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临床研究
ADC最小值对外周带早期前列腺癌与慢性前列腺炎的鉴别诊断价值
方磊 方慧 金利 刘新疆

Cite this article as: FANG L, FANG H, JIN L, et al. The value of apparent diffusion coefficient minimum in differential diagnosis of early prostate cancer and chronic prostatitis in peripheral zone[J]. Chin J Magn Reson Imaging, 2023, 14(7): 93-97.本文引用格式:方磊, 方慧, 金利, 等. ADC最小值对外周带早期前列腺癌与慢性前列腺炎的鉴别诊断价值[J]. 磁共振成像, 2023, 14(7): 93-97. DOI:10.12015/issn.1674-8034.2023.07.016.


[摘要] 目的 探讨表观扩散系数最小值(apparent diffusion coefficient minimum, ADCmin)在鉴别外周带早期前列腺癌(prostate cancer, PCa)与慢性前列腺炎中的诊断价值。材料与方法 回顾性分析经病理学证实的65例早期PCa与39例慢性前列腺炎的MRI资料,病灶均位于前列腺外周带,测量病灶实质的ADC平均值(mean apparent diffusion coefficient, ADCmean)和ADCmin,对两组患者的ADCmean和ADCmin进行差异性分析。采用受试者工作特征(receiver operating characteristic, ROC)曲线和DeLong检验进行评价和比较ADCmean和ADCmin对外周带早期PCa与慢性前列腺炎的诊断效能。结果 早期PCa组ADCmean和ADCmin均小于慢性前列腺炎组,组间差异均有统计学意义(P<0.001)。ADCmean和ADCmin的ROC曲线下面积(area under the curve, AUC)分别为0.888和0.935,使用DeLong检验比较两者的诊断效能差异有统计学意义(P<0.05)。ADCmean最佳截断值为1.008×10-3 mm2/s,诊断早期PCa的敏感度和特异度分别为81.54%、94.87%;ADCmin最佳截断值为0.861×10-3 mm2/s,诊断早期PCa的敏感度和特异度分别为83.08%、94.87%。结论 ADCmin鉴别外周带早期PCa与慢性前列腺炎的诊断效能优于ADCmean,具有较好的临床参考价值。
[Abstract] Objective To explore the value of apparent diffusion coefficient minimum (ADCmin) in differential diagnosis of early prostate cancer (PCa) and chronic prostatitis in peripheral zone.Materials and Methods The MRI data of 65 patients of early PCa and 39 patients of chronic prostatitis with pathology confiemed were retrospectively analyzed, the lesions were all located in the peripheral zone of prostate, the mean apparent diffusion coefficient (ADCmean) and ADCmin of the parenchyma of the lesion were measured, the difference of ADCmean and ADCmin between the two groups were analyzed. The receiver operating characteristic (ROC) curve and DeLong test were used to evaluate and compare the diagnostic efficiency of ADCmean and ADCmin for early PCa and chronic prostatitis in peripheral zone.Results The ADCmean and ADCmin in the early PCa group were lower than those in the chronic prostatitis group, and differences between groups were statistically significant (P<0.001). The area under the curve (AUC) of ADCmean and ADCmin were 0.888 and 0.935, there was statistical difference in diagnostic performance by DeLong test (P<0.05). The optimal cut-off value of ADCmean was 1.008×10-3 mm2/s, the sensitivity and specificity or the diagnosis of early PCa were 81.54%, 94.87%, respectively. The optimal cut-off value of ADCmin was 0.861×10-3 mm2/s, the sensitivity and specificity for the diagnosis of early PCa were 83.08%, 94.87%, respectively.Conclusions The diagnostic efficacy of ADCmin in differentiating early PCa and chronic prostatitis in the peripheral zone is better than that of ADCmean, which has good clinical reference value.
[关键词] 前列腺肿瘤;前列腺癌;慢性前列腺炎;磁共振成像;表观扩散系数
[Keywords] prostatic neoplasms;prostate cancer;chronic prostatitis;magnetic resonance imaging;apparent diffusion coefficient

方磊    方慧    金利    刘新疆 *  

复旦大学附属浦东医院放射科,上海 201399

通信作者:刘新疆,E-mail:lxj6513@163.com

作者贡献声明:刘新疆设计本研究的方案,对文章的知识性内容作批判性审阅,对稿件重要的智力内容进行了修改,获得了上海市卫健委卫生行业临床研究专项和上海市浦东新区卫生系统学科建设项目基金资助;方磊起草和撰写稿件、获取、分析或解释本研究的数据;方慧,金利获取、分析或解释本研究的数据,对稿件重要的智力内容进行了修改;全体作者都同意发表最后的修改稿,同意对本研究的所有方面负责,确保本研究的准确性和诚信。


基金项目: 上海市卫健委卫生行业临床研究专项 202140266 上海市浦东新区卫生系统学科建设项目 PWZbr2022-16
收稿日期:2023-01-02
接受日期:2023-06-25
中图分类号:R445.2  R737.25 
文献标识码:A
DOI: 10.12015/issn.1674-8034.2023.07.016
本文引用格式:方磊, 方慧, 金利, 等. ADC最小值对外周带早期前列腺癌与慢性前列腺炎的鉴别诊断价值[J]. 磁共振成像, 2023, 14(7): 93-97. DOI:10.12015/issn.1674-8034.2023.07.016.

0 前言

       前列腺癌(prostate cancer, PCa)严重危害着全球老年男性的生活健康,根据世界卫生组织的最新统计数据,其发病率和死亡率分别位于男性恶性肿瘤的第2位和第5位[1]。PCa患者的预后与临床TNM分期(tumor node metastasis stage, TNM stage)密切相关,给予早期PCa患者规范化的治疗,可使患者受益最大化[2]。MRI在术前PCa诊断及TNM分期中具有重要作用,其扩散加权成像(diffusion weighted imaging, DWI)及表观扩散系数(apparent diffusion coefficient, ADC)在PCa的诊断及鉴别诊断中有显著价值[3]。早期PCa与慢性前列腺炎均好发于外周带,且具有重叠的MRI征象,在临床工作中易误诊和漏诊,但两者的治疗方式及预后却不同,因此精准诊断非常重要[4]。既往文献对两者的鉴别主要集中在ADC平均值(mean ADC, ADCmean)及MRI序列的选择上[5, 6, 7]。由于ADCmean反映的是扩散受限的平均水平,其测量值在早期PCa和慢性前列腺炎病变中亦存在一定重叠,常规诊断价值受限,而ADC最小值(ADC minimum, ADCmin)反映的是组织中水分子扩散受限最明显的区域,在实际测量中具有简便易行的特点。因此本研究主要探讨ADCmin在鉴别外周带早期PCa和慢性前列腺炎中的诊断价值,并与ADCmean作比较。

1 材料与方法

1.1 临床资料

       回顾性分析2020年11月至2022年11月在复旦大学附属浦东医院行前列腺MRI检查患者的影像学资料。纳入标准:(1)病变位于前列腺外周带,PCa组均符合早期PCa[7, 8, 9](病灶位于前列腺包膜内,TNM分期不超过T2C)的临床诊断;(2)MRI检查后2周内行前列腺穿刺活检或根治性手术;(3)病理结果为PCa或慢性前列腺炎患者。排除标准:(1)MRI检查前有前列腺穿刺或治疗(放化疗等)患者;(2)病变突破前列腺包膜或其他部位有转移灶;(3)图像质量差或其他任何原因导致ADC值无法测量者。本研究遵守《赫尔辛基宣言》,经上海市浦东医院伦理委员会批准,免除受试者知情同意,批准文号:(2023)伦理审字(WZ-01)号。

1.2 MRI检查方法

       采用GE Discovery MR 750W 3.0 T扫描仪,腹部16通道相控线圈,取仰卧位,扫描范围包括前列腺、精囊腺、膀胱及直肠。至少包括T2WI序列和DWI序列,层厚4 mm,层间距1 mm,有或无动态对比增强扫描,T2WI序列行轴位、矢状位及冠状位扫描。(1)T2WI扫描参数:冠状位TR 85 ms,TE 4210 ms;矢状位TR 4975 ms,TE 102 ms;抑脂轴位TR 4678 ms,TE 85 ms;矩阵均为320×320。(2)DWI扫描参数:TR 4600 ms,TE 80 ms,矩阵128×130,b值取0、500、1000 s/mm2,扫描完毕由机器自带软件生成ADC图。(3)动态对比增强扫描参数:期数为6期,使用LAVA序列,TR 6.90 ms,TE 2.60 ms,矩阵260×160,应用高压注射器以3 mL/s的速率经肘静脉注射钆喷酸葡胺对比剂,剂量为0.1 mmol/kg,随后以相同速率注入18 mL生理盐水,高压注射剂型号为MEDRAD® Spectris Solaris EP,从第2期开始注射对比剂。

1.3 图像分析

       由2名具有10年以上前列腺MRI诊断经验的放射科主治医师采用双盲法在GE公司ADW 4.7工作站上分析图像,意见不统一时经共同商讨后解决。先根据前列腺MRI多序列图像确定感兴趣区(region of interest, ROI),存在多发病变时选择体积较大者,根据靶向穿刺记录确保ROI和病理活检位置准确对应,ROI范围尽可能大并尽可能置入病灶中央,但需避开出血、钙化及坏死囊变区,每个病变测量3次并计算平均值。

1.4 统计学分析

       应用SPSS 26.0及MedCalc 20.1统计学软件。首先对计量资料进行正态性检验和方差齐性检验,两组ADCmean和ADCmin均符合正态分布,用(x¯±s)表示,使用独立样本t检验统计分析,比较两组ADCmean和ADCmin的差异,P<0.05为组间差异有统计学意义。绘制受试者工作特征(receiver operating characteristic, ROC)曲线,获得ADCmean和ADCmin的曲线下面积(area under the curve, AUC),应用DeLong检验比较两组AUC之间的差异,P<0.05为差异有统计学意义。

2 结果

2.1 入组病例资料

       最终104名患者病例被纳入本研究,MRI检查后2周内均行经直肠超声(transrectal ultrasonography, TRUS)引导下前列腺靶向穿刺获得病理结果,其中有6例在本院行PCa根治术。早期PCa组65例,年龄55~96(74.83±8.42)岁;慢性前列腺炎组39例,年龄49~90(68.64±9.14)岁。2名医师在病灶回顾性分析和勾勒ROI时无异议。

2.2 外周带早期PCa和慢性前列腺炎的ADCmean和ADCmin对比分析

       外周带早期PCa组的ADCmean和ADCmin均小于外周带慢性前列腺炎组,两组间ADCmean和ADCmin差异具有统计学意义(P<0.001)(表1图12)。

图1  男,75岁,根治术后病理证实左侧外周带早期前列腺癌。1A:抑脂T2WI轴位病灶呈低信号;1B:DWI呈高信号;1C:ADC图呈低信号,ADCmean和ADCmin分别为0.86×10-3 mm2/s、0.64×10-3 mm2/s。
图2  男,62岁,穿刺后病理证实左侧外周带慢性前列腺炎。2A:抑脂T2WI轴位病灶呈低信号;2B:DWI呈高信号;2C:ADC呈稍低信号,ADCmean和ADCmin分别为1.12×10-3 mm2/s、1.07×10-3 mm2/s。DWI:扩散加权成像;ADC:表观扩散系数。
Fig. 1  Male, 75 years old, early prostate cancer in the left peripheral zone is confirmed by pathology after radical surgery. 1A: Fat suppression T2WI axial lesions shows low signal; 1B: DWI shows high signal; 1C: ADC map shows low signal, ADCmean and ADCmin are 8.56×10-3 mm2/s, 6.44×10-3 mm2/s.
Fig. 2  Male, 62 years old, Chronic prostatitis in the left peripheral zone is confirmed by pathology after puncture. 2A: Fat suppression T2WI axial lesions shows low signal; 2B: DWI shows high signal; 2C: ADC shows slightly lower signal, ADCmean and ADCmin are 1.12×10-3 mm2/s, 1.07×10-3 mm2/s. DWI: diffusion weighted imaging; ADC: apparent diffusion coefficient.
表1  两组ADCmean和ADCmin比较
Tab.1  Comparison of ADCmean and ADCmin between the two groups

2.3 ADCmean与ADCmin鉴别诊断外周带早期PCa和慢性前列腺炎的ROC曲线分析

       根据ROC曲线分析,ADCmean和ADCmin对鉴别外周带早期PCa和慢性前列腺炎均表现出很好的诊断价值,AUC分别为0.888和0.935,ADCmin的诊断效能略高于ADCmean值,两组间差异有统计学意义(P<0.05)。ADCmean最佳截断值为1.008×10-3 mm2/s,诊断的敏感度和特异度分别为81.54%、94.87%;ADCmin最佳截断值为0.861×10-3 mm2/s,诊断的敏感度和特异度分别为83.08%、94.87%(表2图3)。

图3  ADCmean与ADCmin鉴别诊断外周带早期PCa和慢性前列腺炎的ROC曲线。ADC:表观扩散系数;PCa:前列腺癌;ROC:受试者工作特征。
Fig. 3  ADCmean and ADCmin for differential diagnosis of early PCa and chronic prostatitis in peripheral zone ROC curve. ADC: apparent diffusion coefficient; PCa: prostate cancer; ROC: receiver operating characteristic.
表2  ADCmean与ADCmin的效能比较
Tab. 2  The efficiency comparison of ADCmean and ADCmin

3 讨论

       面对PCa对男性的健康威胁,基于前列腺影像报告和数据系统(Prostate Imaging Reporting and Data System, PI-RADS)准则的多参数MRI已经广泛应用于PCa的术前诊断、随访及治疗方案的选择中[10, 11, 12, 13, 14, 15, 16]。T2WI和DWI是PI-RADS及PCa影像组学等研究的主要序列[17, 18, 19, 20, 21, 22, 23, 24],外周带早期PCa和慢性前列腺炎在T2WI均可表现为低信号,都可引起水分子扩散受限在DWI上表现为高信号,实际工作中易受主观因素影响而出现误诊或漏诊。利用ADC的定量特性可以提高医师的诊断信心,由于ADCmean受组织异质性等因素的影响,可能无法真实反映肿瘤的生物学行为。本研究应用ADCmin鉴别外周带早期PCa和慢性前列腺炎,并与ADCmean的诊断效能进行对比,结果显示ADCmin的诊断效能更高。

3.1 DWI和ADC值在外周带早期PCa和慢性前列腺炎鉴别诊断中的应用

       DWI是一种以水分子布朗运动为成像原理的功能MRI,优势是可以反映细胞外空间水分子扩散状态及微观结构的特点和变化,但在判定病灶良恶性时因受到T2透射效应和主观因素的影响,低b值常导致信号抑制不足,较高b值时又因信号抑制过多导致结构清晰度降低,造成前列腺良恶性组织的图像对比度不足,而超高b值虽然可以提高病灶检出率,但额外增加了图像失真、后处理软件及时间成本等问题[25, 26, 27]。ADC值可以相对客观地反应组织扩散程度,可消除T2透射效应和主观因素的影响,实际应用中具有简单、易操作、可重复性高的优点。

       有研究[28, 29]表明区域内细胞数量、体积及细胞核浆比例与ADC值大小明显相关,它们决定了细胞外与细胞内空间的比例,而细胞外与细胞内的体积比下降被认为可能是ADC值减低的主要机制。早期PCa和慢性前列腺炎都会引起水分子扩散受限,但是PCa细胞排列更拥挤,细胞核体积增大、通常伴有明显的核仁,而慢性前列腺炎主要为慢性炎症细胞引起的组织破坏,局部可伴有炎性渗出物集聚、小脓肿或纤维结缔组织形成。基于两者的病理特点不同,慢性前列腺炎的扩散受限程度要比PCa低。本研究回顾性定量分析了外周带早期PCa和慢性前列腺炎的ADCmean和ADCmin,结果显示PCa组ADCmean小于慢性前列腺炎组,与既往研究[3,26,30]相仿。此外,早期PCa组ADCmin明显小于慢性前列腺炎组,组间差异具有统计学意义,提示ADCmin亦可以作为鉴别外周带早期PCa和慢性前列腺炎的一种量化工具。

3.2 ADCmean和ADCmin在外周带早期PCa和慢性前列腺炎鉴别诊断中的价值比较

       理论上ADCmean反映的是扩散受限的平均水平,ADCmin反映的是组织中水分子扩散受限最明显的区域,代表的是肿瘤细胞分布最密集的区域。本研究ROC分析结果显示在鉴别外周带早期PCa和慢性前列腺炎方面,ADCmin的AUC大于ADCmean,进一步DeLong检验提示组间差异具有统计学意义,结果表明ADCmin在鉴别早期PCa和慢性前列腺炎时有更好的诊断效能。一诺等[31]研究表明ADCmin在鉴别前列腺良恶性病变中有重要价值,并且ADCmin诊断中高危PCa的诊断效能优于ADCmean。此外,ADCmin在人体其他部位良恶性病变鉴别、病理分级预测及早期疗效评估中均有显著优势[32, 33, 34, 35, 36, 37, 38, 39]。本研究结果与上述文献基本一致,提示ADCmin有较好的临床应用价值。

3.3 本研究的局限性

       本研究存在一些局限性:(1)本研究为回顾性研究,慢性前列腺炎病例数较少,未行PCa Gleason评分的分类研究,可能会使结果产生偏倚;(2)ADCmean和ADCmin的测量受到ROI面积等多种因素影响,可能会存在测量误差。未来可以扩大样本量、依据PCa Gleason评分及采用多b值DWI测量ADC值进行分析。

4 结论

       综上所述,ADCmin作为鉴别外周带早期PCa和慢性前列腺炎的一种量化工具,诊断效能优于ADCmean,具有较好的临床参考价值。

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