本文選題：子宮頸癌 + 磁共振成像��； 參考：《第二軍醫(yī)大學(xué)》2017年碩士論文

【摘要】：宮頸癌是發(fā)病率最高的婦科惡性腫瘤,與其他婦科癌癥采用手術(shù)-病理分期不同,宮頸癌至今仍采用臨床分期,即通過盆腔檢查來確定腫瘤進(jìn)展情況。臨床分期是決定治療方案的關(guān)鍵。然而,盆腔檢查主觀性強(qiáng),常導(dǎo)致分期不準(zhǔn)確,錯(cuò)誤的分期不利于最佳治療方案的選擇。隨著醫(yī)學(xué)影像技術(shù)的發(fā)展,臨床醫(yī)生借助CT、MRI、PET/CT協(xié)助宮頸癌治療前的評(píng)估已十分普遍。MRI因其優(yōu)秀的軟組織分辨率、多參數(shù)、多方位成像模式,在協(xié)助宮頸癌的臨床分期上有著天然優(yōu)勢(shì)。同時(shí)MRI在檢查費(fèi)用以及推廣程度上較PET/CT更具優(yōu)勢(shì),因此被認(rèn)為是評(píng)估宮頸癌的最佳影像學(xué)手段。在MRI各序列中,T1加權(quán)像(T1 weighted image,T1WI)及T2加權(quán)像(T2weighted image,T2WI)是評(píng)價(jià)宮頸癌分期的常用序列。T1WI主要顯示盆腔解剖。T2WI在區(qū)分腫瘤與正常組織方面更具優(yōu)勢(shì),是評(píng)估宮頸癌的主要序列。但常規(guī)MRI在實(shí)際運(yùn)用中仍有諸多不足:受分辨率限制,常規(guī)MRI難以發(fā)現(xiàn)宮頸癌早期病變,而且即使發(fā)現(xiàn)腫塊亦無法明確其良惡性質(zhì)。因此多種磁共振成像新技術(shù)應(yīng)運(yùn)而生。據(jù)國外文獻(xiàn)報(bào)道,通過磁共振參數(shù)調(diào)整,設(shè)置小FOV后T2WI分辨率將明顯提高,即所謂的高清MRI。目前國內(nèi)將該磁共振成像方法運(yùn)用到宮頸癌的分期中尚屬少見。磁共振擴(kuò)散加權(quán)成像(Diffusion weighted images,DWI)是區(qū)別于TIWI,T2WI的另一種磁共振成像方法,水分子在不同組織中的運(yùn)動(dòng)受限差異是DWI的基礎(chǔ)。近幾年有學(xué)者將DWI運(yùn)用到前列腺癌,乳腺癌等惡性腫瘤的評(píng)估中,已驗(yàn)證了其有效性,目前國內(nèi)有報(bào)道認(rèn)為DWI可以提高宮頸癌術(shù)前評(píng)估的準(zhǔn)確性,對(duì)發(fā)現(xiàn)早期宮頸癌病灶以及淋巴結(jié)轉(zhuǎn)移具有一定優(yōu)勢(shì),但目前仍未成熟應(yīng)用。磁共振擴(kuò)散基組光譜成像(diffusion basis spectrum imaging,DBSI)是我院與華盛頓圣路易斯醫(yī)學(xué)院合作開發(fā)的、全新的磁共振擴(kuò)散加權(quán)成像模型,是DWI的升級(jí)。該模型可將水分子擴(kuò)散受限區(qū)進(jìn)一步分為:限制性受限區(qū),該部分代表腫瘤細(xì)胞成分;阻礙性受限區(qū),該部分代表炎性成分;纖維間質(zhì)區(qū),該部分代表纖維成分。進(jìn)而可以將腫瘤組織中不同病理成分區(qū)分出來,并進(jìn)行定量研究,目前該技術(shù)在前列腺癌以及神經(jīng)系統(tǒng)疾病研究中已取得相應(yīng)成果,在婦科腫瘤領(lǐng)域,尚無研究報(bào)道。為評(píng)價(jià)以上幾種磁共振成像新技術(shù)在宮頸癌術(shù)前評(píng)估中的價(jià)值,本研究包括:1、將高清磁共振成像方法及DWI聯(lián)合運(yùn)用到宮頸癌的分期中,以評(píng)估其在協(xié)助宮頸癌分期中的優(yōu)勢(shì)。2.將DBSI首次運(yùn)用到宮頸癌術(shù)前評(píng)估中,驗(yàn)證DBSI圖像中各限制區(qū)與對(duì)應(yīng)病理成分的一致性,初步探索DBSI技術(shù)在精確評(píng)估宮頸癌中的價(jià)值。第一部分:高清磁共振成像聯(lián)合磁共振擴(kuò)散加權(quán)成像在宮頸癌分期中的價(jià)值探討研究目的:通過宮頸癌患者的術(shù)后病理結(jié)果,比較常規(guī)MRI分期、高清MRI分期、高清MRI聯(lián)合磁共振擴(kuò)散加權(quán)成像(diffusion weighted imaging,DWI)分期方法在IB期~IIB期宮頸癌分期中的準(zhǔn)確性。材料與方法:收集2015年3月-2017年3月來我院就診的宮頸癌病人81例,治療前明確臨床分期,行MRI檢查,其中54位患者行常規(guī)MRI檢查,27例患者行高清MRI檢查(小FOV的高清T2加權(quán)像)并行DWI掃描(b值取1000s/mm2)。兩位有經(jīng)驗(yàn)的影像科醫(yī)生在知曉宮頸癌診斷,但不知臨床分期的情況下MRI閱片,重點(diǎn)對(duì)腫瘤的位置,大小,陰道及宮旁侵犯情況作出評(píng)估,并對(duì)每例患者行影像學(xué)分期。隨后患者在本院行廣泛性子宮切除術(shù)加盆腔淋巴結(jié)清掃術(shù)+腹主動(dòng)脈旁淋巴結(jié)切除術(shù),記錄詳細(xì)的手術(shù)及病理資料。以術(shù)后病理結(jié)果為金標(biāo)準(zhǔn),分別將臨床分期、多種磁共振方法協(xié)助所得分期與病理結(jié)果進(jìn)行對(duì)照。數(shù)據(jù)分析使用SAS9.4軟件,分別比較各類方法所得分期與病理結(jié)果的一致性,計(jì)算Kappa系數(shù);采用配對(duì)資料X2檢驗(yàn),比較高清MRI在聯(lián)合運(yùn)用DWI前后在各分期中的診斷差異,P值0.05即有統(tǒng)計(jì)學(xué)意義。結(jié)果:臨床分期、常規(guī)MRI分期、高清MRI分期、高清MRI聯(lián)合DWI分期在IB期~IIB期宮頸癌中總體分期準(zhǔn)確率分別為:(40例/81例)49.38%、(35例/54例)64.81%、(16例/27例)59.26%、(18例/27例)66.67%。常規(guī)MRI分期、高清MRI分期、高清MRI聯(lián)合DWI分期的加權(quán)Kappa系數(shù)分別為:0.333、0.3788、0.473。而臨床分期與病理結(jié)果的加權(quán)Kappa系數(shù)雙側(cè)檢驗(yàn)的P值0.05,說明暫不能認(rèn)為臨床分期與病理結(jié)果存在一致性。因此可以認(rèn)為高清MRI聯(lián)合DWI分期與病理結(jié)果的一致性最好,其次為高清MRI分期,再次為常規(guī)MRI分期,臨床分期最差。在IB期、IIA期、IIB期各個(gè)分期中,高清MRI分期準(zhǔn)確率分別為:62.69%、66.67%、88.89%、高清MRI聯(lián)合運(yùn)用DWI后分期的準(zhǔn)確率分別為:70.73%、74.07%、88.89%。采用卡方檢驗(yàn)比較高清MRI在聯(lián)合運(yùn)用DWI前后在各分期中的診斷差異,P值均大于0.05,差異無統(tǒng)計(jì)學(xué)意義。結(jié)論:常規(guī)MRI協(xié)助下的宮頸癌分期要優(yōu)于臨床分期,高清MRI分期、高清MRI聯(lián)合DWI分期優(yōu)于常規(guī)MRI分期,因此,采用高清MRI聯(lián)合運(yùn)用磁共振擴(kuò)散加權(quán)成像(DWI),可以有效提高宮頸癌分期的準(zhǔn)確性。第二部分:磁共振擴(kuò)散基組光譜成像(DBSI)在宮頸癌術(shù)前評(píng)估中的應(yīng)用初探目的:磁共振擴(kuò)散基組光譜成像(diffusion basis spectrum imaging,DBSI)是一種全新的磁共振功能成像模型及后處理技術(shù)。本研究首次將DBSI應(yīng)用到宮頸癌的病灶成分分析中,以探討DBSI在宮頸癌精準(zhǔn)分期中的潛在應(yīng)用價(jià)值。方法:收集2016年2月-2017年3月來我院就診的宮頸癌病人27例,治療前行高清MRI、磁共振擴(kuò)散加權(quán)成像(DWI)以及磁共振擴(kuò)散基組光譜成像(DBSI),收集的DBSI數(shù)據(jù)及圖像由相關(guān)的軟件進(jìn)行后期處理。所有患者在行MRI檢查后7天內(nèi)行宮頸癌根治手術(shù),將含有病灶的完整宮頸,制成石蠟塊,垂直宮頸長(zhǎng)軸切片,常規(guī)HE染色,制作成大病理切片。并用濱松S60病理切片掃描儀采集整個(gè)病理切片圖像。將組織病理學(xué)圖像與對(duì)應(yīng)層面的MRI圖像進(jìn)行比對(duì),分析兩者的匹配程度。結(jié)果:我們通過高清MRI及DWI清晰地顯示了腫瘤輪廓,再借助DBSI技術(shù)可將腫塊進(jìn)一步分為:限制性受限部分、阻礙性受限部分、纖維間質(zhì)部分。介于目前該研究時(shí)間較短,數(shù)據(jù)后處理復(fù)雜,DBSI細(xì)分的這些部分否與病理成分(腫瘤細(xì)胞成分、炎性成分、纖維成分)相對(duì)應(yīng),仍有待研究進(jìn)一步驗(yàn)證。結(jié)論:DBSI較DWI在對(duì)腫瘤評(píng)估中可以采集更多信息,對(duì)腫瘤病理成分分析更具有優(yōu)勢(shì)。介于本研究尚處于探索階段,暫時(shí)無法證明DBSI細(xì)分的各限制區(qū)與宮頸癌各病理組織成分的對(duì)應(yīng)關(guān)系。但DBSI已顯示出對(duì)宮頸癌精準(zhǔn)分期的潛在優(yōu)勢(shì)。
[Abstract]:Cervical cancer is the highest incidence of gynecologic malignant tumor, which is different from other gynecologic cancers by surgical pathological staging. The clinical stage of cervical cancer is still adopted by the pelvic examination to determine the progress of the tumor. Clinical staging is the key to determine the treatment plan. However, the pelvic examination is highly subjective and often leads to inaccurate staging and error. Staging is not conducive to the choice of the best treatment. With the development of medical imaging technology, clinicians with the aid of CT, MRI, and PET/CT to assist the evaluation of cervical cancer are very common..MRI has a natural advantage in the clinical staging of cervical cancer because of its excellent soft tissue resolution, multi parameter and multi-directional imaging mode. At the same time, MRI is examined. In the MRI sequence, the T1 weighted image (T1 weighted image, T1WI) and the T2 weighted image (T2weighted image, T2WI) are the common sequence.T1WI for evaluating the stage of cervical cancer. The pelvic anatomy is the main display of the pelvic anatomy in the differentiation of the tumor and the normal group. It is more advantageous to evaluate the main sequence of cervical cancer. But there are still a lot of shortcomings in the practice of conventional MRI: restricted by the resolution, it is difficult to detect early lesions of cervical cancer by conventional MRI, and even if it is found that the masses can not identify its good and bad properties. When the magnetic resonance parameters are adjusted, the resolution of T2WI will be greatly improved after setting a small FOV. That is, the so-called high definition MRI. is rarely used in the staging of cervical cancer at present. The magnetic resonance diffusion-weighted imaging (Diffusion weighted images, DWI) is another magnetic resonance imaging method, which is different from TIWI and T2WI, and the water molecules are not The difference in movement restriction in the same tissue is the basis of DWI. In recent years, some scholars have applied DWI to the evaluation of prostate cancer, breast cancer and other malignant tumors. It has been proved that DWI can improve the accuracy of preoperative assessment of cervical cancer, and has a certain advantage in the discovery of early cervical cancer and lymph node metastasis. Diffusion basis spectrum imaging (DBSI) is a new model of magnetic resonance diffusion weighted imaging (MRI) in Saint Louis, Washington, D.C., which is a new model of magnetic resonance diffusion weighted imaging (MRI), which is an upgrade of DWI. This model can further divide the region of the water diffusion restricted zone into a restricted restricted zone. The part represents the composition of the tumor cell; the hindrance restricted area, which represents the inflammatory component; the fibrous interstitial area, which represents the fibrous component. Then it can distinguish the different pathological components in the tumor tissue and make a quantitative study. At present, the technology has achieved the corresponding results in the study of prostate cancer and the nervous system disease, in gynecology. To evaluate the value of these new MRI techniques in preoperative assessment of cervical cancer, this study included: 1, the combined use of high-definition magnetic resonance imaging and DWI to the stage of cervical cancer to assess the advantage of.2. in assisting cervical cancer staging for the first time to apply DBSI to preoperative assessment of cervical cancer. To verify the consistency of the restricted areas and corresponding pathological components in the DBSI image, and to explore the value of DBSI technology in the accurate assessment of cervical cancer. The accuracy of MRI staging, high-definition MRI staging, high definition MRI combined magnetic resonance diffusion weighted imaging (diffusion weighted imaging, DWI) staging in stage IB stage ~IIB stage of cervical cancer. Materials and methods: 81 cases of cervical cancer patients in our hospital in March March 2015 were collected. Before treatment, the clinical stage was clear, and MRI examination was performed, of which 54 patients were suffering from disease. 27 patients underwent high definition MRI examination (high definition T2 weighted image of small FOV) parallel DWI scan (b value 1000s/mm2) in 27 patients. Two experienced imaging doctors were aware of the diagnosis of cervical cancer but did not know the clinical staging of MRI, focusing on the location, size, vagina and para of the intrauterine invasion of the tumor, and each case The patients were treated with imaging stages. Then the patients were treated with extensive hysterectomy plus pelvic lymphadenectomy plus abdominal para aortic lymph node resection, and detailed surgical and pathological data were recorded. The clinical staging and multiple magnetic resonance methods were used to compare the pathological results with pathological results. According to the analysis of SAS9.4 software, the consistency between the stages and the pathological results of various methods was compared and the Kappa coefficient was calculated. The diagnostic difference between high definition MRI and DWI was compared before and after the combined use of DWI by paired data X2 test. The P value 0.05 was statistically significant. Results: clinical staging, conventional MRI staging, HD MRI staging, HD MRI The overall accuracy rate of the combined DWI stage in IB stage ~IIB stage cervical cancer was: (40 cases of /81 cases) 49.38%, (35 cases of /54 cases) 64.81%, (16 cases of /27), 59.26%, and (18 /27 cases) 66.67%. conventional MRI staging, high definition MRI staging, high definition MRI joint DWI stage weighted numbers respectively. The P value of the PPA coefficient bilateral test was 0.05, indicating that there was no agreement between the clinical staging and the pathological results for the time being. Therefore, the best consistency of the combined DWI staging with the pathological results was considered, followed by high definition MRI staging, and the most poor clinical staging was the conventional MRI staging. In IB, IIA, and IIB stages, high definition MRI staging The accuracy rate was 62.69%, 66.67%, 88.89%. The accuracy of the combined use of DWI in high definition MRI was 70.73%, 74.07%, and 88.89%. was compared by chi square test to compare the diagnostic differences between high definition MRI in all stages before and after the combined use of DWI, P values were greater than 0.05, the difference was not statistically significant. Conclusion: the cervical cancer staging under the help of conventional MRI is superior to the clinical stage. Bed stage, high definition MRI staging, high definition MRI combined with DWI staging are superior to conventional MRI staging. Therefore, the accuracy of cervical cancer staging can be improved by high definition MRI combined with magnetic resonance diffusion-weighted imaging (DWI). The second part: magnetic resonance diffusion based group spectral imaging (DBSI) for preoperative evaluation of cervical cancer: magnetic resonance expansion Diffusion basis spectrum imaging (DBSI) is a new magnetic resonance functional imaging model and post-processing technique. This study first applied DBSI to the analysis of the lesion components of cervical cancer in order to explore the potential value of DBSI in the accurate staging of cervical cancer. Method: to collect in March February 2016 -2017 year in our hospital. 27 patients with cervical cancer were treated with high-definition MRI, magnetic resonance diffusion-weighted imaging (DWI) and magnetic resonance diffusion based group spectral imaging (DBSI). The collected DBSI data and images were processed by related software for later treatment. All patients underwent radical cervical cancer surgery within 7 days after MRI examination, and the whole cervix containing the lesion was made into paraffin. Block, vertical section of the long axis of the cervix, routine HE staining, make a large pathological section, and use the S60 pathology slice scanner to collect the whole pathological section image. Compare the histopathological images with the corresponding MRI images and analyze the matching degree. DBSI technique can be used to further divide the lumps into restricted restricted parts, obstructed restricted parts, fibrous interstitial parts. The time is short, data processing is complex, and the parts of DBSI subdivision correspond to the pathological components (tumor cell components, inflammatory components and fibrous components). Further verification is still needed. Conclusion: DB SI can collect more information in tumor evaluation than DWI, and is more advantageous for the analysis of tumor pathology components. It is still at the exploratory stage of this study. It is temporarily unable to prove the corresponding relationship between the restricted areas of DBSI subdivision and the pathological tissue components of cervical cancer. But DBSI has shown the potential advantage of the accurate staging of cervical cancer.

【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R445.2;R737.33

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