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      磁共振彌散加權(quán)成像術(shù)在腹膜轉(zhuǎn)移癌診斷中的應(yīng)用價(jià)值

      2016-12-22 12:38:13張換童彤
      上海醫(yī)藥 2016年23期

      張換+童彤

      摘 要 腹膜轉(zhuǎn)移癌患者的預(yù)后較差,良好的影像學(xué)評(píng)估方法有助于其治療方案的選擇和治療療效的評(píng)估。腹膜轉(zhuǎn)移癌在磁共振彌散加權(quán)成像術(shù)檢查圖像中表現(xiàn)為較之周圍組織明顯的高亮信號(hào),與CT檢查相比能明顯提高腹膜癌的檢出率,尤其是小轉(zhuǎn)移癌灶以及膈下、肝包膜下、網(wǎng)膜囊、腸系膜根部和腸管漿膜表面的腹膜癌的檢出率。

      關(guān)鍵詞 腹膜轉(zhuǎn)移癌 磁共振成像術(shù) 彌散加權(quán)成像術(shù)

      中圖分類號(hào):R735; R730.44 文獻(xiàn)標(biāo)識(shí)碼:A 文章編號(hào):1006-1533(2016)23-0015-03

      The application of diffusion-weighted magnetic resonance imaging in the diagnosis of peritoneal carcinomatosis*

      ZHANG Huan**, TONG Tong***

      (Department of Radiology, Shanghai Cancer Center, Fudan University; Department of Oncology, Shanghai Medical School, Fudan University, Shanghai 200032, China)

      ABSTRACT Peritoneal carcinomatosis is invariably associated with a poor prognosis. A good imaging evaluation method can benefit the options of individualized treatment and the assessment of curative effect. Peritoneal carcinomatosis is manifested as obvious highlight signal compared with the surrounding tissues on the magnitude diffusion-weighted images. Diffusionweighted magnetic resonance imaging, compared with CT, can significantly improve the accuracy in the detection of peritoneal cancer, especially for the small metastatic foci and the peritoneal cancers on some special anatomical sites under the diaphragm and liver capsule and of omental capsule, mesenteric root and intestinal serosal surface.

      KEY WORDS peritoneal carcinomatosis; magnetic resonance imaging; diffusion-weighted imaging

      腹膜轉(zhuǎn)移癌是指惡性腫瘤直接種植于腹膜或經(jīng)各種途徑轉(zhuǎn)移至腹膜腔形成的繼發(fā)性腹膜腫瘤,最常見(jiàn)于卵巢癌、胃癌和結(jié)直腸癌患者,發(fā)生率約分別為71%、15%和10%[1]。腹膜轉(zhuǎn)移癌患者的預(yù)后通常不良,診出后的中位生存期僅約為6個(gè)月[2]。目前,對(duì)腹膜轉(zhuǎn)移癌的最佳治療策略是細(xì)胞減滅術(shù)(cytoreductive surgery, CRS)聯(lián)合腹腔熱灌注化療(hyperthermic intraperitoneal chemotherapy, HIPEC),即通過(guò)手術(shù)切除可視癌灶,再用高濃度化療藥物溶液沖洗腹腔以殺滅殘留癌細(xì)胞,能有效改善患者的生存期[3]。

      腹膜癌指數(shù)(peritoneal cancer index, PCI)是一種通過(guò)評(píng)估腹腔13個(gè)分區(qū)中腹膜癌的分布和大小來(lái)量化腹膜癌負(fù)荷情況的評(píng)分系統(tǒng)(圖1),為現(xiàn)最常用的腹膜轉(zhuǎn)移癌分期系統(tǒng)[4],其評(píng)分被認(rèn)為是腹膜轉(zhuǎn)移癌患者的一個(gè)獨(dú)立預(yù)后因素。此外,對(duì)接受CRS聯(lián)合HIPEC治療的腹膜轉(zhuǎn)移癌患者,PCI評(píng)分也是能否達(dá)到完全性減瘤目標(biāo)的一個(gè)重要影響因素[5-6]。因此,得知準(zhǔn)確的術(shù)前PCI評(píng)分有助于適于CRS聯(lián)合HIPEC治療患者的選擇并預(yù)測(cè)其預(yù)后。

      1 與CT檢查相比,MRI檢查用于腹膜轉(zhuǎn)移癌診斷的優(yōu)勢(shì)

      CT檢查過(guò)去一直是最常用于腹膜轉(zhuǎn)移癌的診斷、術(shù)前分期和隨訪的影像學(xué)評(píng)估方法,但其對(duì)軟組織的分辨力有限,使得檢出小腹膜轉(zhuǎn)移癌灶的靈敏度較低[7-8]。一項(xiàng)研究顯示,相較于術(shù)中發(fā)現(xiàn),術(shù)前CT檢查對(duì)直徑<0.5 cm腹膜轉(zhuǎn)移癌灶的檢出率僅有11%[9]。此外,作為一種單純形態(tài)學(xué)成像術(shù),CT檢查僅能從癌灶大小的形態(tài)學(xué)改變來(lái)評(píng)估治療療效,但不能反映癌灶的早期功能學(xué)改變,而對(duì)亞厘米級(jí)別的癌灶,很難以形態(tài)學(xué)改變來(lái)評(píng)估治療療效。

      MRI具有較高的軟組織分辨力,可多層面、多角度成像,因此MRI檢查可更準(zhǔn)確地反映腹膜癌的分布和大小,更適宜用于腹膜轉(zhuǎn)移癌的術(shù)前分期。一項(xiàng)研究顯示,增強(qiáng)型MRI檢查檢出腹膜癌灶的靈敏度、特異性和準(zhǔn)確度分別為84%、87%和86%,優(yōu)于CT檢查(分別為54%、91%和74%),尤其是對(duì)直徑<1 cm癌灶的檢出率大大提高(分別為75% ~ 80%和22% ~ 33%)[10]。近年來(lái),隨著彌散加權(quán)成像術(shù)(diffusion-weighted imaging, DWI)在腹部疾病影像學(xué)診斷中的廣泛應(yīng)用,臨床上對(duì)腹膜轉(zhuǎn)移癌的檢出能力已得到明顯提高[11-12]。

      2 DWI的基本原理和參數(shù)以及腹膜轉(zhuǎn)移癌在DWI檢查圖像中的表現(xiàn)

      DWI的成像原理基于水分子布朗運(yùn)動(dòng),即在機(jī)體組織中,由于細(xì)胞外微體系結(jié)構(gòu)、主動(dòng)運(yùn)輸機(jī)制和微血管循環(huán)等因素使得水分子彌散運(yùn)動(dòng)得以緩慢進(jìn)行,這種水分子彌散運(yùn)動(dòng)的限制性合成效應(yīng)反映了組織的微環(huán)境。DWI通過(guò)改變所施加的磁場(chǎng)梯度的幅度、持續(xù)時(shí)間和間隔時(shí)間等參數(shù)(即彌散敏感系數(shù)b值),能調(diào)節(jié)對(duì)水分子彌散運(yùn)動(dòng)的敏感性。b值較小時(shí)可得到較高信噪比的圖像,但易受局部組織微循環(huán)灌注的影響,不能正確反映水分子的彌散運(yùn)動(dòng)。b值越高,越能較好地反映實(shí)際的水分子彌散運(yùn)動(dòng)[13]。檢測(cè)到的水分子彌散程度可以表觀擴(kuò)散系數(shù)(apparent diffusion coefficient, ADC)來(lái)量化,其來(lái)源于至少兩個(gè)b值的DWI信號(hào)強(qiáng)度的指數(shù)衰減[13]。腹膜轉(zhuǎn)移癌在DWI檢查圖像上顯示為高亮信號(hào),但ADC值降低,表明水分子彌散受限,這可能與癌灶的多細(xì)胞無(wú)序排列、低血流灌注以及細(xì)胞分子水平的改變有關(guān)。

      腹膜轉(zhuǎn)移癌在DWI檢查圖像上表現(xiàn)為腹膜、網(wǎng)膜或腸系膜的結(jié)節(jié)樣、團(tuán)塊樣或條帶樣高亮信號(hào),增強(qiáng)型MRI檢查圖像上還可見(jiàn)腹膜的增厚和異常強(qiáng)化(正常腹膜強(qiáng)化程度約等同于肌肉組織的強(qiáng)化程度)情況[14]。常規(guī)MRI聯(lián)合DWI檢查能提供準(zhǔn)確的術(shù)前腹膜轉(zhuǎn)移癌的形態(tài)、位置以及淋巴結(jié)腫大和腹水等情況[14]。

      3 DWI檢查在腹膜轉(zhuǎn)移癌診斷中的應(yīng)用

      在DWI檢查圖像中,腹膜轉(zhuǎn)移癌表現(xiàn)為較之周圍組織明顯的高亮信號(hào),尤其是膈下、肝包膜下、網(wǎng)膜囊、腸系膜根部和腸管漿膜表面的腹膜癌的對(duì)比度明顯更高,與CT檢查相比能明顯提高對(duì)腹膜轉(zhuǎn)移癌的檢出率[15-19]。Bozkurt等[16]的研究顯示,聯(lián)合高b值(800 s/mm2)DWI的腹部MRI檢查對(duì)腹膜轉(zhuǎn)移癌灶的檢出率更高,靈敏度由常規(guī)MRI檢查的58%提高到85%。Low等[20]的研究也證實(shí),對(duì)腹膜轉(zhuǎn)移癌患者,聯(lián)合DWI的MRI檢查所得的術(shù)前PCI評(píng)分與術(shù)中所得的PCI評(píng)分高度吻合,常規(guī)MRI、DWI及兩者聯(lián)合檢查對(duì)腹膜轉(zhuǎn)移癌灶的檢出靈敏度分別為73%、71%和90%,特異性分別為90%、90%和91%,表明聯(lián)合DWI的常規(guī)MRI檢查可在很大程度上提高對(duì)腹膜轉(zhuǎn)移癌的檢出靈敏度。

      動(dòng)物模型研究提示,ADC值升高與死亡的腫瘤細(xì)胞密度正相關(guān),ADC值的變化先于癌灶大小的變化,可用作治療早期有效的指標(biāo)[21-22]。一系列對(duì)不同腫瘤類型患者的臨床研究也發(fā)現(xiàn),早于癌灶可測(cè)體積縮小,治療有效患者的ADC值明顯升高,且這些患者在治療前往往預(yù)后不良,表明治療前的ADC值有希望用作治療療效預(yù)測(cè)指標(biāo)[23-26]。但由于腹膜轉(zhuǎn)移癌的解剖位置復(fù)雜且分布廣泛,加之部分癌灶較小等,給對(duì)腹膜轉(zhuǎn)移癌灶測(cè)量ADC值時(shí)感興趣區(qū)域的選擇帶來(lái)了極大困難,目前尚無(wú)相關(guān)文獻(xiàn)可以參考。

      4 DWI檢查用于腹膜轉(zhuǎn)移癌診斷的相對(duì)局限性

      目前,有關(guān)DWI檢查的b值選擇、后處理技術(shù)和數(shù)據(jù)分析方法尚無(wú)國(guó)內(nèi)外統(tǒng)一標(biāo)準(zhǔn)。雖然DWI檢查在腹膜轉(zhuǎn)移癌評(píng)估中有明顯的優(yōu)勢(shì)或潛力,但成本相對(duì)昂貴、圖像采集時(shí)間較長(zhǎng)且空間分辨率相對(duì)較低,圖像質(zhì)量又易受呼吸運(yùn)動(dòng)的影響或干擾,這些不利因素限制了其在臨床上的廣泛應(yīng)用。

      參考文獻(xiàn)

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      [3] Yang XJ, Huang CQ, Suo T, et al. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy improves survival of patients with peritoneal carcinomatosis from gastric cancer: final results of a phase III randomized clinical trial [J]. Ann Surg Oncol, 2011, 18(6): 1575-1581.

      [4] Jacquet P, Sugarbaker PH. Clinical research methodologies in diagnosis and staging of patients with peritoneal carcinomatosis [J]. Cancer Treat Res, 1996, 82: 359-374.

      [5] Yan TD, Sim J, Morris DL. Selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and perioperative intraperitoneal chemotherapy [J]. Ann Surg Oncol, 2007, 14(6): 1807-1817.

      [6] Harmon RL, Sugarbaker PH. Prognostic indicators in peritoneal carcinomatosis from gastrointestinal cancer [J/OL]. Int Semin Surg Oncol, 2005, 2(1): 3 [2016-09-13]. http:// issoonline.biomedcentral.com/track/pdf/10.1186/1477-7800-2-3?site=issoonline.biomedcentral.com.

      [7] Metser U, Jones C, Jacks LM, et al. Identification and quantification of peritoneal metastases in patients with ovarian cancer with multidetector computed tomography: correlation with surgery and surgical outcome [J]. Int J Gynecol Cancer, 2011, 21(8): 1391-1398.

      [8] Coakley FV, Choi PH, Gougoutas CA, et al. Peritoneal metastases: detection with spiral CT in patients with ovarian cancer [J]. Radiology, 2002, 223(2): 495-499.

      [9] Koh JL, Yan TD, Glenn D, et al. Evaluation of preoperative computed tomography in estimating peritoneal cancer index in colorectal peritoneal carcinomatosis [J]. Ann Surg Oncol, 2009, 16(2): 327-333.

      [10] Low RN, Barone RM, Lacey C, et al. Peritoneal tumor: MR imaging with dilute oral barium and intravenous gadoliniumcontaining contrast agents compared with unenhanced MR imaging and CT [J]. Radiology, 1997, 204(2): 513-520.

      [11] Kyriazi S, Collins DJ, Morgan VA, et al. Diffusion-weighted imaging of peritoneal disease for noninvasive staging of advanced ovarian cancer [J]. Radiographics, 2010, 30(5): 1269-1285.

      [12] Low RN, Gurney J. Diffusion-weighted MRI (DWI) in the oncology patient: value of breathhold DWI compared to unenhanced and gadolinium-enhanced MRI [J]. J Magn Reson Imaging, 2007, 25(4): 848-858.

      [13] Kyriazi S, Kaye SB, deSouza NM. Imaging ovarian cancer and peritoneal metastases — current and emerging techniques[J]. Nat Rev Clin Oncol, 2010, 7(7): 381-393.

      [14] Iafrate F, Ciolina M, Sammartino P, et al. Peritoneal carcinomatosis: imaging with 64-MDCT and 3T MRI with diffusion-weighted imaging [J]. Abdom Imaging, 2012, 37(4): 616-627.

      [15] Low RN. MR imaging of the peritoneal spread of malignancy[J]. Abdom Imaging, 2007, 32(3): 267-283.

      [16] Bozkurt M, Doganay S, Kantarci M, et al. Comparison of peritoneal tumor imaging using conventional MR imaging and diffusion-weighted MR imaging with different b values[J]. Eur J Radiol, 2011, 80(2): 224-228.

      [17] Low RN, Sebrechts CP, Barone RM, et al. Diffusion-weighted MRI of peritoneal tumors: comparison with conventional MRI and surgical and histopathologic findings — a feasibility study [J]. AJR Am J Roentgenol, 2009, 193(2): 461-470.

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