發(fā)布時間：2018-05-26 02:07

  本文選題：HIFU + 子宮肌瘤�。� 參考：《重慶醫(yī)科大學(xué)》2017年碩士論文

【摘要】：子宮肌瘤是育齡期婦女中極為常見的良性腫瘤,該腫瘤會導(dǎo)致一系列健康問題。高強(qiáng)度聚焦超聲(High Intensity Focused Ultrasound,HIFU)消融子宮肌瘤是一種無創(chuàng)治療方法,其憑借微創(chuàng)性和保留患者生育能力等特性,正越來越受到婦科醫(yī)生的重視。隨著超聲引導(dǎo)的HIFU技術(shù)廣泛應(yīng)用于臨床,突破超聲圖像(Ultrasound Image,US)質(zhì)量差、噪聲大、視野窄的局限性,將超聲圖像與磁共振圖像(Ultrasound Image and Magnetic resonance image,US-MRI)配準(zhǔn)、融合技術(shù)用于提高超聲消融子宮肌瘤中的影像識別精確度和推進(jìn)智能化培訓(xùn)成為新的緊迫需求。為此超聲醫(yī)療國家工程研究中心HIFU研究團(tuán)隊(duì)基于US-MRI配準(zhǔn)、融合技術(shù)、三維重建技術(shù)等智能技術(shù),開發(fā)出HIFU虛擬現(xiàn)實(shí)系統(tǒng)。本研究旨在評估超聲消融子宮肌瘤中US-MRI配準(zhǔn)、融合技術(shù)的精確影像識別能力和基于US-MRI配準(zhǔn)技術(shù)的虛擬現(xiàn)實(shí)培訓(xùn)的效果,以期為其在超聲消融子宮肌瘤中的運(yùn)用、推廣提供依據(jù)。目的:1.探討US-MRI圖像配準(zhǔn)、融合技術(shù)在超聲消融子宮肌瘤中的標(biāo)定結(jié)構(gòu)及其可行性。2.測量超聲消融子宮肌瘤術(shù)中US-MRI圖像配準(zhǔn)技術(shù)的配準(zhǔn)精確度。3.評估HIFU虛擬現(xiàn)實(shí)系統(tǒng)輔助超聲消融子宮肌瘤手術(shù)定位培訓(xùn)的效果。方法:1.前瞻性地評估78例子宮肌瘤患者78組圖像的配準(zhǔn)與融合效果,篩選配準(zhǔn)標(biāo)定結(jié)構(gòu),評價配準(zhǔn)技術(shù)的性能指標(biāo):配準(zhǔn)精確度、可靠性和臨床可行性。2.根據(jù)“客觀結(jié)構(gòu)化臨床考試”規(guī)則設(shè)計(jì)虛擬測試項(xiàng)目,從信度和效度上評估虛擬培訓(xùn)及測試項(xiàng)目的質(zhì)量。3.2015年12月到2017年1月在重慶醫(yī)科大學(xué)附屬第一醫(yī)院超聲消融治療中心(衛(wèi)生部高強(qiáng)度聚焦超聲腫瘤治療培訓(xùn)基地)參加超聲消融子宮肌瘤手術(shù)培訓(xùn)的學(xué)員8名,學(xué)習(xí)內(nèi)容為HIFU治療前預(yù)定位。學(xué)員分配到虛擬現(xiàn)實(shí)培訓(xùn)組(虛擬組)和傳統(tǒng)培訓(xùn)組(傳統(tǒng)組),每組4人。同一名高級醫(yī)生選出適合學(xué)員定位的患者240例,通過雙盲法(學(xué)員和患者互相不能選擇)分配給每位學(xué)員30例患者,按醫(yī)生定位的順序分為6期,每期每位醫(yī)生完成5例患者的治療前預(yù)定位。以定位時間為指標(biāo)評價學(xué)習(xí)曲線,比較HIFU虛擬現(xiàn)實(shí)系統(tǒng)輔助超聲消融子宮肌瘤手術(shù)定位培訓(xùn)的效果。結(jié)果:1.圖像配準(zhǔn)標(biāo)定結(jié)構(gòu),78組圖像,76組圖像可以實(shí)現(xiàn)圖像配準(zhǔn)操作,2組子宮前位的圖像(因?yàn)閁S與MRI顯示的子宮位置變化過大不能實(shí)現(xiàn)圖像配準(zhǔn))。76組圖像配準(zhǔn)后,清晰度均有提高。子宮、子宮肌瘤、恥骨、骶尾骨都可以根據(jù)邊界線、標(biāo)定點(diǎn)進(jìn)行US與MRI的配準(zhǔn)。用子宮的邊界作為標(biāo)志來配準(zhǔn)同一子宮平面,配準(zhǔn)清晰度顯著增加(P=0.000);用子宮肌瘤的邊界作為標(biāo)志配準(zhǔn)同一子宮肌瘤平面,配準(zhǔn)清晰度顯著增加(P=0.000);用恥骨的邊界作為標(biāo)志配準(zhǔn)同一恥骨平面,配準(zhǔn)清晰度顯著增加(P=0.000);用骶岬作為標(biāo)志點(diǎn)配準(zhǔn)骶尾骨,配準(zhǔn)清晰度顯著增加(P=0.000)。2.配準(zhǔn)的可行性評價結(jié)果,效果A,圖像配準(zhǔn)后清晰度有很好的改善:US與MRI有很好的相關(guān)性,擴(kuò)大了視野,提高了病灶邊界的清晰度。所占比例82.05%。效果B,圖像配準(zhǔn)后清晰度沒有改善:US與MRI沒有相關(guān)性:不能通過配準(zhǔn)圖像進(jìn)行診斷。所占比例2.56%。效果C,在US上已經(jīng)很清楚的,不需要通過配準(zhǔn)圖像進(jìn)行診斷。所占比例為15.38%。3.配準(zhǔn)精確度,子宮圖像中,76組可實(shí)現(xiàn)圖像配準(zhǔn)操作,故以子宮的邊界為配準(zhǔn)標(biāo)志物,配準(zhǔn)子宮的配準(zhǔn)誤差為3.20±0.10mm,以子宮肌瘤的邊界為配準(zhǔn)標(biāo)志物,配準(zhǔn)子宮肌瘤的配準(zhǔn)誤差為3.00±1.25mm。45例患者的內(nèi)膜邊界在US上可見,故以內(nèi)膜的邊界為配準(zhǔn)標(biāo)志物,配準(zhǔn)內(nèi)膜的配準(zhǔn)誤差為2.20±0.45mm;33例患者的骶岬在US上可見,故以骶岬作為配準(zhǔn)標(biāo)志物,配準(zhǔn)骶尾骨的配準(zhǔn)誤差為1.82±0.48mm;22例患者的恥骨邊界在US上可見,故以恥骨邊界為配準(zhǔn)標(biāo)志物,配準(zhǔn)恥骨的配準(zhǔn)誤差為1.64±0.32mm。4.圖像融合效果評價,以子宮肌瘤的邊界作為標(biāo)志配準(zhǔn)圖像后,實(shí)現(xiàn)MRI與US的全局融合。70組融合圖像,3組(4.29%)融合效果為C級(C.融合圖像的清晰度與配準(zhǔn)后的圖像相比病灶邊界及周邊解剖結(jié)構(gòu)沒有改善),67組(95.71%)融合效果為D級(D.融合圖像的清晰度與配準(zhǔn)后的圖像相比病灶邊界及周邊解剖結(jié)構(gòu)的清晰度下降)5.定位能力測試結(jié)果,可信度,Cronbach'sα=0.90。定位能力測試總成績,虛擬組得分40.00±1.63分,傳統(tǒng)組得分26.75±5.74分。虛擬組得分顯著高于傳統(tǒng)組得分(t=4.421,P=0.004)。定位能力測試子項(xiàng)目:(1)定位的設(shè)備操作能力測試項(xiàng)目,可信度Cronbach’sα=0.91,測試成績,虛擬組得分16.25±2.36分,傳統(tǒng)組得分12.00±4.24分。虛擬組得分與傳統(tǒng)組得分相比差異無統(tǒng)計(jì)學(xué)意義(t=1.753,P=0.131);(2)定位中標(biāo)志性解剖結(jié)構(gòu)識別能力測試,可信度Cronbach’sα=0.87,測試成績,虛擬組得分14.00±1.41分,傳統(tǒng)組得分10.50±1.92分。虛擬組得分顯著高于傳統(tǒng)組得分(t=2.942,P=0.026);(3)定位中疑難情況判別能力測試項(xiàng)目,可信度Cronbach’sα=0.88,測試成績,虛擬組得分9.75±2.63分,傳統(tǒng)組得分4.25±1.25分。虛擬組得分顯著高于傳統(tǒng)組得分(t=3.774,P=0.017)。6.學(xué)習(xí)曲線分析,虛擬現(xiàn)實(shí)技術(shù)培訓(xùn)組6期的學(xué)習(xí)曲線和傳統(tǒng)培訓(xùn)組6期的學(xué)習(xí)曲線分析結(jié)果:在定位操作實(shí)踐的1至6期,虛擬現(xiàn)實(shí)技術(shù)培訓(xùn)組的學(xué)習(xí)曲線處于傳統(tǒng)培訓(xùn)組的學(xué)習(xí)曲線下方;其中定位操作實(shí)踐的1至4期,虛擬現(xiàn)實(shí)技術(shù)培訓(xùn)組的學(xué)習(xí)曲線與傳統(tǒng)培訓(xùn)組的學(xué)習(xí)曲線的間距呈現(xiàn)振蕩漸近狀態(tài),從4期以后,虛擬現(xiàn)實(shí)技術(shù)培訓(xùn)組的學(xué)習(xí)曲線與傳統(tǒng)培訓(xùn)組的學(xué)習(xí)曲線呈現(xiàn)平穩(wěn)漸近趨勢。結(jié)論:1.在超聲消融子宮肌瘤中US-MRI的配準(zhǔn)、融合是可以實(shí)現(xiàn)的。US-MRI配準(zhǔn)技術(shù)可以在一定程度上,彌補(bǔ)MRI不能實(shí)時監(jiān)控的缺點(diǎn)和US分辨力低的缺點(diǎn),提高圖像的清晰度、擴(kuò)大視野、輔助醫(yī)生了解US上被偽影擋住的圖像信息,有效提高超聲消融子宮肌瘤中的影像識別效果。2.本研究的評估結(jié)果顯示虛擬現(xiàn)實(shí)考核方案的可信性度、普適性好。虛擬現(xiàn)實(shí)系統(tǒng)輔助培訓(xùn)與傳統(tǒng)的培訓(xùn)相比在學(xué)員的初始學(xué)習(xí)階段具有更好的培訓(xùn)效果。
[Abstract]:Uterine myoma is a very common benign tumor of women of childbearing age. This tumor can lead to a series of health problems. High Intensity Focused Ultrasound (HIFU) ablation of uterine myoma is a noninvasive treatment. It is becoming more and more important for gynecologists with the characteristics of minimally invasive and retention of the patient's fertility. As the ultrasound guided HIFU technology is widely used in clinic, it breaks through the limitations of the poor quality of Ultrasound Image (US), large noise and narrow vision, and registration of ultrasonic images with magnetic resonance images (Ultrasound Image and Magnetic resonance image, US-MRI). Fusion technique is used to improve the image recognition in ultrasonic ablation of uterine myoma. The HIFU research team of the ultrasound medical National Engineering Research Center has developed a HIFU virtual reality system based on US-MRI registration, fusion technology and 3D reconstruction technology. This study aims to evaluate the accuracy of US-MRI registration and fusion technology in ultrasonic ablation of uterine myoma. Image recognition ability and the effect of virtual reality training based on US-MRI registration technology in order to provide the basis for its application in ultrasonic ablation of uterine myoma. Objective: 1. to explore the calibration structure and feasibility of US-MRI image registration, fusion technique in ultrasonic ablation of uterine myoma, and to measure the US-MRI map in the operation of ultrasonic ablation of uterine myoma by ultrasonic ablation. Image registration accuracy.3. evaluated the effect of HIFU virtual reality system assisted ultrasound ablation of uterine myoma operation location training. Method: 1. the registration and fusion effect of 78 groups of images in 78 cases of hysteromyoma were evaluated prospectively, the registration and calibration structure was screened, and the performance indexes of registration techniques were evaluated: accuracy, reliability and presence of registration. Bed feasibility.2. design virtual test project based on the "objective structured clinical examination" rules, evaluate the quality of virtual training and testing project from reliability and validity from December to January 2017 in First Affiliated Hospital of Chongqing Medical University ultrasound ablation treatment center (Department of high intensity focused ultrasound tumor treatment training base of the Ministry of health). 8 students were trained with ultrasonic ablation of uterine myoma. The learning content was pre positioning before HIFU treatment. Students were assigned to the virtual reality training group (virtual group) and the traditional training group (traditional group), with 4 people in each group. The same senior doctor selected 240 patients suitable for the students to locate the students and assigned them to each other by double blind method (students and patients could not choose from each other). 30 patients were divided into 6 stages according to the doctor's positioning order. Each doctor completed the pre location of 5 patients before the treatment. The learning curve was evaluated with the location time as the index, and the effect of the HIFU virtual reality system assisted ultrasound ablation of hysteromyoma was compared. The results were: 1. image registration calibration structure, 78 groups of images, 76 group drawings. Image registration operations can be achieved. 2 groups of images of the anterior uterine position (because of the large changes in the position of the uterus that US and MRI show too large can not achieve image registration) the definition of the.76 group is improved. The uterus, the uterus myoma, the pubic bone, the sacral tail can all be registered with the US and MRI according to the boundary line, and the boundary of the uterus is used as the mark. The registration clarity of the same uterine plane was significantly increased (P=0.000). The registration definition of the same uterus myoma was registered with the boundary of uterine myoma as a sign, and the registration clarity increased significantly (P=0.000). The registration of the same pubic plane with the boundary of the pubis was used as a sign, and the registration clarity increased significantly (P=0.000); sacral headland was used as a sign to registration sacrum. The registration clarity increased significantly (P=0.000).2. registration feasibility evaluation results, the effect was A, the clarity of the image registration after registration was well improved: US and MRI have good correlation, expanded the vision and improved the definition of the focus of the focus. The proportion of 82.05%. effect B, the image registration clarity did not improve: US and MRI have no correlation: no correlation: no It can be diagnosed by registration image. The proportion of 2.56%. is C, which is clear on US. It does not need to be diagnosed by registration image. The proportion is 15.38%.3. registration accuracy. In the uterus image, 76 groups can realize image registration operation, so the uterus boundary is used as the matching mark and registration error of the uterus is 3.20 + 0.10mm. The registration error of uterine myoma is a registration marker. The registration error of the registration of uterine myoma is 3 1.25mm.45 cases, so the inner boundary of the endometrium is visible on the US. Therefore, the boundary of the endometrium is the registration marker, the registration error of the endometrium is 2.20 0.45mm; the sacral headland of the 33 patients can be seen on the US, so the sacral headland is used as the registration marker and registration of the sacral tail. The registration error of bone is 1.82 + 0.48mm, and the pubic boundary of 22 cases is visible on US. Therefore, the registration mark of the pubis is the registration mark of the pubis, the registration error of the pubic bone is 1.64 + 0.32mm.4. image fusion. After the registration image of the uterus myoma, the fusion image of the global fusion.70 group of MRI and US is realized, and the fusion of the 3 groups (4.29%) is fused. The effect was C (the definition of the C. fusion image and the image after registration did not improve), and the 67 group (95.71%) was D level (the clarity of the D. fusion image was compared with the image after registration and the clarity of the lesion boundary and the peripheral anatomical structure decreased). The results of the 5. location test, the reliability, and the Cronbach's The total score of the =0.90. localization ability test, the virtual group score 40 + 1.63 points, the traditional group score 26.75 + 5.74 points. The virtual group score was significantly higher than the traditional group score (t=4.421, P=0.004). The positioning ability test sub project: (1) the positioning equipment operation ability test project, the reliability Cronbach 's alpha =0.91, the test result and the virtual group score 16.25 + 2.36 points, The score of the traditional group was 12 + 4.24 points. There was no significant difference in the score of the virtual group compared with the traditional group (t=1.753, P=0.131); (2) the test of the identification ability of the marker anatomy, the reliability of Cronbach 's a =0.87, the score of the test, the score of the virtual group 14 + 1.41, the score of the traditional group 10.50 + 1.92. The score of the virtual group was significantly higher than that of the traditional group. Group score (t=2.942, P=0.026); (3) the test project of difficult situation discriminant ability, reliability Cronbach 's alpha =0.88, test score, 9.75 + 2.63 score of virtual group score and 4.25 + 1.25 score of traditional group. The score of virtual group was significantly higher than that of the traditional group score (t=3.774, P= 0.017).6. learning curve analysis, and 6 period of virtual reality technical training group. Curve and the learning curve analysis of the 6 phase of the traditional training group: the learning curve of the VR training group is under the learning curve of the traditional training group in the 1 to 6 period of the positioning operation practice; in the 1 to 4 period of the positioning operation practice, the distance between the learning curve of the VR training group and the learning curve of the traditional training group is presented. The oscillation is asymptotically asymptotically. From the 4 phase, the learning curve of the virtual reality technology training group and the learning curve of the traditional training group are asymptotically asymptotically asymptotically. Conclusion: 1. the registration of US-MRI in the ultrasonic ablation uterine myoma and the integration of the.US-MRI registration technology can make up for the shortcomings of the MRI cannot be monitored in real time and U. S has the disadvantages of low resolution, improving the clarity of the image, expanding the vision, assisting the doctor to understand the image information that is blocked by the artifact on the US, effectively improving the image recognition effect in the ultrasonic ablation of the uterine myoma. The evaluation results of this study show that the credibility of the virtual reality assessment scheme is good. The virtual reality system assists training and transmission. Unified training has better training effect than the initial learning stage.
【學(xué)位授予單位】：重慶醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R737.33
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本文編號：1935532