本文選題：腦膠質(zhì)瘤 + 磁共振灌注成像�。� 參考：《鄭州大學(xué)》2017年碩士論文

【摘要】：背景和目的腦膠質(zhì)瘤(brain glioma,BG)是最初起源于神經(jīng)上皮組織膠質(zhì)細(xì)胞的腫瘤,為最常見的腦部原發(fā)性惡性腫瘤,約占所有顱內(nèi)腫瘤的50%以上。BG可以發(fā)生于任何年齡階段,兒童主要發(fā)生于顱底和中線區(qū),多為毛細(xì)胞星形細(xì)胞瘤和室管膜瘤等;成人則以大腦半球腫瘤多見,如星形細(xì)胞瘤、膠母細(xì)胞瘤、室管膜瘤等。BG的臨床表現(xiàn)可分為以顱內(nèi)壓增高引發(fā)的頭痛、惡心、嘔吐及視乳頭水腫等癥狀和以神經(jīng)功能損害引起的肢體運(yùn)動障礙、偏盲及癲癇等兩大類癥狀。不同級別的BG的治療方案和臨床預(yù)后差別很大,因此,手術(shù)前準(zhǔn)確判斷BG的病理級別對治療方案的設(shè)計(jì)、手術(shù)計(jì)劃的確定,術(shù)后放化療措施的制定及評估預(yù)后有顯著的臨床意義�；颊咭坏┏霈F(xiàn)臨床癥狀后,就診時(shí)常規(guī)檢查包括頭顱計(jì)算機(jī)斷層掃描(Computed Tomography,CT)和核磁共振成像(Magnetic Resonance Imaging,MRI)。頭顱CT只是初步判定是否存在著顱內(nèi)占位,而MRI在顯示BG的特點(diǎn)和性質(zhì)方面明顯優(yōu)于CT檢查,故MRI已經(jīng)成為評價(jià)BG的首選影像學(xué)檢查方法并已獲得臨床上的認(rèn)可,而BG的術(shù)前準(zhǔn)確分級往往只依靠常規(guī)MRI檢查往往是不夠的。腫瘤的惡性程度與微血管結(jié)構(gòu)、腫瘤細(xì)胞增殖性有很大的關(guān)系,所以準(zhǔn)確地評估BG血管生成情況對鑒定其惡性程度有著重要的意義。由于BG具有富血管性,其血管結(jié)構(gòu)和正常腦組織血管結(jié)構(gòu)有明顯的差異,表現(xiàn)在固有腦血管與新生血管兩方面;BG的新生血管具有密度大、嚴(yán)重異型扭曲以及血管內(nèi)徑均勻性差的特點(diǎn),因此,新生血管的活躍程度是評價(jià)BG惡性程度的重要指標(biāo),這就給磁共振灌注成像(perfusion weighted imaging,PWI)對BG的診斷、分級及鑒別診斷提供了理論基礎(chǔ)�；谑聚檶Ρ葎┰淼牟煌�,目前臨床上應(yīng)用的灌注技術(shù)分為:經(jīng)靜脈快速團(tuán)注外源性對比劑后,根據(jù)其影響縱向馳豫的是T1-加權(quán)動態(tài)對比增強(qiáng)(dynamic contrast-enhanced,DCE)成像技術(shù)(DCE-MRI)以及影響橫向馳豫的是T_2*/T_2加權(quán)動態(tài)磁敏感對比(dynamic susceptibility contrast,DSC)灌注加權(quán)成像(DSC-PWI);不需要團(tuán)注外源性示蹤劑、以水質(zhì)子作為自身內(nèi)源性示蹤劑的動態(tài)自旋標(biāo)志灌注加權(quán)成像(ASL-PWI)技術(shù)。本研究通過對比DCE-MRI、DSC-PWI與3D-ASL三種灌注技術(shù)的各種參數(shù)在BG病理分級中的價(jià)值,探討這三種技術(shù)的應(yīng)用優(yōu)勢及不足之處,為BG的術(shù)前診斷和病理分級提供新的思路。資料與方法1研究對象:搜集納入鄭州大學(xué)第一附屬醫(yī)院從2015年9月至2016年5月期間內(nèi)首發(fā)的臨床資料完整的經(jīng)常規(guī)影像學(xué)檢查發(fā)現(xiàn)腦實(shí)質(zhì)內(nèi)占位病變的患者為研究對象。術(shù)后證實(shí)為BG患者82例,其中行DCE-MRI掃描的共45例,DSC-PWI掃描的共37例,所有患者均行3D-ASL掃描。術(shù)后病理根據(jù)2016 WHO CNS腫瘤新分類標(biāo)準(zhǔn)進(jìn)行了分級。所有患者均在鄭大一附院神經(jīng)外科手術(shù),獲得的手術(shù)標(biāo)本由本院病理科兩位資深病理專家共同確定BG種類及分級,其中Ⅰ級和Ⅱ級為低級別膠質(zhì)瘤(low grade glioma,LGG),Ⅲ級和Ⅳ級為高級別膠質(zhì)瘤(high grade glioma,HGG)。使用德國Siemens公司3.0T Prasima超導(dǎo)磁共振掃描儀和64通道專用頭頸聯(lián)合專用線圈及配套專用高壓注射器。MRI對比劑為釓噴酸葡胺注射液(Gd-DTPA),商品名:馬根維顯,注射速度均為4ml/s。2方法掃描序列:1 常規(guī)MRI平掃:T1WI、T_2WI、T_2flair軸位、T1WI矢狀位、DWI;2 3D-ASL-PWI;3 DCE-MRI或DSC-PWI序列檢查。(4)增強(qiáng)后T1FLAR軸矢冠掃描。3圖像的處理將獲得的所有原始的灌注數(shù)據(jù)導(dǎo)入Siemens Syngo.via后處理工作站,采用MRI Perfusion軟件進(jìn)行后處理。由三位高年資磁共振科醫(yī)師分別選擇ROI,進(jìn)而得到興趣區(qū)域的定量值。4數(shù)據(jù)處理本研究82例BG患者的灌注成像資料和數(shù)據(jù)應(yīng)用了SPSS 22.0軟件包進(jìn)行統(tǒng)計(jì)學(xué)分析,實(shí)驗(yàn)數(shù)據(jù)采用均數(shù)±標(biāo)準(zhǔn)差((x|-)±s)表示,多組間參數(shù)的比較采用單因素方差分析,組間兩兩比較,采用LSD-t(Least—Significant Difference)檢驗(yàn)。最后采用受試者工作特征(ROC)曲線進(jìn)行統(tǒng)計(jì)學(xué)分析,獲得HGG與LGG的最佳灌注鑒別診斷閾值及相應(yīng)的敏感性、特異性、準(zhǔn)確度,用以判斷相應(yīng)的診斷效能。結(jié)果1、掃描DCE-MRI的45例患者中,HGG的平均Ktrans值與Ve值均明顯高于LGG(P0.01)。根據(jù)單因素方差分析顯示平均Ktrans及Ve值在Ⅱ級和Ⅲ級、Ⅱ級和Ⅳ級之間均有著顯著的統(tǒng)計(jì)學(xué)差異(P0.01),而Ⅲ級和Ⅳ級之間的沒有統(tǒng)計(jì)學(xué)意義(P0.05)。2、掃描DSC-PWI的37例患者中,HGG的r CBV與r CBF值均明顯高于LGG(P0.01)。根據(jù)單因素方差分析Ⅱ級和Ⅲ級、Ⅱ級和Ⅳ級,Ⅲ級和Ⅳ級之間的r CBV和r CBF值均具有明顯的統(tǒng)計(jì)學(xué)差異(P0.01)。3、掃描3D-ASL的82例患者中,在ASL灌注成像的腦血流圖中,腫瘤各項(xiàng)相對血流量灌注指數(shù)TBFmax/對側(cè)半球、對側(cè)白質(zhì)、對側(cè)灰質(zhì)的CBF在高、低級別BG之間有著顯著的統(tǒng)計(jì)學(xué)的差異(P0.01)。4、同時(shí)掃描DSC與ASL的37例患者中,在ASL與PWI灌注成像的腦血流圖中,腫瘤各項(xiàng)相對血流量灌注指數(shù)TBFmax/對側(cè)半球、對側(cè)白質(zhì)、對側(cè)灰質(zhì)的CBF之間沒有的統(tǒng)計(jì)學(xué)意義(P0.05)。5、繪制HGG與LGG的Ktrans值、Ve值、r CBV和r CBF的ROC曲線,可分別獲得的4個(gè)的AUG分別是:0.912、0.879、0.999、0.997。依據(jù)約登指數(shù),可獲得Ktrans、Ve、r CBV和r CBF鑒別HGG與LGG的最佳閾值分別為0.059/min-1、0.357、2.152、2.11;根據(jù)此閾值獲得各個(gè)參數(shù)意見別HGG與LGG的敏感度和特異性,各個(gè)參數(shù)鑒別的敏感度分別為96.4%、93.7%、99.4%、97.4%;特異性分別為84.75%、73.2%、98.2%、95.2%。結(jié)論1、三種MRI灌注技術(shù)均能準(zhǔn)確獲得腫瘤微血管的生長情況和血流動力學(xué)改變信息,對BG術(shù)前病理分級診斷有重要指導(dǎo)意義。2、DCE-MRI技術(shù)中測量出的Ktrans值、Ve值可以作為區(qū)分BG級別的定量指標(biāo)。但二者在鑒別Ⅲ級和Ⅳ級BG間不具有統(tǒng)計(jì)學(xué)差異,這說明了Ⅲ級和Ⅳ級BG的血管透通性相近。3、DSC-PWI技術(shù)中測量出的r CBV、r CBF值與BG的級別密切相關(guān),這可以說明r CBV值與r CBF值可以作為區(qū)分BG級別的定量指標(biāo)。4、3D-ASL與DSC-PWI技術(shù)具有一致的灌注效果,由于ASL安全無創(chuàng)、不用對比劑、可重復(fù)多次檢查,所以在BG腫瘤分級診斷中3D-ASL值得推廣。5、將BG的病理級別和不同的灌注參數(shù)進(jìn)行關(guān)聯(lián)比較時(shí),會發(fā)現(xiàn)r CBV是區(qū)分HGG與LGG最敏感的參數(shù)。
[Abstract]:Background and objective brain glioma (BG), the most common primary malignant tumor of the brain, is the most common primary malignant tumor of the brain, which is the most common primary malignant tumor of the brain. More than 50% of.BG in all intracranial tumors can occur at any age stage. Children mainly occur in the cranial and midline areas, mostly hair cell astrocytomas and ventricular tubes. The clinical manifestations of.BG in adults, such as astrocytoma, gellonoma, and ependymoma, can be divided into two major symptoms, such as headache, nausea, vomiting and papillematous edema caused by increased intracranial pressure, Limb Dyskinesia caused by neurologic impairment, hemiblindness and epilepsy. The treatment plan and the clinical prognosis of BG are very different. Therefore, it is significant to determine the pathological grade of BG before the operation for the design of the treatment plan, the determination of the operation plan, the formulation of the postoperative radiotherapy and chemotherapy measures and the evaluation of the prognosis. Puted Tomography, CT) and nuclear magnetic resonance imaging (Magnetic Resonance Imaging, MRI). Skull CT only preliminarily determines whether there is an intracranial space occupying position, and MRI is obviously superior to CT examination in showing the characteristics and properties of BG, so MRI has become the first choice imaging examination method and has obtained clinical approval, and the preoperative accuracy is accurate. The grade often depends on the conventional MRI examination. The malignancy of the tumor is closely related to the microvascular structure and the proliferation of the tumor cells. Therefore, it is of great significance to evaluate the angiogenesis of BG accurately for the identification of its malignancy. As BG is rich in blood vessel, its vascular structure and normal brain tissue have a vascular structure. The obvious difference is manifested in two aspects of the intrinsic cerebral vessels and the neovascularization; the BG's neovascularization has the characteristics of large density, severe abnormal pattern distortion and poor homogeneity of the blood vessel diameter. Therefore, the activity of the neovascularization is an important index for evaluating the degree of BG malignancy, which gives the perfusion weighted imaging (PWI) to BG. Diagnosis, classification and differential diagnosis provide a theoretical basis. Based on the principle of tracer contrast agent, the clinical application of perfusion technique is divided into: after intravenous rapid injection of exogenous contrast agent, the effect of the longitudinal relaxation is T1- weighted dynamic contrast enhancement (dynamic contrast-enhanced, DCE) imaging (DCE-MRI) and influence The transverse relaxation is T_2*/T_2 weighted dynamic magnetic sensitivity contrast (dynamic susceptibility contrast, DSC) perfusion weighted imaging (DSC-PWI); the dynamic spin marker perfusion weighted imaging (ASL-PWI) technology is not needed for the injection of exogenous tracers and water protons as their own endogenous tracer. This study compares DCE-MRI, DSC-PWI and 3D-ASL three. The value of various parameters of the perfusion technique in the BG pathological classification, to explore the advantages and disadvantages of the three techniques, and to provide new ideas for the preoperative diagnosis and pathological classification of BG. Data and methods 1 subjects were collected and included in the First Affiliated Hospital of Zhengzhou University from September 2015 to May 2016. The whole routine imaging examination found that the patients with cerebral parenchyma occupying lesions were studied. 82 cases of BG patients were confirmed after operation, including 45 cases with DCE-MRI scan, 37 cases of DSC-PWI scan, all patients underwent 3D-ASL scan. The postoperative pathology was classified according to the new classification criteria of 2016 WHO CNS tumor. All patients were in Zheng Dayi. The surgical specimens in the Department of neurosurgery were determined by two senior pathologists in the Department of pathology in our hospital together with the BG type and classification, among which grade I and grade II were low grade glioma (low grade glioma, LGG), grade III and IV were high grade gliomas (high grade glioma, HGG). The German Siemens company 3.0T Prasima superconducting magnetic resonance scan was used. The drawing instrument and 64 channel special head and neck joint special coil and matching special high pressure syringe.MRI contrast agent are Dimeglumine Gadopentetic Acid Injection (Gd-DTPA), commodity name: Ma root dimension show, the injection speed is 4ml/s.2 method scanning sequence: 1 conventional MRI plain scan: T1WI, T_2WI, T_2flair axis, T1WI sagittal, DWI; 2 3D-ASL-PWI; 3 DCE-MRI or DSC-PWI sequence inspection (4) all the original perfusion data obtained by the enhanced.3 image of the enhanced T1FLAR axis sagittal scan were introduced into the Siemens Syngo.via post processing workstation and the MRI Perfusion software was used for post-processing. ROI was selected by three senior senior magnetic resonance physicians respectively, and then 82 cases of BG suffering from the quantitative value.4 data processing in the region of interest were obtained. The perfusion imaging data and data were applied to the SPSS 22 software package for statistical analysis. The experimental data were represented by mean number + standard deviation (x|-) + s. The comparison of multiple groups of parameters was compared with single factor analysis of variance. 22 comparison between groups was compared with LSD-t (Least Significant Difference) test. Finally, the working feature (ROC) curve of the subjects was used. Statistical analysis was carried out to obtain the optimal threshold of HGG and LGG perfusion differential diagnosis and corresponding sensitivity, specificity and accuracy to determine the corresponding diagnostic efficiency. Results 1, the average Ktrans value and Ve value of HGG were significantly higher than that of LGG (P0.01) in the 45 cases of scanning DCE-MRI. The average Ktrans and Ve values were shown to be in II. There were significant statistical differences between grade II and grade II and grade IV (P0.01), but there was no statistical significance between grade III and IV (P0.05).2. In 37 patients with DSC-PWI, HGG R CBV and R CBF values were significantly higher than LGG (P0.01). The values of V and R CBF have significant statistical differences (P0.01).3. In the 82 patients with 3D-ASL, the relative blood flow perfusion index TBFmax/ to the lateral hemisphere, the contralateral white matter, the contralateral gray matter CBF is high, and the low grade BG has a significant difference (P0.01).4, simultaneously scanning the ASL perfusion imaging in the cerebral blood flow chart of ASL perfusion imaging. In the 37 patients with L, the relative blood flow perfusion index TBFmax/ to the lateral hemisphere, the contralateral white matter and the CBF of the side gray matter (P0.05).5 was not found in the cerebral blood flow chart of the perfusion imaging of ASL and PWI, and the Ktrans value of HGG and LGG, Ve, and the 4 of them were respectively: 79,0.999,0.997. can obtain Ktrans, Ve, R CBV and R CBF to identify HGG and LGG as 0.059/min-1,0.357,2.152,2.11, respectively. According to this threshold, the sensitivity and specificity of individual HGG and LGG are obtained, and the sensitivity of each parameter identification is 96.4%, 93.7%, 99.4%, 97.4%; the specificity is 84.75%, 7, respectively. 3.2%, 98.2%, 95.2%. conclusion 1, three kinds of MRI perfusion techniques can accurately obtain the growth of tumor microvessels and the information of hemodynamic changes. It has important guiding significance for the diagnosis of pathological grading before BG, Ktrans value measured in DCE-MRI technology, Ve value can be used as a quantitative index to distinguish BG grade, but the two is to distinguish grade III and grade IV BG. There is no statistical difference. This shows that the vascular permeability of grade III and grade IV BG is similar to that of.3. The R CBV and R CBF value in DSC-PWI technology are closely related to the level of BG. This shows that the R CBV value and R CBF value can be used as a quantitative index to distinguish the grade. Creation, without contrast agent, can be repeated multiple times, so in the BG tumor grading diagnosis, 3D-ASL is worth promoting.5. When comparing the pathological grade of BG with the different perfusion parameters, it will be found that R CBV is the most sensitive parameter to distinguish between HGG and LGG.

【學(xué)位授予單位】：鄭州大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2017
【分類號】：R445.2;R739.41
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本文編號：1792919