<sup>18</sup>F-PSMA-1007 PET/CT与mp-MRI对前列腺癌的检测效能及与病理分级的相关性研究

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18F-PSMA-1007 PET/CT与mp-MRI对前列腺癌的检测效能及与病理分级的相关性研究

周云舒陈晓华陈志强张若弟刘世莉王卓张少茹李鹏李艳梅

Cite this article as: ZHOU Y S, CHEN X H, CHEN Z Q, et al. Study on the detection efficiency of 18F-PSMA-1007 PET/CT and mp-MRI in prostate cancer and its correlation with pathological grade[J]. Chin J Magn Reson Imaging, 2024, 15(2): 71-76, 96.本文引用格式周云舒, 陈晓华, 陈志强, 等. 18F-PSMA-1007 PET/CT与mp-MRI对前列腺癌的检测效能及与病理分级的相关性研究[J]. 磁共振成像, 2024, 15(2): 71-76, 96. DOI:10.12015/issn.1674-8034.2024.02.010.

摘要

[摘要] 目的探讨¹⁸氟标记前列腺特异性膜抗原-1007正电子发射计算机体层摄影（fluorine-18 prostate specific membrane antigen 1007-positron emission tomography/computed tomography, ¹⁸F-PSMA-1007 PET/CT）与多参数磁共振成像（multi-parameter magnetic resonance imaging, mp-MRI）单独及联合对前列腺癌（prostate cancer, PCa）的检测效能，并比较最大标准化摄取值（maximum standardized uptake value, SUVmax）、表观弥散系数（apparent diffusion coefficient, ADC）、SUVmax/ADC、T1、T2、质子密度（proton density, PD）值与PCa病理分级的相关性。材料与方法 回顾性分析我院2020年4月至2022年9月疑似PCa并拟行穿刺活检或手术的患者病例，最终50例患者被纳入研究，其中42例确诊PCa。按照国际泌尿病理协会（International Society of Urological Pathology, ISUP）分级共分为5组，包括中高级别组（分级≥4）25例和低级别组（分级1~3）17例，比较不同分组的SUVmax、ADC及SUVmax/ADC的差异。采用Spearman相关分析SUVmax、ADC、SUVmax/ADC、T1、T2、PD值之间的相关性及分别与ISUP分级的相关性。以病理为金标准，分析¹⁸F-PSMA-1007 PET/CT与mp-MRI单独及联合对前列腺良恶性的检测效能。绘制受试者工作特征（receiver operating characteristic, ROC）并计算曲线下面积（area under the curve, AUC）、敏感度和特异度，评价SUVmax、ADC、SUVmax/ADC及联合参数诊断效能，通过DeLong检验比较AUC间的差异。结果 PCa高级别组与低级别组的ADC值、SUVmax、SUVmax/ADC差异均有统计学意义（P均<0.001）。50例患者的ADC值与SUVmax呈负相关性（r＝-0.516，P<0.05），42例确诊PCa患者的ADC值与ISUP分级呈负相关（r＝-0.616，P<0.05），SUVmax、SUVmax/ADC与ISUP分级呈正相关（r＝0.549、0.639，P均<0.05）。20例完成定量磁共振图像编译（magnetic resonance image compilation, MAGiC）序列患者T1、T2、PD值与ISUP分级无相关性（r＝0.045、0.202、0.028，P均＞0.05）；T1、T2值与ADC值呈正相关（r＝0.616，r＝0.756，P均<0.05），PD值与ADC值呈负相关（r＝-0.506，P<0.05）。SUVmax与T1、T2、PD值没有明显相关性（r＝-0.132，r＝-0.422，r＝0.230，P均>0.05）。ROC曲线分析显示，SUVmax的AUC为0.940，差异有统计学意义（P<0.001），以7.80为临界值，诊断PCa的敏感度为83.33%，特异度为100.00%；ADC值的AUC为0.970，差异有统计学意义（P<0.001），以1.20×10^-3 mm²/s为临界值，诊断PCa的敏感度为95.24%，特异度为87.50%；SUVmax/ADC的AUC为0.970，差异有统计学意义（P<0.001），以6.43×10³为临界值，诊断PCa的敏感度为90.48%，特异度为100%；SUVmax和ADC联合的AUC为0.976，差异有统计学意义（P<0.001），以0.85为临界值，诊断PCa的敏感度为90.48%，特异度为100.00%。结论联合¹⁸F-PSMA-1007 PET/CT与mp-MRI可以提高对PCa的诊断效能；ADC值、SUVmax及SUVmax/ADC能够区分低危与中高危PCa。

[Abstract] Objective To explore the comparison of the detection efficacy of 18-fluoro-labeled prostate specific membrane antigen (¹⁸F-PSMA-1007) positron emission tomography (PET)/computed tomography (CT) and multi-parameter magnetic resonance imaging (mp-MRI) alone and combined with prostate cancer (PCa) and the correlation between maximum standardized uptake value (SUVmax), apparent diffusion coefficient (ADC), SUVmax/ADC, T1, T2, proton density (PD) value and pathological grade of PCa.Materials and Methods A retrospective analysis was made on 50 patients suspected of PCa who were scheduled to undergo biopsy or surgery in our hospital from April 2020 to September 2022, of which 42 cases were diagnosed with PCa. According to the International Society of Urological Pathology (ISUP), the patients were divided into 5 groups. According to ISUP classification, there were 25 cases in high grade group (≥4 grade) and 17 cases in low grade group (1-3 grade). The differences of SUVmax, ADC and SUVmax/ADC in different grade groups were compared. Spearman correlation analysis was used to analyze the correlation among SUVmax value, ADC value, SUVmax/ADC, T1, T2, PD value and ISUP classification. Taking pathology as the gold standard, the efficacy of ¹⁸F-PSMA-1007 PET/CT and mp-MRI alone or in combination in the detection of benign and malignant prostate was analyzed. The diagnostic efficacy of SUVmax, ADC, SUVmax/ADC and combined parameters was evaluated by drawing receiver operating characteristic (ROC) and calculating the area under the curve (AUC), sensitivity and specificity, and the differences of AUC values were compared by DeLong test.Results There were significant differences in ADC, SUVmax, SUVmax/ADC between high-grade group and low-grade group (all P<0.001). Correlation analysis showed that there was a negative correlation between ADC and SUVmax in 50 cases of prostate diseases (r=-0.516, P<0.05), a negative correlation between ADC and ISUP in 42 cases of diagnosed PCa (r=-0.616, P<0.05), and a positive correlation between SUVmax, SUVmax/ADC and ISUP (r=0.549, r=0.639, all P<0.05). Magnetic resonance image compilation (MAGiC) sequence was completed in 20 cases, in which T1, T2, PD values were not correlated with ISUP (r＝0.045, r=0.202, r=0.028, all P>0.05), T1 and T2 values were positively correlated with ADC (r＝0.616, r=0.756, all P<0.05), while PD values were negatively correlated with ADC (r=-0.506, P<0.05). There was no significant correlation between SUVmax and T1, T2, PD (r＝-0.132, r＝-0.422, r＝0.230, all P>0.05). ROC curve analysis showed that the AUC of SUVmax was 0.940 and the difference was statistically significant (P<0.001). With SUVmax=7.80 as the critical value, the sensitivity and specificity for the diagnosis of PCa were 83.33% and 100.00%, and the AUC of ADC was 0.970 and the difference was statistically significant (P<0.001). When ADC was 1.20×10^-3 mm²/s, the sensitivity and specificity for the diagnosis of PCa were 95.24% and 87.50%, respectively. The AUC of SUVmax/ADC combined diagnosis of PCa was 0.970, and the difference was statistically significant (P<0.001). With SUVmax/ADC=6.43×10³ as the critical value, the sensitivity and specificity of PCa diagnosis were 90.48% and 100.00%, respectively. The AUC of combining the two parameters was 0.976, and the difference was statistically significant (P<0.001). Taking 0.85 as the critical value, the sensitivity of diagnosing PCa was 90.48%, and the specificity was 100.00%.Conclusions The combination of ¹⁸F-PSMA-1007 PET/CT and mp-MRI can improve the diagnostic efficiency of PCa. ADC value, SUVmax and SUVmax/ADC can distinguish between low-risk and medium-high-risk PCa.

[关键词] 前列腺癌；前列腺特异度膜抗原；弥散加权成像；最大标准化摄取值；表观弥散系数；磁共振成像；肿瘤分级

[Keywords] prostate cancer；prostate specific membrane antigen；diffusion weighted imaging；maximum standardized uptake value；apparent diffusion coefficient；magnetic resonance imaging；neoplasm grading

作者信息

周云舒 ¹ 陈晓华 ¹ 陈志强 ^{2,
3*} 张若弟 ¹ 刘世莉 ¹ 王卓 ¹ 张少茹 ¹ 李鹏 ³ 李艳梅 ⁴

¹ 宁夏医科大学临床医学院，银川　750004

² 海南医学院第一附属医院放射科，海口　570102

³ 宁夏医科大学总医院放射科，银川　750004

⁴ 宁夏医科大学总医院核医学科，银川　750004

通信作者：陈志强，E-mail：zhiqiang_chen99@163.com

作者贡献声明：：陈志强设计本研究的方案，对稿件重要内容进行了修改；周云舒起草和撰写稿件，获取、分析和解释本研究的数据；张若弟、刘世莉、陈晓华、王卓、张少茹、李鹏、李艳梅获取、分析或解释本研究的数据，对稿件重要内容进行了修改；陈志强获得了宁夏回族自治区重点研发计划和宁夏自然科学基金项目的资助；全体作者都同意发表最后的修改稿，同意对本研究的所有方面负责，确保本研究的准确性和诚信。

出版信息

基金项目： 宁夏回族自治区重点研发计划项目 2019BEG03033 宁夏自然科学基金 2022AAC03472

收稿日期：2023-09-15

接受日期：2023-12-26

中图分类号：R445.2 R735.25

文献标识码：A

DOI: 10.12015/issn.1674-8034.2024.02.010

本文引用格式周云舒, 陈晓华, 陈志强, 等. 18F-PSMA-1007 PET/CT与mp-MRI对前列腺癌的检测效能及与病理分级的相关性研究[J]. 磁共振成像, 2024, 15(2): 71-76, 96. DOI:10.12015/issn.1674-8034.2024.02.010.

正文

0 引言

前列腺癌（prostate cancer, PCa）是老年男性泌尿生殖系统中常见的恶性肿瘤，并导致全球男性死亡率显著上升^[¹^,²^]。随着社会人口的老龄化加剧，PCa的发病率和死亡率呈逐年上升趋势，早期诊断PCa及对其准确分期在临床治疗方案选择、疗效及预后评估意义重大^[³^]。多参数磁共振成像（multi-parameter magnetic resonance imaging, mp-MRI）包括T2WI、弥散加权成像（diffusion weighted imaging, DWI）和动态对比增强MRI（dynamic contrast enhanced-MRI, DCE-MRI），已被引入作为诊断原发性前列腺病变的标准，并有助于指导前列腺活检^[⁴^,⁵^,⁶^]，然而，仍有12%~26%的PCa患者被遗漏^[⁷^]。以前列腺特异性膜抗原（prostate specific membrane antigen, PSMA）为分子靶点的PSMA正电子发射计算机体层摄影（positron emission tomography/computed tomography, PET/CT）技术近年来快速发展，并已被证实对PCa原发灶及复发灶均有很高的诊断效能^[⁸^,⁹^,¹⁰^,¹¹^]。PSMA PET/CT所获得的最大标准化摄取值（maximum standardized uptake value, SUVmax）临界值为5.30时可以区分临床显著性PCa和良性前列腺疾病^[¹²^]。此外，研究发现PET/CT获得的参数SUVmax和mp-MRI获得的参数表观弥散系数（apparent diffusion coefficient, ADC）与PCa的病理分级存在关联^[¹³^]。有学者将SUVmax/ADC作为诊断原发性PCa的分子成像生物标志物，发现可以潜在地改善DWI诊断PCa的低特异性^[¹⁴^]。也有研究发现，T2值和ADC值在区分PCa与非癌性病变中性能相当^[¹⁵^,¹⁶^]。mp-MRI与PSMA PET/CT联合应用越来越受到广泛关注^[¹⁷^,¹⁸^]，然而国内目前却鲜有研究，主要由于PSMA PET/CT普及率不高，各研究团队使用的PSMA PET/CT显像剂不同因而结果有所偏差。此外，该检查成本高，收费昂贵，且患者依从性差。但是，PSMA PET/CT拥有很好的潜力，有待进一步研究挖掘。本研究探索¹⁸F-PSMA-1007 PET/CT与mp-MRI单独及联合对PCa的诊断价值，并分析SUVmax、ADC、SUVmax/ADC、T1、T2、质子密度（proton density, PD）值与PCa病理分级的相关性，旨在探讨分别及联合两种影像学方法对PCa的诊断能力，使患者减少不必要的有创穿刺活检，分析相关参数是否可以预测PCa的病理分级，以有助于辅助临床诊疗。

1 材料与方法

1.1 研究对象

本研究回顾性收集我院2020年4月至2022年9月行mp-MRI和¹⁸F-PSMA-1007 PET/CT检查的前列腺疾病患者的临床、影像及病理资料。纳入标准：（1）均完成mp-MRI和¹⁸F-PSMA-1007 PET/CT检查；（2）组织病理学资料完整；（3）mp-MRI、¹⁸F-PSMA-1007 PET/CT检查时间间隔不超过1个月。排除标准：（1）检查前接受过任何手术和相关治疗；（2）图像质量差，影响感兴趣区（region of interest, ROI）的勾画；（3）病灶最大径<5 mm。

本研究遵守《赫尔辛基宣言》，经宁夏医科大学总医院医学伦理委员会批准，免除受试者知情同意豁免，批准文号：2018-339。

1.2 仪器与方法

mp-MRI检查采用GE SIGNA™ Architect 3.0 T MRI仪以及32通道相控阵表面线圈（美国GE公司）进行检查。扫描体位采取仰卧位，线圈中心对准耻骨联合上方5 cm处，扫描范围自耻骨联合至双侧髂血管分叉处。扫描序列包括T2WI、T1WI、DWI、DCE-MRI、定量磁共振图像编译（magnetic resonance image compilation, MAGiC）序列，各序列详细参数见表1。DCE-MRI共扫描64个时相（共5 min 12 s），于第2时相开始经肘静脉以2.5 mL/s的流速团注对比剂钆双胺（欧乃影，GE Healthcare AS），剂量0.5 mmol/kg，并以生理盐水20 mL冲管。

¹⁸F-PSMA PET/CT检查采用GE Discovery VCT PET/CT扫描仪。由日本住友HM-10回旋加速器生产¹⁸F，德国ABX公司提供PSMA-1007。嘱患者呈仰卧位，¹⁸F-PSMA-1007注射剂量为4.81 MBq/kg。注射后约60~90 min后行全身扫描，扫描范围从颅顶到股骨中段，扫描参数：管电压120 kV，自动调节管电流30~210 mA，螺距0.875，层厚3.75 mm。在相同范围内进行PET扫描，采用三维模式扫描，每个床位采集2.5 min，共采集7~9个床位。用CT对PET图像进行衰减校正，在麦迪克斯工作站进行图像重建和融合。

点击查看表格

表1 各扫描序列参数
Tab. 1 Parameters of each scanning sequence

1.3 图像处理

由两名放射科医师（分别为在前列腺诊断方面有3年经验的住院医师和6年经验的主治医师）对所有病灶的病理结果在与之对应的MRI图像上达成共识。mp-MRI上定义的病灶为图像上信号明显异常的病灶，PET/CT上主要病灶定义为图像中¹⁸F-PSMA高摄取的病灶。在ADW 4.7 READ View工作站上进行后处理，根据重建的ADC图像逐层勾画ROI并计算平均ADC值，并应特别注意避免肿瘤出血、坏死及钙化，同时将ROI匹配到工作站上MAGiC序列扫描的原始图像，勾画范围相似的ROI，软件自动生成3个单独的定量值：T1值、T2值、PD值。同样，由两名核医学科医师（分别为在前列腺诊断方面有3年经验的住院医师和5年经验的主治医师）对所有病灶的病理结果在与之对应的PET图像上达成共识，在工作站进行图像融合及诊断，对PCa病灶勾画三维感兴趣区（volume of interest, VOI)，并测量VOI内SUVmax。

1.4 统计学分析

统计学分析采用MedCalc和SPSS 26.0软件进行。对计量资料进行正态性检验，符合正态分布的以（x¯±s）表示，组间比较用Student's t检验；偏态分布以M（P25，P75）表示，组间比较用Mann-Whitney U检验。计数资料采用频数（率）表示。用Kendall-W协调系数检验两名放射科医师及两位核医学科医师测量数据的一致性。用Spearman相关系数观察每个参数与ISUP分级分组的相关性。采用受试者工作特征（receiver operating characteristic, ROC）曲线分析各参数对PCa的诊断效能，并比较各参数曲线下面积（area under the curve, AUC），计算出95％置信区间（confidence interval, CI）、最佳临界值以及相应的敏感度和特异度值。通过DeLong检验比较AUC间的差异。P<0.05为差异具有统计学意义。

2 结果

2.1 一般资料

50例PCa患者入组，年龄48~81（67.4±8.0）岁。根据病理结果分为PCa组（42例）和非PCa组（8例），非PCa组包括前列腺良性增生和（或）前列腺炎。42例PCa患者根据国际泌尿病理协会（International Society of Urological Pathology, ISUP）分级分为1级7例，2级2例，3级8例，4级11例，5级14例，高级别组（ISUP分级≥4级）25例和低级别组（ISUP分级1~3级）17例。两名放射科医师测量ADC、T1、T2、PD一致性很好（Kendall-W值分别为0.876、0.868、0.849、0.986，P均<0.05）。两名核医学科医师测量SUVmax的一致性很好（Kendall-W值为0.998，P<0.05）。

2.2 PCa高级别组和低级别组间ADC值、SUVmax、SUVmax/ADC的差异

PCa高级别组ADC值均低于低级别组，PCa高级别组SUVmax均高于低级别组，PCa高级别组SUVmax/ADC均高于低级别组。PCa高级别组和低级别组的ADC值、SUVmax、SUVmax/ADC差异有统计学意义（P均<0.001）（表2）。高级别组和低级别组的mp-MRI及¹⁸F-PSMA PET/CT和对应病理图见图1~2。20例行MRI MAGiC序列检查测得病灶T1值为1 200.50（1 108.00, 1 262.75）ms，T2值为75.50（73.25, 82.75）ms，PD值为58.50（47.00, 62.35）pu。

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图1 男，79岁，ISUP分级为高级别组患者。1A：mp-MRI示前列腺移行带大片状异常信号；1B：ADC图示对应位置为低信号，ADC=0.72×10^-3 mm²/s；1C：¹⁸F-PSMA PET/CT示局限性异常高摄取信号灶，SUVmax=11.30；1D：病理（HE ×100）结果为前列腺癌（Gleason评分4+4=8分，IUSP分级为4级）。
图2 男，66岁，ISUP分级为低级别组患者。2A：mp-MRI示前列腺外周带6～9点大片状异常信号；2B：ADC图示对应位置为低信号，ADC=0.77×10^-3 mm²/s；2C：¹⁸F-PSMA PET/CT示局限性异常高摄取信号灶，SUVmax=10.40；2D：病理（HE ×100）结果为前列腺癌（Gleason评分4+3=7分，IUSP分级为3级）。ISUP：国际泌尿病理协会；mp-MRI：多参数磁共振成像；ADC：表观弥散系数；¹⁸F-PSMA PET/CT：¹⁸氟标记前列腺特异性膜抗原-1007正电子发射计算机体层摄影；SUVmax：最大标准化摄取值。
Fig. 1 Male, 79 years old, a high-grade group of patients classified by the ISUP. 1A: Mp-MRI shows large patchy abnormal signal in the transitional zone of the prostate; 1B: ADC diagram shows that the corresponding position is low signal, ADC=0.72×10^-3 mm²/s; 1C: ¹⁸F-PSMA PET/CT shows localized abnormally high uptake signal focus, SUVmax=11.30; 1D: Pathological (HE ×100) result shows prostate cancer (Gleason score 4+4=8, IUSP grade 4).
Fig. 2 Male, 66 years old, a low-grade group of patients classified by the ISUP. 2A: Mp-MRI shows a large abnormal signal at 6-9 o'clock in the peripheral zone of the prostate; 2B: ADC diagram shows that the corresponding position is low signal, ADC=0.77×10^-3 mm²/s; 2C: ¹⁸F-PSMA PET/CT shows localized abnormally high uptake signal focus, SUVmax=10.40; 2D: Pathological (HE ×100) result shows prostate cancer (Gleason score 4+3=7, IUSP grade 3). ISUP: International Society of Urological Pathology; mp-MRI: multi-parameter magnetic resonance imaging; ADC: apparent diffusion coefficient; ¹⁸F-PSMA PET/CT:fluorine-18 prostate specific membrane antigen 1007-positron emission tomography/computed tomography; SUVmax: maximum standardized uptake value.

点击查看表格

表2 不同病理分组患者之间的ADC值、SUVmax、SUVmax/ADC比较
Tab. 2 Comparison of ADC values, SUVmax, and SUVmax / ADC levels between patients with different pathological groups

2.3 各参数与PCa病理分级相关性及各参数之间的相关性结果

相关性分析结果显示，50例前列腺疾病的ADC值与SUVmax呈负相关性（r＝-0.516，P<0.05），42例确诊PCa的ADC值与ISUP分级呈负相关（r＝-0.616，P<0.05），SUVmax、SUVmax/ADC与ISUP分级呈正相关（r＝0.549，r＝0.639，P均<0.05）（图3）。20例行MRI MAGiC序列检查的病例，高级别组与低级别组分别为11例和9例，T1、T2、PD值与ISUP分级没有明显相关性（r＝0.045，r＝0.202，r＝0.028，P均>0.05）；T1、T2值与ADC值呈正相关（r＝0.616，r＝0.756，P均<0.05），PD值与ADC值呈负相关（r＝-0.506，P<0.05），SUVmax与T1、T2、PD值没有明显相关性（r＝-0.132，r＝-0.422，r＝0.230，P均>0.05）。

点击查看大图

图3 SUVmax、ADC、SUVmax/ADC与ISUP分级分组的相关性。2A：SUVmax与ISUP呈正相关（P<0.05）；2B：ADC与ISUP呈负相关（P<0.05）；2C：SUVmax/ADC与ISUP呈正相关（P<0.05）。SUVmax：最大标准化摄取值；ADC：表观弥散系数；ISUP：国际泌尿病理协会。
Fig. 3 Correlation between SUVmax, ADC, SUVmax/ADC and ISUP grading group. 2A: SUVmax is positively associated with ISUP (P<0.05); 2B: ADC is negatively associated with ISUP (P<0.05); 2C: SUVmax/ADC is positively associated with ISUP (P<0.05). SUVmax: maximum standardized uptake value; ADC: apparent diffusion coefficient; ISUP: International Society of Urological Pathology.

2.4 SUVmax、ADC、SUVmax/ADC及联合SUVmax和ADC对PCa诊断效能的分析

ROC曲线（图4）结果显示：SUVmax、ADC值、SUVmax/ADC及联合两种参数的AUC分别为0.940、0.970、0.970、0.976，ADC值的诊断敏感度均高于SUVmax和SUVmax/ADC（P<0.001）。SUVmax、ADC值联合诊断PCa的AUC最高（表3）。

点击查看大图

图4 SUVmax、ADC、SUVmax/ADC独立及联合参数诊断前列腺癌的ROC曲线。SUVmax：最大标准化摄取值，ADC：表观弥散系数；ROC：受试者工作特征。
Fig. 4 ROC curves for independent and combined parameter diagnosis of prostate cancer using SUVmax, ADC, SUVmax/ADC. SUVmax: maximum standardized uptake value; ADC: apparent dispersion coefficient; ROC: receiver operating characteristic.

点击查看表格

表3 SUVmax、ADC、SUVmax/ADC及联合SUVmax和ADC诊断前列腺癌的ROC曲线分析结果
Tab. 3 Results of ROC curve analysis of SUVmax, ADC, SUVmax/ADC and combined with SUVmax and ADC in the diagnosis of prostate cancer

3 讨论

目前，较多国外研究显示⁶⁸Ga-PSMA-11 PET/CT在PCa分期、复发监测和预后方面表现出巨大的优势^[¹⁹^,²⁰^],也有部分报道显示⁶⁸Ga-PSMA-11联合mp-MRI诊断PCa效能明显提高，并且阴性预测值也明显提高^[²¹^]，但¹⁸F-PSMA-1007 PET/CT联合mp-MRI对PCa的诊断效能研究较少，本研究所用¹⁸F-PSMA-1007为国际最新推出的PET显像剂，其主要特点如下：（1）对比⁶⁸Ga较为局限的生产过程，¹⁸F标记可以进行产业化合成，理化性质更优，制备过程简单，产量高，适合规模性生产及批量使用；（2）临床前研究显示，¹⁸F-PSMA-1007相较于⁶⁸Ga-PSMA-11有更高的亲和力和内化率，表达PSMA的病灶可呈现出更为明显的放射性摄取；（3）¹⁸F-PSMA-1007通过肝胆排泄，具有较低的膀胱本底，显像前无须排尿，对于局部复发和输尿管及膀胱区域的病变的显示可能更具优势；（4）放射性同位素¹⁸F具有更长的物理半衰期，有利于集中生产和远距离配送^[²²^,²³^]。故本研究进一步探讨¹⁸F-PSMA-1007 PET/CT参数（SUVmax）与mp-MRI参数（ADC值）单独及联合对前列腺良恶性病变的检测效能，分析SUVmax、ADC值、T1值、T2值、PD值之间的相关性及与ISUP分级分组的相关性。结果显示联合两种影像学方法可以提高PCa的诊断效能；而ADC值、SUVmax、SUVmax/ADC在PCa的高级别组与低级别组中差异有统计学意义，预示着这些参数可以预测PCa的病理分级，并与预后相关。

3.1 ADC值、SUVmax、SUVmax/ADC在预测PCa病理分级中的价值

PSMA是一种Ⅱ型谷氨酸缩肽酶，在PCa细胞中的表达是正常细胞的100~1 000倍，肿瘤分化程度越差，侵袭性越高，PSMA表达水平越高。由于以上生物学特性，使PSMA成为较前列腺特异性抗原（prostate specific antigen, PSA）更具敏感性和特异性的PCa生物靶标^[⁹^,²⁴^-²⁵^]。本研究发现在PCa高级别组和低级别组间ADC值、SUVmax、SUVmax/ADC差异有统计学意义。SUVmax、SUVmax/ADC与ISUP分级分别呈正相关，而ADC值与ISUP分级呈负相关，与CHINNAPPAN等^[¹⁴^]结果一致。这也证实了ADC值、SUVmax、SUVmax/ADC在鉴别前列腺良恶性病变中的临床价值，而且随着PCa分级越差，ISUP评分越高，SUVmax、SUVmax/ADC指标越高，ADC越低，这种趋势可能预示其与预后相关。ADC值与ISUP分级呈负相关，主要由于肿瘤分化程度越低，肿瘤细胞增殖越多，正常间质组织越少，细胞外水分子弥散明显受限，肿瘤病灶DWI信号增高，ADC值降低^[²⁶^,²⁷^,²⁸^]。

3.2 T1、T2、PD值与ADC值、SUVmax及病理分级的相关性分析

本研究20例行MAGiC序列检查患者的T1、T2及PD值与ISUP分级没有显著相关性；T1、T2值与ADC值呈正相关，PD值与ADC呈负相关，ADC值与SUVmax呈负相关性。在HEPP等^[¹⁵^]的研究中，T2值对PCa和慢性前列腺炎的鉴别诊断准确率较高，与ADC值的表现相当，在一些研究中T2值与Gleason评分呈负相关^[²⁹^,³⁰^]，而在本研究中T2值与ISUP分级没有显著相关性，结果与KLINGEBIEL等^[³¹^]一致，差异的存在可能与研究者的样本组成不同有关，例如样本量、病灶位置选取及取值方法等，均会对研究结果产生影响。

3.3 mp-MRI、18F-PSMA PET/CT单独及联合对PCa的诊断效能

mp-MRI参数ADC诊断PCa的敏感度为95.24%，特异度为87.50%，与PARATHITHASAN等^[³²^]研究中的敏感度一致；¹⁸F-PSMA PET/CT诊断PCa敏感度为83.30%，特异度为100.00%；ADC值的AUC为0.97，SUVmax的AUC为0.94，因此尽管发现在特异度方面¹⁸F-PSMA PET/CT检查更有优势，但诊断效能并未优于mp-MRI，这与SOINNI等^[³³^]和ZHOU等^[³⁴^]的研究结果相似。在SOINNI的研究中，mp-MRI在诊断PCa的T分期中明显优于PSMA PET/CT，这是由于PCa局部侵犯的判断依赖于解剖细节的可视化，mp-MRI公认在更高的软组织对比度、更高的空间分辨率和多平面能力方面表现出比CT更显著的优势。然而，PSMA PET/CT由于组织对比度差，对前列腺内肿瘤的检测和定位在很大程度上依赖于PSMA PET信号。因此，病变定位高度依赖于扫描时使用的SUV视觉缩放阈值。在ZHOU等^[³⁴^]的研究中，发现mp-MRI在识别低危和中高危PCa方面比PSMA PET/CT表现出更好的敏感度（85.7% vs. 60.0%）。不可否认的是PSMA PET/CT在检测PCa向邻近组织、附近淋巴结和骨骼的弥散方面更准确^[³⁵^,³⁶^]。此外，SUVmax/ADC诊断PCa的AUC为0.97，敏感度为90.50%，特异度为100.00%，诊断效能与ADC值相似，与CHINNAPPAN等^[¹⁴^]得到的结果（AUC 0.966，敏感度87%，特异度98%）相似。联合ADC值和SUVmax诊断效能均优于ADC值、SUVmax及SUVmax/ADC，敏感度和特异度也较高，提示联合两种影像学检查方法能够相辅相成，提高诊断准确率^[³⁷^,³⁸^]。

3.4 本研究的不足

首先，样本量少，结论还需使用大样本进行验证；其次，由于SUVmax、ADC值和各个弛豫时间定量值是分别获得的，图像的精准匹配及测值存在客观的系统误差；最后，我们只关注前列腺内的病灶，没有对比两种检查方法对PCa周围侵犯及转移情况的检测能力，希望在以后的研究中继续扩大病例库进行深入分析。

4 结论

综上所述，联合¹⁸F-PSMA-1007 PET/CT与mp-MRI可以提高对PCa的诊断效能。ADC值、SUVmax及SUVmax/ADC能够区分低危与中高危PCa，可为临床决策提供相关依据。

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