| BackgroundCurrently, breast cancer is the most common malignant tumor among women, which causes severe damages to women’s health, both physically and mentally. Every year, nearly 1.4 million women are diagnosed as breast cancer around the world, and nearly half a million patients died of breast cancer. Its morbidity ranks the first in America, while its mortality ranks the second in malignant tumor of women, after lung cancer. In China, breast cancer has taken the highest morbidity among female malignant tumors, and there’s a trend that a growing number of young women are involved in this disease. Thus, early diagnosis and treatment are essential to the improvement for survival and quality of life of patients.Studies about the diagnosis and the treatment for breast cancer have shown great progress over recent years, our knowledge for the biologic behavior of breast cancer has also been expanded. Breast cancer is vascular-dependent, after reaching(1-2) mm3, nutrition brought by new vessels is essential to its growth, or it would become necrotic from hypoxia. Therefore, evaluation of vascular condition in an efficient and non-invasive way can provide significant evidence for both diagnosis and treatment. Currently, Mammography and Color Doppler ultrasound are most commonly used in the screening for breast cancer. Both screening techniques diagnose the disease through morphology, therefore, certain weaknesses are shown while hemodynamic changes and spatial anatomic structure of the diseased part are involved. As multi-layered screw CT technique develops at a great speed, CT perfusion imaging (CTPI) has been widely used in researching the diseases of the brain, lung, liver, and kidney, etc. Studies aimed at CTPI on breast diseases have just started around the world. As a new-developed non-invasive radiography estimating micrangium of tissues and organs, CTPI can not only reveal its anatomy, but also show the physiological function of the lesion. CTPI scans a certain layer continuously multiple times at the same time with injecting contrast agents, and then gets access to perfusion color images, perfusion parameter value and time-density curve by processing scan data, so that hemodynamic conditions and biological factors of organs can be evaluated. The great value in diagnosis, guidance treatment and outcome estimation makes CTPI for breast cancer a potential key diagnosis technique in breast diseases.Breast cancer is mainly treated with operations. Though the traditional radical mastectomy is rarely performed now, modified radical mastectomy still takes an important roles, which will cause damages to the beauty of female sex character and body curves. With the continuous improvement of people’s life quality, medical techniques and standardization of the treatment, survival rate of patients with breast cancer has increased significantly, so has patients’ requirement for their treatment. Improve the appearance of breast after surgeries has become a hot topic in both breast and plastic surgery. In the future, breast surgeries tend to cure the disease while the appearance of the breast and mental statue of patients are both well-concerned. For now, both breast-conserving surgeries and breast-rebuilding after modified mastectomy have their weakness:removing too much tissue would result in a less ideal morphology of the breast, while local recurrence may happen if going the other way. If the operator chooses the prosthesis simply based on his/her own experience, it may cause the breasts to be asymmetric in breast-rebuilding surgeries. Get to the root of the matter, these problems are due to the lack of studies of space structures of tumors in the breasts. A standard for the excisional margin of breast-conserving surgeries remains unsettled in clinical studies.With the development of computer science,3D reconstruction has been widely used in the clinical diagnosis and treatment of surgical diseases. The surgical simulation system of 3D reconstruction provides opportunities for surgery simulations, helps select individualized operative methods, reduces unnecessary surgery injuries, and improves the security of the operation. Currently the application of the 3D reconstruction to breast surgery is still at an early stage, and has been confined to the rough pre-operative estimation. In the field of breast surgery, minimal invasive surgery has gradually become an inevitable trend. Therefore, it’s necessary to combine the 3D reconstruction with the breast cancer research.360-degree roasting dynamic images can be obtained in the 3D reconstruction, which shows the location, size, morphology and spatial anatomical relations with the surrounding organs. By applying the 3D reconstruction to the preoperative assessment of breast cancer, the operating method design and the intraoperative navigation, etc, the minimally invasive surgery would be refined and the area of lesion resection would become more accurate.This is the first research that combines breast CT perfusion imaging with 3D reconstruction. Breast CT perfusion imaging diagnoses diseases by the morphology and biological characteristics of the lesions. Besides,3D reconstruction provides information about the anatomical structure of lesions. This conjunction improves the accuracy of early diagnosis of breast cancer. It also makes the prerequisite to minimally invasive surgery and comprehensive therapy of breast cancer. This research will discuss the application value of breast CT perfuming imaging and 3D reconstruction in the diagnosis of breast diseases and their clinical significance in breast surgery.Purpose1.To collect valuable CT data of breast cancer patients, to operate CT perfusion imaging and to discuss the significance of its indicators in diagnosis/differentiate diagnosis for benign/malignant breast tumors.2. To discuss the significance of its indicators in diagnosis/differentiate diagnosis for axillary lymph nodes with/without metastasis in breast cancer.3. To collect valuable CT date of breast tumors patients and to construct an individual 3D reconstruction model by 3D reconstruction.4. To discuss the clinical significance of 3D reconstruction in breast surgeries.5. To combine 3D reconstruction with functional imaging to construct a valuable new diagnosis and treatment pattern for breast tumors.Materials and Methods1. Clinical informationCollect all female patients treated in the Department 2 of General Surgery, Guangdong NO.2 Provincial People’s Hospital during February to July in 2014. Inclusion criteria:(1) Physical examinations/ultrasound/mammography examinations revealed breast tumors; (2) Being able to tolerate surgeries. Exclusion criteria:(1) Under 40 years old; (2) Pregnant; (3) Allergic to contrast agents; (4) Suffering from major organ failure such as heart, liver and kidney; (5) Unable to undergo surgeries for her own reasons.There were 50 patients who fit the criteria above, all female, age ranged from 40 to 69, (49.12±6.43) y on average. Pathology confirmed that 24 of them were suffering from breast cancer (1 invasive ductal carcinoma,2 mucuous carcinoma and 1 ducatal carninoma in situ), and 20 of them are accompanied with metastasis of ipsilateral lymph nodes. Other 26 tumors were benign (19 fibroadenoma,4 phyllodes tumors and 3 chronic granulomatous inflammation). Size of the 50 tumors ranged from (1.05-8.02) cm and (1.60-51.60) cm3,(2.33±1.53) cm and (6.20±10.60) cm3 on average.This study has been approved by ethic committee of that hospital. All patients have signed informed consent form for breast CT perfusion and surgery.2. Equipments2.1 256-slice spiral CT (Philips Brilliance,256-slice Starlight iCT), detectors combination (0.625mm×256);2.2 Double tube high pressure syringe,18G vein detained needle, contrast agents (Iohexol in a does of 300mgI/ml);2.3 The self attached workstation for post processing of the images in 256-slice spiral CT (Philips IntelliSpace Portal, v5.0.2.30010);2.4 Perfusion imaging software:the Functional CT software;2.5 3d reconstruction software:Advanced Vessels Analysis (AVA) software;2.6 DICOM CT image viewer;2.7 Vernier calipers (Precision 0.01mm, range 100mm); measuring cylinders (10ml,25ml,50ml);2.8 Purple light RW DVD CD R16X3. Parameters of CT scanPhilips Brilliance 256-slice Starlight iCT was used in this study. Performed perfusion scan under spiral scan mode with the bedplate moving circularly and repeatedly. Voltage 100KV, Current 60mA, slice thickness and slice gap were both 5mm, matrix 512×512, vision (20-350)mm. Injecting 60ml Iohexol (300mhI/ml) into median cubital vein of right through double tube high pressure syringe in a speed of 5ml/s during the scanning.11 periods were taken in total. Scanned once in every 5 seconds and 2 seconds were taken in each scan.77 scan in total.Transfer the CT date from workstation to DVD, each DVD corresponding to a patient’s CT data, and tag name, age, time, hospitalization and CT number on the DVD, for data transfer and storage.4. Perfusion ImagingImported original perfusion images into the self attached workstation for Post processing of the images in 256-slice spiral CT (Philips IntelliSpace Portal, v5.0.2.30010) and processed data with general mode in Functional CT to produce perfusion color images. Used manual methods to draw the region of interest (ROI). Took thoracic aorta as the afferent artery and used maximal slope method to get perfusion parameter values and the type of time-density curve (TDC) in ROI. Perfusion parameter values:perfusion (PF), peak enhancement image (PEI), time to peak (TTP), blood volume (BV). TDC type according to its shape is divided into four type:outflow type, flow type, platform type, flat type. The selecting of ROI should avoid marginal of the gland, vessels, artifacts and liquefied or necrotic areas in the central of tumors and lymph nodes. The size of the ROI should stay in the range of (15-20) mm and 3 ROI should be selected per slice. At least 2 slices should be measured and averaged while producing perfusion data.5.3D reconstructionThin-layer separated the data where breast tumors are enhanced most obvious into 0.625 mm. Imported the thin-layer data into workstation and used Advanced Vessels Analysis (AVA) to build 2 types of 3D reconstruction:volume rendering (VR) and maximum intensity projection (MIP). Reconstructed the ideal individual 3D model.Enlarged, shrunk, rotated, smoothened, cut, clip and colored the model with 3D reconstruction technology to study the anatomic spatial structure of the tumor and measure the maximum size, volume and the distance between tumor and surrounding tissue.6. Actual operationSelected proper individualized surgical plan under the guidance of actual condition, examinations and 3D reconstruction model of patients. Surgeries were performed in all 50 patients:17 modified radical mastectomies; 7 breast-conserving surgery; 20 tumor resections and 6 segmental resections. Measured the maximum size of the removed tumor with vernier calipers and the volume by drainage approach. Detailed pathology diagnosis was reported to all samples.7. Postoperative follow-upFor patients with benign breast tumors, outpatient and telephone follow-ups were required in the first month and the third month after surgery respectively; for patients with malignant breast tumors, follow-ups were required every month during the first 6 month after surgery, every 3 month half a year after the surgery, and every 6 month 1 year after the surgery.8. Evaluation indicatorsPerfusion imaging results:the comparison between the group of breast cancer tissue and the group of contralateral normal breast tissue, the group of breast cancer tissue and the group of benign breast tumor tissue, the group of breast cancer with lymph nodes metastasis and the group of breast cancer without lymph nodes metastasis in perfusion parameters. The comparison between the group of breast cancer tissue and the group of breast benign tumor tissue in types of TDC. To prove that CT perfusion imaging has clinical significance for the diagnosis/differential diagnosis of benign/malignant breast tumors and axillary lymph node with/without metastasis.3D reconstruction results:the largest diameter, volume, morphology, and margin of the tumor, pectoralis major invasion, skin invasion, blood vessels of tumor,and enlargement of lymph nodes; distance between the tumor and the nipple, distance between the tumor and the skin, distance between the tumor and thoracic wall. Practical surgery results:the largest diameter, volume, morphology, and margin of the tumor, pectoralis major invasion, skin invasion, and lymph nodes metastasis, and incidence of postoperative complications. By analyzing the indicators mentioned above, we are able to evaluate the consistency between the actual tumor condition and the 3D reconstruction model, and find out whether the 3D reconstruction is of clinical value for breast surgery.9. Data analysesSPSS 13.0 was used for all the statistical analyses. Paired t-test was used for the comparison between the group of breast cancer tissue and the group of contralateral normal breast tissue, the group of breast cancer with lymph nodes metastasis and the group of breast cancer without lymph nodes metastasis in perfusion parameters. Paired t-test was used for the comparison between the 3D reconstruction and the pathological specimen on the diameter and volume of tumor. Independent t-test was used for the comparison between the group of breast cancer tissue and the group of benign breast tumor tissue in perfusion parameters. x2 test was used for the comparison between the group of breast cancer and the group of breast benign tumor tissue of types of TDC curve. Statistic results were all presented as Mean ±SD. The difference was considered statistically significant when P<0.05.Results1. perfusion imaging results1.1 There were statistically significant differences in perfusion parameters (PF, PFI, TTP, and BV) between the group of breast cancer tissue and the contralateral normal breast tissue. The average PF, PEI, and BV of breast cancer tissue group was significantly higher than that of the contralateral normal breast tissue group, while the average TTP was significantly lower.1.2 There were statistically significant differences in perfusion parameters (average PF, TTP, and BV) between the group of breast cancer tissue and the benign breast tumor tissue. The average PF and BV of breast cancer tissue group was significantly higher than that of the benign breast tumor group, while the average TTP was significantly lower.1.3 In breast cancer tissue group, the outflow and the platform type TDC made up a relatively higher percentage, while in benign breast tumor tissue group the flow type had a higher percentage. TDC was of statistical significance in the difference between the malignant rates of breast tumors.1.4 There were statistically significant differences in perfusion parameters (average PF and TTP) between the group of breast cancer with lymph nodes metastasis and the group of breast cancer without lymph nodes metastasis. The average PF in the metastasis group was higher than that of the non-metastasis group, while the average TTP was lower.2.3D reconstruction results2.1 3D reconstruction model is a 360-degree roasting dynamic image that can clearly display the location, size, and morphology of the tumor, and spatial anatomical relations with the surrounding organs. The ideal individualized three-dimensional model was constructed.2.2 In the 3D reconstruction model, the tumors diameter in 39 cases were≤2.0 cm,9 cases> 2.0 cm and≤5.0cm, and 3 cases> 5.0 cm; the tumors in 15 cases had irregular form and unclear boundary; in 2 cases pectoralis major was invaded; in 1 case skin was invaded; in 9 cases surrounding blood vessels supplying the tumor were displayed clearly; there were axillary lymph nodes enlargement in 15 cases, and in 2 cases both axillary and supraclavicular lymph nodes were found enlarged. Take pathology findings as the standard, the total detection rate of lymph nodes metastasis was 85%(17/20). There were no statistically significant differences in the tumor maximum diameters or size between the 3D reconstruction and the pathology specimens.2.3 3D reconstruction provides direct visual basis for the choice of operation, surgical approach, breast-conserving surgery design, etc. It can provide important information for the preoperative and intraoperative navigation. Shorten the operation time, reduce the surgical trauma, help to postoperative recovery.Conclusion1.256-slice CT perfusion imaging is of clinical significance for the diagnosis/differential diagnosis of benign/malignant breast tumors.2.256-slice CT perfusion imaging is of clinical significance for the diagnosis/differential diagnosis of axillary lymph node with/without metastasis.3.3D reconstruction model shows the location, size, and morphology of the lesion and its spatial anatomical relations with the surrounding organs at multiple angles.4.3D reconstruction makes the important informations for preoperative evaluation, operation simulation, and minimally invasive surgery.5. Functional imaging-3D reconstruction is a "one-stop" diagnostic method that associates the diagnosis with the treatment of breast tumor diseases. It offers a new and reliable model and a strong basis for the diagnosis and therapy of breast diseases. |
PDF Full Text Request