^(18)F-FDG PET/CT与骨髓活检评估弥漫性大B细胞淋巴瘤骨髓浸润的比较研究

Comparison of ^(18)F-FDG PET/CT and bone marrow biopsy in detection(bone marrow involvement in diffuse large B-cell lymphoma

目的:评估^(18)F-FDG PET/CT与骨髓活检(BMB)对弥漫性大B细胞淋巴瘤(DLBCL)患者骨髓浸润(BMI)的诊断效能,明确PET/CT能否替代BMB成为BMI的诊断手段。方法:回顾性分析2014年1月—2022年4月初诊的224例DLBCL患者,所有患者化疗前均接受PET/CT和BMB检查。比较PET/CT与BMB诊断BMI的敏感度、特异度、阳性预测值、阴性预测值、漏诊率、2种方法的一致性、对分期的影响,比较PET阳性患者中BMB阳性组与BMB阴性组、局灶组与弥漫组血常规、乳酸脱氢酶(LDH)、总生存期(OS)的差别。结果:224例患者中共检出BMI阳性患者33例(14.7%),其中PET/CT检出31例(13.8%),BMB检出17例(7.6%)。PET/CT与BMB检出BMI的敏感度分别为93.9%、51.5%,特异度分别为100.0%、100.0%,阳性预测值分别为100.0%、100.0%,阴性预测值分别为99.0%、92.3%,漏诊率分别为6.1%、48.5%。PET/CT与BMB诊断一致的206例(92.0%),包括191例均阴性,15例均阳性。诊断不一致的18例(8.0%),包括PET阳性BMB阴性16例,PET阴性BMB阳性2例。PET/CT将3例患者由Ⅲ期升级为Ⅳ期,BMB将1例患者由Ⅲ期升级为Ⅳ期。PET阳性患者中,BMB阳性组与BMB阴性组白细胞、中性粒细胞、淋巴细胞、血红蛋白、血小板计数差异无统计学意义(P>0.05),BMB阳性组LDH高于BMB阴性组(P=0.031)。31例PET阳性患者中局灶组20例、弥漫组11例。弥漫组BMB阳性比例明显高于局灶组(81.8%vs 30.0%,P=0.009)。弥漫组血小板计数低于局灶组(P=0.004)。所有患者PET阳性组较PET阴性组、BMB阳性组较BMB阴性组OS均显著缩短(P<0.001)。PET阳性与BMB阳性患者OS差异无统计学意义(P=0.288)。PET阳性患者中BMB阳性组与BMB阴性组中位OS分别为5.8个月、26.4个月,1年OS率分别为(37.3±13.9)%、(64.3±14.9)%(P=0.087)。局灶组与弥漫组OS差异无统计学意义(P=0.424)。结论:PET/CT评估BMI较BMB诊断效能高,PET/CT与BMB诊断的BMI均具有预后意义。PET阳性患者中BMB状态可能存在预后价值。DLBCL患者可首先行PET/CT,PET阴性者可考虑取消BMB,PET阳性者建议进一步行BMB,可在今后研究中进一步探讨其必要性。

Objective To evaluate the role of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography(^(18)F-FDG PET/CT)and bone marrow biopsy(BMB)in detecting bone marrow involvement(BMI)in diffuse large B-cell lymphoma(DLBCL)and then determine whether PET/CT could replace BMB for the assessment of BMI.Methods This is a retrospective analysis of 224 newly diagnosed DLBCL patients who presented to our hospital during January 2014 and April 2022 who received concurrent PET/CT and BMB examination before chemotherapy.Sensitivity,specificity,positive predictive value,negative predictive value and omission diagnostic rate were compared between PET/CT and BMB.Concordance of both techniques and their influences on DLBCL staging were analyzed.In PET-positive patients,blood routine examination,lactate dehydrogenase(LDH)level and overall survival(OS)were compared between BMB-positive and BMB-negative groups as well as focal and diffuse involvement groups.Results In a total of 33 BMI cases(14.7%),31 cases(13.8%)was detected by PET/CT and 17 cases(7.6%)by BMB.For PET/CT and BMB,sensitivity was 93.9%and 51.5%,specificity 100.0%and 100.0%,positive predictive value 100.0%and 100.0%,negative predictive value 99.0%and 92.3%,omission diagnostic rate 6.1%and 48.5%,respectively.Two hundred and six(92%)patients had concordant results between PET/CT and BMB(191 patients were negative for both,15 patients were positive for both).Eighteen(8.0%)patients had a discordant interpretation(16 patients were negative by BMB and positive by PET/CT and 2 patients were positive by BMB and negative by PET/CT).Three patients were upstaged from stageⅢtoⅣby PET/CT and one patient was upstaged from stageⅢtoⅣby BMB.For PET-positive patients,there was no difference in white blood cell,neutrocyte,lymphocyte,hemoglobin and platelet between BMB-positive subgroup and BMB-negative subgroup(P>0.05)while LDH was higher in BMB-positive subgroup than BMB-negative subgroup(P=0.031).Among 31 PET-positive cases,20 cases had focal(1 unifocal and 19 multifocal)while 11 cases had diffuse involvement.Patients with diffuse involvement had a larger proportion of positive BMB compared with focal involvement cases(81.8%vs 30.0%,P=0.009).Platelet was lower in diffuse involvement patients than focal involvement ones(P=0.004).Among all of 224 patients,PET-positive and BMB-positive cases had worse OS than PET-negative and BMB-negative cases respectively(P<0.001).There was no difference on OS between PET-positive and BMB-positive cases(P=0.288).In PET-positive patients,median OS was 5.8 months,26.4 months and 1-year OS probability was(37.3±13.9)%,(64.3±14.9)%for BMB-positive and BMB-negative subgroup respectively(P=0.087).OS was not different between focal and diffuse involvement patients(P=0.424).Conclusion PET/CT showed superior performance in detecting BMI than BMB in DLBCL.Both PET/CT and BMB defined BMI had prognostic values.BMB might had a prognostic value in PET-positive patients.For DLBCL patients,bone marrow status can be assessed firstly by means of PET/CT;in negative cases BMB could be omitted and in positive cases BMB is recommended to be carried out afterwards,which needs further verification.