本文選題：體表惡性腫瘤 + Mohs��； 參考：《中國人民解放軍醫(yī)學(xué)院》2017年博士論文

【摘要】：研究背景及目的:各類非黑色素型體表惡性腫瘤是臨床常見疾病。傳統(tǒng)的手術(shù)擴大切除+分點切緣冰凍病理檢查漏檢率高,常導(dǎo)致臨床上病理回報“切緣干凈”病例腫瘤復(fù)發(fā)。Mohs顯微描記手術(shù)雖然可以完整檢查手術(shù)切緣,降低漏檢率,但由于技術(shù)固有局限,更適合應(yīng)用于面積較小的淺表惡性皮膚腫瘤,同時如何更準(zhǔn)確的確定Mohs手術(shù)的起始邊界目前仍存爭議。MRI已廣泛應(yīng)用于體內(nèi)軟組織的病變的影像學(xué)診斷,但卻很少用于各類體表惡性腫瘤檢查。本研究目的是通過對體表惡性腫瘤在MRI、大體標(biāo)本、病理之間的形態(tài)學(xué)特點和聯(lián)系,探索腫瘤個性化切除范圍的確定標(biāo)準(zhǔn),對臨床精準(zhǔn)切除腫瘤起到指導(dǎo)作用。方法:對臨床上不同類型的、直徑大于1cm的初發(fā)或復(fù)發(fā)體表非黑色素性惡性腫瘤患者,采用頭頸聯(lián)合或體部相控陣線圈進(jìn)行高分辨率薄層掃描,確定體表惡性腫瘤的優(yōu)化掃描方案。并將體表惡性腫瘤MRI影像與腫瘤切除后大體標(biāo)本和最終病理圖像資料進(jìn)行形態(tài)學(xué)比對。采用魚肝油乳劑體外標(biāo)記物進(jìn)行MRI影像學(xué)標(biāo)記,探索在MRI影像學(xué)指導(dǎo)下行體表惡性腫瘤精準(zhǔn)切除的可行性。結(jié)果:本組行MRI檢查的體表惡性腫瘤種類包含了臨床上常見的非黑色素性皮膚體表惡性腫瘤,包括基底細(xì)胞癌、皮膚鱗癌、皮膚纖維肉瘤,病灶在T1WI像與肌肉相比呈等信號或低信號,T2WI像呈高信號,均呈不同程度強化。對隆突性皮膚纖維肉瘤、惡性纖維肉瘤、梭形細(xì)胞肉瘤的瘤體大體邊界可見清晰顯影。對基底細(xì)胞癌皮膚細(xì)微構(gòu)造不能清晰辨別。本次對比研究共6組標(biāo)本,其中一例基底細(xì)胞癌因面積較小,在制作病理切片時切割破碎,故未完成比對。其它5例均成功實現(xiàn)腫瘤相同平面下MRI-大體標(biāo)本-病理的形態(tài)學(xué)比對。魚肝油乳劑體外標(biāo)記物在MRI顯影清晰。纖維肉瘤瘤體在M RI和病理圖像的厚度基本一致,在病理圖像上突破腫瘤實體邊界的瘤細(xì)胞浸潤區(qū)在T1WI對應(yīng)區(qū)域顯示為大小一致的低信號區(qū)。結(jié)論:①采用頭頸聯(lián)合或體部相控陣線圈進(jìn)行高分辨率薄層MRI掃表對團塊狀的非黑色素型體表惡性腫瘤有很好的成像效果,可以準(zhǔn)確客觀反映腫瘤實體的邊界,特別是對腫瘤累及深度反映比較準(zhǔn)確,并且對腫瘤的擴散浸潤區(qū)也有良好的提示作用,因此對術(shù)前判斷腫瘤的真實范圍有重要意義。但對基底細(xì)胞癌這種淺表腫瘤,顯像準(zhǔn)確度較差,難以對腫瘤的實體邊界做出準(zhǔn)確判斷。②通過嚴(yán)謹(jǐn)?shù)牟僮髁鞒?可以實現(xiàn)對體表惡性腫瘤MRI影像、大體標(biāo)本、病理切片的相同斷面的形態(tài)學(xué)對比研究。③通過魚肝油乳體外標(biāo)記,可以更加準(zhǔn)確的通過MRI確定腫瘤的實體邊界和擴散邊界在皮膚的投影位置,有助于確定手術(shù)切口的范圍。④不管是采用Mohs顯微描記手術(shù)還是傳統(tǒng)的擴大切除,起始手術(shù)切口的應(yīng)該是基于術(shù)前對腫瘤真實邊界的判斷而定,而不是根據(jù)腫瘤的體表范圍確定。
[Abstract]:Background and objective: various kinds of non-melanin type surface malignant tumors are common clinical diseases. The high rate of missed detection in frozen pathological examination of traditional extended excision, which often leads to the clinical pathological return of "clean margin" cases tumor recurrence .Mohs micrography surgery although it can completely check the surgical margin, reduce the rate of missed detection. However, due to the inherent limitations of the technique, it is more suitable to be applied to small superficial malignant skin tumors. At the same time, how to determine more accurately the starting boundary of Mohs surgery is still controversial. MRI has been widely used in the imaging diagnosis of soft tissue lesions in vivo. However, it is rarely used for the examination of various kinds of malignant tumors on the body surface. The purpose of this study was to explore the criteria for the determination of the range of tumor personalized resection by means of morphological features and connections among MRI, gross specimens and pathology of malignant tumors on the body surface, and to provide guidance for the accurate resection of tumors in clinical practice. Methods: patients with different types of primary or recurrent non-melanoma with diameter larger than 1cm were scanned with head and neck combined or body phased array coils with high resolution thin layer scanning. To determine the optimal scanning scheme for malignant tumor of body surface. The MRI images of body surface malignant tumors were compared with gross specimens and final pathological images. In order to explore the feasibility of accurate resection of malignant tumor of body surface under the guidance of MRI imaging, cod liver oil emulsion in vitro was used for MRI imaging. Results: the types of malignant tumors of body surface examined by MRI included malignant tumors of non-melanoma skin, including basal cell carcinoma, cutaneous squamous cell carcinoma, cutaneous fibrosarcoma. The lesions showed high signal intensity on T _ 1WI and hyperintensity on T _ 2WI compared with muscle. The gross boundary of Carina dermatofibrosarcoma, malignant fibrosarcoma and spindle cell sarcoma can be seen clearly. The fine structure of the skin of basal cell carcinoma can not be clearly distinguished. In this study, there were 6 groups of specimens. One case of basal cell carcinoma (BCC) was not compared because of its small area. The other 5 cases successfully achieved MRI-gross specimen-pathological morphological comparison under the same tumor plane. The in vitro labeling of cod liver oil emulsion was clear on MRI. The thickness of fibrosarcoma tumor was basically the same in RI and pathological images, and the infiltrating area of tumor cells which broke through the boundary of tumor entity on pathological image was shown to be a low signal region of the same size in the corresponding region on T1WI. Conclusion using head and neck joint or body phased array coils to perform high resolution thin-layer MRI scan has a good imaging effect on mass non-melanin type surface malignant tumor, and can accurately and objectively reflect the boundary of tumor entity. Especially, the depth of tumor involvement is more accurate, and it is also a good indication to the diffusive area of tumor, so it is important to judge the true range of tumor before operation. But for the superficial tumor of basal cell carcinoma, the imaging accuracy is poor, it is difficult to make accurate judgment on the solid boundary of tumor .2 through the rigorous operation procedure, we can realize the MRI image of body surface malignant tumor, gross specimen, Comparative study of Morphology of the same Section of pathological sections. 3. By in vitro labeling of cod liver oil emulsion, MRI can more accurately determine the projection position of the solid boundary and diffusion boundary of the tumor in the skin. To help determine the range of surgical incisions, whether using Mohs micrography or conventional extended resection, the initial incision should be based on preoperative judgment of the true boundary of the tumor. It is not based on the range of the body surface of the tumor.
【學(xué)位授予單位】：中國人民解放軍醫(yī)學(xué)院
【學(xué)位級別】：博士
【學(xué)位授予年份】：2017
【分類號】：R739.5

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