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,第一页，共五十六页。,指南更新,JCO 2007;25:579-586,JCO 2022;32:3048-3058,第二页，共五十六页。,新的淋巴瘤分期,JCO 2022;32:3059-3067,第三页，共五十六页。,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,第四页，共五十六页。,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
2、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,第五页，共五十六页。,18FDG在肿瘤细胞中的摄取,第六页，共五十六页。,FDG在常见淋巴瘤中的摄取,第七页，共五十六页。,进行FDG-PET的要求,Juweid ME,et al.J Clin Oncol 2007;25:571-578.,第八页，共五十六页。,PET图像的解读标准(视觉判断法),Juweid ME,et al.J Clin Oncol 2007;25:571-578.,第九页，共五十六页。
3、,5分类法(Deauville 标准),Barrington S,et al.J Clin Oncol 2022;32:3048,第十页，共五十六页。,举例：治疗前,第十一页，共五十六页。,治疗后：1分,Example of score 1:complete metabolic response with no uptake in normal-size lymph nodes at site of initial disease in left neck(arrow).,第十二页，共五十六页。,举例：治疗前,第十三页，共五十六页。,治疗后：2分,Example of score 2:resi
4、dual uptake of intensity mediastinal blood pool in lymph nodes in left axilla(arrow).Maximum standardized uptake value(SUVmax)in lymph nodes was 1.2;SUVmax in mediastinal blood pool was 1.7.,第十四页，共五十六页。,举例：治疗前,第十五页，共五十六页。,治疗后：3分,Example of score 3:residual uptake of intensity mediastinal blood pool
5、but liver in residual mediastinal mass(arrow).Maximum standardized uptake value(SUVmax)in mass was 1.7;SUVmax in liver was 2.2.,第十六页，共五十六页。,举例：治疗前,第十七页，共五十六页。,治疗后：4分,Example of score 4:residual uptake of intensity liver in residual mediastinal mass(arrow).Maximum standardized uptake value(SUVmax)in
6、mass was 4.5;SUVmax in liver was 3.2.,第十八页，共五十六页。,举例：治疗前,第十九页，共五十六页。,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.,第二十页，共五十六页。,新的指南推荐级别,Experts in nuclear me
7、dicine and radiology applied to lymphoma undertook 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(t
8、ype 3),Barrington S,et al.J Clin Oncol 2022;32:3048,第二十一页，共五十六页。,肿瘤缓解术语,CTCR：complete responseCRu：complete response unconfirmedPR：partial responseSD：stable diseasePD：progressive disease,PET/CTCMR：complete metabolic responsePMR：partial metabolic responseNMR：no metabolic responsePMR：progressive metabo
9、lic disease,Cheson BD,et al.J Clin Oncol 1999;17:1244.,Cheson BD,et al.J Clin Oncol 2022;32:3059,第二十二页，共五十六页。,Interpretation of PET-CT scans,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 aggre
10、ssive NHL is sensitive for bone marrow involvement and may obviate need for biopsy;MRI is modality of choice for suspected CNS lymphoma(type 1)Five-point scale is recommended for reporting PET-CT;results should be interpreted in context of anticipated prognosis,clinical findings,and othermarkers of
11、response;scores 1 and 2 represent CMR;score 3 also probably represents CMR in patients receiving standard treatment(type 1)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 t
12、o score 5,score 5 with no decrease in uptake,and new FDG-avid foci consistent with lymphoma represent treatment failure and/or progression(type 2),Barrington S,et al.J Clin Oncol 2022;32:3048,第二十三页，共五十六页。,PET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周最佳答案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
13、作和图像的解读,第二十四页，共五十六页。,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,第二十五页，共五十六页。,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,第二十六页，共五十六页。,PET与CT用于分期评估的比较,第二十七页，共五十六页。,PET分期评估的结果,第二十八页，共五十六页。,Role of PET-CT for staging,PET-CT should be used for staging in
14、clinical practice and clinical trials but is not routinely recommended in lymphomas with low FDG avidity;PET-CT may be used to select best site to biopsy(type 1)Contrast-enhanced CT when used at staging or restaging should ideally occur during single visit combined with PET-CT,if not already perform
15、ed;baseline findings will determine whether contrast-enhanced PET-CT or lower-dose unenhanced PET-CT will suffice for additional imaging examinations(type 2)Bulk remains an important prognostic factor in some lymphomas;volumetric measurement of tumor bulk and total tumor burden,including methods com
16、bining metabolic activity and anatomical size or volume,should be explored as potential prognosticators(type 3),Barrington S,et al.J Clin Oncol 2022;32:3048,第二十九页，共五十六页。,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,第三十页，共五十六页。,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.,第三十一页，共五十六页。,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?,Cheson BD,et al.J Clin Oncol 1999;17:1244.,第三十二页，共五十六页。,IWG标准的缺点,无法区分肿瘤残留抑或纤维化C
