PETCT在淋巴瘤中的应用

1PET/CT在淋巴瘤中的应用

精选ppt2指南更新JCO2007;25:579-586JCO2021;32:3048-3058精选ppt3新的淋巴瘤分期JCO2021;32:3059-3067精选ppt4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精选ppt5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根底，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，两者结合取长补短精选ppt618FDG在肿瘤细胞中的摄取精选ppt7FDG在常见淋巴瘤中的摄取精选ppt8进行FDG-PET的要求JuweidME,etal.JClinOncol2007;25:571-578.精选ppt9PET图像的解读标准(视觉判断法)JuweidME,etal.JClinOncol2007;25:571-578.精选ppt105分类法(Deauville标准)BarringtonS,etal.JClinOncol2021;32:3048精选ppt11举例：治疗前精选ppt12治疗后：1分Exampleofscore1:completemetabolicresponsewithnouptakeinnormal-sizelymphnodesatsiteofinitialdiseaseinleftneck(arrow).精选ppt13举例：治疗前精选ppt14治疗后：2分Exampleofscore2:residualuptakeofintensity<mediastinalbloodpoolinlymphnodesinleftaxilla(arrow).Maximumstandardizeduptakevalue(SUVmax)inlymphnodeswas1.2;SUVmaxinmediastinalbloodpoolwas1.7.精选ppt15举例：治疗前精选ppt16治疗后：3分Exampleofscore3:residualuptakeofintensity>mediastinalbloodpoolbut<liverinresidualmediastinalmass(arrow).Maximumstandardizeduptakevalue(SUVmax)inmasswas1.7;SUVmaxinliverwas2.2.精选ppt17举例：治疗前精选ppt18治疗后：4分Exampleofscore4:residualuptakeofintensity>liverinresidualmediastinalmass(arrow).Maximumstandardizeduptakevalue(SUVmax)inmasswas4.5;SUVmaxinliverwas3.2.精选ppt19举例：治疗前精选ppt20治疗后：5分Exampleofscore5:residualuptakeinmediastinumwithintensitymarkedlyhigherthannormalliver.Maximumstandardizeduptakevalue(SUVmax)inmasswas13.0;SUVmaxinliverwas2.3.精选ppt21新的指南推荐级别Expertsinnuclearmedicineandradiologyappliedtolymphomaundertookaliteraturereviewandsharedknowledgeaboutresearchinprogress.Recommendationswereformulatedasfollows:Basedonestablishedcurrentknowledge(type1)Toidentifyemergingapplications(type2)Tohighlightkeyareasrequiringfurtherresearch(type3)BarringtonS,etal.JClinOncol2021;32:3048精选ppt22肿瘤缓解术语CTCR：completeresponseCRu：completeresponseunconfirmedPR：partialresponseSD：stablediseasePD：progressivediseasePET/CTCMR：completemetabolicresponsePMR：partialmetabolicresponseNMR：nometabolicresponsePMR：progressivemetabolicdiseaseChesonBD,etal.JClinOncol1999;17:1244.ChesonBD,etal.JClinOncol2021;32:3059精选ppt23InterpretationofPET-CTscansStagingofFDG-avidlymphomasisrecommendedusingvisualassessment,withPET-CTimagesscaledtofixedSUVdisplayandcolortable;focaluptakeinHLandaggressiveNHLissensitiveforbonemarrowinvolvementandmayobviateneedforbiopsy;MRIismodalityofchoiceforsuspectedCNSlymphoma(type1)Five-pointscaleisrecommendedforreportingPET-CT;resultsshouldbeinterpretedincontextofanticipatedprognosis,clinicalfindings,andothermarkersofresponse;scores1and2representCMR;score3alsoprobablyrepresentsCMRinpatientsreceivingstandardtreatment(type1)Score4or5withreduceduptakefrombaselinelikelyrepresentspartialmetabolicresponse,butatendoftreatmentrepresentsresidualmetabolicdisease;increaseinFDGuptaketoscore5,score5withnodecreaseinuptake,andnewFDG-avidfociconsistentwithlymphomarepresenttreatmentfailureand/orprogression(type2)BarringtonS,etal.JClinOncol2021;32:3048精选ppt24PET结果假阳性产生的原因化疗/放疗后的坏死/炎症反响化疗间隔：至少3周〔最正确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标准的操作和图像的解读精选ppt25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精选ppt26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缺乏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精选ppt27PET与CT用于分期评估的比较精选ppt28PET分期评估的结果精选ppt29RoleofPET-CTforstagingPET-CTshouldbeusedforstaginginclinicalpracticeandclinicaltrialsbutisnotroutinelyrecommendedinlymphomaswithlowFDGavidity;PET-CTmaybeusedtoselectbestsitetobiopsy(type1)Contrast-enhancedCTwhenusedatstagingorrestagingshouldideallyoccurduringsinglevisitcombinedwithPET-CT,ifnotalreadyperformed;baselinefindingswilldeterminewhethercontrast-enhancedPET-CTorlower-doseunenhancedPET-CTwillsufficeforadditionalimagingexaminations(type2)Bulkremainsanimportantprognosticfactorinsomelymphomas;volumetricmeasurementoftumorbulkandtotaltumorburden,includingmethodscombiningmetabolicactivityandanatomicalsizeorvolume,shouldbeexploredaspotentialprognosticators(type3)BarringtonS,etal.JClinOncol2021;32:3048精选ppt30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精选ppt31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.精选ppt32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.精选ppt33IWG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精选ppt34PET疗效评估的阳性和阴性预测值精选ppt35基于PET的IHP标准ChesonBD,etal.JClinOncol2007;25:5792007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HL精选ppt36IHP标准的淋巴瘤类型推荐ChesonBD,etal.JClinOncol2007;25:579精选ppt37临床试验中的疗效定义ChesonBD,etal.JClinOncol2007;25:579精选ppt38新的PET疗效定义CMR:completemetabolicresponseScore1,2,or3withorwithoutaresidualmasson5PSPMR:partialmetabolicresponseScore4or5withreduceduptakecomparedwithbaselineandresidualmass(es)ofanysizeAtinterim,thesefindingssuggestrespondingdiseaseAtendoftreatment,thesefindingsindicateresidualdiseaseNMR:nometabolicresponseScore4or5withnosignificantchangeinFDGuptakefrombaselineatinterimorendoftreatmentPMR:progressivemetabolicdiseaseScore4or5withanincreaseinintensityofuptakefrombaselineand/orNewFDG-avidfociconsistentwithlymphomaatinterimorend-of-treatmentassessmentChesonBD,etal.JClinOncol2021;32:3059精选ppt39RoleofPETatendoftreatmentPET-CTisstandardofcareforremissionassessmentinFDG-avidlymphoma;inpresenceofresidualmetabolicallyactivetissue,wheresalvagetreatmentisbeingconsidered,biopsyisrecommended(type1)InvestigationofsignificanceofPET-negativeresidualmassesshouldbecollectedprospectivelyinclinicaltrials;residualmasssizeandlocationshouldberecordedonend-of-treatmentPET-CTreportswherepossible(type3)EmergingdatasupportuseofPET-CTafterrituximab-containingchemotherapyinhigh–tumorburdenFL;studiesarewarrantedtoconfirmthisfindinginpatientsreceivingmaintenancetherapy(type2)AssessmentwithPET-CTcouldbeusedtoguidedecisionsbeforehigh-dosechemotherapyandASCT,butadditionalstudiesarewarranted(type3)BarringtonS,etal.JClinOncol2021;32:3048精选ppt40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精选ppt41背景淋巴瘤包括DLBCL是一个异质性很大的疾病现有的预后因素有助于判断总体预后，但往往难以据此作出个体化的治疗方案选择如何早期筛选出难治性或容易复发的患者，有助于尽早实施解救方案，如化疗、移植或新的靶向药物等，从而改善预后如何早期筛选出预后良好的患者，有助于调整治疗强度，从而减少远期毒性或第二原发肿瘤精选ppt42重要的预后因素--治疗敏感性治疗的敏感性即肿瘤缓解情况往往与预后具有相关性治疗后的缓解状态有助于早期调整治疗方案对于肿瘤缓解状态的判断，PET/CT优于普通增强CTPET/CT可以判断肿瘤内部的代谢情况，从而有助于早期明确治疗的敏感性精选ppt43PET图像的解读方法视觉判断法(IHP标准)5分类法(Deauville标准)半定量法(ΔSUVmax)精选ppt44视觉判断法103例DLBCL接受CHOP±利妥昔单抗的治疗2-4个周期后行CT和PET评价疗效DupuisJ,etal.AnnOncol2021;20(3):503-507.精选ppt45系统性综述TerasawaT,etal.JClinOncol2021;27(11):1906-1914精选ppt46视觉判断法存在的重要问题精选ppt47过低的结果判断一致率一致率：68%一致率：71%HorningSJ,etal.Blood2021;115(4):775-777精选ppt48过高的假阳性率(假阳性：87%)MSKCC研究MoskowitzCH,etal.JClinOncol2021;28(11):1896-1903精选ppt49扫描时间的重要性HüttmannA,etal.JClinOncol2021;28(27):e488-e489精选ppt505分类法(Deauville标准)MeignanM,etal.LeukLymphoma2021;51(12):2171–2180分值定义结果1无摄取阴性2摄取

≤纵隔阴性3摄取>纵隔但≤肝脏阴性4摄取>肝(中度)阳性5摄取>肝(明显)和/或出现新区域摄取阳性X新区域摄取不太可能与淋巴瘤相关NA精选ppt51采用纵隔血池和肝脏作为参照的比较IttiE,etal.JNuclMed2021;51(12):1857-1862精选ppt52半定量法(ΔSUVmax)优点：SUVmax的变化反映了肿瘤的动态代谢半定量标准有助于个体化判断疗效与视