摘要目的 探讨对比增强能谱乳腺X线摄影(CESM)对乳腺可疑钙化的诊断价值及其对外科治疗决策的影响.方法 收集2017年4月至2019年4月于常州市第一人民医院行CESM检查并在低能图上发现可疑钙化的94例患者(共103个病灶),均为女性,年龄26～89岁,平均年龄51岁.所有患者均经穿刺或手术获得病理结果.两名经验丰富的乳腺诊断放射科医师分别为低能图及CESM提出乳腺影像和报告系统(BI-RADS)分类,使用kappa检验评估两种影像BI-RADS分类的观察者间一致性.通过病理与影像的对照,使用受试者工作特征(ROC)曲线分析二者对乳腺可疑钙化的诊断效能,采用Z检验比较ROC曲线下面积(AUC),计算诊断敏感度、特异度.使用组内相关系数(ICC)评估恶性病灶的影像最大径与病理最大径的一致性.两名乳腺诊断放射科医师根据影像表现提供恶性病灶的首选外科治疗方式(保乳治疗或乳房切除),分别与最终的外科治疗方式进行比较,采用McNemars检验比较手术决策的差异.结果 103个病灶包括良性病灶49个,恶性54个.CESM BI-RADS分类的观察者间一致性高于低能图(0.86比0.74).低能图及CESM的敏感度为80.4％、96.2％,特异度为75.0％、94.0％,AUC分别为0.810、0.960,CESM的AUC显著＞低能图(Z=3.66,P＜0.01).低能图及CESM的病灶最大径与病理最大径的ICC分别为0.86、0.96.根据低能图,44.4％(24/54)的患者推荐行保乳治疗,55.6％(30/54)的患者推荐行乳房切除术,与最终外科治疗方式之间差异有统计学意义(P=0.008);根据CESM,27.8 ％(15/54)的患者推荐行保乳治疗,72.2％(39/54)的患者推荐行乳房切除,与最终外科治疗方式之间差异无统计学意义(P=0.125).结论 CESM对乳腺可疑钙化的诊断准确性较高,对病灶大小的评估较准确,为术前手术决策的制定提供了依据.

abstractsObjective To evaluate clinical value of suspicious calcification in the diagnosis and surgical treatment of breast lesions using contrast-enhanced spectral mammography.Methods Ninty-four patients who underwent CESM with suspicious calcification on the low-energy(LE) images in Third Affiliated Hospital of Soochow University from April 2017 to April 2019 were collected.All patients were female,with an average age of 51 years (26 to 89 years).All patients underwent biopsy or surgery to obtain pathological results.Two experienced radiologists provide BI-RADS classification for LE images and CESM.To assess pairwise agreement between BI-RADS classification on CESM and LE images among readers,kappa test were calculated.Using pathology results as the gold standard,the diagnostic efficacy of LE images and CESM were analyzed by receiver operating characteristic (ROC)curve,and Z test was used to compare the areas under the ROC curves (AUC) among them,calculated the sensitivity,specificity.The intraclass correlation coefficient (ICC) was used to analyze the consistency of the maximum image diameter and pathological diameter of malignant lesions.Two experienced radiologists provided the preferred surgical treatment (breast conservation therapy versus mastectomy) for all malignant cases according the imaging findings.McNemars test was used to compare the difference between surgical decision making and final surgical procedure.Results One hundred and three lesions were found in 94 patients,in which 49 were benign and 54 were malignant.Overall agreement on BI-RADS classification between LE imaging and CESM among readers was substantial (0.74 vs 0.86),CESM was higher than LE images.The sensitivity of LE images and CESM were 80.4％,96.2％,specificity was 75.0％,94.0％,AUC were 0.810,0.960 respectively.There was significant difference of the AUC between LE images and CESM (Z=3.66,P＜0.01).The ICC of malignant lesions measured on LE images and CESM and histopathological results were 0.86 and 0.96,respectively.Based on LE images,44.4％(24/54) of patients recommended BCT,55.6％(30/54) of patients recommended mastectomy,the difference was statistically significant (P=0.008).Based on CESM,27.8％(15/54) of patients recommended breast conservation therapy,72.2％(39/54) of patients recommended mastectomy,there was no significant statistically difference with the final surgical procedure (P=0.125).Conclusion CESM has a high diagnostic accuracy for suspicious calcification of breast.And its accuracy in assessing malignant lesion size is higher,which can provide a basis for preoperative surgical decision making.