本文選題：腦轉(zhuǎn)移瘤　切入點(diǎn)：磁共振成像　出處：《浙江大學(xué)》2016年博士論文　論文類型：學(xué)位論文

【摘要】：第一部分3D-BRAVO序列增強(qiáng)掃描在多發(fā)腦轉(zhuǎn)移瘤診斷中的價(jià)值背景和目的腦轉(zhuǎn)移瘤(BM)是顱內(nèi)最常見的腫瘤之一,隨著腫瘤系統(tǒng)治療的改善,影像學(xué)檢查方法的進(jìn)步,腦轉(zhuǎn)移瘤的檢出率增加。其中大約一半以上的腦轉(zhuǎn)移瘤患者為多發(fā)腦轉(zhuǎn)移瘤。目前多發(fā)腦轉(zhuǎn)移瘤的治療方案包括全腦放療(WBRT),立體定向放射外科治療(SRS),手術(shù),藥物治療等。準(zhǔn)確診斷是否存在腫瘤腦轉(zhuǎn)移、腦轉(zhuǎn)移病灶的數(shù)目、大小及部位,對于腦轉(zhuǎn)移患者的分級、治療方案的選擇、預(yù)后的評估都有著非常重要的價(jià)值。近年來,隨著SRS治療在多發(fā)腦轉(zhuǎn)移瘤治療中應(yīng)用的越來越多,通過影像學(xué)檢查精確的確定轉(zhuǎn)移瘤病灶的數(shù)目和大小顯得更為重要。目前臨床上對于可疑腦轉(zhuǎn)移瘤患者的常規(guī)檢查是MR平掃和二維T1加權(quán)增強(qiáng)掃描,三維容積增強(qiáng)掃描應(yīng)用相對較少。而三維顱腦容積磁共振成像(3D-BRAVO)序列采用薄層容積掃描,可明顯減少漏診、提高病灶檢出率。本研究擬通過對比3D-BRAVO序列增強(qiáng)與常規(guī)2D-T1WI增強(qiáng)在診斷多發(fā)腦轉(zhuǎn)移瘤病灶數(shù)目和大小的區(qū)別,探討3D-BRAVO增強(qiáng)掃描在多發(fā)腦轉(zhuǎn)移瘤診斷中的臨床價(jià)值。方法篩選臨床擬診為BM患者45例行頭顱MR平掃及增強(qiáng)檢查,增強(qiáng)掃描序列包括2D-T1WI、3D-BRAVO兩種,根據(jù)3D-BRAVO的圖像為判斷標(biāo)準(zhǔn),對診斷為多發(fā)腦轉(zhuǎn)移瘤的35例患者,分析兩種不同增強(qiáng)掃描方式在顯示的病灶數(shù)目,病灶大小上的區(qū)別。結(jié)果(1)病灶數(shù)目比較：在35例多發(fā)BM患者中,3D-BRAVO增強(qiáng)序列共發(fā)現(xiàn)175個(gè)病化,2D-T1WI增強(qiáng)序列共發(fā)現(xiàn)115個(gè)病灶(包括2個(gè)誤診病灶),以3D-BRAVO增強(qiáng)序列發(fā)現(xiàn)病灶個(gè)數(shù)為準(zhǔn),2D-T1WI增強(qiáng)發(fā)現(xiàn)病灶個(gè)數(shù)的靈敏度為64.57%,漏診率為35.43%。(2)病灶大小比較：本組病例中,以2D-T1WI增強(qiáng)掃描方式中所發(fā)現(xiàn)的113個(gè)病灶為準(zhǔn),測量對應(yīng)病灶在不同掃描方式中的大小,在2D-T1WI增強(qiáng)中所測病灶平均大小為12.06±9.29mm,3D-BRAVO增強(qiáng)中平均大小為12.96+9.75mm,利用配對資料的t檢查,在兩種掃描方式中所測病灶大小存在差異,3D-BRAVO增強(qiáng)序列所測病灶大小大于2D-T1WI增強(qiáng)。結(jié)論在多發(fā)腦轉(zhuǎn)移瘤的診斷中,3D-BRAVO增強(qiáng)掃描比常規(guī)2D-T1WI增強(qiáng)更敏感,能更好地發(fā)現(xiàn)微小轉(zhuǎn)移灶,可以成為腦轉(zhuǎn)移瘤的常規(guī)掃描方式。第二部分238例多發(fā)腦轉(zhuǎn)移瘤立體定向放射外科治療的療效和預(yù)后分析背景和目的腦轉(zhuǎn)移瘤(BM)是指軀體其他部位的惡性腫瘤轉(zhuǎn)移到顱內(nèi),大約20%40%的惡性腫瘤患者會出現(xiàn)腦轉(zhuǎn)移。調(diào)查發(fā)現(xiàn)有超過一半以上的腦轉(zhuǎn)移瘤患者為多發(fā)腦轉(zhuǎn)移瘤。多發(fā)腦轉(zhuǎn)移瘤一般進(jìn)展迅速,預(yù)后差。多發(fā)腦轉(zhuǎn)移瘤的治療在腦轉(zhuǎn)移的治療中占有重要的地位。近年來立體定向放射外科(SRS)在顱內(nèi)轉(zhuǎn)移瘤治療中的運(yùn)用越來越多。但是對于多發(fā)腦轉(zhuǎn)移瘤來說是否適合采取單獨(dú)SRS治療,有無必要聯(lián)合WBRT治療,以及WBRT治療失敗后行挽救性SRS治療是否安全有效等還存在一定爭議,有必要進(jìn)行進(jìn)一步研究總結(jié)。本研究擬通過對238例SRS治療多發(fā)腦轉(zhuǎn)移瘤的回顧性分析,探討SRS治療多發(fā)腦轉(zhuǎn)移瘤的療效以及影響預(yù)后的因素。方法回顧性分析我院2011年8月至2014年12月238例采用SRS治療的多發(fā)腦轉(zhuǎn)移瘤患者,其中SRS治療組共191例,聯(lián)合組22例,SRS挽救組25例。應(yīng)用Kaplan-Meier計(jì)算生存時(shí)間,Log rank法進(jìn)行單因素分析,Cox回歸模型進(jìn)行多因素分析研究各因素對預(yù)后的影響,p0.05為差異有統(tǒng)計(jì)學(xué)意義。結(jié)果238例患者隨訪中位時(shí)間13個(gè)月(2-54),3例失訪,隨訪率為98.7%。全組伽瑪?shù)吨委熀?月局部控制率為88.3%。總的中位生存期為13個(gè)月。單純SRS組、聯(lián)合組、挽救組中位生存期分別為14、10、10個(gè)月(X2=6.818,P=0.033)。全組1年的生存率、2年生存率分別為53.9%,12.3%。單因素分析顯示影響總生存率的預(yù)后因素有：治療方式、顱外病變控制與否、KPS評分,RPA分級。多因素分析顯示KPS評分、顱外病變控制與否影響生存,RPA分級是生存的獨(dú)立預(yù)后因素。結(jié)論SRS對多發(fā)腦轉(zhuǎn)移有較好療效,單純伽瑪?shù)吨委熀吐?lián)合全腦放療的生存無差異,多因素分析顯示KPS評分,顱外疾病控制與否是影響患者生存期的獨(dú)立的因素。而RPA分級、是生存的獨(dú)立預(yù)后因素。第三部分單獨(dú)伽瑪?shù)读Ⅲw定向放射外科治療多發(fā)腦轉(zhuǎn)移瘤的療效分析目的評估單獨(dú)采用伽瑪?shù)斗派渫饪浦委煻喟l(fā)腦轉(zhuǎn)移瘤的療效及其影響因素。方法191例多發(fā)腦轉(zhuǎn)移瘤病人單獨(dú)接受伽瑪?shù)斗派渫饪浦委�。平均腦轉(zhuǎn)移瘤的個(gè)數(shù)為6.1個(gè)(2-26個(gè)),平均腫瘤總體積為58 cm3 (0.03～26.5cm3),平均邊緣劑量為20.5 Gy,其中2-4個(gè)病灶組105例(55.0%),5～10個(gè)組54例(28.3%),≥11個(gè)組32例(16.7%)。結(jié)果191例患者隨訪中位時(shí)間14個(gè)月(4-54),全組患者伽瑪?shù)吨委熀?月腫瘤局部控制率為88.1%。總的中位生存期為14個(gè)月,2～4個(gè)組、5～10個(gè)組、≥11個(gè)組中位生存期分別為14月、13月和13個(gè)月(P=0.683),統(tǒng)計(jì)學(xué)無差異。全組1年的生存率、2年生存率分別為53.9%,12.3%。單因素和多因素分析顯示影響總生存率的預(yù)后因素有：顱外病變控制與否、KPS評分,RPA分級。結(jié)論單獨(dú)SRS對多發(fā)腦轉(zhuǎn)移有較好療效,2～4個(gè)病灶組,5-10個(gè)組,≥11個(gè)組的中位生存期無差別,治療后顱內(nèi)遠(yuǎn)處轉(zhuǎn)移率及急慢性放療副反應(yīng)之間亦無差異,結(jié)合文獻(xiàn)我們認(rèn)為對于2～10病灶的多發(fā)腦轉(zhuǎn)移瘤可以單獨(dú)采用SRS治療。多因素分析顯示KPS評分,顱外疾病控制與否及RPA分級是影響患者生存的預(yù)后的因素。
[Abstract]:The first part of 3D-BRAVO sequence scan in multiple brain metastases background and objective brain metastases (BM) is one of the most common intracranial tumor, with the treatment of improving tumor system, imaging methods progress, increase the rate of detection of brain metastases. Of which about half of the patients with brain metastases for multiple brain metastases. The treatment of multiple brain metastases tumors including whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), surgery, drug treatment. The existence of accurate diagnosis of brain metastasis, number of metastatic brain lesions, size and location, in patients with brain metastasis classification. The choice of treatment and prognosis assessment has a very important value. In recent years, with the increasing application of SRS in the treatment of metastatic tumor in the treatment of multiple brain metastases, number of lesions and confirmed by imaging precision The size is more important. The current clinical routine examination for suspected brain metastasis in patients with MR scan and T1 weighted scan two-dimensional, three-dimensional volume scan application is relatively small. And the 3D brain volume of magnetic resonance imaging (3D-BRAVO) sequence by scanning, can significantly reduce the misdiagnosis, improve the detection rate of lesions. This study intends to enhance and conventional enhanced 2D-T1WI in diagnosis of multiple brain metastases from the number and size of tumor by comparing the 3D-BRAVO sequence, to explore the clinical value of 3D-BRAVO scan in the diagnosis of metastatic tumors in multiple brain. Method of screening of clinically diagnosed BM patients 45 cases were examined by plain and enhanced MR scan enhanced scan sequence including 2D-T1WI, 3D-BRAVO two, according to the 3D-BRAVO image as the judgment standard, 35 cases of diagnosed multiple brain metastasis patients, analysis of two different ways in the enhanced scan of the lesion showed the number of The difference between the lesion size, number of lesions (1). The results of comparison: in 35 cases of multiple BM patients, enhanced 3D-BRAVO sequences were found in 175 patients, enhanced 2D-T1WI sequences were found in 115 lesions (including 2 misdiagnosed lesions), with the enhanced 3D-BRAVO sequence number of lesions were found to prevail, enhanced 2D-T1WI the sensitivity number of lesions was 64.57%, the misdiagnosis rate was 35.43%. (2): the size of the lesions in this group of cases, 113 lesions were found in 2D-T1WI enhancement scanning in the subject, measure the corresponding lesions in different scanning modes in size, in the 2D-T1WI enhancement of the measured mean lesion size was 12.06 + 9.29mm, 3D-BRAVO enhanced the average size of 12.96+9.75mm, using the paired t examination in two scanning modes in the lesion size differences, 3D-BRAVO enhanced sequence the lesion size is greater than 2D-T1WI. Conclusion the diagnosis of metastatic tumor enhancement in multiple brain In the 3D-BRAVO scan is more sensitive than conventional 2D-T1WI enhanced, can better detect micrometastasis can become a routine scanning of brain metastases. In the second part, 238 cases of multiple brain metastatic tumor treatment of stereotactic radiosurgery treatment results and prognostic analysis of background and objective brain metastases (BM) refers to other parts of the body malignant tumor metastasis to the intracranial malignant tumor patients about 20%40% develop brain metastases. The survey found that more than half of the patients with brain metastases for multiple brain metastases. Multiple brain metastasis and poor prognosis. The general progress rapidly, plays an important role in the treatment of brain metastasis in multiple brain metastasis therapy in recent years, stereotactic radiosurgery (SRS) in the treatment of intracranial metastatic tumor in the use of more and more. But it is suitable for tumor take SRS for multiple brain metastasis, there is no need to combined with WBRT treatment After the rescue SRS therapy is safe and effective, there is still a controversial failure and WBRT treatment, it is necessary to carry out further research. This study by retrospective analysis of 238 cases of SRS treatment of multiple brain metastases, SRS on treatment of multiple brain metastases and prognostic factors. Methods: a retrospective analysis in our hospital from August 2011 to December 2014, 238 cases of metastatic SRS treated multiple brain tumor patients, the SRS total of 191 cases of treatment group, combined group of 22 cases, 25 cases of SRS rescue group. Kaplan-Meier is used to calculate the survival time of single factor analysis and Log rank method, Cox regression model to analyze the effect of different factors on prognosis multi factor P0.05, the difference was statistically significant. The time of 13 months follow-up of 238 patients (2-54), 3 cases were lost, follow-up rate of 98.7%. group after gamma knife treatment in June, the local control rate was 88.3%. in the total students The storage period is 13 months. The pure SRS group, combination group, save the median survival time was 14,10,10 months (X2=6.818, P=0.033). The overall 1 year survival rate, 2 year survival rates were 53.9%, single factor 12.3%. analysis showed that the prognostic factors affecting overall survival rate: treatment. Extracranial lesions control or not, KPS score, RPA grade. Multivariate analysis showed that KPS score, extracranial lesions control and affect survival, RPA classification were independent prognostic factors. Conclusion SRS has a better therapeutic effect on multiple brain metastases, single gamma knife combined with whole brain radiotherapy treatment and survival had no significant difference. Multivariate analysis showed that KPS score, extracranial disease control is the independent influence factors for survival. The RPA classification was an independent prognostic factor for survival. Analysis and evaluation of curative effect of third mesh part alone stereotactic gamma knife radiosurgery for the treatment of multiple brain metastases alone. 鐢ㄤ冀鐜涘垁鏀懼皠澶栫娌葷枟澶氬彂鑴戣漿縐葷槫鐨勭枟鏁堝強(qiáng)鍏跺獎(jiǎng)鍝嶅洜绱，

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