乳腺癌MRI影像学特征及其与前哨淋巴结和腋窝淋巴结转移的关系.pdf

乳腺癌是目前临床中较为常见的严重危害女性身心健康的恶性肿瘤，在临床实践中有效实现乳腺癌的早诊断、早评估对指导临床治疗意义重大 1-2。有学者指出，临床中采用手术方案对乳腺癌患者治疗时术中腋窝淋巴结、腋窝淋巴结转移的清扫情况对患者远期预后评MRI features of breast cancer and their relationship with sentinel lymph node andaxillary lymph node metastasisLI Li1,LI Ruirui2,QIAN Chunrui3,MAI Wei41Department of Medical Imaging,4Department of Radiology,Haikou Maternal and Child Health Hospital,Haikou 570203,China;2Depart-ment of Radiology,the First Affiliated Hospital of Hainan Medical University,Haikou 570102,China;3Department of Radiology,Haikou Tra-ditional Chinese Medicine Hospital,Haikou 570216,China摘要：目的 分析乳腺癌MRI影像学特征及其与前哨淋巴结和腋窝淋巴结转移的关系。方法 选择我院2019年5月2022年5月收治的117例乳腺癌患者作为研究对象，其中前哨淋巴结结转移41例，腋窝淋巴结转移34例，无转移42例；对患者行乳腺癌MRI扫描检查；绘制ROC曲线分析诊断腋窝淋巴结转移和前哨淋巴结转移的价值。结果 乳腺癌前哨淋巴结转移、腋窝淋巴结转移患者MRI影像学检查的短长径比低于无转移者，相对表观扩散系数（rADC）值高于无转移，差异有统计学意义（P0.05）；乳腺癌前哨淋巴结转移、腋窝淋巴结转移和无转移患者环形强化情况的差异有统计学意义（P0.05）；乳腺癌MRI影像学特征联合应用预测前哨淋巴结模型为Log(P)=-0.602短长径比+0.675rADC-0.754环形强化+0.895；乳腺癌MRI影像学特征联合应用预测腋窝淋巴结转移模型为Log(P)=-0.685短长径比+0.712rADC-0.695环形强化+0.794；短长径比、rADC、环形强化三指标联合应用预测乳腺癌前哨淋巴结转移的AUC高于各指标单独应用，差异有统计学意义（P0.05）；短长径比、rADC、环形强化三指标联合应用预测腋窝淋巴结转移的AUC高于各指标单独应用，差异有统计学意义（P0.05）。结论 乳腺癌MRI影像学特征与前哨淋巴结和腋窝淋巴结转移高度相关，且MRI影像学特征联合应用可显著有效预测前哨淋巴结转移和腋窝淋巴结转移。关键词：乳腺癌；MRI影像学特征；前哨淋巴结转移；腋窝淋巴结转移Abstract:Objective To explore the MRI imaging features of breast cancer and its relationship with sentinel lymph node andaxillary lymph node metastasis.Methods A total of 117 patients with breast cancer admitted to our hospital from May 2019 toMay 2022 were selected as the study objects,including 41 patients with sentinel lymph node metastasis,34 with axillary lymphnode metastasis and 42 without metastasis.The patients underwent MRI scan for breast cancer.ROC curve was drawn toanalyze the diagnostic value of axillary lymph node metastasis and sentinel lymph node metastasis.Results Breast cancerpatients with sentinel lymph node metastasis and axillary lymph node metastasis had significantly lower ratio of ratio of shortdiameter to long diameter in MRI imaging than those without metastasis.The relative apparent diffusion coefficient(rADC)value was significantly higher than that without metastasis(P0.05).There were significant differences in ring enhancementbetween patients with sentinel lymph node metastasis,axillary lymph node metastasis and those without metastasis(P0.05).The prediction model of sentinel lymph node by combined application of MRI features of breast cancer was Log(P)=-0.602ratio of short diameter to long diameter+0.675rADC-0.754ring enhancement+0.895.The combined application of MRIfeatures to predict axillary lymph node metastasis was Log(P)=-0.685ratio of short diameter to long diameter+0.712rADC-0.695 ring enhancement+0.794.The combined application of ratio of short diameter to long diameter,rADC and ringenhancement in predicting the AUC of sentinel lymph node metastasis was significantly higher than that applied alone,andthe difference was statistically significant(P0.05).Combined application of ratio of short diameter to long diameter,rADCand ring enhancement was significantly higher in predicting axillary lymph node metastasis AUC than that applied alone,andthe difference was statistically significant(P0.05).Conclusion MRI imaging features of breast cancer are highly correlatedwith sentinel and axillary lymph node metastasis.The combined application of MRI imaging features can significantly andeffectively predict sentinel lymph node metastasis and axillary lymph node metastasis.Keywords:breast cancer;MRI imaging features;sentinel lymph node metastasis;axillary lymph node metastasis乳腺癌乳腺癌MRIMRI影像学特征及其与前哨淋巴结和腋窝淋巴结转移的影像学特征及其与前哨淋巴结和腋窝淋巴结转移的关关系系黎 莉1，李蕊蕊2，钱春蕊3，麦 微4海口市妇幼保健院1医学影像科，4放射科，海南 海口 570203；2海南医学院第一附属医院放射科，海南 海口570102；3海口市中医医院放射科，海南 海口 570216收稿日期：2023-01-05基金项目：海南省卫生计生行业科研项目（20A200399）作者简介：黎 莉，主治医师，E-mail:doi 10.12122/j.issn.1674-4500.2023.04.26分子影像学杂志,2023,46(4):724-730 724估具有十分重要的意义 3。研究表明，乳腺癌患者术中腋窝淋巴结、腋窝淋巴结转移的清扫效果较好患者其远期预后质量显著升高 4。前哨淋巴结及腋窝淋巴结转移作为系统性诊断和评估乳腺癌患者的重要参考指标，其有助于患者选择合适的治疗方式并评估预后质量；当前临床上评价和分析前哨淋巴结及腋窝淋巴结转移的金标准是淋巴结切除病理学检查，其作为侵入性操作，容易造成术后短期的血肿、伤口感染等相关并发症 5-7。而MRI作为广泛应用的评估乳腺癌患者临床状态的重要方法，其具有多序列、多参数等优势，可发现隐匿病灶，并可有效确定病变范围，从而提供大量病灶形态学信息。通过分析乳腺癌MRI影像学特征与前哨淋巴结及腋窝淋巴结转之间的关系，有助于医生评估乳腺癌患者病情以及预后质量，更好地为患者治疗提供帮助 8。目前临床中已经有研究分析发现乳腺癌患者的癌肿短径与长径之比越小，其腋窝淋巴结转移可能性越大；癌症肿块早期边缘强化率越大，腋窝淋巴结转移可能性越大，可以通过术前MRI检查分析乳腺癌患者是否发生淋巴结转移，但是关于乳腺癌MRI影像学特征与前哨及腋窝淋巴结转移的研究并不多见 9。本研究拟选择我院收治的乳腺癌患者作为研究对象，分析乳腺癌MRI影像学特征及其与前哨淋巴结和腋窝淋巴结转移的关系，为临床应用提供依据。1 资料与方法1.1 一般资料选择我院2019年5月2022年5月收治的117例乳腺癌患者作为研究对象，其中前哨淋巴结转移41例，腋窝淋巴结转移34例，无转移42例，患者年龄2681（47.937.49）岁。纳入标准：原发性乳腺癌；在我院接受规范化手术切除方案治疗，并经病理学检查确诊前哨淋巴结结转移或腋窝淋巴结转移；纳入前未接受新辅助治疗；有完整的病理学检查报告。排除标准：复发转移乳腺癌；术前行新辅助治疗；未行术前乳腺MRI检查；仅行肿块姑息切除；合并其他恶性肿瘤病史。本研究经我院伦理委员会审议并批准，全部患者均知情同意，并签署知情同意书（伦理审批号：201904017）。1.2 方法采用飞利浦Multiva1.5T MR对患者进行扫描检查，采用乳腺专用线圈，患者检查时取俯卧位，头、肩部及腹部垫高，且上举双臂，乳房自然悬垂，保持乳房与乳腺线圈紧贴且对称。扫描部位包括乳房和腋窝，采用Gd-DTPA作为对比剂，注射速率2.5 mL/s，剂量 0.2mmol/kg，后注射生理盐水20 mL。扫描序列：横轴位压脂T2WI序列：TE 65 ms，TR 2930 ms，矩阵512512，反转角90，层厚5.0 mm，FOV 340 mm340 mm，图像数共 26 层，层间隔 1 mm，扫描时间 3 min。横轴位T2WI：TE 10 ms，TR 540 ms，矩阵512512，反转角90，层厚5.0 mm，FOV 340 mm340 mm，图像数共26层，层间隔1 mm，扫描时间3 min。DWI序列：TE 82ms，TR 5650 ms，b=0,600 s/mm2，矩阵172169，反转角90，层厚5.0 mm，FOV 340 mm340 mm，图像数共26层，层间隔1 mm，扫描时间3 min。动态增强扫描TE3.4 ms，TR 7.0 ms，矩阵512512，反转角10，FOV 340mm340 mm，共扫描10个时相，每时相100层。1.3 图像及后处理将检测数据传输至专用工作站，利用配套后处理软件行数据分析，所有数据均由2位5年以上工作经验的主任医师对数据进行处理和分析。数据采集包括乳腺肿块位置、环形强化、短长径比、时间-信号强度曲线（TIC）、相对表观扩散系数（rADC）、表观扩散系数（ADC）等，选择划定ROI后显示病变区域的最大和最佳层面，避免坏死、出血区域，依照TIC动态增强曲线分为渐进型（I型）、平台型（型）和廓清型（型）3种。1.4 统计学分析采用SPSS20.0软件进行统计学分析，计数资料以n(%)表示，组间差异的比较行卡方检验；计量资料以均数标准差表示，组间差异的比较行LSD-t检验和方差分析；采用Logistic回归模型分析多指标联合应用预测乳腺癌患者前哨淋巴结转移和腋窝淋巴结转移的价值，绘制ROC曲线分析诊断腋窝淋巴结转移和前哨淋巴结转移的价值。以P0.05），乳腺癌前哨淋巴结转移、腋窝淋巴结转移患者MRI影像学检查的短长径比低于无转移者，rADC 值高于无转移患者，差异有统计学意义（P0.05），乳腺癌前哨淋巴结转移、腋窝淋巴结转移和无转移患者环形强化情况的差异有统计学意义（P0.05，表2）。2.3 乳腺癌MRI影像学特征联合应用预测前哨淋巴结模型乳腺癌MRI影像学特征联合应用预测前哨淋巴结模型为Log(P)=-0.602短长径比+0.675rADC-0.754环形强化+0.895（表3）。http:/www.j-分子影像学杂志,2023,46(4):724-730 725表1 各组乳腺癌MRI影像学特征调查结果Tab.1 Investigation results of MRI imaging features of breast cancer in each group(MeanSD)GroupSentinel lymph node metastasis(n=41)Axillary lymph node metastasis(n=34)No transfer(n=42)FPMaximum diameter(cm)2.210.412.190.392.040.421.2010.759Ratio of short diameterto long diameter0.750.050.730.070.860.085.6540.001ADC(10-3mm2/s)0.650.080.630.100.620.090.7540.839rADC(10-1)5.891.025.750.963.840.945.3210.001ADC:Apparent diffusion coefficient;rADC:Relative apparent diffusion coefficient.图1 患者女，30岁，发现右乳肿块1月余Fig.1 Female patient,30 years old,right breast mass discovered for over a month.MRI showed irregular masses in the rightupper and outer breast quadrants,with shallow lobulation and no obvious burrs at the edges.T2WI showed high signal intensity(A,B),DWI showed slightly high signal intensity(C),with an ADC value of approximately 1.0910-3mm2/s(D).Dyn THRIVEdynamic enhancement scan shows significant enhancement like masses(E,F),TIC time signal intensity curve showed a plateautype(G),and the right armpit shows slight enlargement of lymph nodes.Surgical pathology:infiltrating carcinoma of the rightbreast.ABCDEFGH2.4 乳腺癌MRI影像学特征联合应用预测腋窝淋巴结转移模型乳腺癌MRI影像学特征联合应用预测腋窝淋巴结转移模型为Log(P)=-0.685短长径比+0.712rADC-0.695环形强化+0.794（表4）。2.5 乳腺癌MRI影像学特征预测前哨淋巴结转移的诊断价值短长径比、rADC、环形强化3指标联合应用预测乳腺癌前哨淋巴结转移的AUC高于各指标单独应用，差异有统计学意义（P0.001，表5、图4）。2.6 乳腺癌MRI影像学特征预测腋窝淋巴结转移的诊断价值短长径比、rADC、环形强化3指标联合应用预测腋窝淋巴结转移的AUC明显高于各指标单独应用，且差异存在统计学意义（P0.001，表6、图5）。3 讨论乳腺癌前哨淋巴结转移和腋窝淋巴结转移情况是目前临床中对乳腺癌患者进行系统性诊断和评估的重要参考指标，系统性的评估和分析有助于临床中的治疗方式选择、临床分期判断以及预后质量评估，对患者的临床救治提供全面的系统性数据资料 10-11。目前临床上的淋巴结切除后取出病理组织检查并发症较多，可能导致患者出现术后短期的血肿、伤口感染等并发症，部分患者甚至可能出现同侧感觉异常和手臂淋巴结水肿等并发症 12。术前有效且正确评估患者哨淋巴结转移和腋窝淋巴结转移情况具有十分重要的意义 13-14。磁共振技术在目前临床中广泛应用的评估乳腺癌患者病情的重要方法，研究显示，乳腺癌患者病理表现与MRI表现高度相关，生物学及腋窝淋巴结转移间的关系也可采用免疫组织技术和磁共振进行检查，有助分子影像学杂志,2023,46(4):724-730http:/www.j- 726EFA1A2B1B2C1C2C4C3B4B3A4A3D1D2D3D4图2 患者女，34岁，发现右乳肿物1月余Fig.2 Female patient,34 years old,right breast mass discovered for over a month.MRI showed multiple patchy andnodular shadows in the right lateral breast quadrant,with high/slightly high signal intensity(B)on T2WI,uneven highsignal intensity(C)on DWI,and decreased ADC signal intensity(D),with a value of approximately 0.9810-3mm2/s.DynTHRIVE dynamic enhancement scan showed significant uneven enhancement(A),and the TIC time signal intensity curveshowed a plateau(E).The right armpit showed slight lymph node enlargement(F).Surgical pathology:infiltrating ductalcarcinoma of the right breast,grade 3,with cancer metastasis seen in the right axillary sentinel lymph node.ABCDEF图3 患者女，50岁，发现右乳肿物1周Fig.3 Female patient,50 years old,right breast mass discovered for 1 week.MRI showed an abnormal signal mass in thelateral quadrant of the right breast,which was lobulated and has burrs on the edge.T2WI showed slightly high signal(A),DWI showed high signal(C),ADC diffusion was limited(D).Dynamic enhancement scan showed significant unevenenhancement(B),and the dynamic enhancement curve showed an outflow type(E).An enlarged lymph node(F)was seenin the right axilla.Surgical pathology:non-specific infiltrating carcinoma of the right breast;Cancer metastasis could beseen in the right armpit.http:/www.j-分子影像学杂志,2023,46(4):724-730 727表2 患者肿块位置、强化及TIC指标调查结果Tab.2 Results of tumor location,enhancement and TIC indexes(n)GroupSentinel lymph node metastasis(n=41)Axillary lymph node metastasis(n=34)No transfer(n=42)2PLocation of the massOutside1915220.6370.959Inside141212Mammary areola878Ring signYes16133215.1960.001No252110TIC1413223.7430.442221818532TIC:Time-signal intensity curve.IndexRatio of short diameter to long diameterrADCRing enhancementConstant termb-0.6020.675-0.7540.895SE0.1830.2250.2090.232210.8229.00013.01514.882P0.0010.0030.0010.001OR0.5481.9640.4702.44795%CILower limit0.3831.2640.3121.553Upper limit0.7843.0530.7093.856表3 乳腺癌MRI影像学特征联合应用预测前哨淋巴结模型Tab.3 Breast cancer MRI imaging features combined with predictive sentinel lymph node model.IndexRatio of short diameter to long diameterrADCRing enhancementConstant termb-0.6850.712-0.6950.794SE0.2010.1980.1870.203211.61412.93113.81315.299P0.0010.0010.0010.001OR0.5042.0380.4992.21295%CILower limit0.3401.3830.3461.486Upper limit0.7473.0040.7203.293表4 乳腺癌MRI影像学特征联合应用预测腋窝淋巴结转移模型Tab.4 Breast cancer MRI imaging features combined with application to predict axillary lymph node metastasis modelIndexRatio of short diameter to long diameterrADCRing enhancementConstant termAUC0.8730.8560.8940.975SE0.0370.0410.0370.018P0.0010.0010.0010.00195%CILower limit0.7990.7750.8220.940Upper limit0.9460.9370.9661.000表5 乳腺癌MRI影像学特征预测前哨淋巴结转移的价值Tab.5 Value of MRI imaging features of breast cancer in predicting sentinel lymph node metastasis1.00.80.60.40.20.00.00.20.40.60.81.01-SpecificitySensitivityShort and long diameter ratiorADCRing enhancementCombination图4 乳腺癌MRI影像学特征预测前哨淋巴结诊断的ROCFig.4 ROC of sentinel lymph node diagnosis predictedby MRI imaging characteristics of breast cancer.分子影像学杂志,2023,46(4):724-730http:/www.j- 728于检查和评估乳腺癌患者病情，有助于评估患者预后质量 15-16。MRI扫描检查具有多序列、多方位、多参数、多功能的优势，采用该方案对患者进行扫描检查可有效提供大量病灶形态学信息，有助于分析组织病理生理学特征和血液流动力学特征 17。因此临床通过术前MRI扫描检查以无创性方案对患者进行扫描检查以评估患者前哨淋巴结和腋窝淋巴结转移情况，具有十分重要的意义 18。本组研究结果显示，乳腺癌前哨淋巴结转移、腋窝淋巴结转移和无转移患者MRI影像学检查的最大径、ADC、肿块位置、TIC的差异无统计学意义，乳腺癌前哨淋巴结转移、腋窝淋巴结转移患者MRI影像学检查的短长径比低于无转移者，rADC值高于无转移，且患者环形强化情况的差异有统计学意义。有研究分析了216例乳腺癌患者磁共振影像特征与腋窝淋巴结转移的相关性，结果发现腋窝淋巴结转移患者的肿瘤长径较大，ADC值较低，多发病灶比例更高，位置以外上象限居多 19，这与本研究存在一定的差异，可能是因为本研究选取的病例较少，导致结果存在差异。有研究分析了乳腺癌多模态MRI表现在评价前哨淋巴结是否转移的临床应用价值，结果发现，乳腺癌原发肿瘤的位置，短长径比，是否环形强化及rADC值与前哨淋巴结的转移存在一定关系 20，这与本研究的结果相似。本研究Logistic回归模型分析显示，乳腺癌MRI影像学特征联合应用预测前哨淋巴结转移和腋窝淋巴结转移模型分别为Log(P)=-0.602短长径比+0.675rADC-0.754环形强化+0.895和Log(P)=-0.685短长径比+0.712rADC-0.695环形强化+0.794。通过绘制ROC曲线分析MRI影像学特征联合应用预测患者前哨淋巴结转移和腋窝淋巴结转移的AUC高于各指标单独应用。这提示短长径比、rADC以及环形强化联合诊断在预测患者前哨淋巴结转移和腋窝淋巴结转移中价值较高。分析认为，乳腺癌患者出现前哨淋巴结转移和腋窝淋巴结转移的MRI扫描检查表现出现早期强化模式和边缘特征，出现转移患者检查时主要表现为毛刺状与不规则占比较多，未出现转移患者影像学检查则以光滑IndexRatio of short diameter to long diameterrADCRing enhancementJoint applicationAUC0.8600.8760.8670.973SE0.0440.0400.0410.017P0.0010.0010.0010.00195%CILower limit0.7740.7980.7870.939Upper limit0.9460.9540.9471.000表6 乳腺癌MRI影像学特征预测腋窝淋巴结转移的诊断价值Tab.6 Value of MRI imaging features of breast cancer in predicting axillary lymph node metastasis.Short and long diameter ratiorADCRing enhancementCombination1.00.80.60.40.20.00.00.20.40.60.81.01-SpecificitySensitivity图5 乳腺癌MRI影像学特征预测腋窝淋巴结转移诊断的ROCFig.5 MRI imaging characteristics of breast cancer predictthe ROC of axillary lymph node metastasis diagnosis.http:/www.j-分子影像学杂志,2023,46(4):724-730 729表现为主。本组研究结果显示，乳腺癌患者行MRI扫描检查时若出现前哨淋巴结和腋窝淋巴结转移则多呈现明显的淋巴结腋窝转移，肿瘤区域呈现不规则状，患者由于周围肿瘤浸润生长能力强。若患者合并存在腋窝淋巴结转移则表现快速强化，无转移中以中度强化为主。出现腋窝淋巴结转移和前哨淋巴结转移患者主要表现与肿瘤血供程度高度相关 21。肿瘤血供程度越高越丰富，结构特异性相对大，肿瘤恶性程度高，因此出现转移几率更高。rADC可有效评估磁场作用下水分子的微观运动，细胞外空间小，恶性肿瘤细胞组织细胞密度高，且可能受限于大分子对水的吸附和细胞生物膜限制，导致细胞内水分子运动受限，进而导致rADC值降低。综上所述，乳腺癌MRI影像学特征与前哨淋巴结和腋窝淋巴结转移高度相关，且MRI影像学特征联合应用可显著有效预测前哨淋巴结转移和腋窝淋巴结转移。但本研究临床样本数较低，有待后续深入研究和追踪。参考文献：1 Ou XC,Zhu JB,Qu YM,et al.Imaging features of sentinel lymphnodemappedbymultidetector-rowcomputedtomographylymphography in predicting axillary lymph node metastasis J .BMC Med Imaging,2021,21(1):193.2 Song BI.A machine learning-based radiomics model for theprediction of axillary lymph-node metastasis in breast cancer J .Breast Cancer,2021,28(3):664-71.3 Ren T,Lin S,Huang P,et al.Convolutional neural network ofmultiparametric MRI accurately detects axillary lymph nodemetastasisinbreastcancerpatientswithpreneoadjuvantchemotherapy J .Clin Breast Cancer,2022,22(2):170-7.4 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