58例鼻咽癌患者放射性核素骨顯像分析

1、58例鼻咽癌患者放射性核素骨顯像分析摘要目的：探討鼻咽癌、期初診患者骨顯像的診斷價(jià)值。方法：58例未經(jīng)放療、化療的鼻咽癌、期初診患者,均分別行核素骨顯像、骨x線(xiàn)平片、骨ct檢查。核素骨顯像于靜脈注射99mtc-mdp36h后進(jìn)行。結(jié)果：58例鼻咽癌、期初診患者中有13例最后經(jīng)臨床確診為鼻咽癌骨轉(zhuǎn)移。骨顯像診斷骨轉(zhuǎn)移的靈敏度為84.6，特異性為82.2，假陽(yáng)性率為17.7，假陰性率15.4。病灶主要集中于脊椎、肋骨和骨盆。骨顯像與x線(xiàn)、ct檢查對(duì)轉(zhuǎn)移灶診斷的靈敏度分別為84.6、61.5和69.2，核素骨顯像靈敏度明顯高于x線(xiàn)平片和ct（p0.05)。本組病例中，患者有疼痛主訴者骨顯像的陽(yáng)性率高

2、；n分期晚者其陽(yáng)性率也高。結(jié)論：全身骨顯像在診斷鼻咽癌、期初診患者有無(wú)骨轉(zhuǎn)移中有重要的臨床價(jià)值，其靈敏度高于x線(xiàn)平片和ct檢查；骨顯像陽(yáng)性率的高低與疼痛主訴及n分期密切相關(guān)，在病例篩選中可作為首選檢查項(xiàng)目。鼻咽癌多屬低分化鱗狀細(xì)胞癌，遠(yuǎn)處轉(zhuǎn)移發(fā)生率高，在死亡患者中，半數(shù)或半數(shù)以上有骨、肝、肺等處轉(zhuǎn)移13。放射性核素骨顯像有早期發(fā)現(xiàn)骨轉(zhuǎn)移灶的特點(diǎn)，已被臨床高度重視46?，F(xiàn)就我院1996年1月至1997年10月收治的58例鼻咽癌初診患者的骨顯像結(jié)果分析如下。1方法1病例來(lái)源58例未經(jīng)放療、化療的鼻咽癌初診患者，全部經(jīng)病理證實(shí)為鼻咽部低分化鱗狀細(xì)胞癌。其中男性42例，女性16例。年齡最大69歲，最小

3、31歲，中位年齡49.6歲。臨床分期（按1992年福州分期標(biāo)準(zhǔn)）iii期35例，iva16例，ivb7例。全部患者均隨訪(fǎng)至今。所有患者均行骨顯像、x線(xiàn)和ct檢查，骨顯像、x線(xiàn)平片及ct檢查之間時(shí)間間隔不超過(guò)3d。臨床骨轉(zhuǎn)移的確診依據(jù)：臨床隨訪(fǎng)、部分病變行針吸活檢。2方法核素用锝-99m二甲基磷酸鹽（99mtc-mdp）740925mbq，靜脈注射后36h行全身顯像；ect為日本toshibagca-901a/sa型，配低能高分辨準(zhǔn)直器。2.1采集條件矩陣256512，探頭走速1525cm，能峰140kev，窗寬20；前后位和后前位各采集1幅，采集前病人排空小便。2.2骨顯像陽(yáng)性判斷標(biāo)準(zhǔn)與健側(cè)或

4、相鄰正常組織相對(duì)比，病變部位出現(xiàn)放射性分布增高或減低為陽(yáng)性，增高者定義為濃聚灶；減低者定義為減低灶。2結(jié)果58例鼻咽癌、期初診患者中經(jīng)臨床確診為骨轉(zhuǎn)移的有13例。骨顯像為陽(yáng)性的有19例，在此19陽(yáng)性病例人，出現(xiàn)全身多發(fā)性病灶（包括濃聚灶和減低灶）的有13例，出現(xiàn)單發(fā)性病灶的有6例；骨顯像共檢出病灶總數(shù)為72個(gè)，病灶在頭顱有6個(gè)/6例、肋骨36個(gè)/8例、胸骨9個(gè)/6例，脊柱13個(gè)/8例、骨盆5個(gè)/3例，四肢3個(gè)/2例。骨顯像的診斷結(jié)果見(jiàn)表1。表158例鼻咽癌患者骨顯像結(jié)果tab.1theradionuclideboneimagingresultsof58patientswithcorstagee

5、ctclinicaldiagnositotalwithbonemetastasiwithoutbonemetastasipositive11819negative23739total134558由決策矩陣分析可知，骨顯像對(duì)骨轉(zhuǎn)移的診斷靈敏度為84.6，特異性為82.2，假陽(yáng)性率為17.7，假陰性率為15.4。在限定部位，骨顯像與x線(xiàn)平片、ct比較，靈敏度分別為84.6(11/13)、61.5(8/13)、69.2(9/13)。經(jīng)統(tǒng)計(jì)學(xué)處理，骨顯像高于其它二者(p0.05)。骨顯像與患者疼痛的關(guān)系：頭痛6/8例、腰痛6/6例、胸痛3/4例、關(guān)節(jié)痛2/2例骨顯像陽(yáng)性。58例患者中，n分期為n2者5

6、/7例、n3者6/6例骨顯像陽(yáng)性，臨床皆證實(shí)為骨轉(zhuǎn)移。n分期為n0和n1者皆未見(jiàn)骨轉(zhuǎn)移，骨顯像也皆為陰性。3討論鼻咽癌晚期患者常出現(xiàn)全身骨轉(zhuǎn)移。轉(zhuǎn)移途徑大多數(shù)首先經(jīng)淋巴結(jié)轉(zhuǎn)移，隨后進(jìn)入循環(huán)系統(tǒng)而向全身骨轉(zhuǎn)移；少數(shù)也可直接侵及椎靜脈，而向全身骨髂播散。受累骨髂以脊椎、肋骨和骨盆多見(jiàn)13。本組結(jié)果中，經(jīng)臨床最后確診同時(shí)骨顯像也陽(yáng)性的11例病人中，其骨髂病損部位也主要集中于以上部位。從骨顯像診斷結(jié)果看，其靈敏度和特異性都有較高，分別為84.6和82.2，與文獻(xiàn)報(bào)導(dǎo)相似46。與x線(xiàn)和ct相比，骨顯像能進(jìn)行全身掃描，便于發(fā)現(xiàn)全身骨病灶；在限定部位，其對(duì)轉(zhuǎn)移灶早期診斷靈敏度和準(zhǔn)確率也都明顯高于x線(xiàn)平片和c

7、t。所以，為了了解鼻咽癌晚期患者有無(wú)骨轉(zhuǎn)移，骨顯像可做為過(guò)篩首選。疼痛與骨顯像陽(yáng)性率之間有一定關(guān)系。鼻咽癌骨、關(guān)節(jié)轉(zhuǎn)移常出現(xiàn)局部疼痛和壓痛，部位較恒定。出現(xiàn)骨疼的病人其骨病變一般都較明顯，這些病人骨顯像多為陽(yáng)性，但是否轉(zhuǎn)移則與疼痛部位有關(guān)，在本組病例中，出現(xiàn)腰痛、胸痛、四肢關(guān)節(jié)痛的11例患者中，骨顯像皆出現(xiàn)一處或多處濃聚灶，經(jīng)臨床觀(guān)察為骨轉(zhuǎn)移；但在8例頭痛患者中，雖骨顯像結(jié)果6例出現(xiàn)顴骨、額骨濃聚灶，但經(jīng)臨床觀(guān)察此6例患者都不屬于骨轉(zhuǎn)移。因此，一旦鼻咽癌iii、iv期患者主訴腰痛、胸痛、四肢關(guān)節(jié)痛，要重視發(fā)生骨轉(zhuǎn)移的可能性。在n分期中n2分期5/7例、n3分期6/6例骨顯像陽(yáng)性，最后臨床都證實(shí)

8、為骨轉(zhuǎn)移，而n分期為n1和n0者，皆未發(fā)現(xiàn)有骨轉(zhuǎn)移，骨顯像也皆為陰性。說(shuō)明n分期與骨轉(zhuǎn)移密切相關(guān)，這可能是由于鼻咽癌首先出現(xiàn)淋巴結(jié)轉(zhuǎn)移，隨后出現(xiàn)多發(fā)性骨轉(zhuǎn)移有關(guān)。所以，對(duì)n分期晚者骨顯像最好做為常規(guī)檢查項(xiàng)目。核素骨顯像存在一定的假陽(yáng)性和假陰性，本組病例中，骨顯像的假陽(yáng)性率和假陰性分別為17.7和15.4。我們知道骨轉(zhuǎn)移多為多發(fā)性，骨顯像表現(xiàn)為多發(fā)性濃聚灶或多發(fā)性減低灶者，其特異性很高。但表現(xiàn)為單發(fā)灶，特別是點(diǎn)狀濃聚灶者，可以是炎癥、外傷、痛風(fēng)等引起，則特異性較低，在本文假陽(yáng)性的8例患者中，多數(shù)為頭面骨及肋骨單發(fā)性濃聚灶，核醫(yī)學(xué)科亦常不作為“轉(zhuǎn)移灶”診斷。假陰性2例患者中1例為頸椎、1例為骶椎轉(zhuǎn)

9、移，此部位多受前位的甲狀腺及膀胱中尿液影響。因此，對(duì)于骨顯像受甲狀腺及膀胱影響較大難以診斷，而臨床又高度懷疑骨轉(zhuǎn)移者，要結(jié)合x(chóng)線(xiàn)平片、ct檢查進(jìn)行診斷（這2例患者經(jīng)ct、x線(xiàn)檢查證實(shí)為頸椎和骶骨轉(zhuǎn)移）。參考文獻(xiàn)1李振權(quán)，潘啟超，陳劍經(jīng)等.鼻咽癌臨床與實(shí)驗(yàn)研究.廣東：廣東科技出版社，1983.1992022谷銑之，殷蔚伯，劉泰福等.腫瘤放射治療學(xué).北京：北京醫(yī)科大學(xué)、中國(guó)協(xié)和醫(yī)科大學(xué)聯(lián)合出版社，1993.4434443湯釗猷.現(xiàn)代腫瘤學(xué).上海：上海醫(yī)科大學(xué)出版社，1993.5865884林偉,石銳.放射性核素三相骨顯象對(duì)原發(fā)性骨腫瘤良惡性的鑒別診斷.中華核醫(yī)學(xué)雜志，1990,10:1935劉新義

10、，王平輝.鼻咽癌核素骨顯像的臨床價(jià)值.腫瘤研究與臨床，1994,6(1):206吳超權(quán)，杜瑞生.112例鼻咽癌病人放療前核素骨掃描結(jié)果分析.中華放射腫瘤學(xué)雜志，1998,7(4):256p tgz7r4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgshls50clmtwn60eo8wgqv7xav2ohum32wgeauwydiawgmer4i30ka1dkaghn3xtkknbycudxqa7fhyi2chhi92tgkqcwa3ptgz7r4i30ka1dkagtgk tgz7r4i30ka1dkaghn3xtkknbycudxqa7fh

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