本文選題：心臟 + 冠狀動(dòng)脈��； 參考：《武漢大學(xué)》2012年博士論文

【摘要】：第一部分心電門控雙源CT心臟及冠狀動(dòng)脈三維運(yùn)動(dòng)范圍測(cè)量 目的在放射治療計(jì)劃制定中,目標(biāo)器官移動(dòng)的定性與定量信息對(duì)內(nèi)臟邊界范圍的確定非常重要。在左側(cè)乳腺癌的放射治療中,心臟前壁區(qū)域(anterior myocardial territory, AMT),左心室(left ventricle, LV)和冠狀動(dòng)脈不可避免地部分被照射。但是,目前的文獻(xiàn)很少描述心臟和動(dòng)脈的搏動(dòng)。我們采用心電門控多層螺旋CT測(cè)量心臟(包括心臟、心臟前壁區(qū)域、左心室)及冠狀動(dòng)脈(包括左右冠狀動(dòng)脈主干、左前降支、左旋支及右緣支)在上下、前后及左右方向上的活動(dòng)范圍,為胸部腫瘤調(diào)強(qiáng)放射治療(intensity-modulated radiotherapy, IMRT)中心臟和冠狀動(dòng)脈等危及器官(organ at risk, OAR)的計(jì)劃危險(xiǎn)體積(planning risk volume, PRV)的勾畫提供信息。 資料與方法將17例行回顧性心電門控冠脈雙源CT檢查的正常檢查者的圖像資料進(jìn)行分析。分別測(cè)量舒張末期和收縮末期兩個(gè)不同心動(dòng)周期中心臟、心臟前壁區(qū)域、左心室、左右冠脈主干及其主要分支在前后、左右及上下方向上的移動(dòng)范圍。將所得數(shù)據(jù)應(yīng)用SPSS16.0軟件包進(jìn)行分析,得出心臟不同部位,左右冠脈主干及主要分支的三維運(yùn)動(dòng)范圍的均值。 結(jié)果對(duì)于心臟,心臟前壁區(qū)域和左心室前界、右界的運(yùn)動(dòng)范圍約3-5mm,左界和后界的運(yùn)動(dòng)范圍約5-8mm,上界和下屆的運(yùn)動(dòng)范圍約5-6mm,其中心臟前壁區(qū)域和左心室的左界、后界和下屆的運(yùn)動(dòng)范圍最大,大部分方向上的運(yùn)動(dòng)范圍約4-7mm。對(duì)于冠狀動(dòng)脈,前后方向的運(yùn)動(dòng)范圍4mm,左右方向的運(yùn)動(dòng)范圍約4-7mm,上下方向的運(yùn)動(dòng)范圍約4-6mm。 結(jié)論心臟和冠狀動(dòng)脈各部分在心動(dòng)周期中的運(yùn)動(dòng)范圍不一致,心臟前壁區(qū)域和左心室的左界、后界和下屆的運(yùn)動(dòng)范圍最大,左冠狀動(dòng)脈比右冠狀動(dòng)脈的活動(dòng)范圍大。心臟、心臟前壁區(qū)域和冠狀動(dòng)脈在各個(gè)方向上多有4-7mm的運(yùn)動(dòng)范圍。 第二部分心臟和冠狀動(dòng)脈運(yùn)動(dòng)補(bǔ)償降低左側(cè)乳腺癌調(diào)強(qiáng)放射治療中心臟及冠脈照射劑量的策略 目的探討將心臟、心臟前壁區(qū)域、左心室和左右冠脈主干及其主要分支作為危及器官并將第一部分測(cè)得的心臟及冠狀動(dòng)脈三維運(yùn)動(dòng)范圍的數(shù)據(jù)應(yīng)用于制訂左乳腺癌調(diào)強(qiáng)放射治療中危及器官和計(jì)劃危險(xiǎn)體積PRV的勾畫中,能否有效降低左側(cè)乳腺癌IMRT計(jì)劃中心臟前壁區(qū)域及冠脈的照射劑量。 資料與方法在放射治療計(jì)劃數(shù)據(jù)庫(kù)擋案中隨機(jī)選擇早期乳腺癌行保乳手術(shù)治療后的21例患者的計(jì)劃CT圖像,定位CT掃描體位與治療體位相同(仰臥位,雙手置于頭頂),掃描范圍由下頸部至上腹部,層厚2.5mm。由同一放療醫(yī)師勾畫靶區(qū)和危及器官OAR。靶區(qū)包括臨床靶區(qū)(clinical target volume, CTV)和計(jì)劃靶區(qū)(planning target volume, PTV)。CTV為整個(gè)左側(cè)乳腺組織,其前界位于皮下0.5cm；PTV為CTV外放0.8cm。為了計(jì)算所有危及器官的照射劑量,將左冠狀動(dòng)脈主干(left coronary artery, LCA)、右冠狀動(dòng)脈主干(right coronary artery, RCA)及左前降支(left anterior descending,LAD)、左旋支(left circumflex artery, LcxA)、右緣支(right marginal artery, RMA)增加為OARs。將第一部分測(cè)得的心臟、心臟前壁區(qū)域、左心室、左右冠脈主干及其主要分支在心動(dòng)周期中的活動(dòng)范圍作為這些危及器官PRV外放邊緣的依據(jù)。選擇兩種不同的治療計(jì)劃IMRT(H)和IMRT (AMT), IMRT (H)是將心臟作為危及器官,IMRT (AMT)是將心臟前壁區(qū)域代替心臟作為危及器官。由TPS獲得劑量體積參數(shù)Dmean和D2%,Dmean指平均劑量,D2%指危及器官2%體積接受最大劑量照射時(shí)的劑量。所有統(tǒng)計(jì)學(xué)處理均采用SPSS16.0統(tǒng)計(jì)學(xué)軟件包,各個(gè)危及器官的參數(shù)采用配對(duì)t檢驗(yàn),以P0.05為有統(tǒng)計(jì)學(xué)意義。 結(jié)果根據(jù)第一部分所測(cè)得的危及器官(包括心臟、心臟前壁區(qū)域、左心室、左冠狀動(dòng)脈、右冠狀動(dòng)脈、左前降支、左旋支和右緣支)的活動(dòng)范圍,確定相應(yīng)危及器官計(jì)劃危險(xiǎn)體積的外放邊緣,這些外放邊緣具體數(shù)值如表2.1所示。與危及器官的體積相比,心臟、心臟前壁區(qū)域和左心室的PRV分別增加了50.6%±7.9%(95%CI:33%-61%),194.9%±36.4%(95%CI:149.0%-290.0%),76.7%±9.8%(95%CI:56%-91%),而左冠狀動(dòng)脈、右冠狀動(dòng)脈、左前降支、左旋支和右緣支的PRV增加了18.7-42.6倍,如表2.2所示。IMRT(H)和IMRT(AMT)中所有危及器官的Dmean和D2%均在表2.2中。比較心臟作為危及器官的PRV的Dmean, IMRT(H和IMRT(AMT)計(jì)劃中分別增加了5.52%(P0.05)和5.81%(P0.05)；將AMT作為危及器官時(shí),其PRV的Dmean減少了8.35%(P0.05),如圖2.1A、2.1C所示。同樣地,比較危及器官的D2%,IMRT(H)計(jì)劃中LV, LCA, RCA, LAD, LcxA和RMA等大約增加了10%-21%(all the P0.05),如圖2.1B所示；IMRT(AMT)計(jì)劃中心臟、心臟前壁區(qū)域、左心室和左前降支的D2%增加了22-43%(P0.05),如圖2.1D。 IMRT(AMT)計(jì)劃中的平均劑量Dmean和D2%和IMRT(H)計(jì)劃比較,心臟、心臟前壁區(qū)域、左心室和它們的PRV的平均劑量分別下降了14-16%,26-33%,19-23%(所有P0.05)；左前降支LAD和PRV的Dmean分別下降了15%,14%(P0.05),如圖2.1E、2.1G所示。同樣地,心臟、心臟前壁區(qū)域、左心室、左前降支和其PRV的D2%分別大約下降了13%-26%,18%-23%18%-31%,3%-15%(所有P0.05),如圖1F、1H所示。并且左旋支PRV的Dmean下降了13.7%(P0.05)。如圖2.1G所示。 與將心臟和AMT作為危及器官的乳腺IMRT計(jì)劃相比,將心臟、AMT、LV、 LAD作為危及器官的IMRT計(jì)劃的Dmean和D2%分別降低了15-33%、13-31%,兩種計(jì)劃方法間的差別具有統(tǒng)計(jì)學(xué)意義(所有P0.05)。 結(jié)論第一部分測(cè)得的心臟,AMT, LV, LCA, RCA, LAD, LcxA和RMA的運(yùn)動(dòng)范圍可以為這些危及器官的PRV外放邊緣作為參考,從而更準(zhǔn)確的勾畫危及器官的計(jì)劃危險(xiǎn)體積。心臟和冠狀動(dòng)脈運(yùn)動(dòng)補(bǔ)償以及將AMT、LV、LAD、RCA等作為危及器官的乳腺IMRT計(jì)劃比常規(guī)IMRT計(jì)劃能更進(jìn)一步降低心臟和冠脈的照射劑量。
[Abstract]:Part 3 measurement of three-dimensional motion range of cardiac and coronary arteries by dual gated ECG gated CT
Objective in the formulation of radiotherapy planning, the qualitative and quantitative information of target organ movement is very important for determining the visceral boundaries. In the radiotherapy of left breast cancer, the anterior myocardial territory (AMT), the left ventricle (left ventricle, LV) and the coronary arteries are inevitably partially irradiated. The previous literature rarely describes the pulsation of the heart and arteries. We use ECG gated multislice CT to measure the heart (including the heart, the anterior wall area, the left ventricle) and the coronary artery (including the left and right coronary arteries, the left anterior descending branch, the left circumflex, and right margin) in the upper and lower, the back and right direction, and to strengthen the chest tumor. Information is provided for the planned risk volume (planning risk volume, PRV) of endanger organs (organ at risk, OAR), such as the central organs of intensity-modulated radiotherapy (IMRT) and the coronary artery, and the coronary artery (organ at risk, OAR).
Materials and methods the image data of 17 normal examiners of a retrospective ECG gated coronary dual source CT examination were analyzed. The heart, the anterior wall region of the heart, the left ventricle, the left and right main arteries and their main branches were measured in the two different cardiac cycles at the end of diastolic and late systolic stage. The data were analyzed by SPSS16.0 software package, and the mean values of three dimensional motion range of different parts of the heart, left and right coronary arteries and main branches were obtained.
Results for the heart, the region of the anterior wall of the heart and the front of the left ventricle, the movement range of the right boundary is about 3-5mm, the movement range of the left and the posterior boundaries is about 5-8mm, and the upper and next movement ranges about 5-6mm, of which the anterior and left ventricle, the left and the left ventricles of the heart are the largest, and the range of movement in most directions is about 4-7mm. for the crown. The movement range of the artery is 4mm, the motion range of the left and right directions is about 4-7mm, and the range of motion is about 4-6mm.
Conclusions the range of movement of the cardiac and coronary arteries in the cardiac cycle is not consistent. The anterior and left ventricle, the left and the left ventricles of the heart are the largest, and the left coronary artery is more active than the right coronary artery. The heart, the anterior wall area and the coronary arteries have more 4-7mm range in each direction.
The second part is cardiac and coronary artery motion compensation to reduce the dose of central and coronary artery in intensity-modulated radiation therapy for left breast cancer.
Objective to investigate whether the heart, the anterior wall of the heart, the left ventricle and the main branches of the left and right coronary arteries and their main branches are used as endanger organs and the data of the three-dimensional motion of the heart and coronary arteries measured in the first part should be used to draw up the delineation of the risk of organs and the planned risk volume of PRV in the intensity modulated radiation therapy of left breast cancer, and can be effectively reduced. The radiation dose of the anterior wall area and the coronary artery in the IMRT center of the left breast cancer.
Materials and methods the planned CT images of 21 patients with early breast cancer after breast conserving surgery were randomly selected in the radiation therapy program database. The position of the CT scanning body was the same as that of the treatment position (supine position, hands on the top of the head), the scan range from the lower neck to the upper abdomen, and the thickness of 2.5mm. by the same radiation therapist to delineate the target area and danger. The target area of OAR., including the clinical target area (clinical target volume, CTV) and the planned target area (planning target volume, PTV).CTV is the whole left mammary gland, and its front is located in the subcutaneous 0.5cm. The right coronary artery (RCA) and the left anterior descending branch (left anterior descending, LAD), the left lateral branch (left circumflex artery, LcxA) and the right marginal branch were added to the heart, the anterior wall region of the heart, the left ventricle, the left and right trunk of the coronary artery and its main branches in the cardiac cycle. The dynamic range is the basis for the endanger of the outer edge of the organ PRV. Two different treatment plans, IMRT (H) and IMRT (AMT), IMRT (H), are used to replace the heart as a endanger organ. IMRT (AMT) is the replacement of the heart of the heart as a endanger organ. The dose volume parameter Dmean and D2% are obtained by TPS. All the statistical treatments were carried out by SPSS16.0 statistics package, and the parameters of each organ were measured by paired t test, and P0.05 was statistically significant.
Results the range of activity of endanger organs (including the heart, the region of the anterior wall of the heart, the left ventricle, the left coronary artery, the right coronary artery, the left anterior descending branch, the left circumflex, and the right marginal branch) was determined to determine the outer edge of the corresponding risk volume of the organ that endanger the organ, as shown in Table 2.1, as shown in Table 2.1. The PRV of the heart, the anterior wall area and the left ventricle increased by 50.6% + 7.9% (95%CI:33%-61%), 194.9% + 36.4% (95%CI:149.0%-290.0%), 76.7% + 9.8% (95%CI:56%-91%), while the left coronary artery, the right coronary artery, the left anterior descending branch, the left and right branch PRV increased 18.7-42.6 times, as shown in table 2.2,.IMRT (H) and IMRT (AMT) all Dmean and D2%, which endanger organs, are in table 2. 2. Compared to the Dmean of PRV that endanger organs, IMRT (H and IMRT (AMT) plan increased by 5.52% (P0.05) and 5.81% (P0.05), respectively, while AMT as an organ endangering the organ, the PRV is reduced by 8.35%. LCA, RCA, LAD, LcxA, and RMA have increased approximately 10%-21% (all the P0.05), as shown in figure 2.1B; the IMRT (AMT) planning center, the anterior wall area of the heart, the left ventricle and the left anterior descending branch increased.
In the IMRT (AMT) plan, the average dose of Dmean and D2% and IMRT (H) plan were compared. The average dose of the heart, the anterior wall area, the left ventricle and their PRV decreased respectively 14-16%, 26-33%, 19-23% (P0.05), and the left anterior descending LAD and D2%, respectively, decreased by 15%, respectively, as shown in the heart and the anterior wall area. The left ventricle, the left anterior descending branch and the D2% of its PRV decreased by about 13%-26%, 18%-23%18%-31%, 3%-15% (all P0.05), as shown in Fig. 1F, 1H, and Dmean of the left-handed PRV decreased by 13.7% (P0.05). As shown in picture 2.1G.
Comparing heart, AMT, LV, and LAD as the IMRT plan for organ threatening IMRT, Dmean and D2% reduced 15-33% and 13-31%, respectively, compared with the heart and AMT as an organ - threatening mammary gland plan. The difference between the two planning methods was statistically significant (all P0.05).
Conclusion the first part of the heart, AMT, LV, LCA, RCA, LAD, LcxA, and RMA can be used as a reference for the peripheral PRV that endanger the organs as a reference, and thus more accurately delineates the planned dangerous volume of organs that endanger the organs, cardiac and coronary artery motion compensation, and AMT, LV, LAD, RCA, and so on as the mammary gland plan for endanger organs. The conventional IMRT plan can further reduce the radiation dose of the heart and coronary arteries.

【學(xué)位授予單位】：武漢大學(xué)
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2012
【分類號(hào)】：R737.9;R730.44

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