摘要
目的：探讨氢质子磁共振波谱在术前颅内病变的的诊断与鉴别诊断、对胶质瘤术后复发与放射性坏死的鉴别、对胶质瘤的分级、在胶质瘤手术计划的制定及在判断术中胶质瘤是否全切的临床应用价值。
方法：第一部分：前瞻性研究275例病例的磁共振波谱资料(男154例,女121例,年龄1-76岁,平均年龄43.2岁)。根据胆碱、N-乙酰天门冬胺酸的值来判断是肿瘤性或非肿瘤性病变,是胶质瘤或非胶质瘤。根据胆碱峰值、胆碱／N-乙酰天门冬胺酸及肌酸／N-乙酰天门冬胺酸的比值,尤其是瘤周肌酸／N-乙酰天门冬胺酸的比值,对胶质瘤进行分级及鉴别胶质瘤复发或放射性坏死。磁共振波谱诊断与常规病理诊断进行比较。第二部分：根据氢质子磁共振波谱特点,对幕上胶质瘤描绘出肿瘤边界,制定出手术导航计划,指导术中肿瘤的切除。第三部分：19例胶质瘤患者采用术中线圈行氢质子磁共振波谱检查,对其中2例判断其肿瘤性质,对17例判断术中肿瘤是否存在残留。结果：第一部分：275例病例中,非胶质瘤病例100例,胶质瘤及复发胶质瘤病例175例。在非肿瘤性与肿瘤性病变的鉴别中,磁共振波谱诊断正确246例,错误29例,Kappa指数=0.662,Youden指数0.816,符合率89.5%；在胶质瘤与非胶质瘤疾病的鉴别中,磁共振波谱诊断正确238例,错误37例,Kappa指数=0.723,Youden指数0.759,符合率86.5%。33例胶质瘤术后病例,在胶质瘤复发与放射性坏死鉴别中,磁共振波谱诊断正确31例,错误2例,Kappa指数=0.798,Youden指数0.929,符合率93.9%。175例胶质瘤病例,MRS诊断错误30例,在对145例胶质瘤的分级中,低级别胶质瘤组与高级别胶质瘤组的Kappa指数、Youden指数及符合率分别为0.865,0.897,93.8%和0.764,0.771,88.3%。第二部分：分析134例幕上胶质瘤的氢质子磁共振波谱,119例MRS分级正确。根据氢质子磁共振波谱,精确描绘出肿瘤边界。43例行普通神经导航手术,76例行术中磁共振神经导航手术。76例术中磁共振神经导航手术中,低级别胶质瘤22例,间变型6例,高级别胶质瘤48例。肿瘤全切除62例,大部分切除13例,部分切除1例。第三部分：19例采用术中线圈病例中,17例术中氢质子磁共振波谱对肿瘤是否残留均判断不清,2例磁共振波谱诊断正确。
结论：氢质子磁共振波谱在对肿瘤与非肿瘤的病变鉴别,对胶质瘤与非胶质瘤的鉴别,对胶质瘤的复发与放射性坏死的鉴别及在胶质瘤分级方面,尤其是后两个方面,具有较高的临床应用价值；氢质子磁共振波谱能精确定位胶质瘤边界,完善术前手术及导航计划的制定,有效地指导肿瘤手术切除。受多种因素限制,还有待进一步研究来证明术中氢质子磁共振波谱对判断术中胶质瘤是否全切或残留的临床应用作用。
Purpose:To explore the clinical practical value of1H-MRSI in the diagnosis and differential diagnosis of intracranial lesions, in the differentiation between recurrent glioma and radiation necrosis, in the grading of gliomas, in the surgical planning of gliomas and in the judgement to whether glioma was totally resected during the operation.
Methods:Part one:The data o1'H-MRSI was analyzed prospectively in 275 patients(154 males and 121 females; mean age:43.2 years; range:1-76 years). The value of Choline (Cho) and N-acetyle aspartate(NAA) was studied to make clear tumors or nontumorous lesions, and gliomas or non-gliomas. Glioma was graded, recurrent glioma and radiation necrosis was differentiated, according to the value of Cho, the ratio of Cho/NAA and Creatine(Cr)/NAA, especially the ratio of Cr/NAA in the peritumoural regions. Magnetic resonance spectroscopy (MRS) diagnosis was compared with the conventionial histopathology of tumor.
Part two:In correspondence with1H-MRSI, the boundary of each supratentorial gliomas was outlined, surgical planning was prepared with neuro-navigation so as to guide the resection of tumor. Part three:'H-MRSI was performed with intra-operation coil in 19 glioma cases. It was utilized to point out whether the tumor was totally resected or residual in 17 cases. MRS diagnosis was supposed to identify the type of the tumor in 2 cases.
Results:Part one:Among all of the 275 cases, there were 100 cases of non-gliomas, and 175 cases of gliomas and recurrent gliomas. There were 30 incorrect MRS diagnosis in these 175 cases. In the differentiation between nontumorous lesions and tumors, there were 246 correct MRS diagnosis and 29 incorrect, the Kappa index was 0.662, the Youden index was 0.816, and the coincidence ratio was 89.5%. In the differentiation between gliomas and non-gliomas, there were 238 correct MRS diagnosis and 37 incorrect, the Kappa index was 0.723, the Youden index was 0.759, and the coincidence ratio was 86.5%. Of 33 patients who had previous tumor resection, there were 31 correct MRS diagnosis and 2 incorrect, the Kappa index was 0.798, the Youden index was 0.929, and the coincidence ratio was 93.9% in the differentiation between recurrent glioma and radiation necrosis. In the grading of 145 gliomas, the Kappa index, the Youden index, and the coincidence ratio was 0.865,0.897,93.8% vs 0.764,0.771,88.3% in the groups of low grade glioma (LGG) and high grade glioma (HGG) respectively. Part Two:The data of 1H-MRSI was analyzed in 134 gliomas, of which MRS grading was correct in 119 cases. In correspondence with 1H-MRSI, the boundary of these tumors was outlined exactly.43 cases underwent ordinary neuronavigation surgery, and 76 underwent iMRI neuronavigation surgery. Among all of the 76 cases with iMRI neuronavigation surgery, there were 22 LGG,6 anaplastic gliomas, and 48 HGG. Total tumor resection was achieved in 62 cases, subtotal resection 13 cases, and partial resection 1 case. Part three: Among the 19 cases which were examined with intraoperative coil, it was unclear to point out whether the tumor was totally resected or still residual in 17 cases. There were 2 correct MRS diagnosis to dentify the type of the tumor.
Conclusion:There is higher clinical practical value of 1H-MRSI in the differentiation between non-tumorous lesions and tumors, between gliomas and non-gliomas, between recurrent glioma and radiation necrosis, and in the grading of gliomas, especially in the last two.'H-MRSI is helpful to outline the edge of glioma exactly, to prepare for the surgical planning with neuro-navigation perfectly and to guide tumor resection effectively. For several factors, it still need more work to do to confirm the clinical practical value of intra-operative 'H-MRSI in pointing out whether the tumor was totally resected or still residual.
引文
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