多种磁共振成像方法在宫颈癌术前评估中的运用价值探讨

发布时间：2018-05-02 15:07

本文选题：子宫颈癌 + 磁共振成像　；参考：《第二军医大学》2017年硕士论文

【摘要】：宫颈癌是发病率最高的妇科恶性肿瘤,与其他妇科癌症采用手术-病理分期不同,宫颈癌至今仍采用临床分期,即通过盆腔检查来确定肿瘤进展情况。临床分期是决定治疗方案的关键。然而,盆腔检查主观性强,常导致分期不准确,错误的分期不利于最佳治疗方案的选择。随着医学影像技术的发展,临床医生借助CT、MRI、PET/CT协助宫颈癌治疗前的评估已十分普遍。MRI因其优秀的软组织分辨率、多参数、多方位成像模式,在协助宫颈癌的临床分期上有着天然优势。同时MRI在检查费用以及推广程度上较PET/CT更具优势,因此被认为是评估宫颈癌的最佳影像学手段。在MRI各序列中,T1加权像(T1 weighted image,T1WI)及T2加权像(T2weighted image,T2WI)是评价宫颈癌分期的常用序列。T1WI主要显示盆腔解剖。T2WI在区分肿瘤与正常组织方面更具优势,是评估宫颈癌的主要序列。但常规MRI在实际运用中仍有诸多不足:受分辨率限制,常规MRI难以发现宫颈癌早期病变,而且即使发现肿块亦无法明确其良恶性质。因此多种磁共振成像新技术应运而生。据国外文献报道,通过磁共振参数调整,设置小FOV后T2WI分辨率将明显提高,即所谓的高清MRI。目前国内将该磁共振成像方法运用到宫颈癌的分期中尚属少见。磁共振扩散加权成像(Diffusion weighted images,DWI)是区别于TIWI,T2WI的另一种磁共振成像方法,水分子在不同组织中的运动受限差异是DWI的基础。近几年有学者将DWI运用到前列腺癌,乳腺癌等恶性肿瘤的评估中,已验证了其有效性,目前国内有报道认为DWI可以提高宫颈癌术前评估的准确性,对发现早期宫颈癌病灶以及淋巴结转移具有一定优势,但目前仍未成熟应用。磁共振扩散基组光谱成像(diffusion basis spectrum imaging,DBSI)是我院与华盛顿圣路易斯医学院合作开发的、全新的磁共振扩散加权成像模型,是DWI的升级。该模型可将水分子扩散受限区进一步分为:限制性受限区,该部分代表肿瘤细胞成分;阻碍性受限区,该部分代表炎性成分;纤维间质区,该部分代表纤维成分。进而可以将肿瘤组织中不同病理成分区分出来,并进行定量研究,目前该技术在前列腺癌以及神经系统疾病研究中已取得相应成果,在妇科肿瘤领域,尚无研究报道。为评价以上几种磁共振成像新技术在宫颈癌术前评估中的价值,本研究包括:1、将高清磁共振成像方法及DWI联合运用到宫颈癌的分期中,以评估其在协助宫颈癌分期中的优势。2.将DBSI首次运用到宫颈癌术前评估中,验证DBSI图像中各限制区与对应病理成分的一致性,初步探索DBSI技术在精确评估宫颈癌中的价值。第一部分:高清磁共振成像联合磁共振扩散加权成像在宫颈癌分期中的价值探讨研究目的:通过宫颈癌患者的术后病理结果,比较常规MRI分期、高清MRI分期、高清MRI联合磁共振扩散加权成像(diffusion weighted imaging,DWI)分期方法在IB期~IIB期宫颈癌分期中的准确性。材料与方法:收集2015年3月-2017年3月来我院就诊的宫颈癌病人81例,治疗前明确临床分期,行MRI检查,其中54位患者行常规MRI检查,27例患者行高清MRI检查(小FOV的高清T2加权像)并行DWI扫描(b值取1000s/mm2)。两位有经验的影像科医生在知晓宫颈癌诊断,但不知临床分期的情况下MRI阅片,重点对肿瘤的位置,大小,阴道及宫旁侵犯情况作出评估,并对每例患者行影像学分期。随后患者在本院行广泛性子宫切除术加盆腔淋巴结清扫术+腹主动脉旁淋巴结切除术,记录详细的手术及病理资料。以术后病理结果为金标准,分别将临床分期、多种磁共振方法协助所得分期与病理结果进行对照。数据分析使用SAS9.4软件,分别比较各类方法所得分期与病理结果的一致性,计算Kappa系数;采用配对资料X2检验,比较高清MRI在联合运用DWI前后在各分期中的诊断差异,P值0.05即有统计学意义。结果:临床分期、常规MRI分期、高清MRI分期、高清MRI联合DWI分期在IB期~IIB期宫颈癌中总体分期准确率分别为:(40例/81例)49.38%、(35例/54例)64.81%、(16例/27例)59.26%、(18例/27例)66.67%。常规MRI分期、高清MRI分期、高清MRI联合DWI分期的加权Kappa系数分别为:0.333、0.3788、0.473。而临床分期与病理结果的加权Kappa系数双侧检验的P值0.05,说明暂不能认为临床分期与病理结果存在一致性。因此可以认为高清MRI联合DWI分期与病理结果的一致性最好,其次为高清MRI分期,再次为常规MRI分期,临床分期最差。在IB期、IIA期、IIB期各个分期中,高清MRI分期准确率分别为:62.69%、66.67%、88.89%、高清MRI联合运用DWI后分期的准确率分别为:70.73%、74.07%、88.89%。采用卡方检验比较高清MRI在联合运用DWI前后在各分期中的诊断差异,P值均大于0.05,差异无统计学意义。结论:常规MRI协助下的宫颈癌分期要优于临床分期,高清MRI分期、高清MRI联合DWI分期优于常规MRI分期,因此,采用高清MRI联合运用磁共振扩散加权成像(DWI),可以有效提高宫颈癌分期的准确性。第二部分:磁共振扩散基组光谱成像(DBSI)在宫颈癌术前评估中的应用初探目的:磁共振扩散基组光谱成像(diffusion basis spectrum imaging,DBSI)是一种全新的磁共振功能成像模型及后处理技术。本研究首次将DBSI应用到宫颈癌的病灶成分分析中,以探讨DBSI在宫颈癌精准分期中的潜在应用价值。方法:收集2016年2月-2017年3月来我院就诊的宫颈癌病人27例,治疗前行高清MRI、磁共振扩散加权成像(DWI)以及磁共振扩散基组光谱成像(DBSI),收集的DBSI数据及图像由相关的软件进行后期处理。所有患者在行MRI检查后7天内行宫颈癌根治手术,将含有病灶的完整宫颈,制成石蜡块,垂直宫颈长轴切片,常规HE染色,制作成大病理切片。并用滨松S60病理切片扫描仪采集整个病理切片图像。将组织病理学图像与对应层面的MRI图像进行比对,分析两者的匹配程度。结果:我们通过高清MRI及DWI清晰地显示了肿瘤轮廓,再借助DBSI技术可将肿块进一步分为:限制性受限部分、阻碍性受限部分、纤维间质部分。介于目前该研究时间较短,数据后处理复杂,DBSI细分的这些部分否与病理成分(肿瘤细胞成分、炎性成分、纤维成分)相对应,仍有待研究进一步验证。结论:DBSI较DWI在对肿瘤评估中可以采集更多信息,对肿瘤病理成分分析更具有优势。介于本研究尚处于探索阶段,暂时无法证明DBSI细分的各限制区与宫颈癌各病理组织成分的对应关系。但DBSI已显示出对宫颈癌精准分期的潜在优势。
[Abstract]:Cervical cancer is the highest incidence of gynecologic malignant tumor, which is different from other gynecologic cancers by surgical pathological staging. The clinical stage of cervical cancer is still adopted by the pelvic examination to determine the progress of the tumor. Clinical staging is the key to determine the treatment plan. However, the pelvic examination is highly subjective and often leads to inaccurate staging and error. Staging is not conducive to the choice of the best treatment. With the development of medical imaging technology, clinicians with the aid of CT, MRI, and PET/CT to assist the evaluation of cervical cancer are very common..MRI has a natural advantage in the clinical staging of cervical cancer because of its excellent soft tissue resolution, multi parameter and multi-directional imaging mode. At the same time, MRI is examined. In the MRI sequence, the T1 weighted image (T1 weighted image, T1WI) and the T2 weighted image (T2weighted image, T2WI) are the common sequence.T1WI for evaluating the stage of cervical cancer. The pelvic anatomy is the main display of the pelvic anatomy in the differentiation of the tumor and the normal group. It is more advantageous to evaluate the main sequence of cervical cancer. But there are still a lot of shortcomings in the practice of conventional MRI: restricted by the resolution, it is difficult to detect early lesions of cervical cancer by conventional MRI, and even if it is found that the masses can not identify its good and bad properties. When the magnetic resonance parameters are adjusted, the resolution of T2WI will be greatly improved after setting a small FOV. That is, the so-called high definition MRI. is rarely used in the staging of cervical cancer at present. The magnetic resonance diffusion-weighted imaging (Diffusion weighted images, DWI) is another magnetic resonance imaging method, which is different from TIWI and T2WI, and the water molecules are not The difference in movement restriction in the same tissue is the basis of DWI. In recent years, some scholars have applied DWI to the evaluation of prostate cancer, breast cancer and other malignant tumors. It has been proved that DWI can improve the accuracy of preoperative assessment of cervical cancer, and has a certain advantage in the discovery of early cervical cancer and lymph node metastasis. Diffusion basis spectrum imaging (DBSI) is a new model of magnetic resonance diffusion weighted imaging (MRI) in Saint Louis, Washington, D.C., which is a new model of magnetic resonance diffusion weighted imaging (MRI), which is an upgrade of DWI. This model can further divide the region of the water diffusion restricted zone into a restricted restricted zone. The part represents the composition of the tumor cell; the hindrance restricted area, which represents the inflammatory component; the fibrous interstitial area, which represents the fibrous component. Then it can distinguish the different pathological components in the tumor tissue and make a quantitative study. At present, the technology has achieved the corresponding results in the study of prostate cancer and the nervous system disease, in gynecology. To evaluate the value of these new MRI techniques in preoperative assessment of cervical cancer, this study included: 1, the combined use of high-definition magnetic resonance imaging and DWI to the stage of cervical cancer to assess the advantage of.2. in assisting cervical cancer staging for the first time to apply DBSI to preoperative assessment of cervical cancer. To verify the consistency of the restricted areas and corresponding pathological components in the DBSI image, and to explore the value of DBSI technology in the accurate assessment of cervical cancer. The accuracy of MRI staging, high-definition MRI staging, high definition MRI combined magnetic resonance diffusion weighted imaging (diffusion weighted imaging, DWI) staging in stage IB stage ~IIB stage of cervical cancer. Materials and methods: 81 cases of cervical cancer patients in our hospital in March March 2015 were collected. Before treatment, the clinical stage was clear, and MRI examination was performed, of which 54 patients were suffering from disease. 27 patients underwent high definition MRI examination (high definition T2 weighted image of small FOV) parallel DWI scan (b value 1000s/mm2) in 27 patients. Two experienced imaging doctors were aware of the diagnosis of cervical cancer but did not know the clinical staging of MRI, focusing on the location, size, vagina and para of the intrauterine invasion of the tumor, and each case The patients were treated with imaging stages. Then the patients were treated with extensive hysterectomy plus pelvic lymphadenectomy plus abdominal para aortic lymph node resection, and detailed surgical and pathological data were recorded. The clinical staging and multiple magnetic resonance methods were used to compare the pathological results with pathological results. According to the analysis of SAS9.4 software, the consistency between the stages and the pathological results of various methods was compared and the Kappa coefficient was calculated. The diagnostic difference between high definition MRI and DWI was compared before and after the combined use of DWI by paired data X2 test. The P value 0.05 was statistically significant. Results: clinical staging, conventional MRI staging, HD MRI staging, HD MRI The overall accuracy rate of the combined DWI stage in IB stage ~IIB stage cervical cancer was: (40 cases of /81 cases) 49.38%, (35 cases of /54 cases) 64.81%, (16 cases of /27), 59.26%, and (18 /27 cases) 66.67%. conventional MRI staging, high definition MRI staging, high definition MRI joint DWI stage weighted numbers respectively. The P value of the PPA coefficient bilateral test was 0.05, indicating that there was no agreement between the clinical staging and the pathological results for the time being. Therefore, the best consistency of the combined DWI staging with the pathological results was considered, followed by high definition MRI staging, and the most poor clinical staging was the conventional MRI staging. In IB, IIA, and IIB stages, high definition MRI staging The accuracy rate was 62.69%, 66.67%, 88.89%. The accuracy of the combined use of DWI in high definition MRI was 70.73%, 74.07%, and 88.89%. was compared by chi square test to compare the diagnostic differences between high definition MRI in all stages before and after the combined use of DWI, P values were greater than 0.05, the difference was not statistically significant. Conclusion: the cervical cancer staging under the help of conventional MRI is superior to the clinical stage. Bed stage, high definition MRI staging, high definition MRI combined with DWI staging are superior to conventional MRI staging. Therefore, the accuracy of cervical cancer staging can be improved by high definition MRI combined with magnetic resonance diffusion-weighted imaging (DWI). The second part: magnetic resonance diffusion based group spectral imaging (DBSI) for preoperative evaluation of cervical cancer: magnetic resonance expansion Diffusion basis spectrum imaging (DBSI) is a new magnetic resonance functional imaging model and post-processing technique. This study first applied DBSI to the analysis of the lesion components of cervical cancer in order to explore the potential value of DBSI in the accurate staging of cervical cancer. Method: to collect in March February 2016 -2017 year in our hospital. 27 patients with cervical cancer were treated with high-definition MRI, magnetic resonance diffusion-weighted imaging (DWI) and magnetic resonance diffusion based group spectral imaging (DBSI). The collected DBSI data and images were processed by related software for later treatment. All patients underwent radical cervical cancer surgery within 7 days after MRI examination, and the whole cervix containing the lesion was made into paraffin. Block, vertical section of the long axis of the cervix, routine HE staining, make a large pathological section, and use the S60 pathology slice scanner to collect the whole pathological section image. Compare the histopathological images with the corresponding MRI images and analyze the matching degree. DBSI technique can be used to further divide the lumps into restricted restricted parts, obstructed restricted parts, fibrous interstitial parts. The time is short, data processing is complex, and the parts of DBSI subdivision correspond to the pathological components (tumor cell components, inflammatory components and fibrous components). Further verification is still needed. Conclusion: DB SI can collect more information in tumor evaluation than DWI, and is more advantageous for the analysis of tumor pathology components. It is still at the exploratory stage of this study. It is temporarily unable to prove the corresponding relationship between the restricted areas of DBSI subdivision and the pathological tissue components of cervical cancer. But DBSI has shown the potential advantage of the accurate staging of cervical cancer.

【学位授予单位】：第二军医大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R445.2;R737.33

【参考文献】