폐색전증에서 나선형 컴퓨터 전산화 단층촬영의 관찰자간의 일치도에 관한 연구

A Study of Inter-observer Agreements of Spiral Chest Computed Tomography in Diagnosing Pulmonary Embolism

  • 김양기 (순천향대학교 내과학교실) ;
  • 이영목 (순천향대학교 내과학교실) ;
  • 김기업 (순천향대학교 내과학교실) ;
  • 어수택 (순천향대학교 내과학교실) ;
  • 김용훈 (순천향대학교 내과학교실) ;
  • 박춘식 (순천향대학교 내과학교실) ;
  • 황정화 (순천향대학교 방사선과학교실) ;
  • 김동훈 (순천향대학교 방사선과학교실) ;
  • 구동억 (순천향대학교 방사선과학교실) ;
  • 최득린 (순천향대학교 방사선과학교실)
  • Kim, Yang-Ki (Division of Respiratory & Allergy Medicine, Department of Internal Medicine, Soonchunhyang University, School of Medicine) ;
  • Lee, Young Mok (Division of Respiratory & Allergy Medicine, Department of Internal Medicine, Soonchunhyang University, School of Medicine) ;
  • Kim, Ki-up (Division of Respiratory & Allergy Medicine, Department of Internal Medicine, Soonchunhyang University, School of Medicine) ;
  • Uh, Soo-taek (Division of Respiratory & Allergy Medicine, Department of Internal Medicine, Soonchunhyang University, School of Medicine) ;
  • Kim, Yong Hoon (Division of Respiratory & Allergy Medicine, Department of Internal Medicine, Soonchunhyang University, School of Medicine) ;
  • Park, Choon Sik (Division of Respiratory & Allergy Medicine, Department of Internal Medicine, Soonchunhyang University, School of Medicine) ;
  • Hwang, Jung-Hwa (Department of Radiology, Soonchunhyang University, School of Medicine) ;
  • Kim, Dong Hun (Department of Radiology, Soonchunhyang University, School of Medicine) ;
  • Goo, Dong-Erk (Department of Radiology, Soonchunhyang University, School of Medicine) ;
  • Choi, Deuk-Lin (Department of Radiology, Soonchunhyang University, School of Medicine)
  • 투고 : 2005.07.28
  • 심사 : 2005.09.12
  • 발행 : 2005.11.30

초록

연구배경 : 폐색전증은 비특이적인 증상과 징후로 인해 진단이 지연될 수 있고 이로 인해 치명적인 결과를 가져 올 수 있으나 정확한 진단과 적절한 치료를 시행하는 경우 재발 및 사망의 경우가 흔치 않다. 폐색전증과 관련되어 나타나는 예방 가능한 사망의 대부분은 치료실패 보다는 진단이 지연되는 경우에서 기인하므로 보다 정확하고 빠른 검사법을 요구하게 되었다. 나선형 흉부 전산화 단층촬영은 혈전을 직접 관찰할 수 있고 이외의 부가적 진단이 가능하며 최근 multidetector-row spiral CT의 도입으로 중심 및 말초의 혈전도 더 정확한 진단이 가능해져 나선형 흉부 전산화 단층촬영술이 진단에 어느 정도의 신뢰성을 보이는지 비교, 연구하였다. 방 법 : 2002년 9월부터 2004년 9월까지 임상적 소견 및 나선형 흉부 전산화 단층촬영을 통해 폐색전증을 의심하거나 진단하였던 환자 64명을 대상으로 하였다. 진단시의 임상적 소견은 Wells 등의 "Rules for predicting the probability of embolism"을 기준으로 하여 평가하였다. 진단 당시 시행한 나선형 흉부 전산화 단층촬영 소견은 2명의 흉부 방사선과 의사가 독립적이고 맹검의 방식으로 각 병변의 해부학적 위치 및 진단적 근거에 대해 재판독을 시행하였다. 결 과 : 임상적 가능성에 대한 총 점수의 평균값은 $3.91{\pm}0.30$ (0-9)였고 저확률군은 9례, 중등도 확률군은 36례, 고확률군은 5례 였다. 관찰자간의 일치율은 주폐동맥에서 95.0%, 엽폐동맥에서 85.0%, 분절 폐동맥에서 91.2% 및 아분절 폐동맥에서 96.0%를 보였다. 두 관찰자 모두에서 음성소견을 보인 분지를 제외한 후의 일치율은 주폐동맥에서 76.2% (kappa 0.83), 엽폐동맥에서 57.6% (kappa 0.63), 분절 폐동맥에서 51.5% (kappa 0.63) 및 아분절 폐동맥에서 34.6% (kappa 0.49)를 보였다. 결 론 : 폐색전증이 의심되는 경우 진단에 일차적으로 이용되고 있는 나선형 흉부 전산화 단층촬영은 주폐동맥, 엽폐동맥 및 분절 폐동맥에서 관찰자간의 일치율이 높아 신뢰할 수 있는 검사법으로 비교적 신속하고 정확하나 아분절 폐동맥 이하의 작은 폐동맥은 진단적 오차가 커질 수 있다.

Background : A pulmonary embolism often presents with nonspecific symptoms and signs. However, a delayed diagnosis can result in catastrophic outcome. The majority of preventable deaths associated with a pulmonary embolism can be ascribed to a missed diagnosis rather than to the failure of existing treatments. Therefore, accurate and rapid diagnostic methods are essential for the management of a pulmonary embolism. The recent generation of multidetector-row spiral CT scanners appears to outperform other imaging modalities in detecting a central and peripheral pulmonary embolism. However, there are some variations in the interpretations of the findings between observers. This study examined the inter-observer differences of the diagnoses in patients with a pulmonary embolism. Method : 64 patients who were diagnosed with a pulmonary embolism either clinically or with spiral chest CT from 2002 to 2004, were included. Two thoracic radiologists interpreted the multidetector-row spiral CT in terms of the diagnosis of a pulmonary embolism and the location of the thrombus independently. Among 64 patients, 14 patients were excluded because there was no evidence of a pulmonary embolism or there was different interpretation of the pulmonary embolism between radiologists. A clinical diagnosis was based on "Rules for predicting the probability of embolism". Results : The mean score of the patients according to the Wells method was $3.91{\pm}0.30$ (0-9). The accordance of the radiologists was 95% in the main, 85% in the lobar, 91.2% in the segmental, and 96% in the sub-segmental pulmonary arteries. After excluding the negative interpretation from both radiologists, their agreement was 76.2%(${\kappa}.$ 0.83) in the main, 57.6%(${\kappa}.$ 0.63) in the lobar, 51.5%(${\kappa}.$ 0.63) in the segmental, and 34.6%(${\kappa}.$ 0.49) in the sub-segmental pulmonary arteries. Conclusion : Chest CT has been recently applied to patients suspected of having a pulmonary embolism. It was found that spiral CT is a rapid test for diagnosing a thrombus, and there was reliable accordance between the observers from the area of the large pulmonary arteries. However, there was a lack of agreement between the observers in diagnosing thrombi located distal to the sub-segmental arteries.

키워드

참고문헌

  1. Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis 1975;17:259-70 https://doi.org/10.1016/S0033-0620(75)80017-X
  2. Carson JL, Kelly MA, Duff A, Weg JG, Fulkerson WJ, Palevsky HI, et al. The clinical course of pulmonary embolism. N Engl J Med 1992;326:1240-5 https://doi.org/10.1056/NEJM199205073261902
  3. Fedullo PF, Tapson VF. The evaluation of suspected pulmonary embolism. N Engl J Med 2003;349:1247-56 https://doi.org/10.1056/NEJMcp035442
  4. Schoepf UJ, Goldhaber SZ, Costello P. Spiral computed tomography for acute pulmonary embolism. Circulation 2004;109:2160-7 https://doi.org/10.1161/01.CIR.0000128813.04325.08
  5. Ruiz Y, Caballero P, Caniego JL, Friera A, Olivera MJ, Tagarro D, et al. Prospective comparison of helical CT with angiography in pulmonary embolism: global and selective vascular territory analysis. Eur Radiol 2003; 13:823-9
  6. Wells PS, Ginsberg JS, Anderson DR, Kearon C, Gent M, Turpie AG, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998;129:997-1005 https://doi.org/10.7326/0003-4819-129-12-199812150-00002
  7. Han D, Lee KS, Franquet T, Muller NL, Kim TS, Kim HJ, et al. Thrombotic and nonthrombotic pulmonary arterial embolism: spectrum of imaging findings. Radiographics 2003;23:1521-39 https://doi.org/10.1148/rg.1103035043
  8. Khorasani R, Gudas TF, Nikpoor N, Polak JF. Treatment of patients with suspected pulmonary embolism and intermediate-probability lung scan: is diagnostic imaging underused? AJR Am J Roentgenol 1997;169: 1355-7 https://doi.org/10.2214/ajr.169.5.9353458
  9. Miniati M, Pistolesi M, Marini C, di Ricco G, Formichi B, Prediletto R, et al. Value of perfusion scan in the diagnosis of pulmonary embolism: results of the Prospective Investigative Study od Acute Pulmonary Embolism Diagnosis (PISA-PED). Am J Respir Crit Care Med 1996;154:1387-93 https://doi.org/10.1164/ajrccm.154.5.8912753
  10. Loud PA, Grossman ZD, Klippenstein DL, Ray CE. Combined CT venography and pulmonary angiography: a new diagnostic technique for suspected thromboembolic disease. AJR Am J Roentgenol 1998;170:951-4 https://doi.org/10.2214/ajr.170.4.9530042
  11. Cham MD, Yankelevitz DF, Shaham D, Shah AA, Sherman L, Lewis A, et al. Deep venous thrombosis: detection by using indirect CT venography. Radiology 2000;216:744-51 https://doi.org/10.1148/radiology.216.3.r00se44744
  12. Remy-Jardin M, Remy J, Deschildre F, Artaud D, Beregi JP, Hossein-Foucher C, et al. Diagnosis of pulmonary embolism with spiral CT: comparation with pulmonary angiography and scintigraphy. Radiology 1996;200:699-706 https://doi.org/10.1148/radiology.200.3.8756918
  13. Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systemic review. Ann Intern Med 2000;132:227-32 https://doi.org/10.7326/0003-4819-132-3-200002010-00009
  14. Schoepf UJ, Kessler MA, Reiger CT, Herzog P, Klotz E, Wiesgigl S, et al. Multislice CT imaging of pulmonary embolism. Eur Radiol 2001;11:2278-86 https://doi.org/10.1007/s003300100948
  15. Blachere H, Latrabe V, Montaudon M, Valli N, Cou􋹣 ffinhal T, Raherisson C, et al. Pulmonary embolism revealed on helical CT angiography: comparison with ventilation-perfusion scan radionuclide lung scanning. AJR Am J Roentgenol 2000;174:1041-7 https://doi.org/10.2214/ajr.174.4.1741041
  16. Patel S, Kazerooni EA, Cascade PN. Pulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT. Radiology 2003; 227:455-60 https://doi.org/10.1148/radiol.2272011139
  17. Ghaye B, Szapiro D, Mastora I, Delannoy V, Duhamel A, Remy J, et al. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis ? Radiology 2001;219:629-36 https://doi.org/10.1148/radiology.219.3.r01jn32629