肾上腺三维断层解剖及其在影像诊断中的应用
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摘要
肾上腺位于腹膜后隙内,其病变种类繁多,临床表现复杂,故而是临床尤其是医学影像学和外科学研究的热点之一。但由于其位置深在,体积细小,形态各异且毗邻关系复杂,因此其影像学探测尚有一定地难度。近年来临床普遍开展的腹腔镜肾上腺切除术对肾上腺的毗邻关系,特别是和其周围大血管的关系又提出了更高的要求。早期有学者采用CT在横断层上研究了肾上腺的位置、大小和常见疾病的影像学表现,这些研究单纯采用影像学手段,没有断层标本的对照,由于受CT密度分辨力的影响,肾上腺的微小病变难以精确定位和显示。近年来随着多层螺旋CT及其图像后处理功能的快速发展以及MRI快速扫描序列的应用,影像学技术可在横、矢、冠和斜状断层上显示肾上腺的正常解剖和其病变。目前,肾上腺的横断层解剖研究较多,但这些研究方法多采用1例或几例断层标本,仅结合正常的CT或MRI图像,并且缺乏肾上腺微小病变图像的对照研究;本课题组曾对肾上腺的矢状断层解剖进行了初步探讨,只是单纯采用矢状断层标本,没有结合正常肾上腺图像及肾上腺典型微小病变图像对照研究;迄今为止,有关肾上腺的冠状断层解剖尚未见报道,而冠状断层解剖在同时显示双侧肾上腺方面有其独特的优势。
用断层解剖方法研究肾上腺的位置、形态和毗邻关系,可充分保证肾上腺的在体方位,不仅便于和断层影像直接对照研究,更有利于泌尿外科确定肾上腺病变的准确位置,进而有利于各种肾上腺手术的实施。但这方面的研究使用的断层标本数量较少,并且仅限于横断层或矢状断层。
多层螺旋CT及其三维重建技术的临床应用,可重建出肾上腺及其周围器官的三维图像,能充分显示在体方位的。肾上腺及其和周围结构的毗邻关系。近年来MRI快速扫描序列的应用,以及压脂技术,可清晰显示肾上腺及其周围结构的细微解剖,使肾上腺微小病变的精确定位成为可能。然而单纯地采用CT或MRI,由于部分容积效应的存在和密度分辨力的限制,其显示的肾上腺与标本上的真实结构之间尚存有差异,尚需将断层标本和CT及MRI图像结合起来探讨肾上腺的三维断层解剖。
另外采用横、矢和冠状断层标本,并结合肾上腺微小病变的典型表现,来系统探讨正常肾上腺及其病变的影像学表现,这方面的研究报道较少。
本课题使用上腹部横、矢、冠状断层标本,并结合多层螺旋CT(MSCT)图像和三维(3D)图像,MRI断层图像,以及肾上腺微小病变的CT和MRI图像,系统研究肾上腺的三维断层解剖特点和肾上腺微小病变的影像学表现,以期为肾上腺病变的影像诊断和外科治疗提供准确而实用的断层解剖学基础。
本课题共分为5部分:
第一部分肾上腺横断层解剖及CT、MRI
目的为肾上腺病变的横断层影像诊断和外科治疗提供实用的断层解剖和影像诊断学依据。
材料和方法使用20例成人上腹部连续横断层标本、10例健康成人MRI横断层图像及20例无肾上腺病变的临床病人MSCT横断层图像,连续追踪观测了肾上腺在横断面上的形态、位置、毗邻和大小。
结果在连续横断面上,第一肝门层面往往是肾上腺首次出现的层面,左右肾血管出现层面是双侧肾上腺消失的层面。左、右肾上极出现层面是横断层上寻找双侧肾上腺的理想层面。经肝门下方的横断面上,右肾上腺位于下腔静脉后方、肝裸区和右膈脚围成的右肾上腺三角内,左肾上腺位于胃裸区、脾和左膈脚围成的左肾上腺三角内。经左肾上极或右肾上极的横断面上,左肾上腺位于左肾上极前内、胰体后面、脾的内侧和左膈脚围成的四边形区域内,右肾上腺位于右肾上极前内、下腔静脉后壁、肝裸区和右膈脚围成的四边形区域内。
结论连续横断层上左、右。肾上极层面是寻找双侧肾上腺的可靠层面。下腔静脉后壁是识别右肾上腺前界的标志;脾动、静脉则是识别左肾上腺前界的标志。在连续横断层上肾上腺的形态变化较大,肾上腺前方的毗邻结构尤其左肾上腺复杂,故肾上腺病变向前生长时有不同的优势途径。
第二部分肾上腺矢状断层解剖及CT、MRI
目的为肾上腺病变的矢状断层影像诊断和外科治疗提供实用的断层解剖学依据。
材料和方法使用30例成人上腹部连续矢状断层标本、10例健康成人MRI矢状图像及20例无肾上腺病变的临床病人MSCT矢状重建图像,观测了左、右肾上腺的出现断面、形态、大小和毗邻关系。
结果在连续矢状断面上,左肾上腺集中出现在腹主动脉左缘至左肾门之间,而右肾上腺集中出现在下腔静脉左缘至右肾门之间。左、右肾上极内侧缘出现的矢状断面是左、右肾上腺恒定出现的断面,即从正中矢状面开始寻找肾的首次出现断面是快速找到肾上腺的一个简便方法。左、右肾上极内侧缘出现层面是左、右肾上腺呈现最大面积的层面。该层面上左肾上腺呈Y或I形,而右肾上腺形状不规则,可呈多种形状。左肾上腺一般位于左膈脚或左肾与胰体之间。右肾上腺的前方为下腔静脉,后方紧邻右肾或膈,下方有右肾动、静脉走行,上方为膈和肝裸区。
结论在连续矢状断层上,左、右肾上极出现的层面是肾上腺恒定出现的断面,且该层面上双侧肾上腺呈现最大面积。脾动、静脉是识别左肾上腺前界的标志,下腔静脉是识别右肾上腺前界的标志,左、右肾动、静脉分别是识别左、右肾上腺下界的标志。矢状面上右肾上腺的形态变化较大,而左肾上腺的形态相对恒定。
第三部分肾上腺冠状断层解剖及CT、MRI
目的为肾上腺病变的冠状断层影像诊断和外科治疗提供实用的断层解剖学依据。
材料和方法使用31例成人上腹部连续冠状断层标本、10例健康成人MRI冠状图像及5例无肾上腺病变的临床病人MSCT冠状重建图像,连续追踪观测了肾上腺在冠状面上的形态、位置、毗邻和大小。
结果在连续冠状断面上,肾上腺集中出现于下腔静脉后缘前18mm和其后的24mm范围内。左肾上腺的出现一般早于右肾上腺2个层面。在经下腔静脉前份和左肾静脉的冠状面(A_(15))上,左肾上腺位于腹主动脉外侧、左肾静脉上方和左肾前极的内上且呈现多种形态。在经左、右肾门前份的冠状面(A_(18))上,双侧肾上腺的出现率均为100%,并且左、右肾上腺出现最大径线,右肾上腺的长、宽、体厚、内侧肢厚、外侧肢厚分别是32.02±4.12mm,10.91±1.89mm,5.82±0.26mm,2.78±0.08mm,2.62±0.06mm,而左肾上腺的大小分别是28.31±3.46mm,18.40±1.56mm,6.84±0.24mm,3.02±0.08mm,2.86±0.10mm。在经左、右肾窦后份和脾门的冠状面(A_(20))上,右肾上腺位于肝右后叶的裸区和右膈脚之间,而左肾上腺位于胃裸区和左膈脚之间。在经脊髓圆锥和马尾的冠状面(A_(22))上,左肾上腺已消失,而右肾上腺仍位于肝、右肾上极和右膈脚围成的三角内,但形态明显变小。
结论冠状面是显示双侧肾上腺的优势断面。肾上腺的形态变化较大,而肾上腺的厚度较恒定。肾上腺的内、外侧肢厚,尤其外侧肢厚度的变化更能反映肾上腺皮质的改变。
第四部分肾上腺多层螺旋CT图像的三维重建
目的对正常肾上腺进行MSCT三维重建,为肾上腺病变的影像学诊断和外科治疗提供实用的影像断层解剖学依据。
材料和方法使用20例无肾上腺病变的临床病人64层螺旋CT断层图像探讨了肾上腺的三维重建方法,重点研究了肾上腺的整体形态特点及其在正常人体中的位置和毗邻等。
结果1.25mm层厚64层螺旋CT横断层图像上,双侧肾上腺的边界清晰,易于进行肾上腺边界的提取。用VR依次分步重建出的肾上腺及其毗邻结构,边界清楚,立体感强,能动态多角度显示正常肾上腺的形态和位置,以及和周围器官的毗邻关系。
结论正常肾上腺MSCT三维重建图像能动态立体显示肾上腺及其周围结构的毗邻关系,充分体现肾上腺的在体方位,与手术视野中的肾上腺有很好的对应关系,以期为现代泌尿外科施行各种肾上腺手术提供可行而又实用的解剖学基础。
第五部分肾上腺三维断层解剖在影像诊断中的应用
目的为明确肾上腺微小病变的影像诊断依据,阐明肾上腺肿块对毗邻结构推压、侵蚀的影像学表现与断层解剖基础的相关性,并为肾上腺病变的外科治疗提供实用的影像解剖学依据。
材料和方法本研究利用上述的横、矢、冠状断层标本和30例肾上腺病变(22例肾上腺微小病变,8例肾上腺肿块)的CT、MRI横、矢和冠状图像,探讨肾上腺病变的影像学特征及断层解剖学基础。
结果双侧肾上腺后内侧的毗邻关系恒定,上份分别和左、右膈脚相邻,下份则分别和左、右肾上极相毗邻。双侧肾上腺前方的毗邻结构变化较大,右肾上腺前方为下腔静脉,正常右肾上腺可位于下腔静脉和右膈脚之间或位于下腔静脉后外紧贴肝裸区,右肾上腺肿块可将下腔静脉推向前方、前外或前内。右肾上腺外侧和肝裸区及右肝下间隙相邻,右肾上腺的肿块向外生长,肝右后叶的内侧面可出现压迹,亦可突入右肝下间隙。左肾上腺上份的前外侧和胃裸区及网膜囊、胃后壁相邻,左肾上腺上份的病变可突入胃裸区或网膜囊内。左肾上腺下份的前外侧和胰体后界、脾动、静脉相邻,左肾上腺下份的肿块可向前推压脾动、静脉和胰体,出现脾动、静脉受压的征象。左肾上腺的前内侧和腹主动脉的上份及其分支腹腔干和肠系膜上动脉的起始部相邻,左肾上腺的肿块可向右推压腹主动脉及其分支。
结论肾上腺的三维断层解剖学基础可很好地解释肾上腺肿块对毗邻结构推压、侵蚀的影像学表现。肾上腺断面形态多样化,不能用一种类型反映单个肾上腺全貌;肾上腺前方的毗邻结构关系变化较大,决定肾上腺病变向前生长、侵蚀有不同的优势途径和类型。
结论和意义
1.本研究首次使用较大样本的冠状断层标本和薄层冠状铣切标本并结合活体MRI及MSCT冠状图像,详细探讨了肾上腺在连续冠状断面上的断层影像变化规律。冠状面是显示双侧肾上腺的优势断面。冠状面上肾上腺的形态变化较大,而肾上腺的厚度较恒定。肾上腺的内、外侧肢厚,尤其外侧肢厚度的变化更能反映肾上腺皮质的改变。为肾上腺病变的断层影像诊断和肾上腺的外科手术治疗提供实用的断层影像解剖学基础。
2.横、矢和冠状断层标本和临床活体肾上腺CT和MRI图像有很好的对应关系,便于二者之间对照研究,这些研究结果将为肾上腺微小病变的精确影像学诊断提供实用的断层解剖学依据。连续横断层上左、右肾上极层面是寻找双侧肾上腺的可靠层面。下腔静脉后壁是识别右。肾上腺前界的标志;脾动、静脉则是识别左肾上腺前界的标志。在连续矢状断层上,左、右肾上极内侧缘出现的层面是肾上腺恒定出现的断面,且该层面上双侧肾上腺呈现最大面积。左、右肾动、静脉分别是识别左、右肾上腺下界的标志。
3.本研究使用临床活体正常肾上腺多层螺旋CT及三维重建图像,可多角度立体显示肾上腺和其周围结构的毗邻关系,充分体现肾上腺的在体方位,与手术视野中的肾上腺有很好的对应关系,以期为现代泌尿外科施行各种肾上腺手术提供可行而又实用的解剖学基础。
4.本研究将肾上腺的三维断层解剖和肾上腺病变的影像表现结合起来,用断层解剖基础去解释和阐明肾上腺病变的影像学表现,为肾上腺的影像断层解剖奠定坚实的基础。肾上腺的三维断层解剖学基础可很好地解释肾上腺肿块对毗邻结构推压、侵蚀的影像学表现。肾上腺断面形态多样化,不能用一种类型反映单个肾上腺全貌;肾上腺前方的毗邻结构关系变化较大,决定肾上腺病变向前生长、侵蚀有不同的优势途径和类型。
Adrenal glands lie on the extraperitoneal perirenal space.There is a great of diseases taken place in adrenal glands and their clinical manifestations are complicated.Therefore,diseases about the adrenal glands are the investigative interesting subjects in clinical investigations,especially in the medical image and surgery.The deep position of the adrenal glands and their complex relations with nearby structures and viscera complicate the clinical analysis of the many diseases affecting the adrenal glands and bring some difficulties to the imaging investigation of the adrenal glands.The widespread laparoscopic adrenalectomy requires better anatomical information is needed to facilitate diagnosis and surgical treatment of adrenal disease,especially the adjacent relationship and the great vessels of the adrenal glands.Previous studies using CT showed the position,size and some common disease of the adrenal glands in the transverse section,but the allocation and presentation of tiny pathological changes in the adrenal glands can not be carried out without comparison with sectional species.Recently,with the development of multislice spiral CT and its image post processing ability as well as modern high-speed scanning sequence of MRI,imaging technologies provides useful images that more clearly demonstrate the complicated anatomical relationships of the adrenal glands and their diseases on the transverse,sagittal, coronal,and slant sectional images.The sectional anatomies researches of the adrenal glands are mostly reported on the transverse planes;however these studies only adopted few cadavers and are short of images of minimal lesions in adrenal glands combining the CT and MRI images.Therefore,this paper provided initial anatomical research regarding the sectional anatomy of the adrenal glands and related structures and viscera in the coronal plane.Data just include the coronal data without the images of normal adrenal glands and images with minimal lesions. So far,there is no coronal sectional data in the adrenal glands which obtains obvious superiority in demonstrating the bilateral adrenal glands.
Adrenal glands lie in the extraperitoneal peritoneal space.Because of the complex coherence and stretch of the renal fasciae,the adjacencies of adrenal glands and the communicated structures of the peritoneal spaces,especially for the left one,became more complicated and controversial.So the deep research about the above area is valuable for the understanding of the disease spreading and influence between the adrenal glands and their surrounding structures.What' more, it also can clarify the variance and controversy.
Study about the position,shape and adjacent relationship of the adrenal glands and surrounding organs using sectional anatomy can demonstrate the position of the adrenal glands in vivo.That not only facilitates the control study between the imageology and the sectional anatomy,but also conduces to the location of the pathological changes in all kinds of adrenal gland diseases. However,study about this used few cadavers and only limited on sagittal and transversal planes.
With the clinical application of MSCT and three-dimensional reconstruction technique,three-dimensional images of the adrenal glands can be reconstructed, and the position of the adrenal glands and their adjacent relationship in vivo can be displayed thoroughly.Recently,with the development of high-speed scanning sequence of MRI and FS,the tiny structure of the adrenal glands and the ones around it can be clearly displayed,thus the tiny pathological changes in adrenal glands can be precisely location.Nevertheless,due to the Partial volume effect and the density resolution,differences still exist between the images and the specimen. We must re-establish the adrenal glands by combining the images of CT/MRI and the sectional specimens.
Now,systematic study of normal adrenal glands and their pathological changes using serial transverse,sagittal and coronal sectional specimens and their clinical manifestation is scare.
This paper systematically investigates the three dimensions sectional anatomy features of the adrenal glands and their tiny pathological changes,which combine the images of CT/MSCT/3D/MRI and contrast of CT/MRE images about the adrenal glands' pathological changes.That will provide exact and practical data for the imageology diagnose and surgical therapy of the disease take place in adrenal glands.
This study consists of five parts.
Part 1:SECTIONAL ANATOMY AND CT&MRI OF THE ADRENAL GLAND IN THE TRANSVERSE PLANE
Objective The purpose of this study was to provide sectional anatomic data for the transverse imaging diagnosis and surgical treatment of the disease of the adrenal gland.
Methods The shape,location,adjacency,and size of the adrenal gland were investigated using 20 sets of serial transverse sections of upper abdomen of Chinese adult cadavers,transverse MR images of 10 upper abdomens of Chinese adult healthy volunteers and transverse reconstructed MSCT images of 10 patients without lesions in the adrenal gland.
Results On the serial transverse section,the adrenal glands appeared firstly on the plane of the first hepatic hilum plane and disappeared at the level of the renal vessels.It was the best plane for searching the adrenal glands at the level of upper pole of kidney,On the transverse section through the inferior part of renal hilus, right adrenal gland was located in the right adrenal gland triangle behind the inferior vena,the left adrenal gland lied in the fight adrenal gland triangle constituted by bare area of the stomach,spleen and left crura of diaphragm.On the section of the left or right upper pole of kidney,the left adrenal gland was located at the quadrilateral region formed by cephalic side of upper pole of left kidney, posterior side of the body of pancreas,median side of spleen and left crura of diaphragm,while the right adrenal gland lied in the quadrilateral region constituted by posterior wall of the inferior vena cava,bare area of liver,right crura of diaphragm and the cephalic to upper pole of right kidney
Conclusion On the serial transverse planes,the bilateral upper pole of kidney plane is the reliable one to observe the adrenal glands.The posterior wall of the inferior vena is the mark to recognize the anterior of the right adrenal glands;the changes of shape of bilateral adrenal glands on the transverse planes are obvious, the adjacent structures in anterior of the adrenal glands(especially the left adrenal glands) are complicate.Therefore,there are different prevalent pathways for the forward growth of the diseases of the adrenal glands.
Part 2:SECTIONAL ANATOMY AND CT&MRI OF THE ADRENAL GLAND IN THE SAGITTAL PLANE
Objective The purpose of this study was to provide sectional anatomic data for the saglttal imaging diagnosis and surgical treatment of the disease of the adrenal gland.
Methods The shape,location,adjacency,and size of the adrenal gland were investigated using 30 sets of serial sagittal sections of upper abdomen of Chinese adult cadavers,sagittal MR images of 10 upper abdomen of Chinese adult healthy volunteers and sagittal reconstructed MSCT images of 10 patients without lesions in the adrenal gland.
Results On the serial sagittal planes,The left adrenal gland locate generally between the left of the abdominal aorta and the left renal hilus,and the right renal gland locate generally between the left of the abdominal aorta and the right renal hilus.The plane that the appearance of upper pole of bilateral kidneys is the permanent appearance plane of the bilateral adrenal glands:Looking for the plane which the kidney first appear from the sagittal section is an easy way to search adrenal gland.This area appearing in this plane is the biggest of all,on which the left adrenal gland appears like"Y"or"T",the shape of the right adrenal gland is irregular.The left adrenal gland locate generally between left crura of diaphragm/ left kidney and body of pancreas.The anterior of the right adrenal gland is inferior vena,behind of it is right kidney or diaphragm,inferior is right renal artery/vein, superior is diaphragm and the bare area of liver.
Conclusion On the serial sagittal planes,the plane that the appearance of upper pole of bilateral kidneys is the permanent appearance plane of the bilateral adrenal glands,in which area appearing in this plane is the biggest in all planes. The left and right spleen artery/vein is the mark of the anterior of the left adrenal gland,inferior vena is the mark of the anterior of the right adrenal gland,and the right/left kidney artery/vein is the mark to recognize the inferior of the bilateral adrenal glands separately.The changes of shape of right adrenal gland on the sagittal planes are obvious,but the left one is invariant.
Part 3:SECTIONAL ANATOMY AND CT&MRI OF THE ADRENAL GLAND IN THE CORONAL PLANE
Objective The purpose of this study was to provide sectional anatomic data for the coronal imaging diagnosis and surgical treatment of the disease of the adrenal gland.
Methods The shape,location,adjacency,and size of the adrenal gland were investigated using 31 sets of serial coronal sections of upper abdomen of Chinese adult cadavers,coronal MR images of 10 upper abdomen of Chinese adult healthy volunteers and coronal reconstructed MSCT images of 5 patients without lesions in the adrenal gland.
Results On the serial coronal planes,the adrenal glands emerge visualized mainly on the successive coronal sections between 18mm anterior to the posterior margin of inferior vena cava and 24mm posterior to the posterior margin of inferior vena cava.The left adrenal gland was visualized 2 sections earlier than the right adrenal gland in general.On the coronal section through the anterior part of inferior vena cava and left renal vein(A_(15)),the left adrenal gland was located lateral to abdominal aorta,cephalic to left renal vein,and super medial to the anterior pole of left kidney;its shape was varied as well.On the coronal section through the anterior parts of bilateral renal hili(A_(18)),the existing rate of bilateral adrenal gland were 100%,and the maximal measurements of bilateral adrenal gland were visualized.The length,width,thickness of right adrenal body, thickness of medial limb,and thickness of lateral limb was 32.02±4.12mm, 10.91±1.89mm,5.82±0.26mm,2.78±0.08mm,2.62±0.06mm respectively whereas the measurements of left adrenal gland was 28.31±3.46mm,18.40±1.56mm, 6.84±0.24mm,3.02±0.08mm,2.86±0.10mm respectively.On the coronal section through the posterior part of bilateral sinuses and splenic hilus(A_(20)),right adrenal gland was located between the bare area of right posterior lobe of the liver and the right crus of the diaphragm,whereas left adrenal gland was visualized between the bare area of stomach and the left erus of the diaphragm.On the coronal section through the cones medullaris and cauda equina(Az2),left adrenal gland disappeared,whereas right adrenal gland was situated in the triangular region composed by liver,the upper pole of right kidney,and right crus of the diaphragm, however,its measurements become small obviously.
Conclusion The coronal plane is dominant for showing the bilateral adrenal gland.The shapes of adrenal gland are varied whereas the range of values for adrenal thickness was quite narrow.The change of the thickness of adrenal medial and lateral limbs,especially the lateral limb could correctly reflect the change of the adrenal cortex.
Part 4:THREE-DIMENSIONAL RECONSTRUCTION OF MSCT OF THE ADRENAL GLANDS
Objective Through three-dimensional reconstruction of MSCT,to provide pragmatically anatomical and imaging data for imaging diagnosis and surgical treatment.
Methods 20 patients without adrenopathies were investigated to explore the method of three-dimensional reconstruction of 64 slices MSCT of adrenal glands. We focused on their shape as a whole,location and adjacency.
Results In the 64 slices MSCT images,whose SL is 1.25 mm,the adrenal glands were easy to be sketched because of the sharpness borders of bilateral adrenal glands.The shapes as well as the interrelation of the adrenal glands and their adjacent structures reconstructed by VR technology could be disclosed dynamically and multi-angularly because of the clear borders and high three-dimensional quality.
Conclusion Three-dimensional reconstruction of MSCT of normal adrenal glands could display the adrenal glands and their adjacent structures dynamically and tridimensionally.What's more,it also could disclose the position of the adrenal glands in vivo,which corresponded the field of vision in operation very well.So the study could provide feasibly and practically anatomical reference for adrenal operations in modern urinary surgery.
Part 5:THREE DIMENSIONAL SECTIONAL ANATOMIES OF THE ADRENAL GLAND AND ITS APPLICATION IN IMAGING DIAGNOSIS
Objective To clarify the imaging of the normal adrenal gland as a basis for the evaluation of small lesion and infiltrating character and displacement of adrenal mass adjacent to the organs.
Methods The authors have studied the serial sections through the abdomen and studied CT,MRI of the 30 abnormalities(22 small lesions,8 tumors).We investigated the imaging character of the adrenal glands in three dimensional planes.
Results The left perirenal space open upward and stretch with the bare area of liver and the fat in the inferior of the left diaphragm.The adjacent relationship of the posterior and medial of the bilateral adrenal glands is stable.The left and right crura of diaphragm were visualized superior to them,and inferior to the upper pole of the left and right kidney.The anterior adjacent relationship of the bilateral adrenal glands is various,there is inferior vena in the anterior of the right adrenal gland,and it also can locate between the inferior vena and the right crura of diaphragm,or paste the bare area of liver in the posterior and lateral of the inferior vena.The adrenal gland tumor can press the inferior vena to posterior,posterior and lateral,posterior and medial.The lateral fringe of the right adrenal gland locates nearby the bare area of liver and the inferior space of right liver.The right adrenal gland tumor grows laterally,there will be some impression in the medial of posterior lobe of right liver,also enter the inferior space of the right liver.The lateral and anterior of the left adrenal gland is close together with the bare area of liver,omental bursa and the posterior of the stomach.The lesions of the superior of the left adrenal gland can enter the bare area of liver,or the omental bursa.The anterior and lateral of the inferior fringe of the left adrenal gland situates nearby the posterior fringe of the body of pancreas,spleen vessels.The tumor of the inferior of the left adrenal gland can press the spleen vessels and the body of pancreas forward.The anterior and medial of the left adrenal gland and the superior of the abdominal aorta and its branches lies closely with celiac trunk and the initiation part of the superior mesenteric artery,the tumor of this area can press the celiac trunk and its branches.
Conclusion The three-dimensional anatomy of the adrenal glands could explain the impression and erosion to nearby structures clearly by the tumor of the adrenal glands.We found that the shape of normal adrenal gland difference from patient to patient and even in the same patient according to the level of the slice it is difficult to determine.Great changes of the morphologic shape and the anterior structures of the adrenal gland determine the different prominent ways for the diseases of adrenal gland to grow forwards.
CONCLUSIONS AND SIGNIFICANCE
1.This paper provided new anatomical detail regarding the sectional anatomy of the adrenal glands and related structures and viscera in the coronal plane,using multitude specimens and combining the MRI/MSCT images with the thin coronal section specimens.The coronal plane is dominant for showing the bilateral adrenal gland.The shapes of adrenal gland are varied whereas the range of values for adrenal thickness was quite narrow.The change of the thickness of adrenal medial and lateral limbs,especially the lateral limb could correctly reflect the change of the adrenal cortex.Provide better anatomical information to facilitate diagnosis and surgical treatment of adrenal disease.
2.The transverse\sagittal\coronal sectional specimens can match correspond with the CT\MRI images,the results can provide exact sectional anatomy data for the imaging diagnosis of the tiny disease in adrenal glands.On the serial transverse planes,the bilateral upper pole of kidney plane is the reliable one to observe the adrenal glands.The posterior wall of the inferior vena is the mark to recognize the anterior of the right adrenal gland;the spleen vein\artery the mark to recognize the anterior of the left adrenal gland.On the serial sagittal planes,the plane that the appearance of upper pole of bilateral kidneys is the permanent appearance plane of the bilateral adrenal glands,in which area appearing in this plane is the biggest in all planes.The left and right spleen artery/vein is the mark of the anterior of the left adrenal gland.The left and right spleen artery/vein is the mark of the anterior of the left adrenal gland.
3.We apply the images of the polylaminate Spiral CT and three-dimensional reconstruction,therefore,the adrenal gland and its adjacent tissues were displayed clearly from various directions,and this technique can display adrenal glands' position in vivo,which matches with the position during surgery.This provides reliable and practical anatomy data for the adrenal glands surgery treatment in urinary surgery.
4.This study combines the adrenal glands' anatomy of three-dimensional reconstruction with the images of the adrenal glands;explain the image of diseases in adrenal glands using sectional anatomy.The images of the three-dimensional reconstruction could elucidate the impression,corrosion of adrenal glands tumor. We found that the shape of normal adrenal gland difference from patient to patient and even in the same patient according to the level of the slice it is difficult to determine.Great changes of the morphologic shape and the anterior structures of the adrenal gland determine the different prominent ways for the diseases of adrenal gland to grow forwards.
用断层解剖方法研究肾上腺的位置、形态和毗邻关系,可充分保证肾上腺的在体方位,不仅便于和断层影像直接对照研究,更有利于泌尿外科确定肾上腺病变的准确位置,进而有利于各种肾上腺手术的实施。但这方面的研究使用的断层标本数量较少,并且仅限于横断层或矢状断层。
多层螺旋CT及其三维重建技术的临床应用,可重建出肾上腺及其周围器官的三维图像,能充分显示在体方位的。肾上腺及其和周围结构的毗邻关系。近年来MRI快速扫描序列的应用,以及压脂技术,可清晰显示肾上腺及其周围结构的细微解剖,使肾上腺微小病变的精确定位成为可能。然而单纯地采用CT或MRI,由于部分容积效应的存在和密度分辨力的限制,其显示的肾上腺与标本上的真实结构之间尚存有差异,尚需将断层标本和CT及MRI图像结合起来探讨肾上腺的三维断层解剖。
另外采用横、矢和冠状断层标本,并结合肾上腺微小病变的典型表现,来系统探讨正常肾上腺及其病变的影像学表现,这方面的研究报道较少。
本课题使用上腹部横、矢、冠状断层标本,并结合多层螺旋CT(MSCT)图像和三维(3D)图像,MRI断层图像,以及肾上腺微小病变的CT和MRI图像,系统研究肾上腺的三维断层解剖特点和肾上腺微小病变的影像学表现,以期为肾上腺病变的影像诊断和外科治疗提供准确而实用的断层解剖学基础。
本课题共分为5部分:
第一部分肾上腺横断层解剖及CT、MRI
目的为肾上腺病变的横断层影像诊断和外科治疗提供实用的断层解剖和影像诊断学依据。
材料和方法使用20例成人上腹部连续横断层标本、10例健康成人MRI横断层图像及20例无肾上腺病变的临床病人MSCT横断层图像,连续追踪观测了肾上腺在横断面上的形态、位置、毗邻和大小。
结果在连续横断面上,第一肝门层面往往是肾上腺首次出现的层面,左右肾血管出现层面是双侧肾上腺消失的层面。左、右肾上极出现层面是横断层上寻找双侧肾上腺的理想层面。经肝门下方的横断面上,右肾上腺位于下腔静脉后方、肝裸区和右膈脚围成的右肾上腺三角内,左肾上腺位于胃裸区、脾和左膈脚围成的左肾上腺三角内。经左肾上极或右肾上极的横断面上,左肾上腺位于左肾上极前内、胰体后面、脾的内侧和左膈脚围成的四边形区域内,右肾上腺位于右肾上极前内、下腔静脉后壁、肝裸区和右膈脚围成的四边形区域内。
结论连续横断层上左、右。肾上极层面是寻找双侧肾上腺的可靠层面。下腔静脉后壁是识别右肾上腺前界的标志;脾动、静脉则是识别左肾上腺前界的标志。在连续横断层上肾上腺的形态变化较大,肾上腺前方的毗邻结构尤其左肾上腺复杂,故肾上腺病变向前生长时有不同的优势途径。
第二部分肾上腺矢状断层解剖及CT、MRI
目的为肾上腺病变的矢状断层影像诊断和外科治疗提供实用的断层解剖学依据。
材料和方法使用30例成人上腹部连续矢状断层标本、10例健康成人MRI矢状图像及20例无肾上腺病变的临床病人MSCT矢状重建图像,观测了左、右肾上腺的出现断面、形态、大小和毗邻关系。
结果在连续矢状断面上,左肾上腺集中出现在腹主动脉左缘至左肾门之间,而右肾上腺集中出现在下腔静脉左缘至右肾门之间。左、右肾上极内侧缘出现的矢状断面是左、右肾上腺恒定出现的断面,即从正中矢状面开始寻找肾的首次出现断面是快速找到肾上腺的一个简便方法。左、右肾上极内侧缘出现层面是左、右肾上腺呈现最大面积的层面。该层面上左肾上腺呈Y或I形,而右肾上腺形状不规则,可呈多种形状。左肾上腺一般位于左膈脚或左肾与胰体之间。右肾上腺的前方为下腔静脉,后方紧邻右肾或膈,下方有右肾动、静脉走行,上方为膈和肝裸区。
结论在连续矢状断层上,左、右肾上极出现的层面是肾上腺恒定出现的断面,且该层面上双侧肾上腺呈现最大面积。脾动、静脉是识别左肾上腺前界的标志,下腔静脉是识别右肾上腺前界的标志,左、右肾动、静脉分别是识别左、右肾上腺下界的标志。矢状面上右肾上腺的形态变化较大,而左肾上腺的形态相对恒定。
第三部分肾上腺冠状断层解剖及CT、MRI
目的为肾上腺病变的冠状断层影像诊断和外科治疗提供实用的断层解剖学依据。
材料和方法使用31例成人上腹部连续冠状断层标本、10例健康成人MRI冠状图像及5例无肾上腺病变的临床病人MSCT冠状重建图像,连续追踪观测了肾上腺在冠状面上的形态、位置、毗邻和大小。
结果在连续冠状断面上,肾上腺集中出现于下腔静脉后缘前18mm和其后的24mm范围内。左肾上腺的出现一般早于右肾上腺2个层面。在经下腔静脉前份和左肾静脉的冠状面(A_(15))上,左肾上腺位于腹主动脉外侧、左肾静脉上方和左肾前极的内上且呈现多种形态。在经左、右肾门前份的冠状面(A_(18))上,双侧肾上腺的出现率均为100%,并且左、右肾上腺出现最大径线,右肾上腺的长、宽、体厚、内侧肢厚、外侧肢厚分别是32.02±4.12mm,10.91±1.89mm,5.82±0.26mm,2.78±0.08mm,2.62±0.06mm,而左肾上腺的大小分别是28.31±3.46mm,18.40±1.56mm,6.84±0.24mm,3.02±0.08mm,2.86±0.10mm。在经左、右肾窦后份和脾门的冠状面(A_(20))上,右肾上腺位于肝右后叶的裸区和右膈脚之间,而左肾上腺位于胃裸区和左膈脚之间。在经脊髓圆锥和马尾的冠状面(A_(22))上,左肾上腺已消失,而右肾上腺仍位于肝、右肾上极和右膈脚围成的三角内,但形态明显变小。
结论冠状面是显示双侧肾上腺的优势断面。肾上腺的形态变化较大,而肾上腺的厚度较恒定。肾上腺的内、外侧肢厚,尤其外侧肢厚度的变化更能反映肾上腺皮质的改变。
第四部分肾上腺多层螺旋CT图像的三维重建
目的对正常肾上腺进行MSCT三维重建,为肾上腺病变的影像学诊断和外科治疗提供实用的影像断层解剖学依据。
材料和方法使用20例无肾上腺病变的临床病人64层螺旋CT断层图像探讨了肾上腺的三维重建方法,重点研究了肾上腺的整体形态特点及其在正常人体中的位置和毗邻等。
结果1.25mm层厚64层螺旋CT横断层图像上,双侧肾上腺的边界清晰,易于进行肾上腺边界的提取。用VR依次分步重建出的肾上腺及其毗邻结构,边界清楚,立体感强,能动态多角度显示正常肾上腺的形态和位置,以及和周围器官的毗邻关系。
结论正常肾上腺MSCT三维重建图像能动态立体显示肾上腺及其周围结构的毗邻关系,充分体现肾上腺的在体方位,与手术视野中的肾上腺有很好的对应关系,以期为现代泌尿外科施行各种肾上腺手术提供可行而又实用的解剖学基础。
第五部分肾上腺三维断层解剖在影像诊断中的应用
目的为明确肾上腺微小病变的影像诊断依据,阐明肾上腺肿块对毗邻结构推压、侵蚀的影像学表现与断层解剖基础的相关性,并为肾上腺病变的外科治疗提供实用的影像解剖学依据。
材料和方法本研究利用上述的横、矢、冠状断层标本和30例肾上腺病变(22例肾上腺微小病变,8例肾上腺肿块)的CT、MRI横、矢和冠状图像,探讨肾上腺病变的影像学特征及断层解剖学基础。
结果双侧肾上腺后内侧的毗邻关系恒定,上份分别和左、右膈脚相邻,下份则分别和左、右肾上极相毗邻。双侧肾上腺前方的毗邻结构变化较大,右肾上腺前方为下腔静脉,正常右肾上腺可位于下腔静脉和右膈脚之间或位于下腔静脉后外紧贴肝裸区,右肾上腺肿块可将下腔静脉推向前方、前外或前内。右肾上腺外侧和肝裸区及右肝下间隙相邻,右肾上腺的肿块向外生长,肝右后叶的内侧面可出现压迹,亦可突入右肝下间隙。左肾上腺上份的前外侧和胃裸区及网膜囊、胃后壁相邻,左肾上腺上份的病变可突入胃裸区或网膜囊内。左肾上腺下份的前外侧和胰体后界、脾动、静脉相邻,左肾上腺下份的肿块可向前推压脾动、静脉和胰体,出现脾动、静脉受压的征象。左肾上腺的前内侧和腹主动脉的上份及其分支腹腔干和肠系膜上动脉的起始部相邻,左肾上腺的肿块可向右推压腹主动脉及其分支。
结论肾上腺的三维断层解剖学基础可很好地解释肾上腺肿块对毗邻结构推压、侵蚀的影像学表现。肾上腺断面形态多样化,不能用一种类型反映单个肾上腺全貌;肾上腺前方的毗邻结构关系变化较大,决定肾上腺病变向前生长、侵蚀有不同的优势途径和类型。
结论和意义
1.本研究首次使用较大样本的冠状断层标本和薄层冠状铣切标本并结合活体MRI及MSCT冠状图像,详细探讨了肾上腺在连续冠状断面上的断层影像变化规律。冠状面是显示双侧肾上腺的优势断面。冠状面上肾上腺的形态变化较大,而肾上腺的厚度较恒定。肾上腺的内、外侧肢厚,尤其外侧肢厚度的变化更能反映肾上腺皮质的改变。为肾上腺病变的断层影像诊断和肾上腺的外科手术治疗提供实用的断层影像解剖学基础。
2.横、矢和冠状断层标本和临床活体肾上腺CT和MRI图像有很好的对应关系,便于二者之间对照研究,这些研究结果将为肾上腺微小病变的精确影像学诊断提供实用的断层解剖学依据。连续横断层上左、右肾上极层面是寻找双侧肾上腺的可靠层面。下腔静脉后壁是识别右。肾上腺前界的标志;脾动、静脉则是识别左肾上腺前界的标志。在连续矢状断层上,左、右肾上极内侧缘出现的层面是肾上腺恒定出现的断面,且该层面上双侧肾上腺呈现最大面积。左、右肾动、静脉分别是识别左、右肾上腺下界的标志。
3.本研究使用临床活体正常肾上腺多层螺旋CT及三维重建图像,可多角度立体显示肾上腺和其周围结构的毗邻关系,充分体现肾上腺的在体方位,与手术视野中的肾上腺有很好的对应关系,以期为现代泌尿外科施行各种肾上腺手术提供可行而又实用的解剖学基础。
4.本研究将肾上腺的三维断层解剖和肾上腺病变的影像表现结合起来,用断层解剖基础去解释和阐明肾上腺病变的影像学表现,为肾上腺的影像断层解剖奠定坚实的基础。肾上腺的三维断层解剖学基础可很好地解释肾上腺肿块对毗邻结构推压、侵蚀的影像学表现。肾上腺断面形态多样化,不能用一种类型反映单个肾上腺全貌;肾上腺前方的毗邻结构关系变化较大,决定肾上腺病变向前生长、侵蚀有不同的优势途径和类型。
Adrenal glands lie on the extraperitoneal perirenal space.There is a great of diseases taken place in adrenal glands and their clinical manifestations are complicated.Therefore,diseases about the adrenal glands are the investigative interesting subjects in clinical investigations,especially in the medical image and surgery.The deep position of the adrenal glands and their complex relations with nearby structures and viscera complicate the clinical analysis of the many diseases affecting the adrenal glands and bring some difficulties to the imaging investigation of the adrenal glands.The widespread laparoscopic adrenalectomy requires better anatomical information is needed to facilitate diagnosis and surgical treatment of adrenal disease,especially the adjacent relationship and the great vessels of the adrenal glands.Previous studies using CT showed the position,size and some common disease of the adrenal glands in the transverse section,but the allocation and presentation of tiny pathological changes in the adrenal glands can not be carried out without comparison with sectional species.Recently,with the development of multislice spiral CT and its image post processing ability as well as modern high-speed scanning sequence of MRI,imaging technologies provides useful images that more clearly demonstrate the complicated anatomical relationships of the adrenal glands and their diseases on the transverse,sagittal, coronal,and slant sectional images.The sectional anatomies researches of the adrenal glands are mostly reported on the transverse planes;however these studies only adopted few cadavers and are short of images of minimal lesions in adrenal glands combining the CT and MRI images.Therefore,this paper provided initial anatomical research regarding the sectional anatomy of the adrenal glands and related structures and viscera in the coronal plane.Data just include the coronal data without the images of normal adrenal glands and images with minimal lesions. So far,there is no coronal sectional data in the adrenal glands which obtains obvious superiority in demonstrating the bilateral adrenal glands.
Adrenal glands lie in the extraperitoneal peritoneal space.Because of the complex coherence and stretch of the renal fasciae,the adjacencies of adrenal glands and the communicated structures of the peritoneal spaces,especially for the left one,became more complicated and controversial.So the deep research about the above area is valuable for the understanding of the disease spreading and influence between the adrenal glands and their surrounding structures.What' more, it also can clarify the variance and controversy.
Study about the position,shape and adjacent relationship of the adrenal glands and surrounding organs using sectional anatomy can demonstrate the position of the adrenal glands in vivo.That not only facilitates the control study between the imageology and the sectional anatomy,but also conduces to the location of the pathological changes in all kinds of adrenal gland diseases. However,study about this used few cadavers and only limited on sagittal and transversal planes.
With the clinical application of MSCT and three-dimensional reconstruction technique,three-dimensional images of the adrenal glands can be reconstructed, and the position of the adrenal glands and their adjacent relationship in vivo can be displayed thoroughly.Recently,with the development of high-speed scanning sequence of MRI and FS,the tiny structure of the adrenal glands and the ones around it can be clearly displayed,thus the tiny pathological changes in adrenal glands can be precisely location.Nevertheless,due to the Partial volume effect and the density resolution,differences still exist between the images and the specimen. We must re-establish the adrenal glands by combining the images of CT/MRI and the sectional specimens.
Now,systematic study of normal adrenal glands and their pathological changes using serial transverse,sagittal and coronal sectional specimens and their clinical manifestation is scare.
This paper systematically investigates the three dimensions sectional anatomy features of the adrenal glands and their tiny pathological changes,which combine the images of CT/MSCT/3D/MRI and contrast of CT/MRE images about the adrenal glands' pathological changes.That will provide exact and practical data for the imageology diagnose and surgical therapy of the disease take place in adrenal glands.
This study consists of five parts.
Part 1:SECTIONAL ANATOMY AND CT&MRI OF THE ADRENAL GLAND IN THE TRANSVERSE PLANE
Objective The purpose of this study was to provide sectional anatomic data for the transverse imaging diagnosis and surgical treatment of the disease of the adrenal gland.
Methods The shape,location,adjacency,and size of the adrenal gland were investigated using 20 sets of serial transverse sections of upper abdomen of Chinese adult cadavers,transverse MR images of 10 upper abdomens of Chinese adult healthy volunteers and transverse reconstructed MSCT images of 10 patients without lesions in the adrenal gland.
Results On the serial transverse section,the adrenal glands appeared firstly on the plane of the first hepatic hilum plane and disappeared at the level of the renal vessels.It was the best plane for searching the adrenal glands at the level of upper pole of kidney,On the transverse section through the inferior part of renal hilus, right adrenal gland was located in the right adrenal gland triangle behind the inferior vena,the left adrenal gland lied in the fight adrenal gland triangle constituted by bare area of the stomach,spleen and left crura of diaphragm.On the section of the left or right upper pole of kidney,the left adrenal gland was located at the quadrilateral region formed by cephalic side of upper pole of left kidney, posterior side of the body of pancreas,median side of spleen and left crura of diaphragm,while the right adrenal gland lied in the quadrilateral region constituted by posterior wall of the inferior vena cava,bare area of liver,right crura of diaphragm and the cephalic to upper pole of right kidney
Conclusion On the serial transverse planes,the bilateral upper pole of kidney plane is the reliable one to observe the adrenal glands.The posterior wall of the inferior vena is the mark to recognize the anterior of the right adrenal glands;the changes of shape of bilateral adrenal glands on the transverse planes are obvious, the adjacent structures in anterior of the adrenal glands(especially the left adrenal glands) are complicate.Therefore,there are different prevalent pathways for the forward growth of the diseases of the adrenal glands.
Part 2:SECTIONAL ANATOMY AND CT&MRI OF THE ADRENAL GLAND IN THE SAGITTAL PLANE
Objective The purpose of this study was to provide sectional anatomic data for the saglttal imaging diagnosis and surgical treatment of the disease of the adrenal gland.
Methods The shape,location,adjacency,and size of the adrenal gland were investigated using 30 sets of serial sagittal sections of upper abdomen of Chinese adult cadavers,sagittal MR images of 10 upper abdomen of Chinese adult healthy volunteers and sagittal reconstructed MSCT images of 10 patients without lesions in the adrenal gland.
Results On the serial sagittal planes,The left adrenal gland locate generally between the left of the abdominal aorta and the left renal hilus,and the right renal gland locate generally between the left of the abdominal aorta and the right renal hilus.The plane that the appearance of upper pole of bilateral kidneys is the permanent appearance plane of the bilateral adrenal glands:Looking for the plane which the kidney first appear from the sagittal section is an easy way to search adrenal gland.This area appearing in this plane is the biggest of all,on which the left adrenal gland appears like"Y"or"T",the shape of the right adrenal gland is irregular.The left adrenal gland locate generally between left crura of diaphragm/ left kidney and body of pancreas.The anterior of the right adrenal gland is inferior vena,behind of it is right kidney or diaphragm,inferior is right renal artery/vein, superior is diaphragm and the bare area of liver.
Conclusion On the serial sagittal planes,the plane that the appearance of upper pole of bilateral kidneys is the permanent appearance plane of the bilateral adrenal glands,in which area appearing in this plane is the biggest in all planes. The left and right spleen artery/vein is the mark of the anterior of the left adrenal gland,inferior vena is the mark of the anterior of the right adrenal gland,and the right/left kidney artery/vein is the mark to recognize the inferior of the bilateral adrenal glands separately.The changes of shape of right adrenal gland on the sagittal planes are obvious,but the left one is invariant.
Part 3:SECTIONAL ANATOMY AND CT&MRI OF THE ADRENAL GLAND IN THE CORONAL PLANE
Objective The purpose of this study was to provide sectional anatomic data for the coronal imaging diagnosis and surgical treatment of the disease of the adrenal gland.
Methods The shape,location,adjacency,and size of the adrenal gland were investigated using 31 sets of serial coronal sections of upper abdomen of Chinese adult cadavers,coronal MR images of 10 upper abdomen of Chinese adult healthy volunteers and coronal reconstructed MSCT images of 5 patients without lesions in the adrenal gland.
Results On the serial coronal planes,the adrenal glands emerge visualized mainly on the successive coronal sections between 18mm anterior to the posterior margin of inferior vena cava and 24mm posterior to the posterior margin of inferior vena cava.The left adrenal gland was visualized 2 sections earlier than the right adrenal gland in general.On the coronal section through the anterior part of inferior vena cava and left renal vein(A_(15)),the left adrenal gland was located lateral to abdominal aorta,cephalic to left renal vein,and super medial to the anterior pole of left kidney;its shape was varied as well.On the coronal section through the anterior parts of bilateral renal hili(A_(18)),the existing rate of bilateral adrenal gland were 100%,and the maximal measurements of bilateral adrenal gland were visualized.The length,width,thickness of right adrenal body, thickness of medial limb,and thickness of lateral limb was 32.02±4.12mm, 10.91±1.89mm,5.82±0.26mm,2.78±0.08mm,2.62±0.06mm respectively whereas the measurements of left adrenal gland was 28.31±3.46mm,18.40±1.56mm, 6.84±0.24mm,3.02±0.08mm,2.86±0.10mm respectively.On the coronal section through the posterior part of bilateral sinuses and splenic hilus(A_(20)),right adrenal gland was located between the bare area of right posterior lobe of the liver and the right crus of the diaphragm,whereas left adrenal gland was visualized between the bare area of stomach and the left erus of the diaphragm.On the coronal section through the cones medullaris and cauda equina(Az2),left adrenal gland disappeared,whereas right adrenal gland was situated in the triangular region composed by liver,the upper pole of right kidney,and right crus of the diaphragm, however,its measurements become small obviously.
Conclusion The coronal plane is dominant for showing the bilateral adrenal gland.The shapes of adrenal gland are varied whereas the range of values for adrenal thickness was quite narrow.The change of the thickness of adrenal medial and lateral limbs,especially the lateral limb could correctly reflect the change of the adrenal cortex.
Part 4:THREE-DIMENSIONAL RECONSTRUCTION OF MSCT OF THE ADRENAL GLANDS
Objective Through three-dimensional reconstruction of MSCT,to provide pragmatically anatomical and imaging data for imaging diagnosis and surgical treatment.
Methods 20 patients without adrenopathies were investigated to explore the method of three-dimensional reconstruction of 64 slices MSCT of adrenal glands. We focused on their shape as a whole,location and adjacency.
Results In the 64 slices MSCT images,whose SL is 1.25 mm,the adrenal glands were easy to be sketched because of the sharpness borders of bilateral adrenal glands.The shapes as well as the interrelation of the adrenal glands and their adjacent structures reconstructed by VR technology could be disclosed dynamically and multi-angularly because of the clear borders and high three-dimensional quality.
Conclusion Three-dimensional reconstruction of MSCT of normal adrenal glands could display the adrenal glands and their adjacent structures dynamically and tridimensionally.What's more,it also could disclose the position of the adrenal glands in vivo,which corresponded the field of vision in operation very well.So the study could provide feasibly and practically anatomical reference for adrenal operations in modern urinary surgery.
Part 5:THREE DIMENSIONAL SECTIONAL ANATOMIES OF THE ADRENAL GLAND AND ITS APPLICATION IN IMAGING DIAGNOSIS
Objective To clarify the imaging of the normal adrenal gland as a basis for the evaluation of small lesion and infiltrating character and displacement of adrenal mass adjacent to the organs.
Methods The authors have studied the serial sections through the abdomen and studied CT,MRI of the 30 abnormalities(22 small lesions,8 tumors).We investigated the imaging character of the adrenal glands in three dimensional planes.
Results The left perirenal space open upward and stretch with the bare area of liver and the fat in the inferior of the left diaphragm.The adjacent relationship of the posterior and medial of the bilateral adrenal glands is stable.The left and right crura of diaphragm were visualized superior to them,and inferior to the upper pole of the left and right kidney.The anterior adjacent relationship of the bilateral adrenal glands is various,there is inferior vena in the anterior of the right adrenal gland,and it also can locate between the inferior vena and the right crura of diaphragm,or paste the bare area of liver in the posterior and lateral of the inferior vena.The adrenal gland tumor can press the inferior vena to posterior,posterior and lateral,posterior and medial.The lateral fringe of the right adrenal gland locates nearby the bare area of liver and the inferior space of right liver.The right adrenal gland tumor grows laterally,there will be some impression in the medial of posterior lobe of right liver,also enter the inferior space of the right liver.The lateral and anterior of the left adrenal gland is close together with the bare area of liver,omental bursa and the posterior of the stomach.The lesions of the superior of the left adrenal gland can enter the bare area of liver,or the omental bursa.The anterior and lateral of the inferior fringe of the left adrenal gland situates nearby the posterior fringe of the body of pancreas,spleen vessels.The tumor of the inferior of the left adrenal gland can press the spleen vessels and the body of pancreas forward.The anterior and medial of the left adrenal gland and the superior of the abdominal aorta and its branches lies closely with celiac trunk and the initiation part of the superior mesenteric artery,the tumor of this area can press the celiac trunk and its branches.
Conclusion The three-dimensional anatomy of the adrenal glands could explain the impression and erosion to nearby structures clearly by the tumor of the adrenal glands.We found that the shape of normal adrenal gland difference from patient to patient and even in the same patient according to the level of the slice it is difficult to determine.Great changes of the morphologic shape and the anterior structures of the adrenal gland determine the different prominent ways for the diseases of adrenal gland to grow forwards.
CONCLUSIONS AND SIGNIFICANCE
1.This paper provided new anatomical detail regarding the sectional anatomy of the adrenal glands and related structures and viscera in the coronal plane,using multitude specimens and combining the MRI/MSCT images with the thin coronal section specimens.The coronal plane is dominant for showing the bilateral adrenal gland.The shapes of adrenal gland are varied whereas the range of values for adrenal thickness was quite narrow.The change of the thickness of adrenal medial and lateral limbs,especially the lateral limb could correctly reflect the change of the adrenal cortex.Provide better anatomical information to facilitate diagnosis and surgical treatment of adrenal disease.
2.The transverse\sagittal\coronal sectional specimens can match correspond with the CT\MRI images,the results can provide exact sectional anatomy data for the imaging diagnosis of the tiny disease in adrenal glands.On the serial transverse planes,the bilateral upper pole of kidney plane is the reliable one to observe the adrenal glands.The posterior wall of the inferior vena is the mark to recognize the anterior of the right adrenal gland;the spleen vein\artery the mark to recognize the anterior of the left adrenal gland.On the serial sagittal planes,the plane that the appearance of upper pole of bilateral kidneys is the permanent appearance plane of the bilateral adrenal glands,in which area appearing in this plane is the biggest in all planes.The left and right spleen artery/vein is the mark of the anterior of the left adrenal gland.The left and right spleen artery/vein is the mark of the anterior of the left adrenal gland.
3.We apply the images of the polylaminate Spiral CT and three-dimensional reconstruction,therefore,the adrenal gland and its adjacent tissues were displayed clearly from various directions,and this technique can display adrenal glands' position in vivo,which matches with the position during surgery.This provides reliable and practical anatomy data for the adrenal glands surgery treatment in urinary surgery.
4.This study combines the adrenal glands' anatomy of three-dimensional reconstruction with the images of the adrenal glands;explain the image of diseases in adrenal glands using sectional anatomy.The images of the three-dimensional reconstruction could elucidate the impression,corrosion of adrenal glands tumor. We found that the shape of normal adrenal gland difference from patient to patient and even in the same patient according to the level of the slice it is difficult to determine.Great changes of the morphologic shape and the anterior structures of the adrenal gland determine the different prominent ways for the diseases of adrenal gland to grow forwards.
引文
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6. Elaini AB, Shetty SK, Chapman VM, et al. Improved detection and characterization of adrenal disease with PET-CT. Radiographic, 2007,27:755-767
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8.Naya Y,Nagata M,Ichikawa ,et al .Laparoscopic adrenalectomy :comparison of transperitoneal and retroperitoneal approaches.BJU Int ,2002 ,90:199 - 204.
9.Lezoche E ,Guerrieri M,Felicidtti F ,et al . Anterior ,lateral and posterior retroperitoneal approaches in endoscopic adrenalectomy. Surg Endosc 2000(16):96-99.
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12 Rockall AQ, Babar SA, Sohaib SA,et al. CT and MR imaging of the adrenal gland in ACTH-independent cushing syndrome[J].Radiographics,2004, 24(2):435-452.
13 Lockhart ME, Smith JK, Kenney PJ.Imaging of adrenal masses [J]. Eur J Radiol,2002,42(2):95-112.
14 Vincent JM, Morrison ID, Armstrong P, et al. The size of normal adrenal glands on computed tomography[J]. Clin Radiol, 1994,49(7):453-455.
15 Montagne JP, Kressel HK, Korobkin M, et al.Computed tomography of the normal adrenal glands [J]. Am J Roentgenol, 1978,130:963-966.
16 Peppercor PD, Reznek RH. State-of-the-art CT and MRI of the adrenal gland[J].Eur Radiol, 1997,7:822-836.
17 Lingam RK, Sohaib SA, Vlahos I, et al. CT of primary hyperaldosteronism(Conn's Syndrome):the value of measuring the adrenal gland[J]. Am J Roentgenol,2003,181:843-849.
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22.刘树伟,刘汉明,栾铭箴,等.膈下间隙的横断层解剖研究.中华外科杂志,1996,34(2):120-122
23.Zhao Z,Liu S,Li Z,et al.Sectional anatomy of the peritoneal reflections of the upper abdomen on the coronal plane.J Comput Assist Tomogr,2005,29(4):430-437
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2.Rockall AQ,Babar SA,Sohaib SA,et al.CT and MR imaging of the adrenal gland in ACTH-independent cushing syndrome[J].Radiographics,2004,24(2):435-452
3.Lockhart ME,Smith JK,Kenney PJ.Imaging of adrenal masses[J].Eur J Radiol,2002,42(2):95-112
4.Peppercor PD,Reznek RH.State-of-the-art CT and MRI of the adrenal gland[J].Eur Radiol,1997,7:822-836
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