| Cervical cancer is one of the most common gynecologic malignancies,ranking second in the female reproductive system cancer,according to WHO statistics,new cases of cervical cancer are about 500,000 cases per year,of which 85%of cases in developing countries,of up to 131,500,accounting 28.8%for the world’s new cases of cervical cancer.It is about 200,000 women died of the disease each year,of which 53,000 occurred in our country.It is a serious threat to life and health of our women’s diseases.Radical hysterectomy(RH)and pelvic lymph node dissection(PLND)are the standard operation for early cervical cancer.RH is for dissecting the primary lesion,PLND is performed in order to determine whether the metastasis presence in pelvic lymph nodes.Although pelvic lymph node metastasis does not affect the stage,but is an independent risk factor for cervical cancer prognosis of patients.Therefore,to understand the status and individual distribution of pelvic lymph node are the premise of PLND.It is the key that whether the pelvic lymph node present metastasis,especially the normal-sized lymph node present metastasis directly determine the extent and manner of operation of PLND.Because the lymph nodes are concomitant with vessels,the principle of this procedure is to dissect the lymphatic adipose tissue surrounding the pelvic vessels continuously and make the vessels "naked".This process is often easy to damage pelvic vessels and nerves.Therefore,understanding the position of lymph nodes and the relationship among lymph nodes,vessels and nerves is the key to guide surgical procedure and avoid injury.It’s commonly used B ultrasound,computed tomography,magnetic resonance imaging and positron emission tomography-computer tomography to detect lymph nodes in clinic.The ultrasound and PET-CT can also detect the status of the lymph nodes,The ultrasound can only understand the characteristics of lymph node about size,location and shape,but it can’t assess the relationship between lymph node and vessels and nerves.PET-CT is a functional imaging in improving diagnostic accuracy potential of recent research,but it is expensive,time consuming,and low resolution.It can not be a routine examination for early tumor.In clinical practice,the most commonly used technique of tomographic anatomical imaging techniques such as CT and MRI are to assess the staging of pelvic malignancies.Multislice spiral CT provides high-resolution,fast imaging and multi reconstruction to meet precise measurements.MR imaging of soft tissue due to good advantage and better able to distinguish improve the detection of lymph nodes.However,conventional techniques can no longer accurately shows the relationship between the above-described anatomical structures before surgery,and now emerging digital reconstruction technique to solve this problem of a breakthrough.Reconstruction or visualization is a kind of short and morphological methods to obtain three-dimensional model of digital computer technology digitized two-dimensional image processing,through the use of digital medical technology,building different individuals,different digital three-dimensional model of the disease,to understand the individual characteristics of the patient,disease diagnosis and guide treatment of great significance.Previous studies of this research team has fully proved that the use of thin pelvic CT and MRI datasets were successfully constructed in the body of female pelvis,blood vessels,organs,muscle and nerve tissue.But these organizations larger,showing successive courses,easily identifiable in imaging,less difficult to rebuild.But smaller pelvic lymph nodes,was distributed in the surrounding nodular retroperitoneal vessels,diameters of about 3mm～8mm,while the conventional CT and MRI diagnostic images larger thickness,lymph nodes can only display section,it is difficult to meet the requirements for reconstruction.And closely surrounding soft tissue and lymph nodes,identification is difficult,which increases the difficulty of rebuilding the pelvic lymph nodes in the body of digital three-dimensional model.In addition,the two-dimensional image from the cross-sectional imaging only,coronal or sagittal plane lymph node assessment to understand the relationship with the surrounding blood vessels,lymph nodes f’rom the difficulty of operation can not be performed with the surrounding blood vessels and nerves and volume three-dimensional anatomical relationship angle design and evaluate programs.There is currently a lack of established research body and anatomy of pelvic lymph node in the digital three-dimensional model.Therefore,reconstruction of the pelvic lymph nodes in the body digital three-dimensional model is the premise,how to choose the suitable body to rebuild pelvic lymph node imaging data digital three-dimensional model is reconstructed model of the primary problem,is the first purpose of this study in.On the basis of digital three-dimensional reconstruction model will be applied to surgery preoperative evaluation and intraoperative real-time guidance to achieve the transformation of medicine is a hot research.Clinicians in the preoperative use of medical imaging equipment and computer three-dimensional reconstruction of medical image data in patients with three-dimensional reconstruction and visualization,to obtain a three-dimensional model,preoperative surgical risk assessment;formulate a reasonable surgical planning,conduct preoperative simulation;after the surgery will be a three-dimensional model and the actual position of the patient registration is performed under the guidance of individual anatomy of the patient navigation surgery.We are in the early series of studies on cervical cancer,endometrial cancer,ovarian cancer,pelvic mass of unknown origin,uterine fibroids and other diseases of the digital three-dimensional reconstruction,the former guide for preoperative diagnosis and operation plan,get better effect,therefore,the present study intends to build on the basis of body pelvic lymph node digital three-dimensional model,combined with pelvic neurovascular digital three-dimensional model of pre-constructed successfully establish cervical cancer pelvic lymph node dissection digital three-dimensional navigation model to further develop individualized treatment plan is the second objective of this study.To achieve these two objectives,this study in the early basis of a study by the following three elements:1.Comparison of CT and MRI data sets created in the body of the female pelvic lymph node cancer digital three-dimensional model,anatomy and pathology results as the standard lymph node surgery,to verify the authenticity of the model,evaluate and select suitable for reconstruction the source of the data model to optimize the reconstruction;2.After selecting the appropriate data set,and further build normal women without lymph node metastasis,lymph node metastasis in patients with cervical cancer and pelvic lymph node body digital three-dimensional model to compare three groups of pelvic lymph nodes anatomical characteristics.3.Further to the pelvic blood vessels,nerves and lymph nodes combined with the establishment of pelvic lymph node dissection digital three-dimensional navigation models were used to evaluate and preoperative patients without lymph nodes and swollen lymph nodes in cervical cancer who underwent PLND guide.For no lymph nodes in patients with cervical cancer,mainly for the distribution of blood vessels and nerves,and traveled to measure the relationship between guidance PLND,and evaluate digital three-dimensional model of the diagnostic performance of lymph node metastasis.For patients with cervical lymph nodes,mainly for the removal of lymph nodes,the position to observe and measure the three-dimensional model to understand the lymph nodes before surgery,the size,the positional relationship between the peripheral nerves and blood vessels,and evaluate its resectability resection guide lymph nodes removed to evaluate the pelvic lymph node dissection digital three-dimensional model of navigation in reducing complications and improve the success rate of value.Part One:Comparative study of reconstructing digital three-dimensional models of pelvic lymph nodes in vivo based on CT and MRI datasets[OBJECT]Select adapted the data source to reconstruct the model,optimize the reconstruction method and validate the pelvic lymph digital three-dimensional model.[METHORDS]16 patients with Ⅰ A2 to ⅡA2 of cervical cancer were selected during July 2014 to December 2014.The in vivo digital three-dimensional model of pelvic lymph nodes were constructed by CTA and MRI DICOM datasets separately.Then,the number of lymph nodes were counted,the maximum diameter(Dmax),the longest diameters(dmax)and the shortest diameter(dmin)of largest area,the ratio of diameters(R)were calculated.Third,the pelvic lymph nodes were exposed during PLND and photos were collected.Finally,the pelvic lymph nodes and surrounding fat tissue were sent to pathological examination.[RESULT]25 cases in vivo digital three-dimensional model of pelvic lymph node based on CTA and MRI datasets of healthy women were reconstructed:(1)16 sets CTA datasets total constructed 243pelvic lymph nodes,MRI datasets total constructed 145 pelvic lymph nodes.(2)The location and size of pelvic lymph nodes exposed during the PLND consistent with the digital three-dimensional reconstruction model.(3)It were 395 lymph nodes were detected in pathology,the reconstructive ratio of three-dimensional model of pelvic lymph node was 62%based CTA data sets,and 36.71%based on MRI data set.(4)The dmin is 1.04～23.88mm,the mean(3.75±2.39)mm;dmax 1.55～33.90mm,the mean(6.46±3.64)mm;R of 1.00 to 7.48,the mean(2.00±1.11);Dmax of 4.38～48.21mm,the mean(14.65±8.07)mm.[CONCLUSION]In this study,the in vivo digital three-dimensional model of pelvic lymph nodes based on CTA and MRI datasets were successfully constructed,but the lymph nodes reconstructed based on CTA data is more suitable for reconstruction.This provides data to support the reconstruction of the model for subsequent studies,lymph node metastasis model-based diagnostic and surgical navigation.Second Part:Comparative study of the anatomical characteristic of in vivo digital three-dimensional models of pelvic lymph nodes between healthy women and patients with cervical cancer[OBJECT]Comparative study of the anatomical characteristic of in vivo digital three-dimensional models of pelvic lymph nodes between healthy women and patients with cervical cancer[METHORDS]It included 25 healthy female volunteers,25 cases of pathologically confirmed lymph node metastasis(without LN metastasis)to IIA2 IB1 of cervical cancer and 25 patients with pathologically confirmed lymph node metastasis(LN metastasis)stage IIB to stage IB1 cervical cancer,which were collected CTA DICOM data sets,and the pelvic lymph nodes in the body to build digital three-dimensional model,were calculated iliac region,the number of pelvic lymph node area external iliac,internal iliac region,inguinal region and the obturator area,pelvic lymph node measuring the maximum area of the longest diameters dmax,dmin and shortest diameter wire diameters than R,by comparing three different regions of pelvic lymph node size,analysis of normal women and cervical cancer without lymph node metastasis and lymph node metastasis in patients with pelvic body lymph anatomical features digital three-dimensional model.[RESULT]1.the anatomical features of normal female pelvic lymph digital three-dimensional model:(1)successfully constructed 376 based on the normal female CTA datasets in vivo pelvic lymph node digital three-dimensional model,dmin 1.1 to 7.5,the average(3.2±1.2)mm;dmax 1.8～11.9mm,the average(5.7± 2.2)mm;R is 1.0 to 6.4,the average(2.0 ±1.0).(2)the pelvic lymph nodes in different regions of each radial line normal female differences exist,further pairwise comparison:①dmin:inguinal lymph nodes>common iliac,external iliac,internal iliac,and obturator lymph nodes(P<0.05);②dmax:deep inguinal lymph nodes>obturator lymph nodes>common iliac,external iliac,internal iliac lymph nodes(P<0.05);③R:inguinal lymph nodes>obturator lymph nodes>common iliac,external iliac,internal iliac lymph nodes(P<0.05).2.No LN metastasis of pelvic lymph nodes in patients with cervical digital three-dimensional model of anatomical features:(1)successfully constructed of 25 patients without LN metastasis in patients with cervical cancer in the body of pelvic lymph node digital three-dimensional model 408,dmin 1.1 to 9.0 average(3.3±1.6)mm;dmax1.3～14.38mm,the average(6.4±2.7)mm;R is 1.0 to 10.0,the average(2.1 ±1.3).There are differences in different pelvic lymph node region(2)without LN metastasis in patients with cervical cancer each diameter line,further pairwise comparison:①dmin:obturator and inguinal lymph nodes>internal iliac lymph nodes(P<0.01).② dmax:inguinal lymph nodes>obturator lymph nodes>external iliac,internal iliac lymph nodes(P<0.05).③R:obturator lymph nodes and inguinal lymph nodes>external iliac,internal iliac lymph nodes(P<0.05).3.LN pelvic lymph node metastasis in patients with cervical digital three-dimensional model of anatomical features:(1)This study successfully constructed 25 cases of cervical cancer patients LN metastases in the pelvic lymph nodes body digital three-dimensional model 401,dmin 1.0 to 23.9,with an average(3.8±2.4)mm;dmax1.6～33.9mm,the average(6.5± 3.6)mm;R is 1.0 to 7.5,the average(1.7±1.1).(2)the pelvic lymph nodes in different regions of LN metastasis in patients with cervical cancer each diameter line differences,further pairwise comparison:dmin:obturator lymph nodes>external iliac and inguinal lymph nodes(P<0.01),but and common iliac,internal iliac no significant difference in the lymph nodes.dmax:obturator lymph nodes and inguinal lymph nodes>external iliac lymph nodes(P<0.05).R:inguinal lymph nodes>obturator lymph nodes>common iliac,external iliac lymph nodes>internal iliac lymph nodes(P<0.05)4.Compared three groups of digital three-dimensional model of pelvic lymph node anatomy:Between the three common iliac,internal iliac,and obturator lymph nodes have a three-dimensional diameters significantly different,further comparison shows that:①iliac lymph nodes:LN metastasis was significantly dmax larger than normal female group(P = 0.009),but no difference with non LN metastasis.② the iliac lymph nodes:LN metastasis dmin>without LN metastasis dmin(P = 0.007),LN metastasis R<without LN metastasis(P = 0.005),but no significant difference was not LN metastasis group and normal female group;③ obturator lymph nodes:LN metastasis dmin significantly larger than the other two groups(P≤0.001),LN metastasis group R was significantly less than the other two groups(P = 0.013,P 0.003).5.Each of the pelvic lymph node regions dmin normal female and non-LN metastasis was concentrated at about 3mm.dmax concentrated around 6mm,R centered on about 2.0.But LN metastasis of pelvic lymph node of each region dmin concentrated around 5mm,dmax concentrated around 6mm,R centered on about 1.7.Comparison of the three groups have significant differences,it is proposed initial development of cervical lymph node evaluation criteria based on this data analysis dmin)5mm,1.0<R≤1.7[CONCLUSION]In this study,by using the in vivo assessment of normal female pelvic lymph node digital three-dimensional model,without LN metastasis in patients with cervical cancer and cervical cancer pelvic lymph node metastasis LN dimensional diameter line,found no LN metastasis in cervical cancer and pelvic lymph nodes the size of a normal female pelvic lymph nodes little difference,obturator LN patients with lymph node metastasis of dmin increasing trend,R has a decreasing trend,suggesting obturator lymph nodes is the first leg of cervical lymph node metastasis.Preliminary analysis of the development of cervical lymph node evaluation criteria based on this data dmin≥5mm,1.0<R≤1.7.But how to evaluate the effectiveness of follow-up studies still need to be verified.Part Three Establishment of digital three-dimensional navigational model and preliminary application for the pelvic lymph node dissection[OBJECT]Establishment the digital three-dimensional navigational model for pelvic lymph node dissection,measurement the surgical relative anatomical data preoperative,assess the distribution and status of the pelvic lymph nodes,guide surgical procedures,and evaluate its value.[METHORDS]Included in the January 2015 to Dec 2015 Nanfang Hospital of Gynecology admitted to undergoing surgery intended IB 1～ⅡA2 of 38 cases of cervical cancer patients,in preoperative CTA examination,assessment by examination without dmin>10mm of pelvic lymph nodes,collection and utilization of its DICOM datasets three-dimensional reconstruction software built body pelvis,pelvic lymph nodes,blood vessels,obturator nerve digital three-dimensional model of the patient,based on the body of pelvic lymph node dissection digital three-dimensional navigation model of the surgical and adjacent anatomical structures related to distance observation and measurement:(1)pelvic lymph node status,whether the transfer;(2)the location of the lymph nodes,the positional relationship between the distance to the anatomy of major blood vessels and the obturator nerve;(3)the common iliac artery behind the structure;(4)iliac between(7)of the common iliac artery bifurcation and the internal and external iliac vein confluence(ie,common iliac vein bifurcation);artery bifurcation rear structure;length(5)of the common iliac artery;length(6)common iliac vein distance;the relationship(8)obturator nerves and blood vessels.Based on the above information,in real-time guidance of intraoperative surgical procedures,intraoperative photo collection to be in control,recording blood loss,with or without vascular injury,and according to the results of pathological diagnosis efficacy evaluating whether the lymph node[RESULT]1.in this study of 38 patients successfully established in the body of pelvic lymph node dissection digital three-dimensional navigation system,the implementation of the model in real-time navigation surgery,intraoperative findings consistent with the three-dimensional reconstruction model.2.38 cases of cervical cancer a total reconstruction of the pelvic lymph nodes in the body of digital three-dimensional model 461,with no lymph nodes dmin>5mm,1<R<1.7 as the standard diagnosis of lymph node metastasis,in accordance with this standard diagnosis of pelvic lymph node metastasis,the sensitivity was 52.38%and a specificity of 95.22%,the accuracy was 89.37%,47.62%rate of missed diagnosis,misdiagnosis rate was 4.78%,a positive predictive value of 63.46%,negative predictive value of 92.67%3.We found in 19 lymph nodes,which are located next to the lower abdominal region(1),iliac region(4),external iliac region(4),internal iliac region(1)and obturator area(9).Lymph dmin is 10mm～31mm,dmax is 13mm～36mm,R of 1.0 to 1.4.4.(1)the left common iliac artery behind the structure are:the left common iliac vein(90.0%),the left internal and external iliac vein confluence(6.7%),the left external iliac vein(3.3%);(2)the right iliac artery rear side structure:the inferior vena cava(16.7%),common iliac vein confluence(46.7%),the right common iliac vein(20.0%),the left common iliac vein(16.7%).5.(1)the left common iliac artery bifurcation rear structure:the left common iliac vein(90.0%),the left internal and external iliac vein confluence(6.7%),the left external iliac vein(3.3%);(2)on the right side behind the common iliac artery bifurcation structure:bilateral iliac vein confluence(ie,the inferior vena cava bifurcation)(16.7%),the right common iliac vein(66.6%),the left common iliac vein(10.0%),the right internal and external iliac vein confluence(ie,common iliac vein bifurcation)(6.7%).6.bilateral iliac artery length was left(45.77±17.88)mm,the right(40.46±13.28)mm,length distribution of bilateral iliac vein to the left(62.24± 9.75)mm,the right(48.69± 8.44)mm,bilateral iliac artery and vein bifurcation between the distances of the left(26.50±16.41)mm,the right(40.34±14.49)mm.7.the relationship between the obturator neurovascular area is divided into five types.8.Operative time 40min～100min,an average of(67.25±22.26)min,blood loss 20ml～120ml,No case of surgical procedures vascular,nerve damage.[CONCLUSION]Pelvic lymph node resection digital three-dimensional navigation model application value lies in preoperative lymph node status,presence or absence of metastasis,lymph nodes position measuring lymph node size and positional relationship with the surrounding neurovascular anatomy in order to plan surgical approach real-time implementation guide surgery,surgery to reduce the risk and improve the success rate of surgery. |
PDF Full Text Request