主题：PET/CT在恶性肿瘤中的应用 -- 良金百辟
- 复 请问反对的理由
家园 您还是在继续纠结于临床试验的思路 日本人的无症状人群筛检指南－－不是说用于肿瘤患者的临床应用指南－－的理论基础就是错的，所以我才会说他们错了。
对于乳腺钼靶筛查乳腺癌，我并不反对。只是因为目前找不出更好的办法，并且足够便宜易用。如果PET－CT和钼靶筛查的阳性预测值一样，你选哪个？
AFP和宫颈涂片筛查就没啥争议呀。您当然可以争辩
家园 AFP用于什么癌症筛查呀/理论基础错在哪里 家园 肝癌呀 - 复 肝癌呀
家园 AFPy用于肝癌诊断 远非没有争议。何况肿瘤筛查 The sensitivity and specificity of AFP varied widely, and this could not be entirely attributed to the threshold effect
of the different cutoff levels used.
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(Am J Gastroenterol 2006;101:513–523)
Accuracy of Ultrasonography, Spiral CT, Magnetic Resonance, and Alpha-Fetoprotein in Diagnosing Hepatocellular Carcinoma: A Systematic Review
CME
Agostino Colli, M.D.,1 Mirella Fraquelli, M.D., Ph.D.,2 Giovanni Casazza, Ph.D.,3 Sara Massironi, M.D.,1
Alice Colucci, M.D.,1 Dario Conte, M.D.,2 and Piergiorgio Duca, M.D.3
1Department of Internal Medicine, Ospedale “A. Manzoni”, Lecco, 2Postgraduate School of Gastroenterology,
IRCCS Ospedale Maggiore, Milan, and 3Department of Clinical Sciences, Ospedale “L. Sacco”, Milan, Italy
BACKGROUND In patients with chronic liver disease, the accuracy of ultrasound scan (US), spiral computed AND AIM: omography (CT), magnetic resonance imaging (MRI), and alpha-fetoprotein (AFP) in diagnosing hepatocellular carcinoma (HCC) has never been systematically assessed, and present systematic review was aimed at this issue.
METHODS: Pertinent cross-sectional studies having as a reference standard pathological examinations of the explanted liver or resected segment(s), biopsies of focal lesion(s), nd/or a period of follow-up, were identified using MEDLINE, EMBASE, Cochrane Library, and CancerLit. Pooled sensitivity, specificity, and likelihood ratios (LR) were calculated using the random effect model. Summary receiver operating characteristic (SROC) curve and predefined subgroup analyses were made when indicated.
RESULTS: The pooled estimates of the 14 US studies were 60% (95% CI 44–76) for sensitivity, 97% (95% CI 95–98) for specificity, 18 (95% CI 8–37) for LR+, and 0.5 (95% CI 0.4–0.6) for LR; for the 10 CT studies sensitivity was 68% (95% CI 55–80), specificity 93% (95% CI 89–96), LR+ 6 (95% CI
3–12),and LR 0.4 (95% CI 0.3–0.6); for the nine MRI studies sensitivity was 81% (95% CI 70–91), specificity 85% (95%CI 77–93), LR+ 3.9 (95%CI 2–7), and LR 0.3 (95% CI 0.2–0.5). The sensitivity and specificity of AFP varied widely, and this could not be entirely attributed to the threshold effect of the different cutoff levels used.
CONCLUSIONS: US is highly specific but insufficiently ensitive to detect HCC in many cirrhotics or to support an
effective surveillance program. The operative characteristics of CT are comparable, whereas MRI is more sensitive. High-quality prospective studies are needed to define the actual diagnostic role of AFP.
家园 请搜索“汤钊猷” 还是老问题，您对适用人群的概念不清楚。
美国人群HBV感染率是多少？肝癌发病率是多少？
AFP筛查早期肝癌的原创性研究是我国科学家提出来的，初始研究在启东等地进行，那里肝癌发病率远高于发达国家。
- 复 请搜索“汤钊猷”
家园 看来您对系统回顾并不熟悉 Type of Participants：The review only examined studies including patients with chronic liver disease (i.e., cirrhosis or chronic hepatitis) assessed with the aim of detecting the possible presence of HCC.
建议您用这篇文章的纳入标准评价一下你看到的研究
另外，请指教： 某诊断指标的敏感度 特异度 与人群有关？
家园 您终于走上正确的轨道了！ 我很欣慰。这个思路很好。
您可以去看看我给的体检建议，对于AFP筛检给了什么样的前提，呵呵。
于是你可以继续追问为什么临床医生在所谓的SCI论文里经常会报道：在这个研究中，PET－CT的敏感度、特异度、阳性预测值、阴性预测值分别是blablablabla呢？
呵呵
家园 我很遗憾 一个有着不错的流行病学知识的人，不懂得尊重别人或是正常的交流。写的东西像是大学里的女生。不知道哪里来的优越感。
PET/CT对于肿瘤病人的特异性很高
阳性预测值3.3不是它不能用于筛检的借口
日本核医学会04年制定，07年修订的指南没有“理论基础上的错误”-自信心膨胀如此？
现在并没有获得公认的适合肝癌的筛查方案
AFP更远非没有争议
如果希望将来成为一位出色的临床流行病学的学者
应该了解一点临床知识；了解一点循证医学；不要过于迷信大学课堂。那里连如何评价文献都没有教明白。
忠言逆耳 不多说了。
- 复 我很遗憾
家园 您大可坚持您自己的那套“循证医学” 对于循证医学而言，所谓证据如何解释，您似乎并没有搞清楚。我在另一系列中已经充分说明了您的错误思路的本质--将一条概率链上某一环节的证据当作了可以放之四海而皆准的证据，有意无意地忘记结论推断的人群是在不停地变化。
说到系统回顾，临床医生发表的文献有多少发表偏倚？然后又有多少所谓的证据其实是充斥着这些发表偏倚的系统回顾？单个研究的内部有效性是怎么控制的？就靠你所学到的所谓的“系统回顾”法？至于说我所谓迷信大学课堂，并且连如何评价文献都不明白，这个么，呵呵，要不你拿一篇你发表的文章来我评给你看？
日本人很有趣，他们在技术手段上的应用远比其他地方激进，对所谓先进技术的迷恋程度远远高于其他地方，这从内镜的使用指南就可以看到。但从您提交的证据来看，您也是受日系影响颇深。但是希望您不要忘记，您可以保持您激进的风格，在循证医学中同样的证据的解读并非只有你心目中的那一种。
最后，请仔细看看您反复说的这句话
“PET/CT对于肿瘤病人的特异性很高
阳性预测值3.3不是它不能用于筛检的借口”
您能把您的结论及其成立的条件拆分一下么？您知道您这句话成立所需要的逻辑是什么呢？
前提1：PET/CT对于肿瘤病人的特异性很高
前提2：特异性高的方法适合用于筛检
前提3：筛检用于一般人群
前提4：一般人群是肿瘤病人人群
结论：PET/CT适用于一般人群筛检
最后，您非要说阳性预测值只有3.3%不低（我坚持认为这个很低，当然这个高低只是个人感觉，并不是您的错）一点不放，您错在以为阳性预测值与其他筛检方法差不多然后就证明PET/CT可以用了？副作用不考虑了？成本呢？筛检方法的标准到底是什么？有多少条筛选标准？要平时这么做诊断早被带教主任骂我顾头不顾腚骂死了。
您在嘲笑课堂的时候，却恰恰证明了您需要回学校重新系统地学习循证医学，以前那些半吊子的东西早已不堪用了。
最后那句还是留给您吧。
- 复 肝癌呀
家园 请教出处：印象里没读到过肝癌的筛查指南
家园 希望越大,失望越大
家园 不要轻易指摘某一个治疗指南出了原则性错误 因为一个医生 很难比一个国家的医生高明
PPV 3.3%很低吗？
New England Journal of medicine
Volume 356:1399-1409 April 5, 2007 Number 14
Influence of Computer-Aided Detection on Performance of Screening Mammography
外链图片需谨慎，可能会被源头改NCCN Guideline breast cancer screening and diagnosis
外链图片需谨慎，可能会被源头改
本帖一共被 1 帖 引用 (帖内工具实现)家园 那个说PET－CT能查心肌缺血的 你封禁了我对你的反对意见，就以为你是正确的了？
你该炒股炒股，该发财发财，那是你的专长，分享经验，我恭听指教。但在这个事情上，你的想法要害死人的。
家园 Meta analysis of PET in ICM Can J Cardiol. 2007 February; 23(2): 107–119.
CCS/CAR/CANM/CNCS/CanSCMR joint position statement on advanced noninvasive cardiac imaging using positron emission tomography, magnetic resonance imaging and multidetector computed tomographic angiography in the diagnosis and evaluation of ischemic heart disease – executive summary
Cardiac PET MPI interpretation should be carried out only by physicians and institutions with adequate training and experience.
Class I indications
Pharmacological MPI using PET for the diagnosis of CAD (diagnosis is intended for patients with intermediate pretest likelihood of disease) and/or risk stratification of patients who:
have nondiagnostic, noninvasive imaging tests, or when such a test does not agree with clinical diagnosis (Level B evidence);
may be prone to artifact that could lead to an equivocal result on another test, such as obese patients (Level B evidence);
are unable to exercise, or have left bundle branch block or ventricular pacing (Level B evidence).
Class IIa indications
Pharmacological MPI using PET for the diagnosis of CAD (diagnosis is intended for patients with intermediate pretest likelihood of disease) and/or risk stratification of patients who are able to exercise (Level B evidence);
For diagnosis and risk stratification of patients being considered for high-risk noncardiac surgery who have intermediate clinical risk predictors or mild clinical risk predictors with poor functional capacity (less than four metabolic equivalents) (Level B/C evidence).
Class IIb indications
Exercise PET using MPI for the diagnosis of CAD and/or risk stratification (Level B evidence);
Quantification of myocardial flow to determine the hemodynamic significance of a given coronary stenosis or to diagnose balanced multivessel disease (Level B/C evidence);
Quantification of myocardial flow to define impaired microvascular function (eg, syndrome X) (Level B/C evidence).
家园 del