^(18)F-PSMA-1007 PET/CT和mpMRI在前列腺癌原发灶检测及病灶腺体内定位的对比研究

Comparison of^(18)F-PSMA-1007 PET/CT and mpMRI in the detection and intraprostatic localization of primary prostate cancer

目的:^(18)F-前列腺特异性膜抗原(prostate-specific membrane antigen,PSMA)-1007正电子发射体层成像(positron emission tomography,PET)/计算机体层成像(computed tomography,CT)和多参数磁共振成像(multiparametric magnetic resonance imaging,mpMRI)图像与金标准前列腺穿刺病理学检查结果对应,比较两者诊断前列腺癌(prostate cancer,PCa)原发灶的价值,进一步评价最大标准摄取值(maximum standard uptake value,SUV_(max))在预测前列腺原发灶良恶性及PCa危险度分层中的价值。方法:回顾并纳入2019年9月—2022年12月于复旦大学附属肿瘤医院行^(18)F-PSMA-1007 PET/CT检查的疑诊PCa患者共56例。其中48例患者行mpMRI检查。将前列腺分为左右两侧中央腺体区与两侧外周带4个分区,与前列腺穿刺病理学检查结果对应。组间原发灶检出率的差异使用χ^(2)检验或Fisher精确概率检验进行比较。采用Spearman相关分析判断前列腺特异性抗原(prostate-specific antigen,PSA)、Gleason评分(Gleason score,GS)和SUV_(max)之间的相关性。SUV_(max)差异通过Mann-Whitney U检验分析。绘制受试者工作特征(receiver operating characteristic,ROC)曲线,计算曲线下面积(area under curve,AUC),得出SUV_(max)的最佳诊断阈值。结果:以穿刺病理学检查为金标准,57.1%(32/56)患者为PCa,42.9%(24/56)患者为良性(10例患者伴有前列腺炎症)。PCa患者的PSA、SUV_(max)均显著高于良性患者(P=0.002,P<0.001)。基于分区分析构建以SUV_(max)预测前列腺原发灶良恶性的ROC曲线(AUC=0.93),当截断值为9.45时,灵敏度和特异度分别为82.0%和89.6%。基于分区分析,^(18)F-PSMA-1007对PCa分区的检出率相较于mpMRI差异无统计学意义(80.7%vs 77.1%,P=0.568)。^(18)F-PSMA-1007和mpMRI联合使用检测出更多分区的病灶(84.3%,70/83),但与单独^(18)F-PSMA-1007和单独mpMRI相比差异无统计学意义(P=0.540,P=0.238)。穿刺病理学检查为良性的患者,分区分析结果提示前列腺炎症分区的SUV_(max)显著高于良性前列腺组织的分区(P=0.007)。基于患者分析,^(18)F-PSMA-1007检测前列腺原发灶的灵敏度、准确度、阴性预测值略高于mpMRI,分别为78.1%、73.2%、69.6%和76.7%、72.9%、63.2%。在区域淋巴结及骨转移的检出率方面,^(18)F-PSMA-1007均高于mpMRI。PCa原发灶SUV_(max)与PSA水平和GS均呈正相关(r=0.467,P=0.008;r=0.571,P<0.001)。当SUV_(max)≥18.00时,PCa的检出率为100%。通过ROC曲线(AUC=0.79)分析确定SUV_(max)=22.40为区别PCa高危险度和低-中危险度的最佳诊断截断值,灵敏度和特异度分别为62.7%和100.0%。结论:对于PCa原发灶的诊断^(18)F-PSMA-1007有更好的效能,与mpMRI联用可以提高肿瘤范围的检测。半定量指标SUV_(max)对于PCa良恶性和危险度分层有着很好的预测价值。

Objective:To compare the value of^(18)F-prostate-specific membrane antigen(PSMA)-1007 positron emission tomography(PET)/computed tomography(CT)and multiparametric magnetic resonance imaging(mpMRI)images for the diagnosis of primary prostate cancer(PCa)using prostate puncture pathology as gold standard and to evaluate the value of maximum standard uptake value(SUV_(max))in predicting the benignity and malignancy of primary prostate foci and the risk stratification of PCa.Methods:From September 2019 to December 2022,fifty-six patients with suspected PCa who underwent^(18)F-PSMA-1007 PET/CT at the Fudan University Shanghai Cancer Center were retrospectively recruited.Forty-eight of these patients also underwent mpMRI.The prostate was divided into four segments,the left and right central glands and the left and right peripheral zones,corresponding to the pathological findings of the prostate puncture.Differences in detection rates between groups were compared using theχ^(2) test or Fisher’s exact test and sensitivity,specificity,positive predictive value and negative predictive value were calculated for the diagnosis of PCa.Spearman rank correlation analysis was used to determine the correlation between prostate-specific antigen(PSA),the Gleason score(GS)and SUV_(max).Differences in SUV_(max)were analyzed by the Mann-Whitney U test.The area under curve(AUC)was calculated using the receiver operating characteristic(ROC)curve to derive the optimal diagnostic threshold for SUV_(max).Results:About 57.1%(32/56)patients had confirmed PCa by puncture pathology and 42.9%(24/56)patients were benign.There were 10 benign patients with prostate inflammation.PSA and SUV_(max)were significantly higher in PCa patients than in benign patients(P=0.002,P<0.001).The ROC curve for predicting the benignity or malignancy of the primary prostate foci by SUV_(max)was constructed based on the results of segmental lesion detection,with an AUC of 0.93.When SUV_(max)=9.45 was used as the optimal diagnostic threshold,the sensitivity and specificity were 82.0%and 89.6%,respectively.Based on segment analysis,there was no significant difference in detection rate(80.7%vs 77.1%,P=0.568)between^(18)F-PSMA PET/CT and mpMRI.More segmental lesions were detected with the combination of^(18)F-PSMA-1007 PET/CT and mpMRI(84.3%,70/83),but there was no significant difference in detection rate compared to^(18)F-PSMA-1007 PET/CT alone and mpMRI alone(P=0.540,P=0.238,respectively).SUV_(max)was significantly higher in segments with prostate inflammation than in those with benign prostate tissue(P=0.007).Based on patient analysis,the sensitivity,accuracy and negative predictive value of^(18)F-PSMA-1007 PET/CT for detecting primary prostate cancer were slightly higher than that of mpMRI(78.1%vs 76.7%,73.2%vs 72.9%,69.6%vs 63.2%,respectively).In terms of detection of regional lymph nodes and bone metastases,^(18)F-PSMA-1007 were higher than mpMRI.The SUV_(max)of PCa primary foci was positively correlated with both PSA(r=0.467,P=0.008)and GS(r=0.571,P<0.001).The detection rate of PCa was 100%when SUV_(max)≥18.00.SUV_(max)=22.40 was identified by ROC curve(AUC=0.79)as the optimal diagnostic threshold to distinguish between high and low-moderate risk of PCa,with corresponding sensitivity and specificity of 62.7%and 100.0%,respectively.Conclusion:^(18)F-PSMA-1007 PET/CT had better diagnostic efficacy in detecting PCa primary foci and improved the detection of tumor extent in combination with mpMRI.The semi-quantitative index SUV_(max)had promising predictive value for the identification of benign or malignant primary prostate foci and for risk stratification of PCa.