發(fā)布時間：2018-05-19 12:02

  本文選題：斷面解剖 + 松果體區(qū)腫瘤��； 參考：《第三軍醫(yī)大學(xué)》2014年碩士論文

【摘要】：背景 松果體區(qū)位置深在并且重要神經(jīng)結(jié)構(gòu)、頭部動、靜脈叢集中于此，因而實施松果體區(qū)的手術(shù)困難重重。熟悉松果體區(qū)的顯微解剖結(jié)構(gòu)及毗鄰關(guān)系，不但可以降低手術(shù)死亡率和病殘率，而且也能為臨床上松果體區(qū)腫瘤放療計劃的準(zhǔn)確制定和實施提供參考。目前，診斷松果體區(qū)腫瘤主要依靠CT或MRI圖像，其次就是根據(jù)病人的癥狀、年齡、性別以及腦脊液等輔助檢查來綜合作出診斷。CT、MRI對松果體區(qū)域腫瘤均比較敏感，無疑為選擇治療方案提供了很大的方便。但是就松果體這一復(fù)雜區(qū)域而言，目前的二維影像圖像已經(jīng)不能滿足于臨床需要，而在松果體這一區(qū)域，當(dāng)前國內(nèi)外在三維立體方面的研究甚少。本課題擬在斷層解剖學(xué)基礎(chǔ)上對松果體及毗鄰結(jié)構(gòu)進(jìn)行三維立體重建，為松果體區(qū)疾病的臨床影像診斷和治療提供形態(tài)學(xué)基礎(chǔ)。 其次松果體區(qū)腫瘤發(fā)病率雖低，但腫瘤病理構(gòu)成復(fù)雜，根據(jù)2007年世界衛(wèi)生組織CNS腫瘤病理分類，可分為4大類：生殖細(xì)胞瘤、松果體實質(zhì)腫瘤、神經(jīng)上皮腫瘤及其它來源腫瘤,細(xì)分又可分為不同的病理亞型，各病理類型或亞型的腫瘤治療方式及治愈后效果差異都很大�？偨Y(jié)目前的治療方式，主要有手術(shù)、化療、放療及這三種的綜合治療，有的主張手術(shù)治療為首選，有的主張先放療再手術(shù)，治療方式存在極大爭議，目前國內(nèi)外尚無一致意見。為建立松果體區(qū)腫瘤臨床治療路徑提供依據(jù)，我們著重研究該區(qū)腫瘤的影像學(xué)表現(xiàn)、臨床表現(xiàn)、治療方法和病理分型等。 目的 1.人體頭部結(jié)構(gòu)復(fù)雜，尤其是松果體這一區(qū)域，相互間位置關(guān)系對器官功能影響較大，不但是影像學(xué)上較難分析的區(qū)域之一，而且在臨床上該區(qū)疾病的診斷和治療更是一個難點。本實驗通過對松果體區(qū)斷層面的解剖及三維重建模型的研究，可進(jìn)一步熟悉和掌握該區(qū)的解剖結(jié)構(gòu)組成，松果體與周圍結(jié)構(gòu)的關(guān)系，探討腫瘤對周圍結(jié)構(gòu)生長方向、生長形態(tài)可能造成的影響等，為臨床上對區(qū)腫瘤的治療提供新思路及理論指導(dǎo)。 2.采用數(shù)字化可視人(首例中國男性)的數(shù)據(jù)集,對松果體及其相鄰結(jié)構(gòu)的空間位置關(guān)系進(jìn)行斷面解剖學(xué)研究，并對松果體及其相鄰結(jié)構(gòu)進(jìn)行計算機(jī)三維重建和虛擬現(xiàn)實顯示，闡明該區(qū)重要解剖結(jié)構(gòu)的立體形態(tài)、空間位置及相互毗鄰關(guān)系，在此基礎(chǔ)上再將現(xiàn)代影像技術(shù)與立體定向放射治療(SRT)、三維適形(3DCRT)、調(diào)強(qiáng)適形放射治療(IMRT)技術(shù)相結(jié)合應(yīng)用于松果體區(qū)腫瘤的放射治療，以此來改善放療計劃和保證實施過程的精確性，保護(hù)人體正常組織，同時可提高腫瘤的局部控制率，降低復(fù)發(fā)率和放射并發(fā)癥。 3.調(diào)查分析我國西部地區(qū)松果體腫瘤治療模式(手術(shù)治療、放療治療)和該區(qū)腫瘤的病理分型，為了建立松果體區(qū)腫瘤合理化、最優(yōu)化臨床治療路徑。 材料 數(shù)字化可視人(首例中國男性)的數(shù)據(jù)集中的頭部連續(xù)斷面圖像(層厚0.25mm)；10%甲醛固定好的成人尸頭標(biāo)本1例；計算機(jī)、Adobe photoshop CS4、Amira軟件；SIEMENS MAGNETON IMPACT2.0TMA核磁共振。 方法 1.采用數(shù)字化可視人(首例中國男性)的數(shù)據(jù)集，該數(shù)據(jù)集中的連續(xù)斷面有以下優(yōu)點：層厚較薄(層厚0.25mm)、重建后圖像逼真、數(shù)據(jù)精確，對松果體及其毗鄰的結(jié)構(gòu)進(jìn)行斷面解剖學(xué)觀察，并提取相關(guān)斷面圖像信息。將10%甲醛固定好的成人尸頭標(biāo)本進(jìn)行磁共振掃描(層厚3mm)，獲取其橫、冠、矢三方位的斷面圖像。將CVH斷面圖像與對應(yīng)層(從松果體開始出現(xiàn)到松果體消失以及此過程中包含的所有結(jié)構(gòu))的MRI典型圖像進(jìn)行對照研究，提取具有典型標(biāo)志的斷面圖像，進(jìn)行斷面影像解剖結(jié)構(gòu)的對照觀察。 2.在CVH數(shù)據(jù)集的基礎(chǔ)上，利用Photoshop、Amira軟件對顱底區(qū)結(jié)構(gòu)進(jìn)行半自動分割和三維重建，建立人腦松果體區(qū)精確的三維可視化模型，為松果體區(qū)疾病的手術(shù)入路、放射治療計劃的精確制定提供形態(tài)學(xué)依據(jù)。 3.回顧性分析我國西部地區(qū)9家三甲醫(yī)院(名單見末頁附錄)腦外科、放療科近8年收治的資料較完整的松果體腫瘤病例資料，重點分析松果體區(qū)腫瘤手術(shù)治療、放射治療的選擇及治療方法、治療的步驟等。 結(jié)果 1. CVH斷面圖像與對應(yīng)層的MRI圖像對照后，清楚的觀察到松果體區(qū)細(xì)微結(jié)構(gòu)的連續(xù)斷面形態(tài)和規(guī)律；比較主要結(jié)構(gòu)在橫、冠、矢三方位的斷面影像特點，對其中典型的二維層面中主要結(jié)構(gòu)的斷面形態(tài)及毗鄰關(guān)系進(jìn)行描述，為顱底區(qū)占位病變的影像學(xué)研究提供解剖學(xué)依據(jù)。 2.利用Amira軟件在電腦上對斷面結(jié)構(gòu)進(jìn)行分割和三維重建，立體重建了胼胝體、松果體、側(cè)腦室、等結(jié)構(gòu)�？梢暬亟ǖ娜S模型可清楚地顯示松果體和周圍結(jié)構(gòu)的形態(tài)和空間位置關(guān)系，同時可按任意角度旋轉(zhuǎn)、切割，可以單獨的顯示，也可任意組合來顯示，或者整體顯示。 3.共收集到219例，其中手術(shù)治療58例，腫瘤全切除52例，腫瘤次全切6例，有2例手術(shù)死亡、4例圍手術(shù)期死亡、9例術(shù)后出現(xiàn)昏迷或重度昏迷、2例手術(shù)后病情惡化放棄治療；放射治療196例：其中采用立體定向放射治療153例、直線加速器放療43例(其中先行診斷性放療25例)，直線加速器治療中行全中樞照射僅21例。 結(jié)論 1. CVH斷面圖像可較好的顯示松果體區(qū)細(xì)微結(jié)構(gòu)，因為其層厚較薄僅為0.25mm，而通常CT/MRI圖像層厚一般為3～5mm。結(jié)合MRI圖像對照研究后，得出松果體在橫、冠、矢三方位的斷面影像特點，可深入了解松果體區(qū)域細(xì)微結(jié)構(gòu)的連續(xù)薄層斷面形態(tài)規(guī)律，，不僅可以為神經(jīng)外科疾病診斷提供解剖學(xué)基礎(chǔ)，也能提高松果體區(qū)微小病灶的影像確認(rèn)率，可以減少漏診和誤診。 2.通過Amira軟件重建的松果體及周圍的丘腦、海馬、側(cè)腦室、第三腦室等結(jié)構(gòu)清晰，其構(gòu)建模型可較為準(zhǔn)確的揭示松果體與周圍結(jié)構(gòu)的毗鄰關(guān)系，通過三維重建得到的三維立體模型對研究松果體區(qū)復(fù)雜解剖結(jié)構(gòu)具有十分明顯的優(yōu)越性，對研究顱底區(qū)結(jié)構(gòu)間的相互關(guān)系有重要的價值；為臨床醫(yī)生制定松果體區(qū)腫瘤放療計劃、設(shè)計松果體區(qū)手術(shù)入路和在電腦上模擬手術(shù)操作提供了新的手段和新的方法。通過建立松果體區(qū)可視化解剖模型，既為數(shù)字化解剖學(xué)的開展提供了教學(xué)平臺；也為計算機(jī)輔助松果體區(qū)導(dǎo)航手術(shù)和松果體區(qū)腫瘤的放射治療提供立體形態(tài)學(xué)基礎(chǔ)。 3.腦室-腹腔分流術(shù)或三腦室造瘺術(shù)+放療是我國西部地區(qū)松果體區(qū)腫瘤治療最多見的模式，占53.9%；其次為腫瘤切除+放療模式,占21.5%。且各醫(yī)療單位的放射治療在照射方式與照射劑量的選擇上差異甚大,顯示該腫瘤的治療極不規(guī)范，提示建立松果體區(qū)腫瘤診治規(guī)范是十分有必要的。
[Abstract]:Background

CT and MRI can not only reduce the operative mortality and morbidity , but also can provide reference for the accurate formulation and implementation of the tumor radiotherapy plan .

Second , the incidence of tumor is low , but the pathological structure of tumor is complicated . According to the pathological classification of CNS tumor in World Health Organization in 2007 , it can be divided into four major categories : germ cell tumor , substance tumor of pinealbody , neuroepithelial tumor and other source tumors .

Purpose

1 . The structure of the head of human body is complicated , especially in the region of the pine body , the relationship between the position and the position of each other has great influence on the organ function , but it is a difficult problem in the diagnosis and treatment of the disease in clinic .

2 . Based on the data set of the digital visual human ( first Chinese male ) , the spatial position relation of the pine body and its adjacent structure is studied , and the three - dimensional reconstruction and virtual reality display of the pine body and its adjacent structure are carried out . The three - dimensional shape , the spatial position and the adjacent relation of the important anatomical structure in this area are expounded . Based on this , the accuracy of the radiotherapy plan and the guarantee of the implementation process can be improved , the normal tissues of the human body can be protected , and the local control rate of the tumor can be improved , and the recurrence rate and the radiation complication can be reduced .

3 . Investigation and analysis of the tumor therapy mode ( surgical treatment , radiotherapy ) and pathological type of tumor in the western region of our country . In order to establish the rationalization of tumor in the region of the pine body , the clinical treatment path is optimized .

Material

Head continuous cross - sectional image in the data center of digital visual human ( first Chinese male ) ( layer thickness 0.25 mm ) ;
1 case of adult cadaver head specimen with 10 % formaldehyde fixation ;
Computer , Adobe Photoshop CS4 , Amira software ;
The nuclear magnetic resonance ( MRI ) was carried out on the basis of the magnetic resonance imaging method of Siemens - TON IMPACT2 . 0TMA .

method

1 . A digital visual human ( first Chinese male ) data set is adopted , the continuous section of the data set has the following advantages : the layer thickness is thinner ( layer thickness is 0.25 mm ) , the reconstructed image is vivid , the data is accurate , and the cross section image of the cross section image information is extracted .

2 . On the basis of CVH data set , using Photoshop and Amira software to carry out the semi - automatic segmentation and three - dimensional reconstruction of the skull base region structure , the precise three - dimensional visualization model of the human brain pine body region is established , which provides the morphological basis for the precise formulation of the operation approach and the radiation treatment plan of the pine body region disease .

3 . Retrospective analysis of 9 cases of Sanjia Hospital in the western region of our country ( see appendix of the last page of the list ) , the data of the whole body tumor cases treated by radiotherapy department in the last 8 years , the emphasis is on the treatment of tumor operation , the choice of radiation therapy , the treatment method , the treatment step and so on .

Results

1 . After comparing the CVH section image with the MRI image of the corresponding layer , it is clear that the continuous cross - section morphology and law of the fine structure of the pine body area are observed .
The cross - sectional image features of the main structure in the transverse , coronal and sagittal directions are compared , and the cross - sectional shape and the adjacent relation of the main structure in the typical two - dimensional plane are described , and the anatomical basis is provided for the imaging study of the space occupying lesion of the skull base .

2 . Using Amira software to separate and three - dimensionally reconstruct the section structure on the computer , the structure of corpus callosal , pinealbody , lateral ventricle , and so on is reconstructed stereoscopically . The three - dimensional model of visual reconstruction can clearly show the relationship between the shape and the spatial position of the pine body and the surrounding structure , and can rotate and cut according to any angle , can be displayed separately , can be displayed by any combination , or displayed in whole .

3 . 219 cases were collected , including 58 cases of surgical treatment , 52 cases of total tumor resection , 6 cases of tumor subtotal resection , 2 cases of operation death , 4 cases of perioperative death , 9 cases coma or severe coma after operation , 2 cases after operation and abandoned treatment ;
Radiotherapy was performed in 196 cases , including 153 cases with stereotactic radiotherapy , 43 cases with linear accelerator radiotherapy ( including 25 cases of pre - diagnostic radiotherapy ) and 21 cases with straight - line accelerator .

Conclusion

1.CVH section image can better display the fine structure of the pine body area , because its layer thickness is only 0.25 mm , and the thickness of CT / MRI image layer is generally 3 锝

本文編號：1910021