常见体表非黑色素恶性肿瘤的形态学研究

发布时间：2018-07-10 10:36

本文选题：体表恶性肿瘤 + Mohs　；参考：《中国人民解放军医学院》2017年博士论文

【摘要】：研究背景及目的:各类非黑色素型体表恶性肿瘤是临床常见疾病。传统的手术扩大切除+分点切缘冰冻病理检查漏检率高,常导致临床上病理回报“切缘干净”病例肿瘤复发。Mohs显微描记手术虽然可以完整检查手术切缘,降低漏检率,但由于技术固有局限,更适合应用于面积较小的浅表恶性皮肤肿瘤,同时如何更准确的确定Mohs手术的起始边界目前仍存争议。MRI已广泛应用于体内软组织的病变的影像学诊断,但却很少用于各类体表恶性肿瘤检查。本研究目的是通过对体表恶性肿瘤在MRI、大体标本、病理之间的形态学特点和联系,探索肿瘤个性化切除范围的确定标准,对临床精准切除肿瘤起到指导作用。方法:对临床上不同类型的、直径大于1cm的初发或复发体表非黑色素性恶性肿瘤患者,采用头颈联合或体部相控阵线圈进行高分辨率薄层扫描,确定体表恶性肿瘤的优化扫描方案。并将体表恶性肿瘤MRI影像与肿瘤切除后大体标本和最终病理图像资料进行形态学比对。采用鱼肝油乳剂体外标记物进行MRI影像学标记,探索在MRI影像学指导下行体表恶性肿瘤精准切除的可行性。结果:本组行MRI检查的体表恶性肿瘤种类包含了临床上常见的非黑色素性皮肤体表恶性肿瘤,包括基底细胞癌、皮肤鳞癌、皮肤纤维肉瘤,病灶在T1WI像与肌肉相比呈等信号或低信号,T2WI像呈高信号,均呈不同程度强化。对隆突性皮肤纤维肉瘤、恶性纤维肉瘤、梭形细胞肉瘤的瘤体大体边界可见清晰显影。对基底细胞癌皮肤细微构造不能清晰辨别。本次对比研究共6组标本,其中一例基底细胞癌因面积较小,在制作病理切片时切割破碎,故未完成比对。其它5例均成功实现肿瘤相同平面下MRI-大体标本-病理的形态学比对。鱼肝油乳剂体外标记物在MRI显影清晰。纤维肉瘤瘤体在M RI和病理图像的厚度基本一致,在病理图像上突破肿瘤实体边界的瘤细胞浸润区在T1WI对应区域显示为大小一致的低信号区。结论:①采用头颈联合或体部相控阵线圈进行高分辨率薄层MRI扫表对团块状的非黑色素型体表恶性肿瘤有很好的成像效果,可以准确客观反映肿瘤实体的边界,特别是对肿瘤累及深度反映比较准确,并且对肿瘤的扩散浸润区也有良好的提示作用,因此对术前判断肿瘤的真实范围有重要意义。但对基底细胞癌这种浅表肿瘤,显像准确度较差,难以对肿瘤的实体边界做出准确判断。②通过严谨的操作流程,可以实现对体表恶性肿瘤MRI影像、大体标本、病理切片的相同断面的形态学对比研究。③通过鱼肝油乳体外标记,可以更加准确的通过MRI确定肿瘤的实体边界和扩散边界在皮肤的投影位置,有助于确定手术切口的范围。④不管是采用Mohs显微描记手术还是传统的扩大切除,起始手术切口的应该是基于术前对肿瘤真实边界的判断而定,而不是根据肿瘤的体表范围确定。
[Abstract]:Background and objective: various kinds of non-melanin type surface malignant tumors are common clinical diseases. The high rate of missed detection in frozen pathological examination of traditional extended excision, which often leads to the clinical pathological return of "clean margin" cases tumor recurrence .Mohs micrography surgery although it can completely check the surgical margin, reduce the rate of missed detection. However, due to the inherent limitations of the technique, it is more suitable to be applied to small superficial malignant skin tumors. At the same time, how to determine more accurately the starting boundary of Mohs surgery is still controversial. MRI has been widely used in the imaging diagnosis of soft tissue lesions in vivo. However, it is rarely used for the examination of various kinds of malignant tumors on the body surface. The purpose of this study was to explore the criteria for the determination of the range of tumor personalized resection by means of morphological features and connections among MRI, gross specimens and pathology of malignant tumors on the body surface, and to provide guidance for the accurate resection of tumors in clinical practice. Methods: patients with different types of primary or recurrent non-melanoma with diameter larger than 1cm were scanned with head and neck combined or body phased array coils with high resolution thin layer scanning. To determine the optimal scanning scheme for malignant tumor of body surface. The MRI images of body surface malignant tumors were compared with gross specimens and final pathological images. In order to explore the feasibility of accurate resection of malignant tumor of body surface under the guidance of MRI imaging, cod liver oil emulsion in vitro was used for MRI imaging. Results: the types of malignant tumors of body surface examined by MRI included malignant tumors of non-melanoma skin, including basal cell carcinoma, cutaneous squamous cell carcinoma, cutaneous fibrosarcoma. The lesions showed high signal intensity on T _ 1WI and hyperintensity on T _ 2WI compared with muscle. The gross boundary of Carina dermatofibrosarcoma, malignant fibrosarcoma and spindle cell sarcoma can be seen clearly. The fine structure of the skin of basal cell carcinoma can not be clearly distinguished. In this study, there were 6 groups of specimens. One case of basal cell carcinoma (BCC) was not compared because of its small area. The other 5 cases successfully achieved MRI-gross specimen-pathological morphological comparison under the same tumor plane. The in vitro labeling of cod liver oil emulsion was clear on MRI. The thickness of fibrosarcoma tumor was basically the same in RI and pathological images, and the infiltrating area of tumor cells which broke through the boundary of tumor entity on pathological image was shown to be a low signal region of the same size in the corresponding region on T1WI. Conclusion using head and neck joint or body phased array coils to perform high resolution thin-layer MRI scan has a good imaging effect on mass non-melanin type surface malignant tumor, and can accurately and objectively reflect the boundary of tumor entity. Especially, the depth of tumor involvement is more accurate, and it is also a good indication to the diffusive area of tumor, so it is important to judge the true range of tumor before operation. But for the superficial tumor of basal cell carcinoma, the imaging accuracy is poor, it is difficult to make accurate judgment on the solid boundary of tumor .2 through the rigorous operation procedure, we can realize the MRI image of body surface malignant tumor, gross specimen, Comparative study of Morphology of the same Section of pathological sections. 3. By in vitro labeling of cod liver oil emulsion, MRI can more accurately determine the projection position of the solid boundary and diffusion boundary of the tumor in the skin. To help determine the range of surgical incisions, whether using Mohs micrography or conventional extended resection, the initial incision should be based on preoperative judgment of the true boundary of the tumor. It is not based on the range of the body surface of the tumor.
【学位授予单位】：中国人民解放军医学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R739.5

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