本文選題：前列腺癌 + 磁共振成像��； 參考：《第二軍醫(yī)大學(xué)》2014年碩士論文

【摘要】：一、研究背景 在世界范圍內(nèi)，前列腺癌(prostate cancer，PCa)發(fā)病率在男性所有惡性腫瘤中高居第二。在美國，前列腺癌的發(fā)病率已然超過肺癌，成為危害男性健康的頭號腫瘤。在我國等亞洲國家，伴隨人口總數(shù)的增長、人口老齡化的顯現(xiàn)及人們生活習(xí)慣的改變，其發(fā)病率及死亡率均逐年上升。 前列腺癌患者以老年男性人群為主，95%以上明確診斷的患者年齡在45～89歲之間，70%以上前列腺癌患者的年齡大于65歲，平均年齡72歲，高峰年齡段為75～79歲。近年來，，前列腺癌的發(fā)病年齡愈發(fā)呈現(xiàn)出一種年輕化的趨勢。從不同年齡組的發(fā)病情況來看，年齡大于65歲人群的發(fā)病率持續(xù)上升。 前列腺癌組織學(xué)診斷基于以下兩個標準：低倍顯微鏡下組織結(jié)構(gòu)的改變及高倍顯微鏡下細胞的異變。前列腺癌中，95%以上為腺泡上皮來源的腺癌，好發(fā)部位依次為外周帶（75%），移行帶（20%）和中央帶（5%）。85%的腺癌呈多中心性，這可能是腫瘤前列腺內(nèi)部轉(zhuǎn)移的結(jié)果，以外周帶多見。 由于其在判斷患者預(yù)后及療效上具有更高的準確性，且擁有可重復(fù)性強及形態(tài)操作簡單的優(yōu)勢，Gleason分級法是目前臨床上運用最廣泛的前列腺癌病理分級法。此法將腺體的分化程度以及腫瘤在間質(zhì)中的生長方式作為腫瘤分級標準，并以此來評價腫瘤的惡性程度。Gleason分級法主要是在低、中倍顯微鏡下觀察組織結(jié)構(gòu)的改變，并不針對個別腫瘤細胞形態(tài)進行判斷，并同時兼顧腫瘤不同區(qū)域組織結(jié)構(gòu)的變異。 臨床的實際工作中，前列腺癌起病隱匿，一部分患者甚至是在接受前列腺電切或開放手術(shù)時才意外發(fā)現(xiàn)。早期前列腺癌缺乏特異性癥狀，只有當腫瘤侵犯或阻塞尿道或（及）膀胱頸時，才會發(fā)生下尿路刺激或（及）梗阻癥狀，甚至出現(xiàn)急性尿潴留、血尿及尿失禁等急性下尿路癥狀。晚期患者發(fā)生前列腺癌骨轉(zhuǎn)移，易并發(fā)骨骼疼痛、病理性骨折、貧血及脊髓壓迫導(dǎo)致下肢癱瘓等相關(guān)臨床癥狀�？偟膩碚f，前列腺癌的早期臨床癥狀與良性前列腺增生癥（benign prostatehyperplasia，BPH）相似，以排尿障礙為主；晚期臨床表現(xiàn)則以腫瘤組織局部浸潤或（及）遠處轉(zhuǎn)移所引發(fā)的相關(guān)癥狀為主。 由于其起病的隱匿性，前列腺癌的診斷，特別是前列腺癌的早期診斷仍為臨床上的一大難題。因此，改進前列腺癌診斷方法具有相當重要的意義。 現(xiàn)在的臨床工作中已經(jīng)將PSA檢測聯(lián)合直腸指診(digital rectal examination，DRE)以及經(jīng)直腸前列腺超聲檢查（transrectal ultrasonography，TRUS）作為前列腺癌早期篩查指標納入50歲以上中老年男性常規(guī)體檢項目。如果發(fā)現(xiàn)異常，超聲（或核磁）引導(dǎo)下的經(jīng)直腸前列腺穿刺活檢則是下一步。前列腺穿刺活檢的組織病理學(xué)檢查是診斷前列腺癌的金標準，但由于種種原因，此檢查仍存15%—34%的假陰性。在高度懷疑癌變，卻又缺乏病理學(xué)證據(jù)支持時，問題更加凸顯。這種情況下，磁共振成像術(shù)（magnetic resonance imaging MRI）以其在三維空間及軟組織對比上的高分辨率和多序列多參數(shù)成像體系可提供幫助。 MRI被公認是目前臨床前列腺癌的最佳影像學(xué)診斷技術(shù)。近年來，作為一種確定的基礎(chǔ)序列，T2加權(quán)成像技術(shù)(T2-weighted imaging，T2WI)已經(jīng)廣泛應(yīng)用于常規(guī)前列腺MRI形態(tài)學(xué)檢查。在T2WI圖像上，正常前列腺的中央帶及移行帶均表現(xiàn)出低信號，而外周帶則表現(xiàn)為明顯的高信號。前列腺癌的典型表現(xiàn)為高信號的外周帶中出現(xiàn)低信號缺損區(qū)。但是，在外周帶診斷腫瘤將受到前列腺活檢后出血、良性前列腺增生及前列腺炎等因素的影響，同時更大的挑戰(zhàn)來自于對中央帶及移行帶腫瘤的診斷，因為在此區(qū)域腫瘤結(jié)節(jié)將與良性腺組織的信號強度重疊。 與此同時，在MR功能成像方面，動態(tài)增強掃描技術(shù)(dynamic contrastenhanced MRI，DCE-MRI)、擴散加權(quán)成像技術(shù)(diffusion weighted imaging，DWI)及MR波譜成像(magnetic resonance spectroscopy, MRS）等一系列技術(shù)均取得較大發(fā)展，進一步提高了前列腺癌MRI診斷的準確性。而近年來，建立于DWI技術(shù)基礎(chǔ)上，能更為精確分析組織內(nèi)水分子擴散情況的體素內(nèi)無規(guī)則運動核磁成像技術(shù)（intravoxel incoherent motion MR imaging，IVIM-MRI）在前列腺癌診斷領(lǐng)域也獲得了廣泛關(guān)注。 IVIM成像技術(shù)在神經(jīng)系統(tǒng)檢查發(fā)展已經(jīng)超過20年，可以更為全面和精確的分析成像區(qū)域體素內(nèi)水分子的真實擴散情況。目前在臨床上有很多的IVIM成像技術(shù)分析、計算方法，最常用的是經(jīng)典雙指數(shù)模型分析計算。IVIM-MRI技術(shù)就是通過將DWI成像技術(shù)掃描多個不同b值所獲取的水分子擴散數(shù)據(jù)，導(dǎo)入一系列高斯彌散及非高斯彌散理論公式進行運算，從而計算出相應(yīng)的擴散系數(shù)D(slowD)、灌注因子f以及由于灌注因素導(dǎo)致的偽擴散系數(shù)D*(fast D)等參數(shù)。最后對這些參數(shù)進行定量分析，明確組織內(nèi)水分子擴散情況，判斷組織性質(zhì)，明確診斷。本研究重點分析以彌散系數(shù)D、灌注因子f等IVIM-MRI參數(shù)與病理之間的相關(guān)性，探討其在診斷前列腺癌及評估其惡性程度、預(yù)后的應(yīng)用價值。 二、目的 分析體素內(nèi)無規(guī)則運動核磁成像技術(shù)（intravoxel incoherent motion MRimaging，IVIM-MRI）主要參數(shù)擴散系數(shù)D(slow D)、灌注因子f與前列腺病理診斷的相關(guān)性，探討其在診斷前列腺癌與評估其惡性程度及預(yù)后的應(yīng)用價值。 三、方法 計算、分析41例前列腺癌患者IVIM-MRI參數(shù)擴散系數(shù)D及灌注因子f，結(jié)合病理結(jié)果分別對比良性增生組織及腫瘤組織兩組與中高危組及低危組兩組之間的區(qū)別。 所有的測量值均采用平均值±標準差的形式表達。采用SPSS13.0統(tǒng)計軟件處理，組間計量資料的比較采用兩樣本均數(shù)t檢驗，α=0.05。 四、結(jié)果 1、41例前列腺癌患者的DWI及IVIM-MRI相關(guān)參數(shù)中，ADC值（1.616±0.391vs0.775±0.309×10-3mm2/s）和D值（1.323±0.312vs0.547±0.341×10-3mm2/s）在良性增生組織與腫瘤組織兩組之間均表現(xiàn)出了顯著性差異（p0.05）。對于良性增生組織與腫瘤組織中f值的研究則更為有趣。本研究發(fā)現(xiàn)，在包含b=800s/mm2所得數(shù)據(jù)時，良性增生組織與腫瘤組織之間的f值（43.359±37.983vs33.492±23.079%）并不具備顯著性差異（p＞0.05）。只有將b=800s/mm2所得數(shù)據(jù)剔除之后，良性增生組織與腫瘤組織的f值（5.837±3.679vs10.983±7.814%）之間的差異才具有統(tǒng)計學(xué)意義（p0.05）。 2、41例前列腺癌患者的DCE-MRI及IVIM-MRI相關(guān)參數(shù)中，Ktrans值（0.296±0.121vs0.526±0.213min-1）、Ve值（29.631±13.472vs41.569±12.334%）和V值（4.737±2.958vs8.397±6.648%）均與D值、f值（剔除b=800s/mm2P的數(shù)據(jù)之后）一樣在良性增生組織與腫瘤組織兩組間表現(xiàn)出了顯著性差異（p0.05）。并且，IVIM-MRI技術(shù)得到的f值與DCE-MRI技術(shù)參數(shù)Ktrans及VP存在弱正相關(guān)性。 3、在中高危組及低危組的各項相關(guān)參數(shù)之中，僅擴散系數(shù)D值（0.513±0.183vs0.735±0.251×10-3mm2/s）如同同樣代表組織內(nèi)水分子擴散能力的DWI參數(shù)ADC值（0.623±0.142vs0.947±0.103×10-3mm2/s）一樣在兩組間表現(xiàn)出了顯著性差異（p0.05）。檢測組織灌注情況的DCE-MRI各項參數(shù)：Ktrans值（0.562±0.032vs0.507±0.113min-1）、Ve值（39.872±13.637vs37.981±12.739%）和VP值（9.033±7.218vs8.395±6.721%）在兩組之間無顯著性差異（p＞0.05）。同樣值得一提的是，無論包含或剔除b=800s/mm2所測數(shù)據(jù)，f值（包含b=800s/mm2所測數(shù)據(jù)：26.946±15.152vs37.425±19.023%；剔除b=800s/mm2所測數(shù)據(jù)：3.753±3.788vs6.782±6.351%）均沒有如期待中的一樣表現(xiàn)出具有統(tǒng)計學(xué)意義的差異（p＞0.05）。 五、結(jié)論 1、IVIM-MRI參數(shù)中的擴散系數(shù)D和灌注因子f (剔除b=800s/mm2數(shù)據(jù))在腫瘤組織與良性增生組織之間的差異均具有統(tǒng)計學(xué)意義（p 0.05）。對比良性增生組織，在腫瘤組織中，彌散系數(shù)D明顯降低，灌注分數(shù)f則明顯升高，這兩個參數(shù)可能成為一個潛在的前列腺癌鑒別標志。 2、彌散系數(shù)D在中高度惡性腫瘤與低度惡性腫瘤具有顯著性差異，它的降低與腫瘤的惡性程度具有正相關(guān)關(guān)系。 總之，在選取合適的b值后，IVIM-MRI成像技術(shù)可合并到現(xiàn)有的MRI檢查體系中來提高診斷前列腺癌的準確率，并可幫助判斷預(yù)后、減少或消除對比劑的使用及縮短檢查時間。
[Abstract]:First, research background
In the world, the incidence of prostate cancer (PCa) is second in all male malignant tumors. In the United States, the incidence of prostate cancer has exceeded lung cancer and has become the number one tumor that endangers male health. In Asian countries such as China, the population growth, the aging of the population and people's living habits in the Asian countries and so on in our country The rate of morbidity and mortality increased year by year.
The majority of the prostate cancer patients are elderly men, more than 95% of the patients have a clear age of 45~89 years of age, more than 70% of the prostate cancer patients are older than 65, the average age is 72 years and the peak age is 75~79 years. In recent years, the age of the prostate cancer is becoming more and more young. From the perspective of disease, the incidence of people over 65 years of age continues to rise.
The histologic diagnosis of prostate cancer is based on the following two criteria: changes in tissue structure under low magnification and microscopically under microscope. In prostate cancer, more than 95% are adenocarcinoma derived from acinar epithelium, and the good location is the peripheral zone (75%). The transitional zone (20%) and the central band (5%).85% are multicentric adenocarcinoma, which may be a tumor The outcome of the internal metastases of the prostate is common in the peripheral zone.
Because of its high accuracy in judging the prognosis and curative effect of the patients, and having the advantages of strong repeatability and simple operation, Gleason classification is the most widely used pathological classification of prostate cancer in clinic. This method uses the degree of differentiation of glands and the growth mode of tumor in the interstitial as the standard of tumor classification. In order to evaluate the malignancy degree of the tumor, the.Gleason classification method is mainly to observe the changes of the tissue structure under the low and medium size microscope, not to judge the morphology of the individual tumor cells, and at the same time take into account the variation of the tissue structure in different regions of the tumor.
In clinical practice, prostate cancer is insidious, and some patients are even undiscovered when they are undergoing prostatic resection or open surgery. Early prostate cancer lacks specific symptoms. Only when the tumor invades or obstruct the urethra or (and) the neck of the bladder, the lower urinary tract irritation or (and) obstruction or even acute urine occurs. Acute lower urinary tract symptoms such as retention, hematuria, and urinary incontinence. Advanced patients have bone metastases of prostate cancer, complicated with bone pain, pathological fractures, anemia, and spinal cord compression leading to lower limb paralysis. In general, the early clinical symptoms of prostate cancer and benign prostatic hyperplasia (benign prostatehyperplasia, BPH) Urinary dysfunction is the main cause. Late clinical manifestations are mainly related to local infiltration or distant metastasis of tumor tissue.
The diagnosis of prostate cancer, especially the early diagnosis of prostate cancer, is still a major clinical problem because of its insidious disease. Therefore, it is of great significance to improve the diagnostic method of prostate cancer.
In the current clinical work, PSA detection (digital rectal examination, DRE) and transrectal prostate ultrasound (transrectal ultrasonography, TRUS) are included in the early screening for prostate cancer as an early screening indicator for normal physical examination in middle-aged and elderly men over 50 years of age. If abnormal, ultrasound (or NMR) is guided Transrectal prostate biopsy is the next step. Histopathological examination of prostate biopsy is the gold standard for the diagnosis of prostate cancer, but for a variety of reasons, the examination remains 15% to 34% false negative. The question is more prominent when highly suspected canceration and lack of pathological evidence. In this case, magnetic resonance imaging (MA Gnetic resonance imaging MRI can provide help for its high resolution and multi sequence multi parameter imaging system in three-dimensional space and soft tissue contrast.
MRI is recognized as the best imaging diagnostic technique for the current clinical prostate cancer. In recent years, as a basic sequence, T2 weighted imaging (T2-weighted imaging, T2WI) has been widely used in conventional prostate MRI morphological examination. On T2WI images, the central and migrating bands of normal anterior glands show low signal, but outside of the normal gland. The typical manifestation of the prostate cancer is the low signal defect area in the peripheral zone of the high signal. However, the diagnosis of the tumor in the peripheral zone will be affected by the factors such as postbiopsy bleeding, benign prostatic hyperplasia and prostatitis, while the greater challenge comes from the tumor in the central and the transitional zone. Diagnosis is made because the nodule in this area will overlap with the signal intensity of benign gland tissue.
At the same time, in MR functional imaging, dynamic contrastenhanced MRI (DCE-MRI), diffusion weighted imaging (diffusion weighted imaging, DWI) and MR spectral imaging (magnetic resonance) have made great progress, which further improved the accuracy of the diagnosis of prostate cancer. In recent years, on the basis of DWI technology, the intravoxel incoherent motion MR imaging (IVIM-MRI), which can more accurately analyze the diffusion of water molecules in tissue, has also received extensive attention in the field of diagnosis of prostate cancer.
IVIM imaging technology has been developed for more than 20 years in nervous system examination. It can be more comprehensive and accurate to analyze the true diffusion of water molecules in the imaging region. At present, there are many clinical IVIM imaging techniques, calculation methods, and the most commonly used double exponential model analysis and calculation.IVIM-MRI technology is through the DWI A series of Gauss dispersion and non Gauss dispersion theory formulas are introduced to calculate the water molecular diffusion data obtained by several different b values. The corresponding diffusion coefficient D (slowD), perfusion factor F, and the pseudo diffusion coefficient D* (fast D) caused by the perfusion factor are calculated. In this study, we analyzed the correlation between IVIM-MRI parameters such as diffusion coefficient D, perfusion factor F and pathology, and discussed the value of the diagnosis of prostate cancer and the evaluation of its malignant degree and prognosis.
Two, the purpose
The correlation between the main parameter diffusion coefficient D (slow D) of intravoxel incoherent motion MRimaging (IVIM-MRI), the perfusion factor F and the pathological diagnosis of the prostate was analyzed, and the value of its application in the diagnosis of prostate cancer and the assessment of its malignancy and precondition was discussed.
Three, method
The diffusion coefficient D and perfusion factor F of IVIM-MRI in 41 patients with prostate cancer were analyzed. The difference between the two groups of benign hyperplastic tissues and tumor tissues and the two groups in the middle risk group and the low risk group were compared with the pathological results.
All the measured values were expressed in the form of mean standard deviation. SPSS13.0 statistical software was used to deal with the data. The comparison of the data between groups was compared with two samples, t test, and alpha =0.05..
Four, the result
In the DWI and IVIM-MRI related parameters of 1,41 patients with prostate cancer, the ADC value (1.616 + 0.391vs0.775 + 0.309 x 10-3mm2/s) and D value (1.323 + 0.312vs0.547 + 0.341 x 10-3mm2/s) showed significant difference between the benign proliferative tissue and the tumor tissue (P0.05). The study on the benign proliferative tissue and the f value in the tumor tissue was more important. It was found that the value of F (43.359 + 37.983vs33.492 + 23.079%) between benign hyperplastic tissue and tumor tissue was not significantly different (P > 0.05) when the data included b=800s/mm2 (P > 0.05). Only after the elimination of the data obtained from b=800s/mm2, the F value of benign hyperplastic tissue and tumor tissue was (5.837 + 3.679vs10.983 + 7.814%). The difference was statistically significant (P0.05).
In the DCE-MRI and IVIM-MRI related parameters of 2,41 cases, the value of Ktrans (0.296 + 0.121vs0.526 + 0.213min-1), Ve value (29.631 + 13.472vs41.569 + 12.334%) and V value (4.737 + 2.958vs8.397 + 6.648%) were all with D. The F values (after eliminating the data) showed significant difference between the benign hyperplasia and the tumor tissue two groups. Sex difference (P0.05). Moreover, the F value obtained by IVIM-MRI technology is weakly positively correlated with DCE-MRI technical parameters Ktrans and VP.
3, among the relevant parameters of middle and high risk group and low risk group, only the D value of diffusion coefficient (0.513 + 0.183vs0.735 + 0.251 x 10-3mm2/s) shows significant difference (P0.05) like the ADC value of DWI parameter (0.623 + 0.142vs0.947 + 0.103 * 10-3mm2/s) that also represents the diffusion capacity of water molecules in the tissue (P0.05). The parameters of DCE-MRI: Ktrans value (0.562 + 0.032vs0.507 + 0.113min-1), Ve value (39.872 + 13.637vs37.981 + 12.739%) and VP value (9.033 + 7.218vs8.395 + 6.721%) have no significant difference between the two groups (P > 0.05). It is also worth mentioning that the F values (26.946) are included or excluded from the b= 800s/mm2 data. 15.152vs37.425 + 19.023%, excluding the data measured by b=800s/mm2: 3.753 + 3.788vs6.782 + 6.351%) did not show a statistically significant difference as expected (P > 0.05).
Five. Conclusion
1, the difference between the diffusion coefficient D and the perfusion factor f (b=800s/mm2 data) in the IVIM-MRI parameters was statistically significant between the tumor tissue and the benign hyperplastic tissue (P 0.05). In the benign hyperplasia tissue, the dispersion coefficient D decreased significantly in the tumor tissue and the perfusion fraction f increased significantly, and these two parameters may become a potential one. Identification of prostate cancer.
2, the diffusion coefficient D has significant difference between the middle and high malignant tumor and the low malignant tumor, and its decrease is positively correlated with the malignancy degree of the tumor.
In summary, after selecting the appropriate b value, the IVIM-MRI imaging technique can be incorporated into the existing MRI examination system to improve the accuracy of the diagnosis of prostate cancer, and can help to judge the prognosis, reduce or eliminate the use of contrast agents and shorten the time of examination.
【學(xué)位授予單位】：第二軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R737.25

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相關(guān)期刊論文 前6條

1 陳敏;李春媚;;前列腺癌磁共振成像診斷要點與臨床治療方案選擇[J];磁共振成像;2011年03期

2 孫美玉;B. Turkbey;P.A. Pinto;H. Mani;M. Bernardo;Y.L. Mckinney;;3T MR多參數(shù)成像對前列腺癌檢測價值與病理組織學(xué)對照研究[J];國際醫(yī)學(xué)放射學(xué)雜志;2010年03期

3 T.Franiel;B.Hamm;H.Hricak;焦惠;;前列腺癌的MR動態(tài)增強成像和藥代動力學(xué)模型[J];國際醫(yī)學(xué)放射學(xué)雜志;2011年03期

4 B.Turkbey;V.P.Shah;M.Bernardo;J.Kruecker;唐光健;;表觀擴散系數(shù)與3T MRI所見前列腺癌臨床危險度評分的相關(guān)性研究[J];國際醫(yī)學(xué)放射學(xué)雜志;2011年02期

5 葉定偉;李長嶺;;前列腺癌發(fā)病趨勢的回顧和展望[J];中國癌癥雜志;2007年03期

6 曾洪武;王培軍;;磁共振擴散加權(quán)與彌散張量成像原理分析及比較[J];中國醫(yī)學(xué)影像技術(shù);2005年12期

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