多模态影像融合技术与颅底-颞下区肿瘤的诊断和治疗
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摘要
目的:评价多模态影像融合技术联合计算机辅助设计在颅底-颞下区肿瘤诊断和治疗中的应用及效果。方法:选择2011年2月至2018年9月于北京大学口腔医院诊治的颅底-颞下区肿瘤患者资料进行回顾性分析,共入选病例17例,术前所有患者进行平扫CT、增强CT及MRI影像扫描。在导航软件中将平扫CT、增强CT及MRI影像融合后,三维重建肿瘤、血管及颅颌面骨,计算机辅助设计手术方案,并联合导航引导下穿刺活检或手术,术后定期随访,分析患者资料,评价应用效果。结果:17例病例均取得满意的多模态影像融合,在同一帧图像上精确显示通过不同图像描记的病变、颅颌面骨及重要血管。联合计算机辅助三维重建及导航引导穿刺或手术设计,进行术前评估及手术方案设计,取得了良好的应用效果,尤其对肿瘤体积较小、复发及边界不清的病例效果显著。4例利用融合图像进行术前诊断与评估后行手术探查(无术中导航引导,其中3例手术切除,1例仅取活检),3例行导航引导穿刺活检,12例行导航引导手术切除(其中2例先行导航穿刺活检)。所有患者均成功实施穿刺或手术,1例脑膜瘤复发患者术中出现脑脊液漏,1例腮腺深叶肿瘤患者术后面瘫,穿刺活检病理诊断阳性率为100%(3/3)。手术切除的15例经术中导航检查及术后影像验证显示完全切除14例,次全切除1例,术后随访3～94个月(中位随访时间9个月)。结论:充分利用多模态影像优势,准确分析肿瘤、血管及颅颌面骨的三维空间位置关系,有助于颅底-颞下区肿瘤的术前规划,联合导航技术可进一步提高穿刺活检及手术治疗的精准性和安全性。
Objective: To explore the value of incorporated multimodal image fusion technology with computer-aided design of the skull base-infratemporal tumor treatment. Methods: A retrospective study was carried out to enroll seventeen patients with skull base-infratemporal tumors treated at Peking University Hospital of Stomatology from February 2011 to September 2018. Plain CT,enhanced CT and MRI data were imported into the i Plan 3. 0 software(BrainLab navigation system),and the image fusion was performed for each patient preoperatively. Then the three-dimensional images of the tumor,vital vessels and craniofacial bones were reconstructed to prepare virtual operation design. We evaluated the application of multimodal image fusion technology that had been incorporated with computer-aided planning during the navigation-guided biopsy or surgery,through the analysis of the biopsy and operation data and regular follow-up postoperatively. Results: The mean age of 17 patients(7 males and 10 females) was 46 years. Primary tumors occurred in 11 cases,and recurrent tumors in 6 cases. The size of the 17 tumors ranged from 2. 9 cm to 9 cm,and the mean size was 4. 35 cm. There were 7 cases with skull base bone destruction and/or intracranial extension,and 10 cases with tumors adjacent to the skull base. Highquality multimodal fused images were obtained in all the 17 cases. The spatial-position relationships of the tumors,adjacent craniomaxillofacial bones and vital vessels labeled with different colors were displayed well on the generated fusion images. The multimodal image fusion technology that incorporated with computer-aided three-dimensional reconstruction and then applied in navigation-guided biopsy or surgery showed that,preoperative analysis and virtual operation design functioned with good results,especially in cases with small tumor size,recurrence or ill-defined borders in the skull base-infratemporal region. Operation was carried out in 16 cases after preoperative diagnosis and assessment,and 1 case was performed by navigation-guided biopsy only. The proportions of navigation-guided surgery and biopsy were 70. 6%(12/17) and 17. 6%(3/17) individually. The positive rate of pathologic diagnosis using navigation-guided biopsy was 100%(3/3). All the navigation-guided biopsies or operations were carried out successfully. Complications included 1 case of cerebrospinal fluid leak from a recurred meningioma patient postoperatively,and 1 case of facial paralysis resulting from parotid-gland deep lobe tumor. Most(14/15) tumors got complete removal with safe boundary through intra-operative navigation verification and post-operative imaging confirmation,except for one case of subtotal resection to avoid the injury of cavernous sinus. The pathological results of the tumors could be classified to mesenchymal(10),adenogenous(3),neurogenic(3) or epithelial(1) resources. The follow-up time ranged from 3 to 94 months,with the median follow-up time of 9 months. Conclusion: Taking full advantages of individualized multimodal images,could help analyze the three-dimensional spatial position relationship of tumors,vital vessels and craniofacial bones properly,and then complete the virtual operation design well. The incorporated multimodal image fusion technology with navigation technology may improve the accuracy and safety of core needle biopsy and surgical treatment of skull base-infratemporal tumors.
Objective: To explore the value of incorporated multimodal image fusion technology with computer-aided design of the skull base-infratemporal tumor treatment. Methods: A retrospective study was carried out to enroll seventeen patients with skull base-infratemporal tumors treated at Peking University Hospital of Stomatology from February 2011 to September 2018. Plain CT,enhanced CT and MRI data were imported into the i Plan 3. 0 software(BrainLab navigation system),and the image fusion was performed for each patient preoperatively. Then the three-dimensional images of the tumor,vital vessels and craniofacial bones were reconstructed to prepare virtual operation design. We evaluated the application of multimodal image fusion technology that had been incorporated with computer-aided planning during the navigation-guided biopsy or surgery,through the analysis of the biopsy and operation data and regular follow-up postoperatively. Results: The mean age of 17 patients(7 males and 10 females) was 46 years. Primary tumors occurred in 11 cases,and recurrent tumors in 6 cases. The size of the 17 tumors ranged from 2. 9 cm to 9 cm,and the mean size was 4. 35 cm. There were 7 cases with skull base bone destruction and/or intracranial extension,and 10 cases with tumors adjacent to the skull base. Highquality multimodal fused images were obtained in all the 17 cases. The spatial-position relationships of the tumors,adjacent craniomaxillofacial bones and vital vessels labeled with different colors were displayed well on the generated fusion images. The multimodal image fusion technology that incorporated with computer-aided three-dimensional reconstruction and then applied in navigation-guided biopsy or surgery showed that,preoperative analysis and virtual operation design functioned with good results,especially in cases with small tumor size,recurrence or ill-defined borders in the skull base-infratemporal region. Operation was carried out in 16 cases after preoperative diagnosis and assessment,and 1 case was performed by navigation-guided biopsy only. The proportions of navigation-guided surgery and biopsy were 70. 6%(12/17) and 17. 6%(3/17) individually. The positive rate of pathologic diagnosis using navigation-guided biopsy was 100%(3/3). All the navigation-guided biopsies or operations were carried out successfully. Complications included 1 case of cerebrospinal fluid leak from a recurred meningioma patient postoperatively,and 1 case of facial paralysis resulting from parotid-gland deep lobe tumor. Most(14/15) tumors got complete removal with safe boundary through intra-operative navigation verification and post-operative imaging confirmation,except for one case of subtotal resection to avoid the injury of cavernous sinus. The pathological results of the tumors could be classified to mesenchymal(10),adenogenous(3),neurogenic(3) or epithelial(1) resources. The follow-up time ranged from 3 to 94 months,with the median follow-up time of 9 months. Conclusion: Taking full advantages of individualized multimodal images,could help analyze the three-dimensional spatial position relationship of tumors,vital vessels and craniofacial bones properly,and then complete the virtual operation design well. The incorporated multimodal image fusion technology with navigation technology may improve the accuracy and safety of core needle biopsy and surgical treatment of skull base-infratemporal tumors.
引文
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[12]顾恒乐,聂生东.多模医学图像配准和融合方法及其临床应用进展[J].中华放射肿瘤学杂志,2016,25(8):902-906.
[13] Inoue HK,Nakajima A,Sato H,et al. Image fusion for radiosurgery,neurosurgery and hypofractionated radiotherapy[J]. Cureus,2015,7(3):e252.
[14] Nemec SF,Donat MA,Mehrain S,et al. Ct-mr image data fusion for computer assisted navigated neurosurgery of temporal bone tumors[J]. Eur J Radiol,2007,62(2):192-198.
[15] Zhang SX,Han PH,Zhang GQ,et al. Comparison of spect/ct,mri and ct in diagnosis of skull base bone invasion in nasopharyngeal carcinoma[J]. Biomed Mater Eng,2014,24(1):1117-1124.
[16] Guo YX,Sun ZP,Liu XJ,et al. Surgical safety distances in the infratemporal fossa:three-dimensional measurement study[J].Int J Oral Maxillofac Surg,2015,44(5):555-561.
[17]吴东东,卜博,陈晓雷,等.融合MRI与CT图像的多模态神经导航技术在颅底显微外科手术中的应用[J].解放军医学院学报,2015,(5):411-414.
[18] Hayashi N,Kurimoto M,Hirashima Y,et al. Efficacy of navigation in skull base surgery using composite computer graphics of magnetic resonance and computed tomography images[J]. Neurol Med Chir(Tokyo),2001,41(7):335.
[2]魏宏权.咽旁隙和颞下窝肿瘤的外科治疗进展[J].中国耳鼻咽喉颅底外科杂志,2018,24(2):91-96,102.
[3]郭玉兴,彭歆,刘筱菁,等.导航技术在颅底-颞下区肿瘤手术中的应用[J].中华口腔医学杂志,2013,48(11):645-647.
[4]郭传瑸,郭玉兴.外科导航技术引导的颅底肿瘤穿刺活检[J].中国实用口腔科杂志,2014,7(6):321-324.
[5] Guo R,Guo YX,Feng Z,et al. Application of a computer-aided navigation technique in surgery for recurrent malignant infratemporal fossa tumors[J]. J Craniofac Surg,2015,26(2):e126-132.
[6] Leong JL,Batra PS,Citardi MJ. CT-MR image fusion for the management of skull base lesions[J]. Otolaryngol Head Neck Surg,2006,134(5):868-876.
[7] Guo Y,Guo C. Maxillary-fronto-temporal approach for removal of recurrent malignant infratemporal fossa tumors:Anatomical and clinical study[J]. J Craniomaxillofac Surg,2014,42(3):206-212.
[8] Yacoub A,Anschuetz L,Schneider D,et al. Minimally invasive lateral endoscopic multiport approach to the infratemporal fossa:a cadaveric study[J]. World Neurosurg,2018,112:e489-e496.
[9]李成才,姚国杰,杜威,等.多模态影像融合在颅底肿瘤的诊断、治疗中的应用价值[J].中国临床神经外科杂志,2018,23(3):145-148.
[10] O'Neill BE,Hochhalter CB,Carr C,et al. Advances in neuro-oncology imaging techniques[J]. Ochsner J,2018,18(3):236-241.
[11]赵岩,孙健,杨学军.多模态影像融合技术在神经外科的应用及进展[J].中国现代神经疾病杂志,2012,12(6):645-650.
[12]顾恒乐,聂生东.多模医学图像配准和融合方法及其临床应用进展[J].中华放射肿瘤学杂志,2016,25(8):902-906.
[13] Inoue HK,Nakajima A,Sato H,et al. Image fusion for radiosurgery,neurosurgery and hypofractionated radiotherapy[J]. Cureus,2015,7(3):e252.
[14] Nemec SF,Donat MA,Mehrain S,et al. Ct-mr image data fusion for computer assisted navigated neurosurgery of temporal bone tumors[J]. Eur J Radiol,2007,62(2):192-198.
[15] Zhang SX,Han PH,Zhang GQ,et al. Comparison of spect/ct,mri and ct in diagnosis of skull base bone invasion in nasopharyngeal carcinoma[J]. Biomed Mater Eng,2014,24(1):1117-1124.
[16] Guo YX,Sun ZP,Liu XJ,et al. Surgical safety distances in the infratemporal fossa:three-dimensional measurement study[J].Int J Oral Maxillofac Surg,2015,44(5):555-561.
[17]吴东东,卜博,陈晓雷,等.融合MRI与CT图像的多模态神经导航技术在颅底显微外科手术中的应用[J].解放军医学院学报,2015,(5):411-414.
[18] Hayashi N,Kurimoto M,Hirashima Y,et al. Efficacy of navigation in skull base surgery using composite computer graphics of magnetic resonance and computed tomography images[J]. Neurol Med Chir(Tokyo),2001,41(7):335.