FDG PET/CT联合99Tcm-SC前哨淋巴结显像诊断乳腺癌

^99Tc^m-硫胶体(SC)乳腺前哨淋巴结(SLN)显像是判断乳腺癌第1站淋巴结是否有转移的一种方法，对乳腺癌治疗方案的设计具有一定的指导作用；而^18F-脱氧葡萄糖(FDG)PET／CT显像则从乳腺癌原发病灶及其转移淋巴结的异常代谢结合形态方面进行诊断。本研究联合以上两种方法对部分乳腺癌患者进行研究，现报道如下。     

利用四维锥形束CT指导肺癌内靶区的勾画

目的 研究四维锥形束CT(4D-CBCT)指导肺癌内靶区勾画的可行性。方法 简单随机法选取本院24例肺癌患者。平静呼吸下CT模拟定位获得CT图像,首次治疗前4D-CBCT扫描获得4D-CBCT中位图像,将4D图像重建算法更改为3D,获得3D-CBCT图像。图像融合算法取骨配准,分别在定位CT、4D-CBCT中位图像、3D-CBCT图像上勾画大体肿瘤靶区(GTV),定义GTV到临床靶区(CTV)的外扩边界为7 mm,获得CTV_CT、ITV_4D和ITV_3D,基于CTV_CT在三维方向上外扩5 mm得到ITV_CT。比较靶区间中心点位置、体积、相似度和相互包含关系的差异。结果 ITV_CT与ITV_3D在中下叶组的头脚方向上,靶区中心点位置差异有统计学意义(Z=-2.027,P<0.05)。在靶区体积方面,ITV_CT最大,与ITV_3D相比差异有统计学意义(Z=-2.941,P<0.05),ITV_4D最小,但与ITV_3D相比差异无统计学意义(P>0.05)。ITV_CT与ITV_3D相似度均数<75%,ITV_4D与ITV_3D相似度均数>90%(Z=-2.940、-2.975,P<0.05)。ITV_CT、ITV_4D未被ITV_3D包含的比例均数为40%和5%(Z=-2.952、-3.185,P<0.05)。结论 4D-CBCT的中位图像可以缩小内靶区的勾画范围,为肺癌的自适应放疗提供选择。     

SPECT/CT同机图像融合技术诊断肺动脉栓塞的临床价值

目的探讨SPECT/CT同机图像融合技术对肺动脉栓塞(PE)的诊断价值。方法选择58例可疑肺动脉栓塞(PE)患者,分别进行肺通气/灌注(V/P)显像、螺旋CT血管造影(SCTA)、SPECT/CT同机扫描以及图像融合处理,比较对PE诊断的灵敏度和特异性及准确性的差异。结果V/P显像,SCTA,SPECT/CT对PE诊断的灵敏度、特异性及准确性分别为90.00%、64.29%、77.59%;73.33%、85.71%、79.31%;90.00%、85.71%、87.93%。结论总体看,在PE诊断中,SPECT/CT融合图像技术准确性优于SCTA和V/P显像。     

局限期前列腺癌放疗精囊临床靶区勾画范围的研究

目的 探讨局限期前列腺癌精囊临床靶区（CTV）的勾画范围。方法 114例接受根治性放疗的局限期中、高危前列腺癌患者行定位CT扫描,对比欧美指南共同参考的精囊亚临床灶范围的病理结果,得到精囊长轴距起点1.0 cm和2.0 cm处的精囊截面,确定精囊近端1.0 cm和2.0 cm的解剖范围,然后测量两个截面距精囊起始平面的最大垂直距离（D_10H、D_20H）和最小垂直距离（D_10L、D_20L）,并与欧美指南规定的勾画范围对比,进一步指导高剂量区精囊CTV的勾画范围。结果D_10H、D_10L、D_20H、D_20L平均值分别为（10.6 ± 1.8）、（2.1 ± 2.0）、（17.2 ± 2.9）和（8.8 ± 2.7）mm,包括95%病例的D_10H和D_20H分别为13.5和21.5 mm,多因素分析显示,D_10H和D_20H与精囊倾斜角度和横断面最大径相关（R²=0.64和0.77, P<0.01）。对比欧美指南规定的精囊靶区勾画方法,即自精囊起始平面开始沿人体长轴方向垂直向上勾画1.0 cm或2.0 cm作为CTV时,分别有65.8%（75/114）及17.5%（20/114）的病例无法完全包含根部1.0 cm或2.0 cm的精囊。结论 局限期中、高危前列腺癌勾画高剂量区精囊CTV时,按照现行欧美指南的画法存在部分亚临床病灶漏照风险。若要包含1.0 cm 近端精囊,推荐前内侧部垂直向上勾画1.4 cm、后外侧部垂直向上勾画0.5 cm可包含95%病例的亚临床病灶;若要包含2.0 cm 近端精囊,前内侧部垂直向上勾画2.2 cm即可,后外侧部可适当降低,但不低于1.4 cm。     

光动力学疗法治疗乳癌术后内乳区淋巴结转移

目的探讨光动力学疗法治疗乳癌根治术后内乳区淋巴结转移的作用和方法。方法2005年6月至2005年12月，选择经内乳区淋巴结显像证实有内乳区淋巴结转移的12例乳癌患者，于胸骨旁肋间隙经穿刺针导入柱状激光光纤，进行光动力学照射。术后3个月再行内乳区淋巴结显像复查。激光仪波长630nm，光敏剂血卟啉剂量5mg／kg；柱状激光光纤，末端输出功率密度300mW／cm^2，照射时间15min。结果9枚直径0．5～1．0cm内乳区淋巴结完全消失，4枚直径1．1～1．3cm明显缩小。结论光动力学照射内乳区淋巴结是治疗乳癌内乳区淋巴结转移的有效方法。     

探讨SPECT/CT图像融合对骨转移瘤的增益价值

目的 探讨SPECT/CT图像融合技术在诊断骨转移瘤中的应用价值.方法 回顾性分析2010年1月～2013年1月在我院核医学科进行肺癌术前查体的患者资料,其中376例为全身骨显像（whole-body bone scintigraphy,WBBS）,172例为局部SPECT/CT（single photon emission computed tomography-computed tomography）融合图像检查,对两种检查能够提供有效诊断的比例进行统计学比较.以临床诊断或随访结果为最终判定标准,对两组显像方式的灵敏度、特异度、阳性预测值、阴性预测值、准确度进行比较.结果 SPECT/CT的诊断效能明显高于WBBS（Z=2.769,P =0.006）.SPECT/CT显像的灵敏度为94.4％、特异度为89.0％、阳性预测值为86.1％、阴性预测值为95.7％、准确度为91.5％,明显高于SPECT的82.4％（χ^2 =4.281,P=0.039）、80.1％（χ^2=4.085,P=0.043）、54.7％（χ^2=21.658,P =0.000）、94.0％（χ^2 =0.392,P=0.531）、80.6％（χ^2=10.012,P=0.002）.结论 SPECT/CT图像融合较WBBS能够提高骨转移瘤患者的诊断符合率,能够为临床医生提供更多有价值的诊断信息.     

局部晚期鼻咽癌诱导化疗后原发病灶靶区勾画的探讨

目的 探讨局部晚期鼻咽癌诱导化疗后原发病灶(GTVnx)靶区勾画。方法 选择2012-2013年收治的52例局部晚期鼻咽癌患者,诱导化疗2~3周期后行CT定位、标记及图像采集;同期采取相同体位行鼻咽部MRI平扫及增强扫描,采集T₁W₁增强图像;分别在CT图像及MRI图像进行GTV_nx勾画;转移淋巴结、CTV1、CTV2及正常组织均在CT图像进行勾画;通过放疗计划系统进行MRI/CT图像GTV_nx靶区融合;两套靶区给予相同处方剂量及正常组织限量,物理师进行调强放疗计划设计。比较不同图像下诱导化疗后GTV_nx、各靶区照射体积及剂量、正常组织受量变化。结果 在局部晚期鼻咽癌诱导化疗后GTV_nx勾画中,MRI图像勾画靶体积大于CT图像[(43.14±28.40)、(40.09±27.04)cm³,t=3.791,P<0.001];MRI图像勾画靶体积与诱导化疗前原发病灶体积差值[(27.90±11.86)cm³]小于CT图像勾画体积差值[(30.64±11.86)cm³](t=3.948,P<0.001)。两套计划原发病灶靶区照射体积比较,融合靶区计划(41.71±26.86)cm³大于CT图像计划[(38.65±25.66)cm³](t=4.098,P<0.001),但靶区剂量及正常组织受量差异无统计学意义。结论 采用MRI图像进行局部晚期鼻咽癌诱导化疗后原发病灶靶区勾画、MRI/CT靶区图像融合进行放疗计划设计,增加原发灶靶区体积及照射体积,可能减少诱导化疗后放射治疗靶区勾画漏靶发生。     

18F-FLT PET/CT显像在非小细胞肺癌放疗靶区勾画中的作用

目前临床大多以CT检查结果为常规放疗靶区勾画的依据.NSCLC合并肺不张、胸腔积液或阻塞性肺炎时,CT上较难判断肿瘤真实边界,不同医师勾画的GTV存在较大差异.18^F-FDG PET显像越来越多地被用于指导放疗靶区的勾画,不过其在肿瘤诊断中存在一定的假阳性或假阴性[4].18^F-FLT能反映肿瘤细胞增殖状态,较18^F-FDG有更高的特异性.笔者观察了14例NSCLC患者的18F-FDG和18^F-FLT PET/CT显像结果与CT检查结果对诊断分期和GTV勾画的影响,探讨18F-FLT在NSCLC放射治疗计划制定中的作用.     

影像技术在乳腺癌内乳淋巴结转移检测方面的研究进展

在乳腺癌疾病研究中,内乳淋巴结转移是继研究腋窝淋巴结转移之外又一研究重点,运用影像学技术对其转移征象的检测仍处于初步探索中。目前淋巴结闪烁显像,X线技术,超声及其造影,CT及其核磁技术等各种影像技术已在该方面有所进展。     

99Tc m-利妥昔单抗SPECT/CT乳腺癌前哨淋巴结显像的临床评价

目的:探讨 99Tc m-利妥昔单抗（ 99Tc m-Rituximab）SPECT/CT对乳腺癌前哨淋巴结（SLN）的诊断效能。 方法:回顾性分析2019年7月至2020年7月于海南省肿瘤医院经组织病理学检查证实的22例女性乳腺癌患者的临床资料,患者年龄37~...     

Novel eradicative high-dose rate brachytherapy for internal mammary lymph node metastasis from breast cancer

AIM:To develop a method of delivering an eradicative high radiotherapeutic dose safely preserving the surrounding skin in the treatment of internal mammary lymph node metastasis (IMLNM) of breast cancer. METHODS:We report a 38-year-old female patient with a solo IMLNM showing no response to 60 Gy in 2.5 Gy fractions of external beam radiotherapy. To eradicate this tumor, a boost brachytherapy plan was created after percutaneous insertion of an applicator needle into the IMLNM lesion avoiding the pleura and vessels under ultrasound monitoring. According to the dose distribution, the required thickness of a spacer between the skin and the tumor was determined, and hyaluronic gel was injected up to this thickness under ultrasound monitoring. We evaluated skin doses, target doses and clinical outcome. RESULTS:All procedures were performed easily. Sixteen Gy (34.7 Gy equivalent in 2 Gy fractions calculated by the linear quadratic model at α/β = 10:EQ 2, α/β = 10 , cumulative total was 101.9 Gy EQ 10) to 100% of the target volume was irradiated with cumulative maximum skin dose of 70 Gy EQ 2, α/β = 3 which was 98.7 Gy EQ 2, α/β = 3 without spacer. No procedure related-or late complications and no local recurrence at the treated site were observed for three years until expiration. CONCLUSION:We consider that this procedure will provide an eradicative high-dose irradiation to IMLNM of breast cancer, preserving skin from overdose complications.     

Clinical relevance of sentinel lymph nodes in the internal mammary chain in breast cancer patients

Purpose Despite the widespread use of sentinel lymph node (SLN) biopsy in breast cancer patients, some controversy exists about the correct management of extra-axillary nodes, especially those located in the internal mammary chain. The aim of this study was to evaluate the incidence of SLNs in this region, calculate the lymphoscintigraphic and surgical detection rates and evaluate the clinical impact on staging and therapeutic decisions.Methods The study involved 383 consecutive women diagnosed with early breast cancer with T1 or T2 tumours. Eight patients had a bilateral tumour, which brought the total to 391 lesions. Lymphoscintigraphy was performed on the day before surgery by injection of ^99mTc-labelled nanocolloid. The injection site was subdermal (68 patients), peritumoural (107 patients) or intratumoural (216 patients). During surgery a gamma probe was used to guide the surgeon and the SLNs were removed. SLNs were analysed by a conventional pathological study and processed for H&E examination and immunohistochemistry.Results Lymphoscintigraphy detected at least one SLN in 369 out of the 391 procedures (94.4%). SLNs were found in the axillary chain in 367 cases and in the internal mammary chain in 55. In two of these 55 cases (3.6%), the SLN was the only one detected. There was no drainage to the internal mammary chain in any case of subdermal injection but such drainage was found in 15.9% of cases with peritumoural injection and 17.6% of those with intratumoural injection. Compared with tumours located in the outer quadrants, a higher percentage of tumours located in the inner quadrants showed drainage to the internal mammary chain (p<0.001). A total of 42 SLNs in the internal mammary chain could be removed in 32 patients without appreciable morbidity. In 20 cases both axillary and internal mammary SLNs were negative, in four both were positive, and in five axillary SLNs were positive and internal mammary SLNs were negative. More interestingly, in the remaining patient with both axillary and internal mammary SLNs, the axillary SLN was negative while malignant cells were found in the internal mammary region. In the evaluation of the clinical impact of internal mammary SLN biopsy, we found that staging was modified from pN1a to pN1c in four patients and, more importantly, from pN0 to pN0(i+) in one patient. The change in stage led to a modification of the postoperative treatment plan with respect to radiotherapy and systemic therapy.Conclusion Evaluation of the SLNs in the internal mammary chain provides more accurate staging of breast cancer patients. If internal mammary sampling is not performed, patients can be understaged. This technique can offer a better indication of those patients who will benefit from selective treatment options like radiotherapy to this region or systemic therapy.     

前哨淋巴结阳性乳腺癌患者腋窝转移危险因素的研究

目的研究前哨淋巴结（sentinellymphnode,SLN）阳性乳腺癌患者腋窝非前哨淋巴结（NSI-N）转移的危险因素,验证纪念斯隆一凯特琳癌症中心（MSKCC）腋窝NSLN转移预测模型评估乳腺癌患者的临床应用价值。方法回顾性地分析军事医学科学院附属医院普外科2000年,11月至2011年3月175例成功行SLN活检且结果阳性、随即行腋窝淋巴结清扫的乳腺癌患者临床病理资料,使用MSKCC预测模型计算每例患者腋窝NSLN转移风险,利用校正曲线和受试者操作特性曲线（ROC）下面积（AUC）评估该模型预测的准确性。结果原发肿瘤大小、肿瘤是否多发、阳性SLN数、阳性SLN转移率、阴性SLN数与腋窝NSLN转移相关,P值分别为0．0018、0．0029、0．0049、0．0007、0．0002。多因素Logistic回归分析发现,原发肿瘤大小、肿瘤是否多发和阳性SI．N数是NSI．N转移的独立危险因素,P值分别为0．0022、0．0160、0．0176。校正曲线显示预测值曲线和真实值曲线趋势相近,MSKCC预测模型被验证的AUC值为0．79。结论对于SLN转移阳性的乳腺癌患者,原发肿瘤越小、肿瘤单发、阳性SLN数越少、阴性SLN数越多、阳性SLN转移率越低,其腋窝NSLN转移可能性越低,可对是否行腋窝淋巴结清扣提供参考。MSKCC预测模型可较准确地预测腋窝NSI．N的转移风险。     

Evaluation of axillary status in breast cancer. CT-based determination of sentinel lymph node size

Purpose:
To determine whether the location and size of sentinel lymph nodes (SLN) on CT are predictive of the axillary lymph node status in patients with breast cancer. Material and Methods:
Forty patients with confirmed breast cancer underwent 5-mm CT of both breasts and axillae and the most inferior lymph node in the affected axilla was designated the SLN. Based on CT assessment of the axillary lymph node status, 22 (55%) patients then underwent dye- and gamma probe (DGP)-guided SLN biopsy followed by axillary dissection; 18 (45%) underwent dissection without prior SLN biopsy. The localization and status of the SLN determined on CT and by DGP-guided biopsy were compared. Biopsied and excised nodes were subjected to histopathologic examinations. Results:
All SLN identified on CT were close to the lateral thoracic artery and their localization corresponded well with SLN identified by the DGP-guided method. The positive predictive value of CT diagnosis was 100%. Histopathologic examination of excised nodes confirmed that none of the SLN biopsies was false-negative. Conclusion:
Our CT criteria were highly accurate for identification and diagnostic assessment of SLN and useful for evaluating the axillary status in patients with breast cancer.     

乳腺癌前哨淋巴结活检技术的临床应用

目的:探讨前哨淋巴结活检(Sentinel lymph node biopsy,SLNB)在乳腺癌外科中的应用,并评价其准确性及可行性.方法:对2002-01～2004-01我院收治的161例Ⅰ、Ⅱ期乳腺癌病例,在常规行乳腺癌手术前均进行SLNB,即肿瘤局部皮内联合注射99mTc-DX及美蓝,根据核素示踪及美蓝染色结果寻找SLN并摘除,行冰冻病理检查.将SLNB结果与术后腋窝淋巴结病理结果进行分析.结果:161例中149例发现SLN,检出率为92.5%(149/161);共检出SLN273个,平均1.83个/例.比较SLNB与术后病理结果,SLNB检出灵敏度为96.1%(49/51),准确性98.7%(147/149),假阴性率3.9%(2/51),假阳性率0。结论:SLN可比较准确地反映腋窝淋巴结状况,SLNB是乳腺癌治疗中的实用技术.     

Equivalent cross-relaxation rate imaging for sentinel lymph node biopsy in breast carcinoma.

Sentinel lymph node biopsy (SLNB) is an important technique for detecting axillary lymph node metastasis in breast carcinoma patients. However, false-negative results are a problem. Equivalent cross-relaxation rate (ECR) imaging (ECRI) is a measurement method that can be used to quantitatively evaluate a change in the structural organization of lymph nodes by magnetic resonance imaging (MRI). We performed axillary ECRI in an attempt to decrease the false-negative results of SLNB. Regions without metastases showed a higher ECR value. On the other hand, regions with metastases showed a lower ECR value. The ECR images were compared with macroscopic histology images in which the presence or absence of axillary lymph node metastasis could be evaluated. ECRI is a potentially useful method for evaluating the efficacy of SLNB.     

The hidden sentinel node and SPECT/CT in breast cancer patients

Purpose  In a minority of breast cancer patients, lymphoscintigraphy shows no lymphatic drainage and ‘hidden’ sentinel nodes may remain undiscovered. The purpose of this study was to explore the additional value of the recently introduced hybrid SPECT/CT in breast cancer patients with axillary non-visualisation on planar images. The role of blue dye and careful palpation of the axilla was evaluated in patients in whom axillary sentinel nodes remained hidden after SPECT/CT. Methods  Fifteen breast cancer patients with non-visualisation on planar lymphoscintigraphy and 13 women with only extra-axillary sentinel nodes underwent SPECT/CT following late planar imaging without re-injection of the radiopharmaceutical. Results  SPECT/CT visualised lymphatic drainage in eight of the 15 patients (53%) with non-visualisation on planar imaging, depicted nine of the 14 harvested sentinel nodes (64%) and three of five tumour-positive sentinel nodes. In two of the 13 patients (15%) with only extra-axillary sentinel nodes on their planar lymphoscintigram, SPECT/CT showed an axillary sentinel node that appeared to be uninvolved. Careful exploration of the axilla with the combined use of blue dye, a gamma probe and intra-operative palpation revealed an axillary sentinel node in the remaining 18 patients. SPECT/CT showed the exact anatomical location of all visualised sentinel nodes. Conclusion  SPECT/CT discovered ‘hidden’ sentinel nodes in the majority of patients with non-visualisation, but was less valuable in patients with only extra-axillary lymphatic drainage on the planar images. Exploration of the axilla in patients with persistent non-visualisation improved the identification of axillary (involved) sentinel nodes.     

Evaluation of patient effective dose from sentinel lymph node lymphoscintigraphy in breast cancer: a phantom study with SPECT/CT and ICRP-103 recommendations

Objective

To evaluate the effective dose delivered to patients undergoing sentinel lymph node (SLN) lymphoscintigraphy by taking into account both the transmission dose using the CT component of a SPECT/CT system and the ^99mTc internal emission dose.

Materials and methods

An adult female humanoid phantom and a set of thermoluminescent dosimeters were used in dose measurement from the CT transmission irradiation. The choice of measurement organs in the humanoid was guided by the recommendations described in the International Commission on Radiological Protection report number 103 (ICRP-103). The effective doses due to ^99mTc internal emission source were re-calculated from measurement data reported in our previous study on the same subject with the use of tissue weighting factors of ICRP-103.

Results

CT transmission dose is the main contribution to the patient total effective dose for both 1-day and 2-day lymphoscintigraphy protocols and for different surgical procedures. Patients undergoing SLN lymphoscintigraphy receive about the same amount of total effective dose of about 3 mSv for both 1-day and 2-day protocol, regardless of whether the tissues containing radioactivity would be excised at surgery or not.

Conclusion

Although the total effective dose from using SPECT/CT is equivalent to the annual natural background radiation of about 3 mSv, nuclear medicine physicians should be aware of the increase in effective dose for SLN lymphoscintigraphy using hybrid imaging technique of SPECT/CT when compared to conventional planar ⁵⁷Co flood source for transmission scan. Results from the current study provide update information in radiation exposure to patients undergoing SLN lymphoscintigraphy with the use of SPECT/CT.