【摘要】：背景與目的在世界范圍內(nèi),直腸癌都是醫(yī)學診治中最常見的惡性消化道腫瘤之一。近年來,醫(yī)生的手術(shù)方式在條件允許下傾向于選擇直腸全系膜切除術(shù)(total mesorectal excision),也稱為TME手術(shù)——該手術(shù)通過切除完整的直腸系膜來有效降低直腸癌術(shù)后局部復發(fā)率。但是當環(huán)周切緣(circumferential resection margin,CRM)陽性,即癌腫浸潤到或穿透直腸固有筋膜,TME原則也就失去了其價值。因此,通過磁共振連續(xù)切片(冠狀面)的方法,觀察完整直腸癌腫及系膜的邊界切緣是否有腫瘤侵犯,是評價直腸全系膜切除術(shù)手術(shù)效果的重要指標。研究證實,新輔助放化療利于直腸腫瘤的完整切除,增加患者的保肛的機會以及降低患者的局部復發(fā)風險,其中約20%左右的患者能獲得病理完全緩解(pathologic complete response,p CR)[1,2]。目前腫瘤治療的發(fā)展方向是個體化治療,對直腸癌患者進行準確術(shù)前分期以篩選出需要新輔助放化療的患者以及可以直接手術(shù)的患者至關(guān)重要。術(shù)前利用高分辨率磁共振成像(High Resolution MRI,HR-MRI)的較為清晰地顯示直腸壁的層次的能力來對直腸癌患者進行較為精確的分期就顯得尤為重要,因為這決定患者的個體化的治療策略。本課題分析并評價高分辨率MRI在評估直腸腫瘤患者環(huán)周切緣以及術(shù)前分期中的價值。方法前瞻性地分析40名原發(fā)性直腸癌患者,26男,14女,平均年齡52.3歲,范圍32~74歲,所有患者的術(shù)前腸鏡病理均顯示為直腸腺癌,均簽署相關(guān)知情同意書,于術(shù)前行高分辨率磁共振檢查,請2位放射科醫(yī)師閱片并分析評估所有患者的MRI-T分期、N分期、CRM狀態(tài)及直腸系膜筋膜狀態(tài)后將其與患者手術(shù)后的病理結(jié)果進行比較并分別計算相關(guān)預測指標的準確度、敏感度、特異度、陽性預測值(Positive Predictive Value,PPV)及陰性預測值(negative predictive value,NPV)。術(shù)前及術(shù)后直腸癌分期標準來自第7版《AJCC癌癥分期手冊》。結(jié)果1)患者中有25位腫瘤位于上段直腸(62.5%),7例患者腫瘤位于中段直腸(17.5%),8例患者腫瘤位于遠端直腸(20.0%);2)基于MRI的術(shù)前T分期預測的敏感性(sensitivity)、特異性(specificity)、陽性預測值(PPV)及陰性預測值(NPV)分別為95.8%,87.5%,92%和93.3%(Kappa=0.84,P0.05);基于MRI的環(huán)周切緣(CRM)預測敏感性(sensitivity)、特異性(specificity)、陽性預測值(PPV)及陰性預測值(NPV)分別為90%,96.7%,90%和96.7%(Kappa=0.61,P0.05);MRI-N分期預測的準確度(accuracy)、敏感性(sensitivity)、特異性(specificity)、陽性預測值(PPV)及陰性預測值(NPV)分別為85%、73.3%、92%、84.6%及96.7%(Kappa=0.44,P0.05)。結(jié)論醫(yī)生可以通過高分辨率MRI來有效地評估直腸癌患者的直腸系膜筋膜以及環(huán)周切緣,而這兩者是影響患者手術(shù)效果的重要因素,從而精確制定患者的個體化治療方案。
[Abstract]:Background & objective rectal cancer is one of the most common malignant digestive tract tumors in medical diagnosis and treatment worldwide. In recent years, doctors have tended to choose (total mesorectal excision), also known as TME surgery, for rectal cancer under conditions permitting-this procedure can effectively reduce the local recurrence rate of rectal cancer by removing complete mesorectum. But when the circumferential margin (circumferential resection is positive, that is, the cancer infiltrates or penetrates the proper fascia of the rectum, the TME principle also loses its value. Therefore, it is an important index to evaluate the effect of total mesorectal resection by means of continuous section (coronal plane) of magnetic resonance (MRI) to observe the tumor invasion at the margin of mesentery and complete rectal cancer. Neoadjuvant chemotherapy is beneficial to complete resection of rectal tumors, increase the chance of anal preservation and reduce the risk of local recurrence. About 20% of the patients can obtain complete pathological remission of (pathologic complete responsep CR (12 / 2). At present, the development direction of tumor therapy is individualized treatment. It is very important to select the patients who need neoadjuvant radiotherapy and chemotherapy and those who can be operated directly. It is very important to use (High Resolution MRI HR-MRI (high resolution magnetic resonance imaging) to clearly display the level of rectal wall in order to stage rectal cancer patients accurately, because this determines the individual treatment strategy of patients with rectal cancer. The purpose of this study was to analyze and evaluate the value of high resolution MRI in the evaluation of peri-circumferential margin and preoperative staging of rectal neoplasms. Methods Forty patients with primary rectal cancer were analyzed prospectively, with an average age of 52.3 years and a range of 32 to 74 years. All the patients were diagnosed as rectal adenocarcinoma by endoscopy, and all of them signed the relevant informed consent. High resolution magnetic resonance imaging was performed before operation. Two radiologists were asked to read the films and analyze and evaluate the MRI-T staging status and mesenteric fascia status of all patients. After comparing the results with the pathological results of the patients after surgery, the accuracy and sensitivity of the related predictors were calculated, respectively. Specificity, positive predictive value (Positive Predictive) and negative predictive value (negative predictive value). The preoperative and postoperative staging criteria for rectal cancer were derived from the 7th edition of the AJCC Cancer staging Manual. Results 1) 25 patients were located in the upper rectum (62.5%), 7 patients were located in the middle rectum (17.5%), 8 patients were located in the distal rectum (20.0%) the predictive value of sensitive (sensitivity), specific (specificity), positive value based on MRI for preoperative T staging was (PPV) and negative. The predictive value of sex (NPV) was 95.2% and 93.3% respectively (Kappa 0.84%), the predictive value of (sensitivity), specific (specificity), positive predictive value of circumferential margin (CRM) based on MRI and negative predictive value of (PPV) were 96.7% and 96.7% (Kappa 0.61P0.05) respectively, and the accuracy of (accuracy), sensitive (sensitivity), (specificity), positive predictive value of MRI-N staging was 96.7% and 96.7% respectively (Kappa 0.61P0.05), and the predictive value of (sensitivity), specific (specificity), positive predictive value and negative predictive value of circumferential (CRM) based on MRI were 96.7% and 96.7% (Kappa 0.61P0.05) respectively. The values of (PPV) and (NPV) were 84.6% and 96.7% respectively (P 0.05). Conclusion High resolution MRI can be used to evaluate the mesenteric fascia and circumferential margin of rectal cancer effectively.
【學位授予單位】：濟南大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735.37

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相關(guān)期刊論文 前1條

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本文編號：2150957