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腹部肿瘤靶向治疗的影像学评价:现状与展望

唐磊 薛华丹 金征宇

唐磊, 薛华丹, 金征宇. 腹部肿瘤靶向治疗的影像学评价:现状与展望[J]. 协和医学杂志, 2017, 8(2-3): 82-89. doi: 10.3969/j.issn.1674-9081.2017.03.001
引用本文: 唐磊, 薛华丹, 金征宇. 腹部肿瘤靶向治疗的影像学评价:现状与展望[J]. 协和医学杂志, 2017, 8(2-3): 82-89. doi: 10.3969/j.issn.1674-9081.2017.03.001
Lei TANG, Hua-dan XUE, Zheng-yu JIN. Radiological Evaluation of the Response of Abdominal Tumors to Targeted Therapy: Current Status and Prospect[J]. Medical Journal of Peking Union Medical College Hospital, 2017, 8(2-3): 82-89. doi: 10.3969/j.issn.1674-9081.2017.03.001
Citation: Lei TANG, Hua-dan XUE, Zheng-yu JIN. Radiological Evaluation of the Response of Abdominal Tumors to Targeted Therapy: Current Status and Prospect[J]. Medical Journal of Peking Union Medical College Hospital, 2017, 8(2-3): 82-89. doi: 10.3969/j.issn.1674-9081.2017.03.001

腹部肿瘤靶向治疗的影像学评价:现状与展望

doi: 10.3969/j.issn.1674-9081.2017.03.001
基金项目: 

国家自然科学基金 81371715

北京市医管局青苗计划 QML20161102

详细信息
    通讯作者:

    金征宇  电话:010-69155442, E-mail:jin_zhengyu@163.com.cn

  • 中图分类号: R445;R73

Radiological Evaluation of the Response of Abdominal Tumors to Targeted Therapy: Current Status and Prospect

More Information
  • 摘要:

    靶向治疗是腹部肿瘤个体化精准医疗的重要组成部分, 在胃肠间质瘤的疗效尤为显著, 被誉为"现代抗肿瘤治疗的典范"。影像学是目前临床评价腹部肿瘤靶向治疗疗效的常用手段。由于肿瘤靶向治疗后组织学变化多样, 实体肿瘤疗效评价标准(response evaluation criteria in solid tumors, RECIST)存在形态学偏倚; Choi及mChoi、SACT(size and attenuation CT)、MASS(morphology, attenuation, size and structure)等标准联合CT值指标, 解决了肿瘤坏死囊变导致体积增大的问题。正电子发射断层显像(positron emission tomography, PET)、磁共振扩散加权成像(diffusion-weighted imaging, DWI)、磁共振动态增强扫描(dynamic contrast enhanced magnetic resonance imaging, DCE-MRI)及单能CT等新技术的探索应用, 一系列功能影像学参数[标准摄取值(standard uptake value, SUV)、表观扩散系数(apparent diffusion coefficient, ADC)、Ktrans、碘浓度值等]为肿瘤靶向治疗疗效的预测和治疗后早期评估提供了新的潜力指标。图像纹理分析技术则可深入挖掘影像学信息, 提供丰富量化参数供临床评效参考。影像医生应通过多学科诊疗协作组(multi-disciplinary team, MDT)等模式加强与临床沟通及开展联合科研, 积极探索新的参数和标准, 进一步提高腹部肿瘤靶向治疗疗效预测和评价水平。

  • 图  1  一例肠系膜转移性GIST患者甲磺酸伊马替尼治疗后3个月复查,实性病灶近完全囊变,但长径由治疗前6.8 cm(图 1A,箭头)增大为治疗后18.0 cm(图 1B,箭头),增大165%;CT值由治疗前85 HU下降为治疗后17 HU,下降80%;RECIST标准评价为PD,Choi标准评价为PR,此患者TTP>36个月,预后良好

    GIST:胃肠间质瘤;RECIST:实体肿瘤疗效评价标准;PD:治疗进展;PR:部分缓解;TTP:肿瘤进展时间

    图  2  一例小肠GIST患者(图 2A)及一例GIST肝脏转移患者(图 2B)肿块(箭头)均较大,多灶囊变、出血与实性肿瘤成分嵌插分布,难以准确测量实性部分病变大小

    GIST:同图 1

    图  3  一例胃GIST患者靶向治疗DWI早期预测疗效,治疗前T2WI图像显示胃体小弯侧外生性肿物,混杂长T2信号,侵及肝门区(图3A,箭头);DWI图像显示肿瘤呈明显高信号(图3D,箭头);治疗后1周肿瘤体积变化不大(图3B),而DWI信号显著降低(图3E);治疗后3个月体积明显缩小(图3C),疗效达PR,DWI上肿瘤高信号区基本消失(图3F)

    GIST、PR:同图 1;DWI:磁共振扩散加权成像;T2WI:T2加权成像

    表  1  RECIST标准与Choi标准

    疗效 RECIST标准 Choi标准
    CR 全部病灶消失,无新发病灶 同RECIST标准
    PR CT测量肿瘤长径缩小≥30%;无新发病灶; 无不可测病灶的明显进展 CT测量肿瘤长径缩小≥10%和/或肿瘤静脉期CT值减小≥15%;无新发病灶;无不可测病灶的明显进展
    SD 不符合CR、PR或PD标准,无肿瘤进展引起的症状恶化 同RECIST标准
    PD 肿瘤长径增大≥20%;出现新发病灶 肿瘤长径增大≥10%,且肿瘤静脉期CT值变化不符合PR标准;出现新发病灶;新的瘤内结节或原有瘤内结节体积增大
    RECIST、PR、PD:同图 1;CR:完全缓解;SD:病变稳定
    下载: 导出CSV

    表  2  实体肿瘤疗效影像学评价标准

    标准 病变 核心参数 核心标准
    RECIST 实体瘤 长径 长径总和下降≥30%为PR,长径总和上升≥20%为PD
    EASL 肝癌 活性成分 直径下降≥50%为PR,上升≥25%为PD
    mRECIST 肝癌 活性成分 直径下降≥30%为PR,上升≥20%为PD
    RECICL 肝癌 坏死 坏死降低率下降≥50%为PR,实性上升≥50%为PD
    vRECIST 肝癌 强化组织容积 强化体积下降≥65%为PR,上升≥73%为PD
    Choi GIST CT值 CT值下降≥15%为PR,长径上升≥20%为PD
    SACT 肾癌 CT值 非肺部病灶CT值下降≥40HU为FR
    MASS 肾癌 CT值 实性成分伴显著坏死或CT值下降≥40HU为FR
    mChoi 肝癌 CT值 长径下降≥10%且CT值下降≥15%为PR
    PR、PD、GIST:同图 1;FR:治疗有效
    下载: 导出CSV
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