纖維蛋白原聯合多層螺旋CT術前預測結直腸癌淋巴結轉移_《中國普外基礎與臨床雜志》

作者：

汪曉東 ¹ , 歐陽書睿 ² , 呂東昊 ² , 莊磊 ² , 蔣善明 ² , 鄧磊 ² , 李崢艷 ³ , 李立 ¹

1.四川大學華西醫院肛腸外科（成都 610041）;;
2.四川大學華西臨床醫學院（成都 610041）;;
3.四川大學華西醫院放射科（成都 610041）;

關鍵詞：

結直腸腫瘤螺旋計算機體層攝影術術前分期淋巴結轉移形態學標準纖維蛋白原多模式術前評估

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目的　建立聯合纖維蛋白原(FIB)水平的最佳形態學標準評估結直腸癌術前淋巴結轉移。
方法　納入連續的690例接受根治術的結直腸癌患者，所有患者術前均使用多層螺旋CT(MSCT)行全腹增強掃描。若發現異常局域淋巴結則測量其最大短軸軸徑(MSAD)、最大長軸軸徑(MLAD)以及軸徑比(MSAD/MLAD)，并計算每個分界值預測結直腸癌淋巴結轉移的準確度、敏感度、特異度、陽性預測值和陰性預測值; 聯合術前血清FIB水平鑒別轉移性或炎性淋巴結; MSCT聯合FIB和單用MSCT兩種策略的預測結果　與術后病理檢查結果　進行比較。
結果　本研究納入有異常淋巴結顯示的患者100例,其中轉移性淋巴結與非轉移性淋巴結的影像特點比較差異無統計學意義(P gt;0.05)。MSAD的最佳分界值為6 mm，其診斷淋巴結轉移的敏感度為46.8%，特異度為68.4%，準確度為55.0%，陽性預測值為70.7%，陰性預測值為44.1%。MLAD的最佳分界值為8 mm，其診斷淋巴結轉移的敏感度為43.5%，特異度為63.2%，準確度為51.0%，陽性預測值為65.9%，陰性預測值為40.7%。以高纖維蛋白原血癥(FIB≥3.5 g/L)鑒別診斷MSAD lt;6 mm或MLAD lt;8 mm的轉移性小淋巴結，其診斷價值有統計學意義（Kappa=0.256，P=0.047）。MSAD(6 mm)聯合高纖維蛋白原血癥與單用MSAD(6 mm)相比敏感度更高 (79.0%比46.8%,P lt;0.001)，但準確度相似 (66.0%比55.0%,P gt;0.05)，特異度更低(44.7%比68.4%,P=0.037)。與單用MLAD(8 mm)相比，聯合高纖維蛋白原血癥敏感度(80.6%比43.5%,P lt;0.001)和準確度 (66.0%比51.0%,P=0.031)都更高，且特異度沒有明顯降低(42.1%比63.2%,P gt;0.05)。
結論　本研究推薦采用MSAD≥6 mm或MLAD≥8 mm作為結直腸癌淋巴結轉移的診斷標準。此外，聯合高纖維蛋白原血癥對淋巴結轉移進行鑒別，可以提高術前分期的敏感度和準確度。

引用本文： 汪曉東,歐陽書睿,呂東昊,莊磊,蔣善明,鄧磊,李崢艷,李立. 纖維蛋白原聯合多層螺旋CT術前預測結直腸癌淋巴結轉移. 中國普外基礎與臨床雜志, 2009, 16(9): 757-762. doi: 復制

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2.	汪曉東, 宋歡, 呂東昊, 等. 術前聯合評估直腸上段癌與手術方案選擇的隨機對照試驗 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(4): 322-326.
3.	Dworák O. Number and size of lymph nodes and node metastases in rectal carcinomas [Ｊ]. Surg Endosc, 1989; 3(2): 96-99.
4.	Monig SP, Baldus SE, Zirbes TK, et al. Lymph node size and metastatic infiltration in colon cancer [Ｊ]. Lancet, 1986; 6(6): 579-581.
5.	Karantanas AH, Yarmenitis S, Papanikolaou N, et al. Preoperative imaging staging of rectal cancer [Ｊ]. Dig Dis, 2007; 25(1): 20-32.
6.	汪曉東, 劉丹, 呂東昊, 等. 術前纖維蛋白原水平與結直腸癌病理分期的關系 [Ｊ]. 中華實用診斷與治療雜志, 2009; 23(7): 643- 645.
7.	汪曉東, 高強, 周小雁, 等. 多層螺旋CT聯合纖維蛋白原或血清淀粉樣蛋白A對直腸癌外科決策的隨機對照研究 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(7): 575-580.
8.	Greene FL, Page DL, Fleming ID, et al Eds. AJCC cancer staging manual [M]. 6th ed. New York (NY): Springer Verlag, 2002: 113-124.
9.	Kulinna C, Scheidler J, Strauss T, et al. Local staging of rectal cancer: assessment with double-contrast multislice computed tomography and transrectal ultrasound [Ｊ]. J Comput Assist Tomogr, 2004; 28(1): 123-130.
10.	Grabbe E, Lierse W, Winkler R. The perirectal fascia: morphology and use in staging of rectal carcinoma [Ｊ]. Radiology, 1983; 149(1): 241-246.
11.	Hodgman CG, MacCarty RL, Wolff BG, et al. Preoperative staging of rectal carcinoma by computed tomography and 0.15 T magnetic resonance imaging. Preliminary report [Ｊ]. Dis Colon Rectum, 1986; 29(7): 446-450.
12.	Noji T, Kondo S, Hirano S, et al. Computed tomography evaluation of regional lymph node metastases in patients with biliary cancer [Ｊ]. Br J Surg, 2008; 95(1): 92-96.
13.	Theoni RF. Colorectal cancer: cross-sectional imaging for st-aging of primary tumor and detection of local recurrence [Ｊ]. AJR Am J Roentgenol, 1991; 156(5): 909-915.
14.	Matsuoka H, Nakamura A, Masaki T, et al. Preoperative staging by multidetector-row computed tomography in patients with rectal carcinoma [Ｊ]. Am J Surg, 2002; 184(2): 131-135.
15.	McCormick JT, Gregorcyk SG. Preoperative evaluation of colorectal cancer [Ｊ]. Surg Oncol Clin N Am, 2006; 15(1): 39-49.
16.	Pomerri F, Maretto I, Pucciarelli S, et al. Prediction of rectal lymph node metastasis by pelvic computed tomography measurement [Ｊ]. Eur J Surg Oncol, 2009; 35(2): 168-173.
17.	Muthusamy VR, Chang KJ. Optimal methods for staging re-ctal cancer [Ｊ]. Clin Cancer Res, 2007; 13(22 Pt 2): 6877s-6884s.
18.	王瓊, 謝嶸, 張青云, 等. 結直腸癌患者血漿纖維蛋白原的檢測及其臨床意義 [Ｊ]. 中華腫瘤雜志, 2005; 27(9): 544-546.
19.	Costantini V, Zacharski LR. The role of fibrin in tumor metastasis [Ｊ]. Cancer Metastasis Rev, 1992; 11(3-4): 283-290.
20.	Palumbo JS, Potter JM, Kaplan LS, et al. Spontaneous he-matogenous and lymphatic metastasis, but not primary tumor growth or angiogenesis, is diminished in fibrinogen-deficient mice [Ｊ]. Cancer Res, 2002; 62(23): 6966-6972.
21.	Rickles FR, Hancock WW, Edwards RL, et al. Antimetastatic agents. Ⅰ. Role of cellular procoagulants in the pathogenesis of fibrin deposition in cancer and the use of anticoagulants and/or antiplatelet drugs in cancer treatment [Ｊ]. Semin Thromb Hemost, 1988; 14(1): 88-94.
22.	汪曉東, 張瓊文, 呂東昊, 等. 64排多層螺旋CT和血清淀粉樣蛋白A聯合評估結腸癌對手術方案選擇的影響 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(3): 232-237.
23.	汪曉東, 尹源, 陸玫竹, 等. 經直腸超聲聯合血清淀粉樣蛋白A術前評估中低位直腸癌與手術決策的隨機對照試驗 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(5): 404-409.
24.	吳俊華, 汪曉東, 高強, 等. 64排多層螺旋CT和血清淀粉樣蛋白A聯合評估下段直腸癌對手術方案選擇的影響 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(2): 156-161.
25.	汪曉東, 呂東昊, 宋歡, 等. 多模式術前評估系統對中低位直腸癌手術方案選擇的價值：一項隨機對照試驗 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(6): 487-492.

1. Lafreniere R. What’s new in general surgery: surgical oncology [Ｊ]. J Am Coll Surg, 2004; 198(6): 966-988.
2. 汪曉東, 宋歡, 呂東昊, 等. 術前聯合評估直腸上段癌與手術方案選擇的隨機對照試驗 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(4): 322-326.
3. Dworák O. Number and size of lymph nodes and node metastases in rectal carcinomas [Ｊ]. Surg Endosc, 1989; 3(2): 96-99.
4. Monig SP, Baldus SE, Zirbes TK, et al. Lymph node size and metastatic infiltration in colon cancer [Ｊ]. Lancet, 1986; 6(6): 579-581.
5. Karantanas AH, Yarmenitis S, Papanikolaou N, et al. Preoperative imaging staging of rectal cancer [Ｊ]. Dig Dis, 2007; 25(1): 20-32.
6. 汪曉東, 劉丹, 呂東昊, 等. 術前纖維蛋白原水平與結直腸癌病理分期的關系 [Ｊ]. 中華實用診斷與治療雜志, 2009; 23(7): 643- 645.
7. 汪曉東, 高強, 周小雁, 等. 多層螺旋CT聯合纖維蛋白原或血清淀粉樣蛋白A對直腸癌外科決策的隨機對照研究 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(7): 575-580.
8. Greene FL, Page DL, Fleming ID, et al Eds. AJCC cancer staging manual [M]. 6th ed. New York (NY): Springer Verlag, 2002: 113-124.
9. Kulinna C, Scheidler J, Strauss T, et al. Local staging of rectal cancer: assessment with double-contrast multislice computed tomography and transrectal ultrasound [Ｊ]. J Comput Assist Tomogr, 2004; 28(1): 123-130.
10. Grabbe E, Lierse W, Winkler R. The perirectal fascia: morphology and use in staging of rectal carcinoma [Ｊ]. Radiology, 1983; 149(1): 241-246.
11. Hodgman CG, MacCarty RL, Wolff BG, et al. Preoperative staging of rectal carcinoma by computed tomography and 0.15 T magnetic resonance imaging. Preliminary report [Ｊ]. Dis Colon Rectum, 1986; 29(7): 446-450.
12. Noji T, Kondo S, Hirano S, et al. Computed tomography evaluation of regional lymph node metastases in patients with biliary cancer [Ｊ]. Br J Surg, 2008; 95(1): 92-96.
13. Theoni RF. Colorectal cancer: cross-sectional imaging for st-aging of primary tumor and detection of local recurrence [Ｊ]. AJR Am J Roentgenol, 1991; 156(5): 909-915.
14. Matsuoka H, Nakamura A, Masaki T, et al. Preoperative staging by multidetector-row computed tomography in patients with rectal carcinoma [Ｊ]. Am J Surg, 2002; 184(2): 131-135.
15. McCormick JT, Gregorcyk SG. Preoperative evaluation of colorectal cancer [Ｊ]. Surg Oncol Clin N Am, 2006; 15(1): 39-49.
16. Pomerri F, Maretto I, Pucciarelli S, et al. Prediction of rectal lymph node metastasis by pelvic computed tomography measurement [Ｊ]. Eur J Surg Oncol, 2009; 35(2): 168-173.
17. Muthusamy VR, Chang KJ. Optimal methods for staging re-ctal cancer [Ｊ]. Clin Cancer Res, 2007; 13(22 Pt 2): 6877s-6884s.
18. 王瓊, 謝嶸, 張青云, 等. 結直腸癌患者血漿纖維蛋白原的檢測及其臨床意義 [Ｊ]. 中華腫瘤雜志, 2005; 27(9): 544-546.
19. Costantini V, Zacharski LR. The role of fibrin in tumor metastasis [Ｊ]. Cancer Metastasis Rev, 1992; 11(3-4): 283-290.
20. Palumbo JS, Potter JM, Kaplan LS, et al. Spontaneous he-matogenous and lymphatic metastasis, but not primary tumor growth or angiogenesis, is diminished in fibrinogen-deficient mice [Ｊ]. Cancer Res, 2002; 62(23): 6966-6972.
21. Rickles FR, Hancock WW, Edwards RL, et al. Antimetastatic agents. Ⅰ. Role of cellular procoagulants in the pathogenesis of fibrin deposition in cancer and the use of anticoagulants and/or antiplatelet drugs in cancer treatment [Ｊ]. Semin Thromb Hemost, 1988; 14(1): 88-94.
22. 汪曉東, 張瓊文, 呂東昊, 等. 64排多層螺旋CT和血清淀粉樣蛋白A聯合評估結腸癌對手術方案選擇的影響 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(3): 232-237.
23. 汪曉東, 尹源, 陸玫竹, 等. 經直腸超聲聯合血清淀粉樣蛋白A術前評估中低位直腸癌與手術決策的隨機對照試驗 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(5): 404-409.
24. 吳俊華, 汪曉東, 高強, 等. 64排多層螺旋CT和血清淀粉樣蛋白A聯合評估下段直腸癌對手術方案選擇的影響 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(2): 156-161.
25. 汪曉東, 呂東昊, 宋歡, 等. 多模式術前評估系統對中低位直腸癌手術方案選擇的價值：一項隨機對照試驗 [Ｊ]. 中國普外基礎與臨床雜志, 2009; 16(6): 487-492.

《中國普外基礎與臨床雜志》

纖維蛋白原聯合多層螺旋CT術前預測結直腸癌淋巴結轉移

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《中國普外基礎與臨床雜志》

纖維蛋白原聯合多層螺旋CT術前預測結直腸癌淋巴結轉移

摘要 全文 圖表 視頻 參考文獻 施引文獻 補充材料

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