基于2011及2020年版病理分级系统双层探测器光谱CT评估实性肺腺癌病理分级的价值

The value of dual-layer spectral CT in assessment of solid lung adenocarcinoma based on 2011 and 2020 pathological grading system

目的:探讨光谱CT评价基于2011及2020年版病理分级系统不同病理分级实性肺腺癌的价值。方法:回顾性分析2019年1月至2021年9月在上海交通大学医学院附属仁济医院经手术证实的76例实性肺腺癌的临床及影像资料。根据2011及2020年国际肺癌研究协会提出的病理分级系统进行分组(低级别组为G1、G2级,高级别组为G3级),并以临床分期Ⅰ~Ⅱ为非进展期,Ⅲ~Ⅳ为进展期。采用独立样本t检验或Mann-Whitney U检验比较高级别组与低级别组的临床特征(性别、年龄、吸烟史、临床分期)、常规CT参数(肿瘤大小、形态学特征、平扫CT值及动静脉期强化幅度)及能谱参数[碘含量、有效原子序数、单能量CT值(CT_(40 keV)~CT_(200 keV))及其曲线斜率k值]。采用受试者操作特征曲线及曲线下面积(AUC)分析各参数诊断肺腺癌病理分级的效能,AUC间比较采用Z检验。结果:76例患者中,按照2011版病理分级系统,低级别组59例、高级别组17例;按照2020版病理分级系统,低级别组46例、高级别组30例。临床非进展期62例,按照2021版病理分级系统,低级别组50例、高级别组12例;2020版病理分级系统,低级别组37例、高级别组25例。临床进展期14例,2011及2020版病理分级结果均相同,均为低级别组9例、高级别组5例。对于非进展期肺腺癌,2011版病理分级系统中高级别组动脉期的强化幅度、k值、CT_(40 keV)~CT_(60 keV)以及静脉期的强化幅度、k值、CT_(40 keV)~CT_(70 keV)低于低级别组(P<0.05),其余指标两组间比较差异无统计学意义(P>0.05);2020版病理分级系统中高级别组动脉期的CT_(60 keV)及静脉期的CT_(50 keV)~CT_(70 keV)均显著低于低级别组(P<0.05)。2011和2020版病理分级系统进展期肺腺癌中高级别组的临床特征及CT参数与低级别组比较差异无统计学意义(P>0.05)。在非进展期腺癌中,动脉期的强化幅度、k值、CT_(40 keV)~CT_(60 keV)以及静脉期的强化幅度、k值、CT_(40 keV)~CT_(70 keV)对于2011版高级别肺腺癌具有较高的鉴别诊断效能(AUC为0.700~0.853),以静脉期CT_(50 keV)最佳;但对于2020版高级别组肺腺癌,动脉期CT_(60 keV)及静脉期CT_(50 keV)~CT_(70 keV)的鉴别诊断效能均较低(AUC为0.652~0.688),以静脉期CT_(60 keV)最佳,当联合使用吸烟史及静脉期CT_(60 keV)时,检出效能略有提高(AUC=0.772),但差异无统计学意义(Z=0.93,P=0.176)。结论:光谱CT的能谱参数有助于区分实性肺腺癌的病理分级,且对于2011版高级别组肺腺癌的评价效能略优于2020版。

Objective To explore the value of spectral CT in the preoperative evaluation of solid lung adenocarcinoma with different pathological grades based on the 2011 and 2020 version of the pathological grading system.Methods A total of 76 cases of solid lung adenocarcinoma confirmed by surgery in Renji Hospital,School of Medicine,Shanghai Jiao Tong University,from January 2019 to September 2021 were analyzed retrospectively.All cases were divided into groups according to the grading system for invasive adenocarcinoma proposed by the International Association for the Study of Lung Cancer(IASLC)in 2011 and 2020(G_(low) group included G1 and G2 adenocarcinoma,G_(high) group included G3 adenocarcinoma).The tumors with stageⅠandⅡwere non-advanced and the tumors with stageⅢandⅣwere advanced.The clinical manifestations(gender,age,smoking history and stage),routine CT parameters(tumor size,morphological characteristics,plain CT value and enhancement degree)and spectral parameters[iodine concentration,effective atomic number,enhanced monochromatic CT attenuation values of 40-200 keV(CT_(40 keV)-CT_(200 keV)),and the slope of spectral curve(k value)]were compared between G_(low) group and G_(high) group using independent sample t-test or Mann-Whitney U test.And the efficacy of each parameter for indicating G_(high) adenocarcinoma was analyzed using receiver operating characteristic curve analysis and area under the curve(AUC),and the Z test was used to compare the AUC.Results Seventy-six cases were included(59 cases of G_(low) group and 17 cases of G_(high) group in 2011 version;46 cases of G_(low) group and 30 cases of G_(high) group in 2020 version).Among the 76 cases,62 cases were non-advanced stage(50 cases of G_(low) group and 12 cases of G_(high) group in 2011 version;37 cases of G_(low) group and 25 cases of G_(high) group in 2020 version)and 14 cases were advanced stage(9 cases of G_(low) group and 5 cases in G_(high) group in both 2011 and 2020 version).Among the non-advanced adenocarcinomas,the CT parameters of enhancement degree,k value and CT_(40 keV)-CT_(60 keV)in arterial phase and enhancement degree,k value and CT_(40 keV)-CT_(70 keV)in venous phase of G_(high) group in 2011 grading system were significantly lower than those of G_(low) group(P<0.05),while other parameters were similar between G_(low) and G_(high) group in 2011 grading system(P>0.05);and the CT parameters of CT_(60 keV)in arterial phase and CT_(50 keV)-CT_(70 keV)in venous phase of G_(high) group in 2020 grading system were significantly lower than those of G_(low) group(P<0.05).Among the advanced adenocarcinomas,all of the clinical and CT parameters were similar between G_(low) and G_(high) group in both 2020 and 2011 grading systems(P>0.05).For the non-advanced adenocarcinomas,there was medium to good efficacy of the CT parameters of enhancement degree,k value and CT_(40 keV)-CT_(60 keV)in arterial phase and enhancement degree,k value and CT_(40 keV)-CT_(70 keV)in venous phase for diagnosing 2011 grading system G_(high) adenocarcinoma(AUC=0.700-0.853),with CT_(50 keV)in venous phase as the best;while the diagnosis efficacy of CT parameters of CT_(60 keV)in arterial phase and CT_(50 keV)-CT_(70 keV)in venous phase was poor for 2020 grading system G_(high) adenocarcinoma(AUC=0.652-0.688),with CT_(60 keV)in venous phase as the best.After combining smoking history and CT_(60 keV)in venous phase,the diagnosis efficacy for 2020 grading system G_(high) adenocarcinoma was slightly improved(AUC=0.772),but the difference had no significance(Z=0.93,P=0.176).Conclusion The spectral parameters are useful for distinguishing the pathological grades of solid lung adenocarcinoma.And the detecting efficacy for G_(high) adenocarcinoma of IASLC 2011 version is slightly better than that of 2020 version.