伪连续性动脉自旋标记技术对高级别胶质瘤及原发性脑淋巴瘤的鉴别诊断价值研究

发布时间：2018-04-12 11:33

本文选题：伪连续性动脉自旋标记 + 高级别胶质瘤　；参考：《河北医科大学》2014年硕士论文

【摘要】：原发性恶性脑肿瘤较常见，以高级别胶质瘤居多，而原发性中枢神经系统淋巴瘤相对少见，但近年来发病率呈逐渐上升趋势。高级别胶质瘤以手术治疗为主，而化疗和放射治疗对淋巴瘤比较敏感，因此正确地鉴别高级别胶质瘤与淋巴瘤对制定最佳的临床治疗方案至关重要。传统MRI常不容易鉴别脑胶质瘤与淋巴瘤。对于很多疾病来说，研究组织的灌注能提供病变的特征、诊断及功能改变的信息。目前临床上有多种技术可以研究组织灌注，如CT灌注成像，MRI灌注加权成像（MR perfusion weighted imaging，PWI）以及核素成像。但是这些技术都需要注射对比剂，或/和有电离辐射。从20世纪90年代发展起来的磁共振动脉自旋标记技术（Arterial Spin Labeling,ASL）可以显示组织灌注，而不用对比剂，也没有辐射。由于其技术复杂，对软硬件要求高，近几年才初步用于临床。伪连续性动脉自旋标记技术（pseudo-continuous arterial spin labeling，pCASL）是在原有ASL技术基础上的发展和改进，比原有ASL技术更加稳定和可靠。与传统应用广泛的MR灌注成像不同，它不需应用对比剂，利用磁化标记的动脉血质子作为内源性示踪剂定量测量肿瘤的血流灌注信息，更容易为患者所接受。目前这项新技术在脑肿瘤鉴别诊断中的作用还没有得到充分的评估和认识。目的： 1进一步认识高级别胶质瘤与淋巴瘤的病理学表现，有效地将病理学表现与影像学结果结合起来。 2应用pCASL技术定量评估肿瘤的血流灌注情况，分析pCASL技术在鉴别高级别胶质瘤与原发性脑胶质瘤方面的应用价值，为临床寻找一种可靠的影像学方法鉴别脑肿瘤，帮助制定正确的诊疗决策。方法： 1查阅2010-2013年于河北省邯郸市中心医院放射科行MR检查的所有胶质瘤及淋巴瘤患者的影像资料； 2找到同时进行了常规MR检查及pCASL检查的患者； 3排除数据资料不完整的患者，如只进行了常规MR检查而没有pCASL图像的高级别胶质瘤患者或在pCASL检查前进行过化疗或类固醇激素治疗的淋巴瘤患者； 4对每个肿瘤在其增强部位各选择5个感兴趣区，每个感兴趣区大小一致，均为17.56mm2，先分别测量肿瘤的血流量，再取平均值，得到肿瘤的平均血流量（mTBF）； 5于肿瘤感兴趣区相同扫描层面的对侧正常脑灰质部分去5个感兴趣区，以同样的方法计算平均血流量，即mBFgm；计算肿瘤的相对血流量：rTBF=（mTBF/mBFgm）×100； 6对比分析高级别胶质瘤与淋巴瘤的mTBF及rTBF值有无统计学差异； 7绘制ROC曲线，找到鉴别两种肿瘤的最佳临界值； 8对比两灌注参数的ROC曲线下面积有无差异，分析两参数鉴别肿瘤的能力有无明显差别. 结果 1按照本研究的纳入排除标准，最后研究对象共包括31例患者，其中20例为高级别胶质瘤患者，11例为原发性脑淋巴瘤患者。 2高级别胶质瘤患者年龄22-65岁，平均年龄47.4岁，包括12例多形性胶质细胞瘤、3例星形细胞瘤及5例复发性多形性胶质细胞瘤； 3淋巴瘤患者年龄38-82岁，平均年龄60.9岁，其中包含一例对化疗无效的复发性淋巴瘤患者。 4高级别胶质瘤mTBF值明显高于淋巴瘤（92.1±34.7mL/min/100mgvs.53.6±30.5mL/min/100mg，P=0.008）。两肿瘤比较，rTBF值的差异也有统计学意义（182.3±69.5vs.92.5±44.9，P=0.002）。 5根据ROC曲线分析可得，mTBF鉴别高级别胶质瘤与淋巴瘤的最佳临界值为57.9mL/min/100mg，灵敏度为90%，特异度为54.6%；rTBF鉴别诊断两种肿瘤的最佳临界值为141.1，灵敏度为65%，特异度为100%。 6对两个参数的ROC曲线下面积分析显示，两者曲线下面积无明显统计学差异(0.873vs.0.909，P=0.287)。结论 1高级别胶质瘤与原发性脑淋巴瘤比较，肿瘤的灌注参数--mTBF及rTBF均明显增高，说明应用这两个参数可以有效鉴别高级别胶质瘤与淋巴瘤。 2分别以mTBF57.9mL/min/mg及rTBF141.1作为最佳临界值鉴别诊断高级别胶质瘤与原发性脑淋巴瘤，具有较高的诊断敏感度及特异度。对两者ROC曲线下面积对比分析，，无明显统计学差异，说明两者鉴别肿瘤的能力相当，无明显差别。 3pCASL技术是一项新的技术，可以作为一种可靠、简便、准确的方法来鉴别诊断脑肿瘤，帮助临床医师制定正确的诊疗方案，具有重要临床意义，是未来ASL技术发展的趋势。
[Abstract]:Primary malignant brain tumors are common in high - grade gliomas , while primary central nervous system lymphoma is relatively rare , but the incidence of primary central nervous system lymphoma is gradually increasing in recent years . High - grade gliomas are mainly surgical treatment , and chemotherapy and radiotherapy are very sensitive to lymphoma . Therefore , it is important to correctly identify high - grade gliomas and lymphomas for the development of optimal clinical treatment regimens . Traditional MRI is often not easy to distinguish between glioma and lymphoma .

Tissue perfusion , such as CT perfusion imaging , MR perfusion weighted imaging ( PWI ) , and nuclear imaging , are currently available in the study of tissue perfusion for many diseases . However , these techniques require injection of contrast agents , or / and ionizing radiation . Magnetic resonance arterial spin labeling techniques developed in the 1990s may exhibit tissue perfusion without contrast agents and no radiation .

The pseudo - continuous arterial spin labeling ( pCASL ) has been developed and improved on the basis of the original technique , which is more stable and reliable than the original one . Compared with the conventional MR perfusion imaging , it does not need to apply contrast agent , and it is more easy to measure tumor ' s blood perfusion information by using magnetized labeled arterial blood proton as the endogenous tracer .

Purpose :

1 . To further understand the pathological manifestations of high - grade glioma and lymphoma , and to effectively combine pathological findings with imaging findings .

2 . Using the technique of pCASL to quantitatively evaluate the perfusion of tumor , the application value of pCASL technique in identifying high - grade gliomas and primary glioma was analyzed , and a reliable imaging method was used to identify brain tumors and help formulate correct diagnosis and treatment decisions .

Method :

1 Refer to the image data of all glioma and lymphoma patients who underwent MR examination at the central hospital of Handan City , Hebei Province , 2010 - 2013 ;

2 patients with simultaneous normal MR examination and pCASL examination were found ;

3 Patients with incomplete data data , such as patients with high - grade glioma without the pCASL image or lymphoma patients who had undergone chemotherapy or steroid hormone treatment prior to the pCASL examination , for example only with routine MR examination ;

4 , 5 regions of interest were selected for each tumor in each region of interest , and the size of each region of interest was consistent with 17.56mm2 , respectively , the blood flow rate of tumor was measured , and then the average value was taken to obtain the mean blood flow ( mTBF ) of the tumor ;

5 regions of interest on the contralateral normal gray matter at the same scanning level in the region of interest of the tumor , and the mean blood flow rate , i.e . , mBFgm , was calculated by the same method ;
Relative blood flow of tumor was calculated : rTBF = ( mTBF / mBFgm ) 脳 100 ;

6 . There was no statistical difference between mTBF and rTBF in high - grade gliomas and lymphoma .

7 Draw ROC curve , find the best critical value for identifying two kinds of tumors ;

8 Compared with the ROC curve of the two perfusion parameters , there was no significant difference in the ability of the two parameters to identify the tumor .

Results

1 According to the exclusion criteria of this study , the final study consisted of 31 patients , of whom 20 were high - grade glioma patients and 11 were primary brain lymphoma patients .

2 high - grade glioma patients ranged from 22 to 65 years , with a mean age of 47.4 years .

Patients with lymphoma aged 38 - 82 years with an average age of 60.9 years , including one case of recurrent lymphoma with ineffective chemotherapy .

The mTBF value of high - grade glioma was significantly higher than that of lymphoma ( 92.1 卤 34.7mL / min / 100mgvs . 53.6 卤 30.5 mL / min / 100 mg , P = 0.008 ) . The difference of rTBF between the two tumors was statistically significant ( 182.3 卤 69.5vs . 92.5 卤 44.9 , P = 0.002 ) .

5 According to ROC curve analysis , the optimal critical value of mTBF was 57.9 mL / min / 100mg , sensitivity was 90 % and specificity was 54.6 % .
The optimal critical value of rTBF was 141.1 , the sensitivity was 65 % , and the specificity was 100 % .

The area under ROC curve of two parameters showed that there was no statistically significant difference between the two curves ( 0.873 vs . 0.909 , P = 0.287 ) .

Conclusion

1 High - grade glioma was compared with primary brain lymphoma , and the perfusion parameters of tumor - mTBF and rTBF increased significantly , indicating that the two parameters could be used to identify high - grade gliomas and lymphoma .

2 The diagnosis of high grade gliomas and primary brain lymphoma with mTBF57.9 mL / min / mg and rTBF141.1 were used as the best critical value .

3pCASL technology is a new technique , which can be used as a reliable , simple and accurate method for the differential diagnosis of brain tumors . It can help clinicians to develop the correct diagnosis and treatment plan , which has important clinical significance and is the trend of future development .

【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R739.41

【参考文献】