18F-FDG PET/CT对初诊弥漫大B细胞淋巴瘤骨髓浸润的诊断及预后评估价值

Diagnostic and Prognostic Value of 18F-FDG PET/CT in Bone Marrow Infiltration of Newly Diagnosed Diffuse Large B-Cell Lymphoma

目的:评价18F-FDG PET/CT对初诊弥漫大B细胞淋巴瘤(DLBCL)骨髓浸润的诊断价值,并与骨髓活检(BMB)结果进行比较,探讨18F-FDG PET/CT诊断的骨髓浸润及其他因素是否有独立的预后预测价值。方法:纳入94例在南京医科大学附属上海一院临床医学院行PET/CT检查的初诊DLBCL患者,PET/CT检查前后2周内行骨髓活检,检查后行规范化治疗。记录各病例的PET/CT骨髓摄取表现。骨髓浸润的诊断标准为BMB阳性或影像学随访证实有PET/CT局灶性骨髓浸润灶。比较PET/CT骨髓不同摄取表现的患者临床资料差异并对照分析PET/CT与BMB诊断骨髓浸润的价值。Kaplan-Meier法绘制生存曲线分析患者组间无进展生存期(PFS)差异,log-rank检验比较组间PFS率差异,COX回归模型分析影响PFS的独立危险因素。结果:94例DLBCL患者中,18F-FDG PET/CT表现为局灶性骨髓摄取(f PET)34例,超级骨髓摄取(s BMU)7例,高于肝实质的弥漫均匀性摄取(d PET)11例,其余42例骨髓摄取未见异常(n PET)。n PET组BMB均阴性,s BMU组BMB均阳性,而d PET、f PET组的BMB阳性率分别为27.3%(3/11)和20.6%(7/34)。d PET组的血红蛋白水平及白细胞数均显著低于n PET组(P<0.001,P=0.026)。与f PET组比较,s BMU组更易伴B症状及乳酸脱氢酶水平升高。全部患者共诊断骨髓浸润44例,其中BMB阳性17例,BMB诊断骨髓浸润的灵敏度、特异性分别为38.6%(17/44)、100%(50/50)。将f PET及s BMU作为PET骨髓浸润阳性标准,PET/CT诊断骨髓浸润的灵敏度、特异性分别为93.2%(41/44)、100%(50/50)。Kaplan-Meier分析结果显示,n PET与d PET组的2年PFS率无明显差异(P>0.05),而s BMU组的2年PFS率明显低于f PET组(P<0.001)。多因素分析显示,高分期(HR=9.010,P=0.04)及s BMU(HR=3.964,P=0.002)是影响PFS的独立危险因素。结论:DLBCL的18F-FDG PET/CT骨髓摄取增高可表现为d PET、f PET和s BMU,其中f PET和s BMU可取代骨髓活检诊断骨髓浸润,d PET虽然不完全除外骨髓浸润可能,但不影响预后,因此可诊断为骨髓浸润阴性。sBMU为独立的预后危险因素。

Objective:To explore the diagnostic value of 18F-FDG PET/CT in bone marrow infiltration(BMI)of newly diagnosed diffuse large B-cell lymphoma(DLBCL),compared with the results of bone marrow biopsy(BMB)and investigate whether the BMI diagnosed by 18F-FDG PET/CT and other factors have independent prognostic values.Methods:Ninety-four newly diagnosed DLBCL patients who underwent PET/CT in Clinical Medical College of Shanghai General Hospital of Nanjing Medical University were included.BMB was performed within 2 weeks before or after PET/CT,and standardized treatment was performed after PET/CT.The manifestations of bone marrow(BM)FDG uptake were recorded.The diagnostic criteria of BMI were BMB positive or focal BM FDG uptake confirmed by imaging follow-up.The relationship between clinical features and BM FDG uptake and the values of PET/CT and BMB in the diagnosis of BMI was analyzed.The progression-free survival(PFS)was analyzed by Kaplan-Meier survival curves,log-rank test was used to compare PFS rate,and Cox regression model was used to analyze the independent risk factors affecting PFS.Results:Among 94 DLBCL patients,34 patients showed focal BM uptake(fPET),7 patients showed super BM uptake(sBMU),11 patients showed diffuse homogenous uptake higher than liver(dPET),and the other 42 patients had normal BM uptake(nPET)(lower than liver).BMB positive was found in all sBMU patients,in 20.6%(7/34)of fPET patients,and in 27.3%(3/11)of dPET patients.All nPET patients had negative BMB results.dPET patients were associated with lower hemoglobin level and leukocyte count compared with nPET group(P<0.001,P=0.026).Compared with fPET patients,sBMU patients were more likely to have B symptoms and elevated lactate dehydrogenase(LDH).A total of 44 patients were diagnosed BMI,including 17 cases with BMB+.The sensitivity and specificity of BMB in the diagnosis of BMI was 38.6%(17/44)and 100%(50/50),respectively.Using fPET and sBMU as criteria of PET BMI,the diagnostic sensitivity and specificity of PET/CT was 93.2%(41/44)and 100%(50/50),respectively.Kaplan-Meier analysis showed that there was no significant difference in 2-year PFS rate between nPET and dPET patients(P>0.05),while sBMU patients had lower 2-year PFS rate compared with fPET patients(P<0.001).Multivariate analysis showed that higher Ann Arbor stage(HR=9.010,P=0.04)and sBMU(HR=3.964,P=0.002)were independent risk factors affecting PFS.Conclusions:Increased BM FDG uptake of DLBCL can be manifested as dPET,fPET and sBMU.fPET and sBMU can replace BMB to diagnose BMI.Although dPET cannot completely exclude the possibility of BMI,it does not affect the prognosis,so it can be diagnosed as PET BMI negative.sBMU is an independent prognostic risk factor.