系统活检联合弹性成像及彩虹灌注靶向活检对前列腺癌的诊断价值

doi:10.3877/cma.j.issn.1672-6448.2019.06.008

目的

探讨在系统活检的基础上联合实时弹性成像（RTE）及彩虹灌注成像（ITM）靶向活检对前列腺癌的诊断价值。

方法

选取2017年4月至2018年9月就诊于哈尔滨医科大学附属第一医院拟行前列腺穿刺活检的患者103例，所有患者均先行RTE靶向活检及ITM靶向活检，最后行超声造影（TRUS）引导下8针系统活检（SB）。对3种活检方法联合与单一SB的前列腺癌检出率进行比较，分别绘制最大组织应变值（PSI）、ITM可疑恶性区域与对侧区域达峰时间差、达峰强度差诊断前列腺癌的ROC曲线图，并对其诊断效能进行分析。

结果

103例患者中，3种活检方法联合共检出前列腺癌44例，RTE靶向活检、ITM靶向活检、SB分别检出35例、34例、30例。3种活检方法联合应用较单一SB多检出14例患者，在SB的基础上联合RTE及ITM靶向活检可提高前列腺癌的检出率（42.7% vs 29.1%，χ²=4.133，P=0.043）。根据RTE靶向活检病理结果分析，前列腺癌与非前列腺癌患者之间最大组织应变指数（PSI）差异具有统计学意义（t=3.234，P<0.05）。PSI诊断前列腺癌的ROC曲线下面积为0.756，当PSI为10.35时，其敏感度及特异度最高，分别为0.829、0.647。在ITM中，前列腺癌与非前列腺癌患者可疑区域的达峰时间、达峰强度、以及可疑区域与对侧区域的达峰时间差、达峰强度差均有统计学意义（t=-3.877、3.597、3.493、5.157，P均<0.05）。达峰时间差诊断前列腺癌的ROC曲线下面积为0.789，达峰时间差为6.055 s时，敏感度及特异度最高，分别为0.735、0.812；达峰强度差诊断前列腺癌的ROC曲线下面积为0.819，达峰强度差为18.16 dB时，敏感度及特异度最高，分别为0.647、0.928。

结论

在前列腺SB的基础上联合RTE及ITM靶向活检可提高前列腺癌的检出率，并且RTE及ITM技术对于前列腺癌具有一定的诊断价值。

关键词: 经直肠超声检查, 前列腺肿瘤, 弹性成像技术, 灌注成像, 活组织检查，针吸

Objectives

To evaluate the value of real-time elastography (RTE)-guided targeted biopsy and inflow time mapping (ITM)-guided targeted biopsy for the detection of prostate cancer on the basis of systemic biopsy (SB).

Methods

A total of 103 patients suspected of having prostate cancer were selected from April 2017 to September 2018 at the First Affiliated Hospital of Harbin Medical University. All patients underwent RTE-guided targeted biopsy and ITM-guided targeted biopsy before 8-core SB. The detection rates for prostate cancer were compared between the combination method and SB alone. The ROC curves of peak strain index (PSI), peak time difference, and peak intensity difference in ITM for the diagnosis of prostate cancer were plotted between the suspicious malignant area and its contralateral areas to evaluate the diagnostic efficacy.

Results

Among the 103 patients with suspected prostate cancer, 35, 34, and 30 patients were detected with prostate cancer by RTE-targeted biopsy, ITM, and SB, respectively. When combining the three biopsy methods together, 14 more patients were detected compared with SB alone. Adding RTE-targeted biopsy and ITM-targeted biopsy on the basis of SB can increase the detection rate of prostate cancer (42.7% vs 29.1%, χ²=4.133, P=0.043). According to the pathological results of RTE-targeted biopsy, there was a significant difference in PSI values between the benign and malignant lesions (t=3.234, P<0.05). Prostate cancer was detected with the highest sensitivity (82.9%) and specificity (64.7%) when using a PSI threshold value of≥10.35, and the area under the curve (AUC) value was 0.756. In ITM, the differences in peak time, peak intensity, peak time difference, and peak intensity difference were statistically significant between the benign and malignant lesions (t=-3.877, 3.597, 3.493, and 5.157, respectively; P<0.05). The AUC of the peak time difference for the diagnosis of prostate cancer was 0.789. When the peak time difference was 6.055 s, the sensitivity and specificity were the highest, which were 0.735 and 0.812, respectively. The AUC of the peak intensity difference for the diagnosis of prostate cancer was 0.819. When the peak intensity difference was 18.16 dB, the sensitivity and specificity were the highest, which were 0.647 and 0.928, respectively.

Conclusion

Adding RTE-targeted biopsy and ITM-targeted biopsy on the basis of SB can improve the detection rate of prostate cancer compared to conventional SB. RTE and ITM have appreciated value in the differentiation of benign and malignant lesions in the prostate.

Key words: Transrectal ultrasonography, Elasticity imaging techniques, Prostatic neoplasms, Perfusion imaging, Biopsy, needle

图1 患者，男性，58岁，前列腺体积约38.27 ml，前列腺特异性抗原（PSA）为13.03 μg/L。超声实时弹性成像（RTE）图示最大组织应变指数为5.69，左图中圆圈A表示感兴趣区即可疑恶性区域，圆圈B表示正常组织区域，靶向活检病理结果提示前列腺增生

图2 患者，男性，61岁，前列腺体积约22.25 ml，前列腺特异性抗原（PSA）为16.52 μg/L。超声实时弹性成像（RTE）图示最大组织应变指数为50.33，左图中圆圈A表示感兴趣区即可疑恶性区域，圆圈B表示正常组织区域，靶向活检穿刺病理结果提示前列腺癌，Gleason评分4＋4，侵及神经

图3 患者，男性，67岁，前列腺体积约110.37 ml，前列腺特异性抗原（PSA）为7.3 μg/L。超声彩虹灌注成像（ITM）图呈典型前列腺增生灌注模式，选取右侧叶内腺一快进区域作为可疑区域（红色圆圈所示），同时选取对侧正常组织为对称区域（黄色圆圈所示）；右图中红色曲线、黄色曲线分别代表可疑恶性区域与正常组织区域的达峰时间-强度曲线），靶向活检病理结果提示前列腺增生

图4 患者，男性，54岁，前列腺体积约11.60 ml，前列腺特异性抗原（PSA）为17.54 μg/L。图a为前列腺彩虹灌注成像（ITM）图，左侧外周带可见一快进高增强结节，选取其作为可疑区域（红色圈所示），同时选取对侧正常组织为对称区域（黄色圈所示）；图b为可疑恶性区域与对侧区域的时间-强度曲线（红色曲线与黄色曲线分别代表可疑恶性区域与正常组织区域的达峰时间-强度曲线），靶向活检穿刺病理结果提示前列腺癌，Gleason评分4＋4

图5 超声实时弹性成像最大组织应变值诊断前列腺癌的ROC曲线

图6 超声彩虹灌注成像可疑恶性区域与对称区域的达峰时间差值、达峰强度差值诊断前列腺癌的ROC曲线

表1 2组前列腺ITM患者的ROI1达峰时间、达峰强度以及ROI1与ROI2达峰时间差、达峰强度差比较（±s）

组别	例数	ROI1达峰时间（s）	ROI1与ROI2达峰时间差（s）	ROI1达峰强度（dB）	ROI1与ROI2达峰强度差（dB）
前列腺癌（靶向活检阳性）	34	27.07±4.56	7.55±4.19	69.38±10.89	20.34±10.04
非前列腺癌（靶向活检阴性）	69	32.58±5.75	4.12±3.34	59.13±10.52	7.37±4.69
t值	?	-3.877	3.597	3.493	5.157
P值	?	<0.05	<0.05	<0.05	<0.05

表1 2组前列腺ITM患者的ROI1达峰时间、达峰强度以及ROI1与ROI2达峰时间差、达峰强度差比较（±s）

组别	例数	ROI1达峰时间（s）	ROI1与ROI2达峰时间差（s）	ROI1达峰强度（dB）	ROI1与ROI2达峰强度差（dB）
前列腺癌（靶向活检阳性）	34	27.07±4.56	7.55±4.19	69.38±10.89	20.34±10.04
非前列腺癌（靶向活检阴性）	69	32.58±5.75	4.12±3.34	59.13±10.52	7.37±4.69
t值	?	-3.877	3.597	3.493	5.157
P值	?	<0.05	<0.05	<0.05	<0.05

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Value of systemic biopsy combined with real-time elastography and inflow time mapping-guided targeted biopsy in diagnosis of prostate cancer

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Value of systemic biopsy combined with real-time elastography and inflow time mapping-guided targeted biopsy in diagnosis of prostate cancer