60minInjectionPositionReleasePreparation:fastingatleast6h,resting10-15min.Injection:5-10mCiDistribution:quiet/comfortable/dimroom,voiding,positioningAcquisition:transmission<1min,WB:6-7bedposition,3min/bedReconstruction:图像分析18F-FDGPET正常影像肺癌孤立性肺结节（SPN）的鉴别诊断非小细胞肺癌临床分期不明原因的恶性胸腔积液或肺不张疑有肺肿瘤肺癌治疗后瘢痕、放射性损伤与肿瘤残余及复发的鉴别疗效监测寻找原发病灶和其他转移灶

肺PET-CT检查适应证Table1.DetectionofprimarylungcancerAuthorCasesTechSensSpecAccGupta61PET93%85%92%Wahl23PETCT100%100%100%80%100%83%Puhaylongsod87PET97%82%92%Hubuer23PET100%67%92%Paulus45PET100%93%98%Vaylet26PET90%90%Total265PET97%86%95%临床分期小细胞肺癌(smallcelllungcarcinoma,SCLC)恶性程度高，癌细胞生长快，远处转移早，确诊时往往已出现远处转移，主要采用化疗，外科手术意义不大。因此，对于小细胞肺癌的临床分期价值有限。非小细胞肺癌(nonsmallcelllungcarcinoma,NSCLC)非小细胞肺癌首选手术治疗。肺癌的临床分期是根据原发肿瘤病灶的大小及侵犯情况(T)、区域淋巴结转移(N)及远处转移(M)(TNM)分为0期-Ⅳ期。肺癌分期的主要目的是区分可切除和不可切除病例。Table2.DeterminationofmetastaticinvolvementoflungcancerAuthorCasesTechSensSpecAccBuchpiguel26PETCT93%93%83%42%90%78%Patz21PETCT100%85%73%54%Sasaki9PETCT86%73%100%92%Scott25PET66%86%84%Bury20PETCT90%63%80%66%Madar20PET100%100%100%Valk76PETCT83%63%94%73%91%70%Total197PET88%88%91%疗效观察意义早期了解肿瘤对治疗的反应，可及时调整治疗方案。表现肿瘤对放化疗有效首先表现为肿瘤生长减缓或停止，代谢减低，随后才出现肿瘤体积的缩小或消失。FDGPET/CT显像可在治疗的早期显示肿瘤组织的代谢变化，对早期评价疗效具有重要意义。脑肿瘤胶质瘤（glioma）生物学特性：良恶性的相对性。星性胶质细胞瘤。其它：少突胶质细胞瘤、室管膜瘤。PET/CT显像根据胶质瘤细胞对FDG摄取程度可鉴别其良恶性，有助于判断预后胶质细胞瘤Ⅰ级病灶的放射性浓聚程度低于正常脑组织。胶质细胞瘤Ⅱ-Ⅲ级多表现为高代谢，尤以病灶边缘明显，病灶中心可表现为低代谢；部分Ⅱ级可表现为低代谢。胶质细胞瘤Ⅲ、Ⅳ级表现为高代谢病灶，肿瘤病灶显示为放射性异常浓聚影，甚至高于邻近脑皮质，当肿瘤内部发生出血、坏死时，相应部位可表现为放射性分布缺损。疗效评价放、化疗肿瘤细胞对FDG摄取减低是放、化疗有效的标志。在肿瘤治疗过程中，应用FDGPET/CT显像进行动态观察，根据病灶对FDG摄取变化判断肿瘤细胞对治疗的反应。手术治疗早期发现残留或复发病灶。CT/MRI对鉴别肿瘤治疗后复发抑或术后手术疤痕存有一定困难。而FDGPET/CT则有很强的优势。术后形成的疤痕组织糖代谢水平远低于复发的肿瘤组织，表现为低或无代谢；而复发的肿瘤组织表现为高代谢。颅内恶性淋巴瘤颅内恶性淋巴瘤对FDG的摄取甚高，一般SUV在5-10以上。颅内恶性淋巴瘤对FDG的摄取减低是治疗有效的指标。根据肿瘤对FDG摄取变化，早期评价治疗效果、检测有无复发。颅内转移瘤高代谢病灶脑转移瘤具有较强的FDG浓聚，表现为高代谢。若病灶内有出血、坏死、囊性变或液化，相应部位呈放射性分布明细减低或缺损。小部分脑转移瘤FDG摄取并不很高，分布水平仅略高于相邻的脑白质。原发病灶未明，颅内先发现转移灶，进行FDGPET/CT全身显像有助于分析原发灶。判断放、化疗疗效，鉴别治疗后病灶残留、复发抑或疤痕形成。头颈部肿瘤放疗前放疗后Table4.SensitivityfordetectionofprimaryheadandneckcancerAuthorCasesTechSensJabour12PETCT/MRI100%92%keisser48PET100%Lindholm14PET100%Greven25PET89%Mukherji5PETTl-201CT100%60%80%Kege34PETMRI91%68%Total138PET97%Table5.DetectionoflymphnodemetastasisinheadandneckcancerAuthorCasesTechSensSpecAccJabour9PETMRI74%69%99%98%95%95%Slosman20PETCT100%94%75%50%95%85%Lindholm7PET86%Graven25PET92%80%84%Rege34PETMRI94%91%Braams12PETMRI91%36%88%94%88%88%Total107PET90%86%91%Table6.DefferentiationofheadandneckcancerrecurrencevsscarAuthorCasesTechSensSpecAccChaiken15PETMRI100%80%78%100%87%25%Greven18PET80%100%94%Greven11PET100%83%91%Rege34PETMRI100%67%14%50%63%63%Zeitouni7PET100%100%100%Total85PET96%75%87%甲状腺癌应用指针Tg水平升高但131I全身显像阴性的甲状腺癌的随访。乳腺癌Table7.DetectionofprimarybreastcancerAuthorCasesTechSensSpecAccHoh26PETMAMMO85%70%86%57%85%67%Niewag11PET91%100%95%Dahdashti32PET88%100%91%Wang23PET93%91%100%Total92PET89%94%93%Table8.DetectionofaxillaryinvolvementofbreastcancerAuthorCasesTechSensSpecAccWahl8PET83%100%88%Crowe28PET90%100%95%Jacobs16PET100%93%94%Scheidhauer9PETMAMMO89%72%93%94%Utech124PET100%64%Crippa25PET85%85%Wang23PET80%90%87%Total233PET90%89%92%淋巴瘤Table9.DetectionoflymphomaAuthorCasesTechSensSpecAccHenrich11PETCT100%82%Zanzi5PET100%Newman16PETCT100%91%100%100%100%91%Schonberger17PET100%Rodriguez23PET100%Schonberger16PET94%Total88PET99%100%96%治疗前治疗后消化道肿瘤胃癌食管癌治疗前治疗后大肠癌Table10.DifferentiationoflocallyrecurrentcolorectaltumorvsscarAuthorCasesTechSensSpecAccSchlay18PETIS92%40%100%50%94%43%Strauss29PET95%100%97%Engenhart21PET95%Ito15PETMRI100%91%100%100%Pounds33PET96%53%Schonberger76PETCT93%60%97%79%95%68%Total192PET95%99%97%胰腺癌Table10.DetectionoflocallypancreaticcancerAuthorCasesTechSensSpecAccBares47PET94%100%96%Stollfuss43PETCT95%80%90%74%95%78%Stollfuss44PETCTERCP93%83%93%87%78%91%90%81%92%Inokuma25PETTl-20196%64%Higashi54333PETCTUSEUS95%97%90%91%85%93%62%67%93%80%83%84%Total210PET95%91%94%局限性小病灶难以检出糖尿病的影响血糖水平低于130mg/dl患者检出率86％。血糖水平超过130mg/dl患者检出率42％。急慢性胰腺炎、活动性胰腺结核延迟显像可能对鉴别胰腺癌和胰腺炎有一定的帮助。临床意义

FDGPET/CT对胰腺癌的诊断、临床分期、疗效评价、检测术后肿瘤复发及判断预后具有重要的临床意义。临床分析

由于糖尿病、高血糖、急慢性胰腺炎、活动性胰腺结核可出现假阳性及假阴性。肝癌表11.FDGPET/CT鉴别肝内良恶性肿瘤价值肝内病灶例数符合率％腺癌及肉瘤肝转移66100（66/66）胆管癌8100(8/8)肝细胞癌2370(16/23)泌尿生殖系统肿瘤肾癌肾癌对FDG的摄取与肿瘤细胞的生长速度有关，生长快的肿瘤摄取程度高，生长缓慢的肿瘤摄取偏低。灵敏度约70％假阴性问题：葡萄糖转运体-1表达水平由于FDG主要经由泌尿系统排泄，肾内可残留较多的放射性，对肾内肿瘤的诊断产生影响。膀胱癌FDG主要经由泌尿系统排泄，膀胱内有较高的放射性，对膀胱肿瘤的诊断产生影响。对策调低灰阶；大量饮水，必要时使用利尿剂；延迟显像。前列腺癌妇科肿瘤CancerofunknownprimaryThecriteriaforthediagnosisofCUP

Biopsy-provenmalignancyNoprimarytumorfoundafterathoroughmedicalhistoryorphysicalexaminationNormallaboratorytestresults,includingtheresultsofacompletebloodcount,bloodchemistry,chestX-ray,computedtomographyscanoftheabdomenandpelvis,andmammographyorprostate-specificantigentest

Cancer2004,100:1776-1785.

a58-year-oldmalewithbrainmetastasis(besurgicallyremoved).A:ThewholebodyMIPPETimageshowedincreaseduptake(redarrow).B:Focustraceruptakewasshownintherightapex(redarrow).Histologyconfirmedtobegiantcellcarcinoma.A63-year-oldfemalewithaxillarylymphnodemetastasis.PET/CTimagesviewedtracerfocusaccumulationinleftbreastatearlyphase(Cross),SUVave2.2,SUVmax2.6,andthelesionwasobservedmoreclearlyatdelayedphase,SUVave2.6,SUVmax3.5.Itwasconfirmedtobeinvasiveductalcarcinomabyhistology.化疗方案：肽素+顺铂→二氟脱氧胞苷+顺铂18F-FDGPET/CT对肿瘤的诊断价值隐匿的早期肿瘤病灶的探测肿瘤良、恶性的鉴别肿瘤的临床分期寻找肿瘤原发灶疗效评价鉴别治疗后瘢痕、残留或复发灶协助放疗计划的制定2000HCFA(TheHealthCareFinancingAdministration)MedicareCoverageforPETScans

DiagnosticevaluationofsolitarypulmonarynodulesStagingnon-smallcelllungcancerDiagnosticevaluation,stagingandre-stagingcolorectalcancerStagingandre-stagingbothHodgkin’sandnon-Hodgkin’slymphomaStagingandrestagingofmelanomaDiagnosis,staging,andrestagingofesophagealcancerDiagnosis,staging,andrestagingofheadandneckcancer(excludingbrainandthyroidtumors)Diagnosis,staging,andrestagingofbreastcancerMyocardialviabilityLocalizationofrefractoryepilepsyDementia.18F-FDG鉴别肿瘤良恶性的局限性急性炎症、活动性结核病灶个别良性病变分化程度较高的肝细胞癌泌尿系统肿瘤非特异性肿瘤阳性显像剂99mTc-MIBI肿瘤显像为一种脂溶性阳离子化合物。通过被动弥散进入细胞。恶性肿瘤组织血流灌注增加、肿瘤细胞活性使肿瘤细胞线粒体膜内外的电位差增加、MIBI在线粒体膜内负电荷吸引进入线粒体增多。征象：早期相T/NT比值增高，延迟相T/NT比值进一步增高。99mTc-MIBI肿瘤显像99mTc-MIBI肿瘤Pgp显像－Pgp与肿瘤MDR(multidrugresistance)密切相关。－MIBI为Pgp的作用底物。Pgp表达水平增高则将更多MIBI泵出肿瘤细胞外，肿瘤组织摄取MIBI减少。

－99mTc-MIBI肿瘤Pgp显像可反映Pgp水平，从而预测MDR的产生及肿瘤化疗疗效。方法血流灌注相：2sec/frame×1min早期相：注射后5-30min。延迟相：注射后1-3h。a:99mTcO4-b:Perfusionphasec:Earlyphased:Delayphase(AandB)Presentativepositivecase(RI,71.76)ofsolitarycoldthyroidnoduleinrightlobehistologicallydiagnosedaspoorlydifferentiatedcarcinoma.(A)Earlyimagewithtraceraccumulationinnodule(ER,2.62).(B)Delayedimagewithtracerretentioninlesion(DR,4.50).(CandD)Representativenegativecase(RI,−40.64)ofsolitarycoldthyroidnoduleinleftlobethatprovedtobemicrofolliculargoiter.(C)Earlyimagewithtraceruptakeinnodule(ER,2.81).(D)Delayedimagewithnearlycompletetracerwashoutfromnodule(DR,1.67).a:女，42y。MIBI：左乳腺及左腋窝局灶性浓聚。术后病理：左乳浸润性导管Ca伴左腋窝淋巴结转移。b:女，37y。右乳MIBI轻度浓聚。病理：右乳纤维腺瘤。甲状腺静态显像示左叶甲状腺“冷结节”。99mTc-MIBI示局部明显浓聚。乳腺Ca灵敏度85％，特异性81％。直径小于1cm包块灵敏度低。假阳性：乳腺纤维腺瘤。腋窝淋巴结：阳性预测值83％，阴性预测值82％。肺Ca灵敏度78％-96％，特异性70-90.9％。

纵隔淋巴结。小细胞肺Ca化疗效果预测及疗效评价。甲状腺Ca

“冷结节”的灵敏度83％-100％，特异性72％。临床应用通过肿瘤细胞膜上Na＋-K＋-ATP酶系统主动转运入细胞。与血流灌注、肿瘤细胞活力等有关。主要以