PETCT在淋巴瘤中的應用

1PET/CT在淋巴瘤中的應用

精選ppt2指南更新JCO2007;25:579-586JCO2021;32:3048-3058精選ppt3新的淋巴瘤分期JCO2021;32:3059-3067精選ppt4內(nèi)容背景介紹PET/CT用于淋巴瘤的分期評估PET/CT用于淋巴瘤治療后評估PET/CT用于淋巴瘤治療中期評估精選ppt5背景知識PET：正電子發(fā)射型計算機斷層顯象，是以人體解剖結(jié)構(gòu)為根底，利用正電子核素標記藥物的示蹤作用，顯示人體內(nèi)物質(zhì)代謝，細胞增殖，血流灌注及臟器功能狀態(tài)。缺點是不能準確測量腫瘤大小CT：顯示人體解剖結(jié)構(gòu)及形態(tài)學改變，有較強的空間分辨率PET/CT：PET和CT圖像同機融合，一次成象獲得全身PET和CT的圖象，將功能影象與解剖形態(tài)學優(yōu)化組合，兩者結(jié)合取長補短精選ppt618FDG在腫瘤細胞中的攝取精選ppt7FDG在常見淋巴瘤中的攝取精選ppt8進行FDG-PET的要求JuweidME,etal.JClinOncol2007;25:571-578.精選ppt9PET圖像的解讀標準(視覺判斷法)JuweidME,etal.JClinOncol2007;25:571-578.精選ppt105分類法(Deauville標準)BarringtonS,etal.JClinOncol2021;32:3048精選ppt11舉例：治療前精選ppt12治療后：1分Exampleofscore1:completemetabolicresponsewithnouptakeinnormal-sizelymphnodesatsiteofinitialdiseaseinleftneck(arrow).精選ppt13舉例：治療前精選ppt14治療后：2分Exampleofscore2:residualuptakeofintensity<mediastinalbloodpoolinlymphnodesinleftaxilla(arrow).Maximumstandardizeduptakevalue(SUVmax)inlymphnodeswas1.2;SUVmaxinmediastinalbloodpoolwas1.7.精選ppt15舉例：治療前精選ppt16治療后：3分Exampleofscore3:residualuptakeofintensity>mediastinalbloodpoolbut<liverinresidualmediastinalmass(arrow).Maximumstandardizeduptakevalue(SUVmax)inmasswas1.7;SUVmaxinliverwas2.2.精選ppt17舉例：治療前精選ppt18治療后：4分Exampleofscore4:residualuptakeofintensity>liverinresidualmediastinalmass(arrow).Maximumstandardizeduptakevalue(SUVmax)inmasswas4.5;SUVmaxinliverwas3.2.精選ppt19舉例：治療前精選ppt20治療后：5分Exampleofscore5:residualuptakeinmediastinumwithintensitymarkedlyhigherthannormalliver.Maximumstandardizeduptakevalue(SUVmax)inmasswas13.0;SUVmaxinliverwas2.3.精選ppt21新的指南推薦級別Expertsinnuclearmedicineandradiologyappliedtolymphomaundertookaliteraturereviewandsharedknowledgeaboutresearchinprogress.Recommendationswereformulatedasfollows:Basedonestablishedcurrentknowledge(type1)Toidentifyemergingapplications(type2)Tohighlightkeyareasrequiringfurtherresearch(type3)BarringtonS,etal.JClinOncol2021;32:3048精選ppt22腫瘤緩解術(shù)語CTCR：completeresponseCRu：completeresponseunconfirmedPR：partialresponseSD：stablediseasePD：progressivediseasePET/CTCMR：completemetabolicresponsePMR：partialmetabolicresponseNMR：nometabolicresponsePMR：progressivemetabolicdiseaseChesonBD,etal.JClinOncol1999;17:1244.ChesonBD,etal.JClinOncol2021;32:3059精選ppt23InterpretationofPET-CTscansStagingofFDG-avidlymphomasisrecommendedusingvisualassessment,withPET-CTimagesscaledtofixedSUVdisplayandcolortable;focaluptakeinHLandaggressiveNHLissensitiveforbonemarrowinvolvementandmayobviateneedforbiopsy;MRIismodalityofchoiceforsuspectedCNSlymphoma(type1)Five-pointscaleisrecommendedforreportingPET-CT;resultsshouldbeinterpretedincontextofanticipatedprognosis,clinicalfindings,andothermarkersofresponse;scores1and2representCMR;score3alsoprobablyrepresentsCMRinpatientsreceivingstandardtreatment(type1)Score4or5withreduceduptakefrombaselinelikelyrepresentspartialmetabolicresponse,butatendoftreatmentrepresentsresidualmetabolicdisease;increaseinFDGuptaketoscore5,score5withnodecreaseinuptake,andnewFDG-avidfociconsistentwithlymphomarepresenttreatmentfailureand/orprogression(type2)BarringtonS,etal.JClinOncol2021;32:3048精選ppt24PET結(jié)果假陽性產(chǎn)生的原因化療/放療后的壞死/炎癥反響化療間隔：至少3周〔最正確6-8周〕放療間隔：8-12周造血因子的骨髓刺激增生的胸腺組織某些攝取FDG的良性疾病免疫細胞的影響不標準的操作和圖像的解讀精選ppt25內(nèi)容背景介紹PET/CT用于淋巴瘤的分期評估PET/CT用于淋巴瘤治療后評估PET/CT用于淋巴瘤治療中期評估精選ppt26傳統(tǒng)CT分期評估的缺點僅根據(jù)病變/淋巴結(jié)的形態(tài)和大小決定臨床意義對于結(jié)外病變的判斷能力缺乏評估能力受掃描區(qū)域或部位的限制需要增強掃描，無法用于碘過敏的患者精選ppt27PET與CT用于分期評估的比較精選ppt28PET分期評估的結(jié)果精選ppt29RoleofPET-CTforstagingPET-CTshouldbeusedforstaginginclinicalpracticeandclinicaltrialsbutisnotroutinelyrecommendedinlymphomaswithlowFDGavidity;PET-CTmaybeusedtoselectbestsitetobiopsy(type1)Contrast-enhancedCTwhenusedatstagingorrestagingshouldideallyoccurduringsinglevisitcombinedwithPET-CT,ifnotalreadyperformed;baselinefindingswilldeterminewhethercontrast-enhancedPET-CTorlower-doseunenhancedPET-CTwillsufficeforadditionalimagingexaminations(type2)Bulkremainsanimportantprognosticfactorinsomelymphomas;volumetricmeasurementoftumorbulkandtotaltumorburden,includingmethodscombiningmetabolicactivityandanatomicalsizeorvolume,shouldbeexploredaspotentialprognosticators(type3)BarringtonS,etal.JClinOncol2021;32:3048精選ppt30內(nèi)容背景介紹PET/CT用于淋巴瘤的分期評估PET/CT用于淋巴瘤治療后評估PET/CT用于淋巴瘤治療中期評估精選ppt31基于CT的IWG標準1999年IWG制定了淋巴瘤療效評價和預后評估指南IWG指南統(tǒng)一了原本各異的療效評估標準該指南得到了臨床醫(yī)生和監(jiān)管機構(gòu)的廣泛認可，并用于大量新藥的審批程序ChesonBD,etal.JClinOncol1999;17:1244.精選ppt32療效評估標準1999年，IWG國際工作小組發(fā)布了?NHL療效評估標準?療效體格檢查淋巴結(jié)淋巴結(jié)腫塊骨髓CR正常正常正常正常CRu正常正常正常不確定正常正?？s小>75%正?；虿淮_定PR正常正常正常陽性正?？s小≥50%縮小≥50%無關(guān)肝/脾縮小縮小≥50%縮小≥50%無關(guān)Relapse/PD肝/脾增大新病變新病變或增大新病變或增大再發(fā)ChesonBD,etal.JClinOncol1999;17:1244.精選ppt33IWG標準的缺點無法區(qū)分腫瘤殘留抑或纖維化CRu的解讀容易發(fā)生歧義沒有針對骨髓以外結(jié)外病變的評價精選ppt34PET療效評估的陽性和陰性預測值精選ppt35基于PET的IHP標準ChesonBD,etal.JClinOncol2007;25:5792007年IHP制定了新的淋巴瘤療效評價標準IHP標準是對于IWG標準的改進和補充IHP標準適用于以治愈為目的的淋巴瘤類型，特別是DLBCL和HL精選ppt36IHP標準的淋巴瘤類型推薦ChesonBD,etal.JClinOncol2007;25:579精選ppt37臨床試驗中的療效定義ChesonBD,etal.JClinOncol2007;25:579精選ppt38新的PET療效定義CMR:completemetabolicresponseScore1,2,or3withorwithoutaresidualmasson5PSPMR:partialmetabolicresponseScore4or5withreduceduptakecomparedwithbaselineandresidualmass(es)ofanysizeAtinterim,thesefindingssuggestrespondingdiseaseAtendoftreatment,thesefindingsindicateresidualdiseaseNMR:nometabolicresponseScore4or5withnosignificantchangeinFDGuptakefrombaselineatinterimorendoftreatmentPMR:progressivemetabolicdiseaseScore4or5withanincreaseinintensityofuptakefrombaselineand/orNewFDG-avidfociconsistentwithlymphomaatinterimorend-of-treatmentassessmentChesonBD,etal.JClinOncol2021;32:3059精選ppt39RoleofPETatendoftreatmentPET-CTisstandardofcareforremissionassessmentinFDG-avidlymphoma;inpresenceofresidualmetabolicallyactivetissue,wheresalvagetreatmentisbeingconsidered,biopsyisrecommended(type1)InvestigationofsignificanceofPET-negativeresidualmassesshouldbecollectedprospectivelyinclinicaltrials;residualmasssizeandlocationshouldberecordedonend-of-treatmentPET-CTreportswherepossible(type3)EmergingdatasupportuseofPET-CTafterrituximab-containingchemotherapyinhigh–tumorburdenFL;studiesarewarrantedtoconfirmthisfindinginpatientsreceivingmaintenancetherapy(type2)AssessmentwithPET-CTcouldbeusedtoguidedecisionsbeforehigh-dosechemotherapyandASCT,butadditionalstudiesarewarranted(type3)BarringtonS,etal.JClinOncol2021;32:3048精選ppt40內(nèi)容背景介紹PET/CT用于淋巴瘤的分期評估PET/CT用于淋巴瘤治療后評估PET/CT用于淋巴瘤治療中期評估精選ppt41背景淋巴瘤包括DLBCL是一個異質(zhì)性很大的疾病現(xiàn)有的預后因素有助于判斷總體預后，但往往難以據(jù)此作出個體化的治療方案選擇如何早期篩選出難治性或容易復發(fā)的患者，有助于盡早實施解救方案，如化療、移植或新的靶向藥物等，從而改善預后如何早期篩選出預后良好的患者，有助于調(diào)整治療強度，從而減少遠期毒性或第二原發(fā)腫瘤精選ppt42重要的預后因素--治療敏感性治療的敏感性即腫瘤緩解情況往往與預后具有相關(guān)性治療后的緩解狀態(tài)有助于早期調(diào)整治療方案對于腫瘤緩解狀態(tài)的判斷，PET/CT優(yōu)于普通增強CTPET/CT可以判斷腫瘤內(nèi)部的代謝情況，從而有助于早期明確治療的敏感性精選ppt43PET圖像的解讀方法視覺判斷法(IHP標準)5分類法(Deauville標準)半定量法(ΔSUVmax)精選ppt44視覺判斷法103例DLBCL接受CHOP±利妥昔單抗的治療2-4個周期后行CT和PET評價療效DupuisJ,etal.AnnOncol2021;20(3):503-507.精選ppt45系統(tǒng)性綜述TerasawaT,etal.JClinOncol2021;27(11):1906-1914精選ppt46視覺判斷法存在的重要問題精選ppt47過低的結(jié)果判斷一致率一致率：68%一致率：71%HorningSJ,etal.Blood2021;115(4):775-777精選ppt48過高的假陽性率(假陽性：87%)MSKCC研究MoskowitzCH,etal.JClinOncol2021;28(11):1896-1903精選ppt49掃描時間的重要性HüttmannA,etal.JClinOncol2021;28(27):e488-e489精選ppt505分類法(Deauville標準)MeignanM,etal.LeukLymphoma2021;51(12):2171–2180分值定義結(jié)果1無攝取陰性2攝取

≤縱隔陰性3攝取>縱隔但≤肝臟陰性4攝取>肝(中度)陽性5攝取>肝(明顯)和/或出現(xiàn)新區(qū)域攝取陽性X新區(qū)域攝取不太可能與淋巴瘤相關(guān)NA精選ppt51采用縱隔血池和肝臟作為參照的比較IttiE,etal.JNuclMed2021;51(12):1857-1862精選ppt52半定量法(ΔSUVmax)優(yōu)點：SUVmax的變化反映了腫瘤的動態(tài)代謝半定量標準有助于個體化判斷療效與視