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Analysis of the Features of 18F-FDG PET/CT and Enhanced CT in Patients with Primary Pulmonary Mucinous Adenocarcinoma
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摘要:
目的 对原发性肺黏液腺癌(primary pulmonary mucinous adenocarcinoma，PPMA)的18F-脱氧葡萄糖(fluorodeoxy glucose，FDG)正电子发射断层显像/计算机体层成像(positron emission tomography/computed tomography, PET/CT)与增强CT影像特征进行总结，以期为该病的临床诊疗提供参考。 方法 回顾性纳入2015年7月至2018年2月中日友好医院经手术或穿刺病理证实的全部PPMA患者。对其18F-FDG PET/CT和增强CT影像学资料进行归纳、总结。 结果 共入选25例符合纳入和排除标准的PPMA患者，全部行18F-FDG PET/CT显像检查，其中6例行增强CT扫描。18F-FDG PET/CT显像示孤立性PPMA 7例、弥漫性多发PPMA 18例，前者形态学表现为肺部孤立性病灶，边缘可见分叶征与棘突，实性成分摄取18F-FDG不均匀，空洞或囊性密度区对18F-FDG低摄取或无摄取；弥漫性多发PPMA形态学表现为双肺多发病灶，分布、大小、形态不一，包括多发结节或团块5例，实变影5例，结节、团块、空洞、磨玻璃密度影、斑片影及实变影等多种形态占位混合存在8例。实变影为弥漫性多发PPMA最典型的形态学表现(11例)，实变灶密度极不均匀，其内均含囊性密度区，CT值较低(-71~79 Hu)，可见肺叶膨隆征(6例)、病理性支气管充气征(4例)、血管造影征(3例)、周围磨玻璃密度影(7例)。弥漫性多发PPMA对18F-FDG摄取程度不一，囊性成分低于实性成分。增强CT示，4例呈不均匀强化，2例无强化。以结节、团块或空洞为主的病灶对18F-FDG摄取程度与CT强化程度无线性相关；以实变影为主的病灶对18F-FDG摄取程度与CT强化程度呈正相关。 结论 增强CT示PPMA病灶可无强化或不均匀强化。18F-FDG PET/CT显像示PPMA病灶常表现为结节、斑片影等多种占位形式与实变影混合存在，可通过其特征性表现，包括肺叶膨隆、病理性支气管充气征、血管造影征以及代谢程度与病灶密度呈正相关等，与肺部感染性疾病进行鉴别诊断。 Abstract:Objective To evaluate the value and characteristics of 18F-FDG PET/CT and enhanced CT in primary pulmonary mucinous adenocarcinoma (PPMA), in order to provide reference for the clinical diagnosis and treatment of the disease. Methods Data of enhanced CT and 18F-FDG PET/CT imaging and clinical information of 25 patients with PPMA confirmed by pathology in China-Japan Friendship Hospital from July 2015 to February 2018 were retrospectively reviewed. Results A total of 25 PPMA patients were enrolled. Among them, 25 patients underwent the examination of 18F-FDG PET/CT imaging, and 6 cases underwent enhanced CT scan. Seven cases had one lesion, which morphologically manifested as a solitary lung lesion with lobulation signs, spinous processes on the edge, and uneven uptake of 18F-FDG with low or no uptake in hollow or cystic density areas; 18 cases showed diffuse multiple lesions in both lungs with different distribution, size and shape, including 5 cases with multiple nodules/masses, 5 with consolidations, and 8 with diversified lesions including nodules, masses, cavities, ground glass opacities, patches, and consolidations. Consolidation shadow is the most typical morphological manifestation of diffusely multiple PPMA (11 cases). The density of consolidation foci was extremely uneven, and all of them contain areas of cystic density. They had low CT value(-71-79 Hu), and characteristic features were found, including pulmonary lobe bulging sign (6 cases), pathological air bronchus sign (4 cases), angiographic sign (3 cases) and surrounding ground glass density(7 cases). The uptake of 18F-FDG varied with the density of lesions. The cystic component was lower than the solid component. Contrast-enhanced CT showed heterogeneous enhancement in 4 cases and no enhancement in 2 cases. The degree of 18F-FDG uptake in lesions dominated by nodules, masses or cavities was not linearly correlated with the degree of CT enhancement, but that in lesions dominated by consolidation was positively correlated with the degree of CT enhancement. Conclusions Contrast-enhanced CT shows PPMA lesions with no enhancement or heterogeneous enhancement. PPMA is often manifested as nodules, patchy shadows, and other space-occupying forms mixed with consolidation shadows on 18F-FDG PET/CT imaging, which has characteristic manifestations, including pulmonary lobe bulge and pathological air bronchi. Angiographic signs and the degree of metabolism are positively correlated with the density of lesions, which are used for differential diagnosis of pulmonary infectious diseases. 作者贡献：韩萍萍负责病例收集、PET/CT图像解读、论文撰写；富丽萍负责PET/CT图像解读、论文修订；张凌负责CT图像解读；冯宏响提供病例并协助论文修订；史艳芬负责病理图片解读；郑玉民负责病例收集、PET/CT图像解读、论文修订。利益冲突：所有作者均声明不存在利益冲突 -
图 1 原发性肺黏液腺癌患者18F-FDG PET/CT显像特征
A.单发团块：患者男性，66岁，右肺下叶不均匀密度团块，大小3.2 cm×3.9 cm，病灶实性成分18F-FDG摄取增高(红色箭头)，囊性成分18F-FDG摄取减低(蓝色箭头)；B.弥漫性多发病灶(有“母瘤”)：患者男性，77岁，右肺中叶较大结节，呈分叶状，边缘可见毛刺征，18F-FDG摄取显著增高(“母瘤”，红色箭头)；双肺另可见散在磨玻璃密度小结节，18F-FDG摄取轻度增高(十字交叉)；C. 弥漫性多发病灶(无“母瘤”)：患者女性，21岁，双肺多发不规则结节，18F-FDG摄取不同程度增高，未见“母瘤”；D.实变影：患者女性，70岁，左肺上叶舌段实变影，18F-FDG摄取程度不一，实性成分(红色箭头)摄取度远高于囊性成分(蓝色箭头)，SUVmax为18.0；E.实变影：患者男性，65岁，右肺下叶实变影整体密度低，18F-FDG摄取亦较低，SUVmax为2.2
18F-FDG：18F-脱氧葡萄糖；PET/CT：正电子发射断层显像/计算机体层成像；SUVmax：最大标准摄取值
图 2 原发性肺黏液腺癌患者实变影PET/CT显像特征(箭头)
A.实变影密度不均匀，含有较多囊性密度区；B.肺叶膨隆征；C.病理性支气管充气征；D.血管造影征
PET/CT：同图 1
图 3 原发性肺黏液腺癌患者增强CT与18F-FDG PET/CT显像
A. 单发结节：患者男性，62岁，右肺下叶实性结节(红色十字交叉)，周边可见磨玻璃成分，18F-FDG轻度摄取(SUVmax：1.5)，增强CT示强化明显(ΔHu：73)；B.多发空洞：患者男性，69岁，双肺多发空洞，最大者位于左肺上叶(蓝色十字交叉)，增强CT无明显强化，18F-FDG摄取不均匀增高(SUVmax：7.2~16.6); C. 实变影：患者女性，50岁，右肺下叶实变影，边缘可见强化，18F-FDG摄取高(红色箭头，SUVmax：6.5)；病灶内无强化部分无18F-FDG摄取(蓝色箭头)
18F-FDG、PET/CT、SUVmax：同图 1 -
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