Texture Analysis of Sequential Images of T2-weighted Imaging and Diffusion-weighted Imaging for Predicting the Efficacy of Chemoradiotherapy in Cervical Squamous Cell Carcinoma
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摘要:目的 探讨MRI检查T2加权成像(T2-weighted imaging, T2WI)及弥散加权成像(diffusion-weighted imaging, DWI)图像纹理参数与宫颈鳞状细胞癌放化疗疗效的相关性。方法 回顾性纳入2015年2月至2016年1月北京协和医院接受放化疗的宫颈鳞状细胞癌患者，并根据其预后分为疾病进展组和疾病稳定组。采用TexRAD软件对两组患者放化疗前T2WI、DWI序列图像进行纹理分析，得到空间尺度滤波器(spatial scale filter，SSF)半径值为2、4、6的图像纹理参数。比较两组患者图像纹理参数差异，采用多因素Cox回归分析图像纹理参数与宫颈鳞状细胞癌患者放化疗疗效的相关性。采用受试者工作特征(receiver operating characteristic, ROC)曲线分析各图像纹理参数预测宫颈鳞状细胞癌放化疗后疾病进展的性能。结果 共121例符合纳入和排除标准的宫颈鳞状细胞癌患者入选本研究。其中疾病进展组46例，疾病稳定组75例。T2WI序列图像中，疾病进展组与疾病稳定组患者的图像纹理参数均值(SSF2、SSF4、SSF6)、偏度(SSF2、SSF4)、熵(SSF4、SSF6)均有显著性差异(P均<0.05)；DWI序列图像中，疾病进展组与疾病稳定组患者的图像纹理参数均值(SSF2、SSF4、SSF6)、偏度(SSF4、SSF6)、峰度(SSF2、SSF4)均有显著性差异(P均<0.05)。多因素Cox回归分析结果显示，T2WI序列图像纹理参数均值(SSF2、SSF4、SSF6)及DWI序列图像纹理参数均值(SSF2、SSF6)、熵(SSF2、SSF4、SSF6)、偏度(SSF4、SSF6)与宫颈鳞状细胞癌放化疗疗效具有相关性(P<0.05)。ROC曲线分析结果显示，图像纹理参数均值(T2WI-SSF2、T2WI-SSF4、T2WI-SSF6、DWI-SSF2、DWI-SSF6)、偏度(DWI-SSF6)可预测宫颈鳞状细胞癌放化疗后的疾病进展，曲线下面积(area under the curve, AUC)为0.625~0.746。其中，均值(T2WI-SSF4)的预测效能最高(AUC：0.746)，其次为均值(T2WI-SSF2，AUC：0.725)、均值(T2WI-SSF6，AUC：0.703)。结论 基线MRI检查T2WI、DWI图像纹理参数与宫颈鳞状细胞癌放化疗疗效具有相关性，其均值、偏度可预测宫颈鳞状细胞癌放化疗后疾病进展，且以均值的预测效能最高。Abstract:Objective To investigate the correlation of the texture parameters of T2-weighted imaging (T2WI) and diffusion-weighted imaging (DWI) with the efficacy of chemoradiotherapy in cervical squamous cell carcinoma.Methods Patients with squamous cell carcinoma of the cervix that underwent chemoradiotherapy from February 2015 to January 2016 in Peking Union Medical College Hospital were included retrospectively, and were divided into the disease-progressive group and the disease-stable group according to their prognosis. Texture analysis of baseline T2WI and DWI images before chemoradiotherapy was carried out with Texrad software, and the texture parameters of spatial scale filter (SSF) with radius values of 2, 4 and 6 were obtained. The differences of texture parameters between the two groups were compared, and the correlation between the texture parameters and the curative of chemoradiotherapy in patients with cervical squamous cell carcinoma was analyzed by multivariate Cox regression. Receiver operating characteristic (ROC) curve was used to analyze the performance of texture parameters in predicting disease progression after chemoradiotherapy in patients with cervical squamous cell carcinoma.Results A total of 121 patients with squamous cell carcinoma of the cervix that met the inclusion and exclusion criteria were enrolled in this study. There were 46 cases in the disease-progressive group and 75 cases in the disease-stable group. In T2WI sequential images, there were significant differences in the texture parameters of means (SSF2, SSF4, SSF6), skewness (SSF2, SSF4), and entropy (SSF4, SSF6) between disease-progressive group and disease-stable group (all P < 0.05). In DWI sequential images, there were significant differences in the texture parameters of means (SSF2, SSF4, SSF6), skewness (SSF4, SSF6), and kurtosis (SSF2, SSF4) between the two groups (all P < 0.05). Multivariate Cox regression analysis showed that the texture parameter of means (SSF2, SSF4, SSF6) of T2WI and the texture parameters of means (SSF2, SSF6), entropy (SSF2, SSF4, SSF6) and skewness (SSF4, SSF6) of DWI were correlated with the efficacy of chemoradiotherapy in patients with cervical squamous cell carcinoma (P < 0.05). The Results of ROC analysis showed that the texture parameter of means (T2WI-SSF2, T2WI-SSF4, T2WI-SSF6, DWI-SSF2, DWI-SSF6) and skewness (DWI-SSF6) could predict the progression of cervical squamous cell carcinoma after chemoradiotherapy in patients with cervical squamous cell carcinoma. The area under the curve (AUC) was 0.625-0.746. Among them, the mean of T2WI-SSF4 was the most effective (AUC: 0.746), followed by the mean of T2WI-SSF2 (AUC: 0.725) and the mean of T2WI-SSF6 (AUC: 0.703).Conclusions The texture parameters of baseline T2WI and DWI sequences were correlated with the curative effect of chemoradiotherapy in patients with cervical squamous cell carcinoma. The parameters of means and skewness can predict the progression of cervical squamous carcinoma after chemoradiotherapy, and the mean has a higher predictive power.
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图 1 MRI检查DWI序列图像纹理分析示意图
A.病灶ROI内的DWI图像及SSF 2、4、6图像纹理参数示意图；B.SSF 0、2、3、4、5、6图像纹理参数分析结果示意图
DWI：弥散加权成像；ROI：感兴趣区；SSF：空间尺度滤波器表 1 疾病进展组与疾病稳定组T2WI序列图像纹理参数比较
纹理参数 疾病进展组(n=46) 疾病稳定组(n=75) P值 SSF2 均值 -10.49±39.80 23.18±44.64 0.000 标准差 196.55±146.14 176.52±79.19 0.330 熵 6.21±0.38 6.09±0.38 0.083 正性像素均值 136.49±111.75 141.71±67.66 0.749 偏度 -0.20±1.14 0.36±0.98 0.006 峰度 3.56±5.68 3.47±4.63 0.921 SSF4 均值 -77.20±114.50 15.93±87.27 0.000 标准差 274.70±209.93 228.59±115.02 0.121 熵 6.42±0.43 6.23±0.44 0.019 正性像素均值 158.35±131.36 179.13±134.13 0.406 偏度 -0.66±0.77 -0.21±0.91 0.007 峰度 1.94±1.93 1.95±2.29 0.990 SSF6 均值 -173.73±220.73 -38.99±138.36 0.000 标准差 357.91±295.41 280.95±144.38 0.058 熵 6.61±0.47 6.37±0.50 0.008 正性像素均值 193.85±189.00 190.23±152.54 0.908 偏度 -0.58±0.65 -0.49±0.80 0.511 峰度 0.75±1.09 1.09±2.04 0.233 T2WI：T2加权成像；SSF：同图 1 
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表 2 疾病进展组与疾病稳定组DWI序列图像纹理参数比较
纹理参数 疾病进展组(n=46) 疾病稳定组(n=75) P值 SSF2 均值 90.23±70.23 137.98±92.76 0.003 标准差 177.82±99.68 184.03±73.59 0.715 熵 5.42±0.67 5.35±0.52 0.544 正性像素均值 178.08±100.63 208.95±98.85 0.100 偏度 0.26±0.52 0.22±0.41 0.601 峰度 0.96±2.02 0.32±0.79 0.047 SSF4 均值 259.14±188.83 356.65±210.77 0.011 标准差 277.17±163.90 265.50±110.31 0.671 熵 5.58±0.67 5.46±0.56 0.265 正性像素均值 344.81±207.11 412.02±205.43 0.084 偏度 0.23±0.62 0.03±0.48 0.047 峰度 0.50±1.51 -0.01±0.70 0.036 SSF6 均值 428.56±288.62 544.30±273.42 0.029 标准差 302.58±179.16 290.13±115.29 0.675 熵 5.61±0.69 5.48±0.57 0.262 正性像素均值 487.95±293.02 576.29±265.70 0.090 偏度 0.12±0.49 -0.09±0.34 0.012 峰度 -0.08±0.88 -0.32±0.57 0.104 DWI、SSF：同图 1
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表 3 图像纹理参数与宫颈鳞癌放化疗后疾病进展相关性的Cox回归分析阳性结果
纹理参数 HR(95% CI) P值 T2WI-SSF2-均值 0.984(0.968~1.000) 0.045 T2WI-SSF4-均值 0.996(0.991~1.000) 0.044 T2WI-SSF6-均值 0.996(0.993~0.999) 0.019 DWI-SSF2-均值 0.959(0.935~0.983) 0.001 DWI-SSF2-熵 0.327(0.163~0.654) 0.002 DWI-SSF4-熵 0.462(0.257~0.831) 0.010 DWI-SSF4-偏度 1.897(1.019~3.531) 0.043 DWI-SSF6-均值 0.988(0.978~0.999) 0.033 DWI-SSF6-熵 0.488(0.275~0.867) 0.014 DWI-SSF6-偏度 3.882(1.755~8.587) 0.001 T2WI：同表 1；DWI、SSF：同图 1
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