松果体区三维模型构建与松果体区肿瘤放射治疗的研究

发布时间：2018-05-19 12:02

  本文选题：断面解剖 + 松果体区肿瘤　； 参考：《第三军医大学》2014年硕士论文

【摘要】：背景 松果体区位置深在并且重要神经结构、头部动、静脉丛集中于此，因而实施松果体区的手术困难重重。熟悉松果体区的显微解剖结构及毗邻关系，不但可以降低手术死亡率和病残率，而且也能为临床上松果体区肿瘤放疗计划的准确制定和实施提供参考。目前，诊断松果体区肿瘤主要依靠CT或MRI图像，其次就是根据病人的症状、年龄、性别以及脑脊液等辅助检查来综合作出诊断。CT、MRI对松果体区域肿瘤均比较敏感，无疑为选择治疗方案提供了很大的方便。但是就松果体这一复杂区域而言，目前的二维影像图像已经不能满足于临床需要，而在松果体这一区域，当前国内外在三维立体方面的研究甚少。本课题拟在断层解剖学基础上对松果体及毗邻结构进行三维立体重建，为松果体区疾病的临床影像诊断和治疗提供形态学基础。 其次松果体区肿瘤发病率虽低，但肿瘤病理构成复杂，根据2007年世界卫生组织CNS肿瘤病理分类，可分为4大类：生殖细胞瘤、松果体实质肿瘤、神经上皮肿瘤及其它来源肿瘤,细分又可分为不同的病理亚型，各病理类型或亚型的肿瘤治疗方式及治愈后效果差异都很大。总结目前的治疗方式，主要有手术、化疗、放疗及这三种的综合治疗，有的主张手术治疗为首选，有的主张先放疗再手术，治疗方式存在极大争议，目前国内外尚无一致意见。为建立松果体区肿瘤临床治疗路径提供依据，我们着重研究该区肿瘤的影像学表现、临床表现、治疗方法和病理分型等。 目的 1.人体头部结构复杂，尤其是松果体这一区域，相互间位置关系对器官功能影响较大，不但是影像学上较难分析的区域之一，而且在临床上该区疾病的诊断和治疗更是一个难点。本实验通过对松果体区断层面的解剖及三维重建模型的研究，可进一步熟悉和掌握该区的解剖结构组成，松果体与周围结构的关系，探讨肿瘤对周围结构生长方向、生长形态可能造成的影响等，为临床上对区肿瘤的治疗提供新思路及理论指导。 2.采用数字化可视人(首例中国男性)的数据集,对松果体及其相邻结构的空间位置关系进行断面解剖学研究，并对松果体及其相邻结构进行计算机三维重建和虚拟现实显示，阐明该区重要解剖结构的立体形态、空间位置及相互毗邻关系，在此基础上再将现代影像技术与立体定向放射治疗(SRT)、三维适形(3DCRT)、调强适形放射治疗(IMRT)技术相结合应用于松果体区肿瘤的放射治疗，以此来改善放疗计划和保证实施过程的精确性，保护人体正常组织，同时可提高肿瘤的局部控制率，降低复发率和放射并发症。 3.调查分析我国西部地区松果体肿瘤治疗模式(手术治疗、放疗治疗)和该区肿瘤的病理分型，为了建立松果体区肿瘤合理化、最优化临床治疗路径。 材料 数字化可视人(首例中国男性)的数据集中的头部连续断面图像(层厚0.25mm)；10%甲醛固定好的成人尸头标本1例；计算机、Adobe photoshop CS4、Amira软件；SIEMENS MAGNETON IMPACT2.0TMA核磁共振。 方法 1.采用数字化可视人(首例中国男性)的数据集，该数据集中的连续断面有以下优点：层厚较薄(层厚0.25mm)、重建后图像逼真、数据精确，对松果体及其毗邻的结构进行断面解剖学观察，并提取相关断面图像信息。将10%甲醛固定好的成人尸头标本进行磁共振扫描(层厚3mm)，获取其横、冠、矢三方位的断面图像。将CVH断面图像与对应层(从松果体开始出现到松果体消失以及此过程中包含的所有结构)的MRI典型图像进行对照研究，提取具有典型标志的断面图像，进行断面影像解剖结构的对照观察。 2.在CVH数据集的基础上，利用Photoshop、Amira软件对颅底区结构进行半自动分割和三维重建，建立人脑松果体区精确的三维可视化模型，为松果体区疾病的手术入路、放射治疗计划的精确制定提供形态学依据。 3.回顾性分析我国西部地区9家三甲医院(名单见末页附录)脑外科、放疗科近8年收治的资料较完整的松果体肿瘤病例资料，重点分析松果体区肿瘤手术治疗、放射治疗的选择及治疗方法、治疗的步骤等。 结果 1. CVH断面图像与对应层的MRI图像对照后，清楚的观察到松果体区细微结构的连续断面形态和规律；比较主要结构在横、冠、矢三方位的断面影像特点，对其中典型的二维层面中主要结构的断面形态及毗邻关系进行描述，为颅底区占位病变的影像学研究提供解剖学依据。 2.利用Amira软件在电脑上对断面结构进行分割和三维重建，立体重建了胼胝体、松果体、侧脑室、等结构。可视化重建的三维模型可清楚地显示松果体和周围结构的形态和空间位置关系，同时可按任意角度旋转、切割，可以单独的显示，也可任意组合来显示，或者整体显示。 3.共收集到219例，其中手术治疗58例，肿瘤全切除52例，肿瘤次全切6例，有2例手术死亡、4例围手术期死亡、9例术后出现昏迷或重度昏迷、2例手术后病情恶化放弃治疗；放射治疗196例：其中采用立体定向放射治疗153例、直线加速器放疗43例(其中先行诊断性放疗25例)，直线加速器治疗中行全中枢照射仅21例。 结论 1. CVH断面图像可较好的显示松果体区细微结构，因为其层厚较薄仅为0.25mm，而通常CT/MRI图像层厚一般为3～5mm。结合MRI图像对照研究后，得出松果体在横、冠、矢三方位的断面影像特点，可深入了解松果体区域细微结构的连续薄层断面形态规律，，不仅可以为神经外科疾病诊断提供解剖学基础，也能提高松果体区微小病灶的影像确认率，可以减少漏诊和误诊。 2.通过Amira软件重建的松果体及周围的丘脑、海马、侧脑室、第三脑室等结构清晰，其构建模型可较为准确的揭示松果体与周围结构的毗邻关系，通过三维重建得到的三维立体模型对研究松果体区复杂解剖结构具有十分明显的优越性，对研究颅底区结构间的相互关系有重要的价值；为临床医生制定松果体区肿瘤放疗计划、设计松果体区手术入路和在电脑上模拟手术操作提供了新的手段和新的方法。通过建立松果体区可视化解剖模型，既为数字化解剖学的开展提供了教学平台；也为计算机辅助松果体区导航手术和松果体区肿瘤的放射治疗提供立体形态学基础。 3.脑室-腹腔分流术或三脑室造瘘术+放疗是我国西部地区松果体区肿瘤治疗最多见的模式，占53.9%；其次为肿瘤切除+放疗模式,占21.5%。且各医疗单位的放射治疗在照射方式与照射剂量的选择上差异甚大,显示该肿瘤的治疗极不规范，提示建立松果体区肿瘤诊治规范是十分有必要的。
[Abstract]:Background

CT and MRI can not only reduce the operative mortality and morbidity , but also can provide reference for the accurate formulation and implementation of the tumor radiotherapy plan .

Second , the incidence of tumor is low , but the pathological structure of tumor is complicated . According to the pathological classification of CNS tumor in World Health Organization in 2007 , it can be divided into four major categories : germ cell tumor , substance tumor of pinealbody , neuroepithelial tumor and other source tumors .

Purpose

1 . The structure of the head of human body is complicated , especially in the region of the pine body , the relationship between the position and the position of each other has great influence on the organ function , but it is a difficult problem in the diagnosis and treatment of the disease in clinic .

2 . Based on the data set of the digital visual human ( first Chinese male ) , the spatial position relation of the pine body and its adjacent structure is studied , and the three - dimensional reconstruction and virtual reality display of the pine body and its adjacent structure are carried out . The three - dimensional shape , the spatial position and the adjacent relation of the important anatomical structure in this area are expounded . Based on this , the accuracy of the radiotherapy plan and the guarantee of the implementation process can be improved , the normal tissues of the human body can be protected , and the local control rate of the tumor can be improved , and the recurrence rate and the radiation complication can be reduced .

3 . Investigation and analysis of the tumor therapy mode ( surgical treatment , radiotherapy ) and pathological type of tumor in the western region of our country . In order to establish the rationalization of tumor in the region of the pine body , the clinical treatment path is optimized .

Material

Head continuous cross - sectional image in the data center of digital visual human ( first Chinese male ) ( layer thickness 0.25 mm ) ;
1 case of adult cadaver head specimen with 10 % formaldehyde fixation ;
Computer , Adobe Photoshop CS4 , Amira software ;
The nuclear magnetic resonance ( MRI ) was carried out on the basis of the magnetic resonance imaging method of Siemens - TON IMPACT2 . 0TMA .

method

1 . A digital visual human ( first Chinese male ) data set is adopted , the continuous section of the data set has the following advantages : the layer thickness is thinner ( layer thickness is 0.25 mm ) , the reconstructed image is vivid , the data is accurate , and the cross section image of the cross section image information is extracted .

2 . On the basis of CVH data set , using Photoshop and Amira software to carry out the semi - automatic segmentation and three - dimensional reconstruction of the skull base region structure , the precise three - dimensional visualization model of the human brain pine body region is established , which provides the morphological basis for the precise formulation of the operation approach and the radiation treatment plan of the pine body region disease .

3 . Retrospective analysis of 9 cases of Sanjia Hospital in the western region of our country ( see appendix of the last page of the list ) , the data of the whole body tumor cases treated by radiotherapy department in the last 8 years , the emphasis is on the treatment of tumor operation , the choice of radiation therapy , the treatment method , the treatment step and so on .

Results

1 . After comparing the CVH section image with the MRI image of the corresponding layer , it is clear that the continuous cross - section morphology and law of the fine structure of the pine body area are observed .
The cross - sectional image features of the main structure in the transverse , coronal and sagittal directions are compared , and the cross - sectional shape and the adjacent relation of the main structure in the typical two - dimensional plane are described , and the anatomical basis is provided for the imaging study of the space occupying lesion of the skull base .

2 . Using Amira software to separate and three - dimensionally reconstruct the section structure on the computer , the structure of corpus callosal , pinealbody , lateral ventricle , and so on is reconstructed stereoscopically . The three - dimensional model of visual reconstruction can clearly show the relationship between the shape and the spatial position of the pine body and the surrounding structure , and can rotate and cut according to any angle , can be displayed separately , can be displayed by any combination , or displayed in whole .

3 . 219 cases were collected , including 58 cases of surgical treatment , 52 cases of total tumor resection , 6 cases of tumor subtotal resection , 2 cases of operation death , 4 cases of perioperative death , 9 cases coma or severe coma after operation , 2 cases after operation and abandoned treatment ;
Radiotherapy was performed in 196 cases , including 153 cases with stereotactic radiotherapy , 43 cases with linear accelerator radiotherapy ( including 25 cases of pre - diagnostic radiotherapy ) and 21 cases with straight - line accelerator .

Conclusion

1.CVH section image can better display the fine structure of the pine body area , because its layer thickness is only 0.25 mm , and the thickness of CT / MRI image layer is generally 3 锝

本文编号：1910021