能谱CT诊断非小细胞肺癌纵隔淋巴结转移的应用价值

doi:10.19723/j.issn.1671-167X.2020.04.026

摘要/Abstract

摘要：

目的: 探讨能谱CT (dual energy CT, DECT) 诊断非小细胞肺癌 (non-small cell lung cancer, NSCLC) 纵隔淋巴结转移的应用价值。方法: 选择2018年4月至2019年10月在北京大学第三医院接受胸部DECT检查且经术后病理诊断证实的NSCLC患者病例资料进行回顾性分析,共收集到病例57 例,两名放射科医师共同分析患者术前CT图像,将轴位图像上所有短径 (short-axis diameter, S)≥5 mm的纵隔淋巴结纳入本研究。测量淋巴结形态学参数长径(long-axis diameter, L)、S、短径与长径比值(ratio of short-axis diameter to long-axis diameter, S/L)以及能谱参数动脉期及静脉期碘浓度 (iodine concentration, IC)、标准化碘浓度 (normalized iodine concentration, NIC)、能谱曲线斜率及有效原子序数。比较转移与非转移淋巴结形态学指标及其能谱参数的差异,将有统计学差异的参数纳入Logistic回归方程筛选出有诊断价值的参数,并生成诊断淋巴结转移的联合变量,对淋巴结S、静脉期NIC及联合变量进行受试者工作特征 (receiver operating characteristic, ROC)曲线分析。结果: 57例患者中,术后病理诊断证实转移淋巴结49 枚,非转移淋巴结938 枚。CT轴位上共检出S≥5 mm纵隔淋巴结163 枚 (转移淋巴结49 枚,非转移淋巴结114 枚)。转移淋巴结的S、L及S/L均显著大于非转移淋巴结 (P<0.05), 转移淋巴结的能谱参数均显著低于非转移性淋巴结 (P<0.05)。S是诊断淋巴结转移的最佳单一形态学指标,ROC曲线下面积 (area under curve, AUC) 为0.752,阈值8.5 mm,灵敏度67.4%,特异度73.7%,准确率71.8%。静脉期NIC为最佳单一能谱参数,AUC为0.861,阈值0.53,灵敏度95.9%,特异度70.2%,准确率77.9%。多因素分析显示S、静脉期NIC是转移淋巴结的独立预测因子。联合S、静脉期NIC诊断淋巴结转移的AUC为0.895,灵敏度 79.6%,特异度 87.7%,准确率85.3%,明显高于S (P<0.001)、静脉期NIC (P=0.037)。结论: DECT定量参数鉴别NSCLC患者纵隔淋巴结转移的价值优于形态学参数,联合S和静脉期NIC可提高术前诊断淋巴结转移的准确率。

关键词: 非小细胞肺癌, 淋巴结转移, 体层摄影术, X射线计算机

Abstract:

Objective: To validate the value of dual energy CT (DECT) in the differentiation of mediastinal metastatic lymph nodes from non-metastatic lymph nodes in non-small cell lung cancer (NSCLC). Methods: In the study, 57 surgically confirmed NSCLC patients who underwent enhanced DECT scan within 2 weeks before operation were enrolled. Two radiologists analyzed the CT images before operation. All mediastinal lymph nodes with short diameter≥5 mm on axial images were included in this study. The morphological parameters [long-axis diameter (L), short-axis diameter (S) and S/L of lymph nodes] and the DECT parameters [iodine concentration (IC), normalized iodine concentration (NIC), slope of spectral hounsfield unit curve (λHU) and effective atomic number (Zeff) in arterial and venous phase] were measured. The differences of morphological parameters and DECT parameters between metastatic and non-metastatic lymph nodes were compared. The parameters with significant difference were analyzed by the Logistic regression model, then a new predictive variable was established. Receiver operator characteristic (ROC) analyses were performed for S, NIC in venous phase and the new predictive variable. Results: In 57 patients, 49 metastatic lymph nodes and 938 non-metastatic lymph nodes were confirmed by surgical pathology. A total of 163 mediastinal lymph nodes (49 metastatic, 114 non-metastatic) with S≥5 mm were detected on axial CT images. The S, L and S/L of metastatic lymph nodes were significantly higher than those of non-metastatic lymph nodes (P<0.05). The DECT parameters of metastatic lymph nodes were significantly lower than those of non-metastatic lymph nodes (P<0.05). The best single morphological parameter for differentiation between metastatic and nonmetastatic lymph nodes was S (AUC, 0.752; threshold, 8.5 mm; sensitivity, 67.4%; specificity, 73.7%; accuracy, 71.8%). The best single DECT parameter for differentiation between metastatic and nonmetastatic lymph nodes was NIC in venous phase (AUC, 0.861; threshold, 0.53; sensitivity, 95.9%; specificity, 70.2%; accuracy, 77.9%). Multivariate analysis showed that S and NIC were independent predictors of lymph node metastasis. The AUC of combined S and NIC in the venous phase was 0.895(sensitivity, 79.6%; specificity, 87.7%; accuracy, 85.3%), which were significantly higher than that of S (P<0.001) and NIC (P=0.037). Conclusion: The ability of quantitative DECT parameters to distinguish mediastinal lymph node metastasis in NSCLC patients is better than that of morphological parameters. Combined S and NIC in venous phase can be used to improve preoperative diagnostic accuracy of metastatic lymph nodes.

Key words: Non-small cell lung cancer, Lymph node metastasis, Tomography, X-ray computed

中图分类号:

R734.2

朱巧,任翠,张艳,李美娇,王晓华. 能谱CT诊断非小细胞肺癌纵隔淋巴结转移的应用价值[J]. 北京大学学报（医学版）, 2020, 52(4): 730-737.

Qiao ZHU,Cui REN,Yan ZHANG,Mei-jiao LI,Xiao-hua WANG. Comparative imaging study of mediastinal lymph node from pre-surgery dual energy CT versus post-surgeron verifications in non-small cell lung cancer patients[J]. Journal of Peking University (Health Sciences), 2020, 52(4): 730-737.

图/表 8

图1

图2

表1

表2

表3

表4

非小细胞肺癌纵隔转移与非转移淋巴结能谱CT参数比较( $\bar{x}±s$ )"

Characteristic	Metastatic (n=49)	Non-metastatic (n=114)	t	P
Arterial phase
IC/(100 μg/cm³)	22.14±5.11	24.94±3.79	-3.448	<0.001
NIC	0.25±0.04	0.36±0.09	-10.300	<0.001
λHU	2.13±0.21	2.33±0.23	-5.194	<0.001
Zeff	8.07±0.46	8.34±0.51	-3.213	0.002
Venous phase
IC/(100 μg/cm³)	27.24±5.68	30.26±5.60	-3.139	0.002
NIC	0.43±0.07	0.60±0.14	-10.875	<0.001
λHU	2.46±0.31	2.84±0.29	-7.405	<0.001
Zeff	8.25±0.37	8.55±0.45	-4.052	<0.001

表4

表5

图3

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Items	Doctor A
Items	ICC	95%CI	ICC	95%CI
S	0.872	0.566-0.947	0.849	0.743-0.912
L	0.891	0.643-0.954	0.932	0.873-0.963
Arterial phase
IC	0.930	0.303-0.980	0.897	0.818-0.942
NIC	0.880	0.798-0.930	0.853	0.730-0.919
λHU	0.891	0.690-0.952	0.839	0.614-0.923
Zeff	0.949	0.723-0.982	0.920	0.864-0.954
Venous phase
IC	0.833	0.484-0.929	0.901	0.420-0.967
NIC	0.891	0.690-0.952	0.839	0.614-0.923
λHU	0.903	0.335-0.970	0.812	0.340-0.927
Zeff	0.869	0.150-0.960	0.927	0.874-0.958

Group	L/mm	S/mm	S/L
Metastatic (n=49)	13.10±2.99	9.90±2.55	0.76±0.09
Non-metastatic (n=114)	11.38±2.91	7.72±1.96	0.69±0.08
t	3.432	5.899	5.075
P	0.001	<0.001	<0.001

Items		AUC	Sensitivity/%	Specivicity/%	Positive predictive value/%	Negative predictive value/%	Accuracy/%
Parameter threshold
S	8.50	0.752(0.672-0.832)	67.4(52.5-80.1)	73.7(64.6-81.5)	52.4(43.3-61.3)	84.0(77.6-88.8)	71.8(64.2 -78.5)
L	10.94	0.654(0.564-0.745)	79.6(65.7-89.8)	50.0(40.5-59.5)	40.6(35.2-46.3)	85.1(76.1-91.1)	58.9(50.9 -66.5)
S/L	0.76	0.734(0.644-0.825)	57.1(42.2-71.2)	84.2(76.2-90.4)	60.9(48.8-71.7)	82.1(76.6-86.4)	76.1(68.8-82.4)
Arterial phase
IC	22.23	0.660(0.561-0.759)	61.2(46.2-74.8)	70.2(60.9-78.4)	46.9(38.1-55.8)	80.8(74.4-85.9)	67.5(59.7-74.6)
NIC	0.31	0.850(0.793-0.908)	91.8(80.4-97.7)	69.3(60.0-77.6)	56.3(49.1-63.2)	95.2(88.5-98.1)	76.1(68.8-82.4)
λHU	2.11	0.754(0.674-0.834)	57.1(42.2-71.2)	84.2(76.2-90.4)	60.9(48.8-71.7)	82.1(76.6-86.4)	76.1(68.8-82.4)
Zeff	8.34	0.657(0.569-0.744)	73.5(58.9-85.1)	56.1(46.5-65.4)	41.9(35.5-48.5)	83.1(75.0-89.0)	61.4(53.4-68.9)
Venous phase
IC	25.56	0.643(0.544-0.742)	44.9(30.7-59.8)	83.3(75.2-89.7)	53.7(40.9-66.0)	77.9(73.0-82.1)	71.8(64.2-78.5)
NIC	0.53	0.861(0.806-0.915)	95.9(86.0-99.5)	70.2(60.9-78.4)	58.0(50.9-64.8)	97.6(91.1- 99.4)	77.9(70.8-84.0)
λHU	2.72	0.807(0.736-0.878)	81.6(68.0-91.2)	66.7(57.2-75.2)	51.3(44.0-58.5)	89.4(82.2-93.9)	71.2(63.6-78.0)
Zeff	8.74	0.701(0.624-0.779)	89.8(77.8-96.6)	52.6(43.1-62.1)	44.9(39.6-50.3)	92.3(83.7-96.6)	63.8(55.9-71.2)
LogitP	0.56	0.895(0.846-0.943)	79.6(65.7-89.8)	87.7(80.3-93.1)	73.6(62.6-82.3)	90.9(85.1- 94.6)	85.3(78.9-90.3)