1、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 JCO 2007;25:579-586 JCO 2014;32:3048-3058 新的淋巴瘤分期 JCO 2014;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：
2、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 Juweid ME,et al.J Clin Oncol 2007;25:571-578.PET图像的解读标准(视觉判断法)Juweid ME,et al.J Clin Oncol 2007;25:571-578.5分类法(Deauville 标准)Barrington S,et al.J Clin Oncol 2014;32:3048 举例：治疗前 治疗后：1分 Example of score 1
3、:complete metabolic response with no uptake in normal-size lymph nodes at site of initial disease in left neck(arrow).举例：治疗前 治疗后：2分 Example of score 2:residual uptake of intensity mediastinal blood pool but liver in residual mediastinal mass(arrow).Maximum standardized uptake value(SUVmax)in mass wa
4、s 4.5;SUVmax in liver was 3.2.举例：治疗前 治疗后：5分 Example of score 5:residual uptake in mediastinum with intensity markedly higher than normal liver.Maximum standardized uptake value(SUVmax)in mass was 13.0;SUVmax in liver was 2.3.新的指南推荐级别 Experts in nuclear medicine and radiology applied to lymphoma unde
5、rtook a literature review and shared knowledge about research in progress.Recommendations were formulated as follows:Based on established current knowledge(type 1)To identify emerging applications(type 2)To highlight key areas requiring further research(type 3)Barrington S,et al.J Clin Oncol 2014;32
6、:3048 肿瘤缓解术语 CT CR：complete response CRu：complete response unconfirmed PR：partial response SD：stable disease PD：progressive disease PET/CT CMR：complete metabolic response PMR：partial metabolic response NMR：no metabolic response PMR：progressive metabolic disease Cheson BD,et al.J Clin Oncol 1999;17:1
7、244.Cheson BD,et al.J Clin Oncol 2014;32:3059 Interpretation of PET-CT scans 1.Staging of FDG-avid lymphomas is recommended using visual assessment,with PET-CT images scaled to fixed SUV display and color table;focal uptakein HL and aggressive NHL is sensitive for bone marrow involvement and may obv
8、iate need for biopsy;MRI is modality of choice for suspected CNS lymphoma(type 1)2.Five-point scale is recommended for reporting PET-CT;results should be interpreted in context of anticipated prognosis,clinical findings,and othermarkers of response;scores 1 and 2 represent CMR;score 3 also probably
9、represents CMR in patients receiving standard treatment(type 1)3.Score 4 or 5 with reduced uptake from baseline likely represents partial metabolic response,but at end of treatment represents residual metabolicdisease;increase in FDG uptake to score 5,score 5 with no decrease in uptake,and new FDG-a
10、vid foci consistent with lymphoma represent treatment failure and/or progression(type 2)Barrington S,et al.J Clin Oncol 2014;32:3048 PET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
11、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 Role of PET-CT for staging 1.PET-CT should be used for staging in clinical practice and clinical trials but is not routinely recommended in lymphomas with low FDG avidity;PET-CT may be used
12、 to select best site to biopsy(type 1)2.Contrast-enhanced CT when used at staging or restaging should ideally occur during single visit combined with PET-CT,if not already performed;baseline findings will determine whether contrast-enhanced PET-CT or lower-dose unenhanced PET-CT will suffice for add
13、itional imaging examinations(type 2)3.Bulk remains an important prognostic factor in some lymphomas;volumetric measurement of tumor bulk and total tumor burden,including methods combining metabolic activity and anatomical size or volume,should be explored as potential prognosticators(type 3)Barringt
14、on S,et al.J Clin Oncol 2014;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 Cheson BD,et al.J Clin Oncol 1999;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
15、 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 Cheson BD,et al.J Clin Oncol 1999;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 Cheson BD,et al.J Clin Oncol 2007;25:579 2007年IHP制定了新
16、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 IHP标准的淋巴瘤类型推荐 Cheson BD,et al.J Clin Oncol 2007;25:579 临床试验中的疗效定义 Cheson BD,et al.J Clin Oncol 2007;25:579 新的PET疗效定义 CMR:complete metabolic response Score 1,2,or 3 with or without a residual mass on 5PS PMR:partial metabolic response Score 4 or 5 with reduced uptake compared with baseline and residual mass(es)of any size At interim,these findings suggest responding disease At end of treatment,these findings indicate residual disease
