正常人喉的三维重建及喉癌生长浸润特征的研究
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摘要
目的
喉癌是耳鼻咽喉-头颈外科最为常见的恶性肿瘤之一,手术是目前主要的治疗手段。由于喉形态不规则、结构复杂及肿瘤空间三维浸润生长,手术切除喉癌原发病灶要求准确把握肿瘤的浸润范围和空间立体构造,科学确定手术的切除范围。切缘阳性是肿瘤治疗失败的主要原因之一。熟练掌握肿瘤的浸润范围不仅是精确界定手术切缘的前提,而且是减少切缘阳性的有效手段,精确的手术切缘决定了喉癌患者术后生存率、解剖结构的保留和喉功能重建。本研究采用基于3D-Doctor 3.5软件的三维重建技术,实验一对正常人喉标本连续组织切片,国内首次建立了全喉连续组织切片数据库,确保了对正常人喉标本形态结构的正确认识；实验二通过组织切片与MSCT及其三维重建的比较,为喉部的影像学检查提供解剖学依据,指导MSCT在喉部的临床应用；实验三通过成人喉癌切除标本连续组织切片及三维重建,观察喉癌三维空间形态结构和生长浸润特征,将人体器官可视化应用在喉癌形态学研究中,通过对喉癌的空间结构特征的全面了解,熟悉喉癌的生长浸润特征,确定喉癌手术的立体切缘,使喉部分切除手术的更加合理,指导临床喉癌的手术治疗。
方法
1.制作华北地区正常人喉30例(男21,女9)连续切片,片厚5-15μm,间隔300μm取片,常规HE染色。专业微距照相系统获取切片图像。建立正常喉标本的连续组织切片数据集。在专业图形工作站INTEL XEON 5472(双路)上用3D-Doctor 3.5软件三维重建,对喉大体标本与重建虚拟标本的进行形态学研究；选取四组临床上喉癌常见浸润途径的参照径线,测量相应形态参数。
2.采集山西省正常志愿者30名(男12,女18)喉MSCT薄层扫描图像,用3D-Doctor 3.5软件三维重建,比较连续组织切片与MSCT三维重建虚拟标本的喉的形态学测量数据,相关测量参数同实验一。
3.收集喉癌患者的整块手术切除标本3例(声门上型、声门型和跨声门型,T3,T4),沿肿瘤长轴切开标本并制作连续切片,专业微距照相系统获取喉癌病理切片图像,在专业图形工作站INTEL XEON 5472(双路)上用3D-Doctor 3.5软件三维重建喉癌的虚拟模型,与术前MSCT及其重建图像比较,熟悉喉癌的连续切片病理组织学特点及其浸润特征。
4. SPSS16.0统计软件处理数据,以P<0.05为显著性标准。
结果
1.1与之前测量研究不同的是,甲状软骨声带附着处位于其前缘中点以上0.718mm±0.487,95%可信区间为0.369mm-1.066mm。甲状软骨声带附着处至甲状软骨上下切迹的距离和距离之比无性别上的统计学差异(P>0.05),除此以外,喉部其他结构的形态学测量数据都有性别差异(P<0.05)。
1.2甲状软骨和环状软骨大体标本实测值比连续切片三维重建虚拟标本实测值偏大,但无统计学差异(P>0.05)。
1.3杓状软骨位于甲状软骨后上1/2-2/3。除了声带附着深度(在声带末端至声带附着边缘的距离)为1.665mm-1.736mm,肌突至甲状软骨内膜距离为3.651mm-3.715mm以外,其余的指标均有性别差异(P<0.05)
1.4喉的会厌前间隙和声门旁间隙的测量：会厌前间隙在正中矢状面上的面积80.930mm2±8.911,在旁正中矢状面上的面积为84.757 mm2±15.482。声门旁间隙在经声带的水平切面上的面积为172.400 mm2±6.968,在经声带膜部中点冠状切面上的面积为248.751 mm2±5.543,在杓状软骨后缘冠状切面上的面积为221.893 mm2±9.473,在杓间切迹处冠状切面上的面积为186.678 mm2±13.249。喉间隙在不同切面上的面积测量为临床医师对喉癌的间隙浸润情况的估计提供了解剖学数据参考。
1.5喉癌常见浸润途径上选定的四组参照径线的测量：会厌软骨茎末端至前联合的距离男为5.122mm±1.031,女为4.051mm±0.944；舌骨会厌韧带会厌端至室带的距离男为23.807±3.747,女为20.638mm±2.748；杓会厌襞中点至室带的距离男为21.708mm±4.724,女为18.423mm±4.245；声带水平至甲杓肌外缘距离男为3.322±0.724,女为2.371mm±1.032；声带水平至甲状软骨板内膜的距离男为7.245±1.524,女为6.833mm±1.425。所有测量参数均有性别差异(P<0.05)。
1.6声带突离断的位置：由于声带突末端至声韧带附着边缘距离为1.665mm-1.736mm,声带突长男为5.194mm,女为4.092mm。因此,在声带突前1/3和1/2之间离断声带突较为合适。
1.7甲状软骨开窗术改良,要点：(1)确定开窗圆心：先以甲状软骨后缘中点为圆心,以甲状软骨后缘中点至杓状软骨肌突投影点距离为半径,在甲状软骨板上做第一条弧线标记；以肌突投影点为圆心,以顶底间距的一半为半径在甲状软骨板上做第二条弧线；两条弧线的交点即为开窗圆心；。(2)从外向内逐层去除窗口内的甲状软骨,用力要适度,可避免开窗后软骨断裂；(3)沿窗后下缘向内或以环杓后肌可确定肌突。术中注意事项：(1)避免损伤喉上神经外支。(2)避免损伤梨状窝粘膜。
2 MSCT图像中甲状软骨、会厌软骨和环状软骨显示清晰,杓状软骨显示不全,喉间隙内容结构无法显示。MSCT重建模型的喉软骨测量数据与组织切片相比无显著性差异(P>0.05)。用3D-Doctor 3.5软件切割MSCT三维重建图形,得到6个与组织切片同一层次的分割图像,MSCT重建切割平面与组织切片上的会厌前间隙和声门旁间隙面积进行比较,结果无显著性差异(P>0.05)。喉癌常见间隙浸润途径上,四组参照径线的组织切片与MSCT测量比较,结果显示：声带水平至甲状软骨板内膜的距离MSCT组测量结果较组织切片组小,其他参数的MSCT组测量结果较组织切片组大,但均无统计学差异(P>0.05)。
3喉癌连续切片的断面观察,较清晰分辨肿瘤与正常组织的界限。在断面切面中肿瘤呈类圆形、不规则形等,肿瘤部分色泽较正常灰暗,且肿瘤实质部分呈现不均质性,有些区域较致密,有些区域疏松,色泽呈现差异,而且肿瘤越大这种不均质现象越明显。喉癌三维重建喉癌的空间形态是不规则的,肿瘤生长是空间性三维生长,无方向性,可以向周围任何组织浸润生长。
结论
1建立了全喉连续组织切片的数据集。三维重建得到的虚拟喉标本与真实大体标本基本一致,与正常中国人体喉部解剖学数值基本一致。三维重建的虚拟喉可以作为作教学科研的辅助工具,为临床应用提供解剖学指导。
2 MSCT对超过其分辨率的细微结构显示欠佳,其三维重建的细节效果不如组织切片的完整、清晰。MSCT及其三维重建适合临床应用,可以作为临床医疗诊断和影像学检查的辅助工具。
3喉癌切除标本连续切片三维重建的虚拟图形提供了直观、形象的肿瘤立体图形,有助于临床医师熟悉喉癌的空间形态结构和生长浸润特征,提高喉癌诊治水平。
创新点：
1.完成了国内首次喉部的连续组织切片的制作,建立了喉的组织切片数据库。
2.利用专业图形工作站处理组织切片数据,实现虚拟喉组织切片的三维重建,从多角度、多层面直观显示喉的组织结构形态特征,显示效果优于MSCT三维重建的虚拟喉,更有效地指导临床,有助于确定喉癌手术的立体切缘。
Objective
Laryngeal cancer is one of the common malignant tumors in Otolaryngology-Head and Neck Surgery, surgical operation is the primary measurement of laryngeal carcinoma at present. As the irregular morphous, the complex structure and 3D feature of the growth of tumor infiltration, surgical eradication of the primary laryngeal lesion called for an accurate grasp of the scope of tumor infiltration, spatial 3D structure and the scientifical surgical resectional scope. Positive margin is one of the major surgical operation failures. Master of carcinoma infiltration is not only the premise of precisely defined scope of surgical margin, but also the effective means of reducing positive margin. Precise surgical margin determines the survival rate of laryngeal cancer patients, the preserve retention of anatomical structure and reconstruction of laryngeal function. In this study, based on 3D-Doctor 3.5 software and 3D reconstruction techniques, serial slice of the normal 3D reconstruction of laryngeal specimens were produced in the experiment one, to establish a whole database of serial tissue sections of normal larynx, to ensure the normal throat samples of correct understanding of morphological structure; experiment 2 by the comparison between serial slices and MSCT and 3D reconstruction for laryngeal imaging provide anatomical basis for guiding the clinical application of MSCT in the throat; serial slices of laryngeal biopsy specimens and 3D reconstruction were completed. Observation of 3D morphology of laryngeal cancer invasion and growth characteristics were finished, visualization of human organs was used in laryngeal morphology study on laryngeal cancer through a comprehensive understanding of spatial structure, familiarity with the invasive growth of laryngeal features and determination of the laryngeal operation of 3D cutting margin, so that partial laryngectomy will be more reasonable to guide the clinical treatment of laryngeal cancer surgery.
Methods:
1. Serial slices of 30 (21male,9female) normal whole laryngeal specimen from the north region of China were produced, thickness of slice is 5-15μm, the slice was selected every 300μm, HE stained. The photos of serial slices were acquired by professional miscrospur photograph system. A whole database of serial tissue sections of normal larynx was established. Comparative study was executed between general specimens and the virtual specimens after 3D reconstructions with 3D-Doctor 3.5 software in the graphic workstation of INTEL XEON 5472 (double route). Four reference diameters of clinical laryngeal invasion pathways were selected and the corresponding morphological parameters were measured.
2. MSCT images of 30 volunteers (12male,18female) normal necks were acquired and 3D reconstruction of MSCT images were accomplished by 3D-Doctor 3.5 software in the professional graphics workstation of INTEL XEON 5472 (double route), and measurement data of the serial slices and MSCT images were compared with the 3D reconstruction of serial sections, which the measurements parameters are same to that of experiment one.
3.3 specimens with en bloc surgical resection in laryngeal carcinoma patients were collected, which including supraglottic type, glottic type and straddled glottic type, T3, T4) were cut along the long axis of tumor specimens so as to produce serial sections, slice images were obtained by professional microspur photograph system, and virtual model of 3D reconstruction of laryngeal carcinoma were accomplished by 3D-Doctor 3.5 software in the professional graphics workstation of INTEL XEON 5472 (double route). Compared with the image of preoperative MSCT, the serial sections of laryngeal cancer and its histological features of infiltration characteristics were grasped.
Results:
1.1 Difference with the previous measurements studies, the attachment of vocal cord is above 0.718mm±0.487,95%confidence interval for the 0.369mm-1.066mm. The distances from the attachment of vocal cord in thyroid carrlage to the superior notch and the distance to inferior notch and their rate of the gender are no significant difference (P>0.05), except that, the other measurements data are significant difference on the gender (P<0.05).
1.2 The measuring data of general specimens are more than that of the virtual specimens of serial slices, but the difference is not significant (P>0.05).
1.3 Arytenoid cartilage lie in the posterior 1/2-2/3 of thyroid cartilage. In addition to the depth of vocal cord attached (in the vocal cords vocal cords attached to the edge of the end of the distance) to 1.665mm-1.736mm, muscular process to the thyroid cartilage endosteum distance 3.651mm-3.715mm, the rest of the indicators are gender differences (P<0.05).
1.4 Measurements of pre-epiglottic and paraglottic space:pre-epiglottic space in the sagittal plane of the area 80.930mm2±8.911, in the adjacent area of the median sagittal plane 84.757 mm2±15.482. Paraglottic space after vocal cord level in the area of section 172.400 mm2±6.968, the middle point in the film by the vocal cord on coronal section area of 248.751 mm2±5.543, in the arytenoid cartilage posterior coronal section area of 221.893 mm2±9.473, notch between the ladle Department coronal section area of 186.678 mm2±13.249.The area measurements of laryngeal spaces in the different section provide an anatomic reference data for clinicians on the infiltration of laryngeal cancer.
1.5 Measurements of four reference diameters on common infiltration paths of laryngeal cancer: the distance of the stem end of the epiglottis to the anterior commissure was males 5.122mm±1.031, females 4.051mm±0.944; the distance of the epiglottic end of hyoepiglottic ligament to ventricular bands was male 23.807±3.747, female 20.638mm±2.748; the distance of midpoint of aryepiglottic fold to ventricular bands was male 21.708mm±4.724, female to 18.423mm±4.245; the distance of vocal cord to the outer edge of thyroarytenoid muscle was male 3.322±0.724, female 2.371mm±1.032; the distance of vocal cord to endosteum of thyroid carlilage lamina was male 7.245±1.524, female 6.833mm±1.425. Gender differences in all measured parameters were significant (P<0.05).
1.6 Transection position of vocal process:Because the distance of the posterior end of vocal process to the attachment edge of vocal cord was 1.665mm-1.736mm, the length of vocal process was male 5.194mm, female 4.092mm. Therefore, transaction position at the anterior 1/3 and 1/2 of vocal process is more appropriate.
1.7 Thyroid cartilage fenestration improvements, main points:(1) determine the window center of a circle:Using the midpoint of the posterior border of thyroid cartilage center of the circle to the midpoint of posterior margin of the thyroid cartilage to the muscular process of arytenoid cartilage from the projection point for the radius, the thyroid cartilage marker board to do the first arc; muscle process as center of a circle, with half of the distance between top and bottom radius of the thyroid cartilage board to do the second arc; two windows shall be centered on the intersection curve;. (2) from the outside layer to remove the thyroid cartilage window, hard to be modest, avoid cartilage fracture; (3) along the lower edge of the windows or cricoarytenoid muscle to determine muscle process. Operation Notes:(1) to avoid the external branch of superior laryngeal nerve injury. (2) to avoid injury pyriform sinus mucosa.
2. MSCT image of the thyroid cartilage, epiglottic cartilage and cricoid cartilage showed clearly, arytenoid cartilage showed incomplete, the structure in the laryngeal space can not be displayed. The virtual model of MSCT reconstruction were measured and compared with serial slices of the laryngeal cartilage was no significant difference (P> 0.05). Using 3D-Doctor 3.5 software, cutting 3D reconstruction of MSCT virtual model,6 cutting plane were obtained as the same level of serial slices, the area of pre-epiglottic space and paraglottic space were compared between MSCT and serial slices, the results there was no significant difference (P>0.05). In the common ways of laryngeal cancer infiltration, four reference diameters measurements were compared between tissue sections and MSCT, the results showed:the distance of vocal cords to the thyroid cartilage endosteum of MSCT less than that of serial slices, the other parameters of MSCT are more than serial slices, but there were all no significant difference (P>0.05).
3. Serial sections of the cross-section observation of laryngeal carcinoma were observed, boundaries were distinguished clearly between tumor and normal tissue. In the cross-section aspect, type of tumor was round, irregular-shaped and so on, the color of the tumor is darker than the normal, and the tumor showed substantial part of the heterogeneity, with some regions more dense in some regions, loose, color rendering differences, but the larger is the tumor,the more obvious kinds of phenomena are not homogeneous. Laryngeal space shape is irregular, tumor growth is the spatial 3D growth and no direction, which can be invasivetowords the growth of any organization around in the 3D reconstruction model of laryngeal carcinoma.
Conclusion
1. The data sets of serial slices of whole normal larynx were established. The virtual specimens of 3D reconstruction are identified with the real general specimen basically, and provided the anatomical data fo clinical applications and imaging.
2. MSCT in excess of its fine structure shows poor resolution, the details of serial slices are more full and clear than MSCT 3D reconstruction. Based on the human laryngeal serial slices,3D reconstruction is apt to medical teaching and research. MSCT and its 3D reconstruction is apt to clinical applications and can be used as clinical diagnosis and imaging examination of the auxiliary tool.
3. The virtual model of Laryngeal resection specimens of 3D reconstruction of serial sections provide a visual image of the tumor 3D graphics, help clinicians are familiar with the spatial laryngeal morphology and growth characteristics of infiltration, improve diagnosis and treatment of laryngeal carcinoma.
Creative point:
1. Complete firstly the serial slices of larynx, and establish the database of tissue slices of larynx.
2. Using professional graphics workstation processing tissue slices, to accomplish virtual 3D reconstruction of laryngeal tissue sections. From multiple perspectives, multiple levels, visually display morphological characteristics of the organizational structure of larynx, which is better than the 3D reconstruction of MSCT, is more effective in guiding the clinics, and is helpful to determine the 3D cutting edge of laryngeal surgery.
喉癌是耳鼻咽喉-头颈外科最为常见的恶性肿瘤之一,手术是目前主要的治疗手段。由于喉形态不规则、结构复杂及肿瘤空间三维浸润生长,手术切除喉癌原发病灶要求准确把握肿瘤的浸润范围和空间立体构造,科学确定手术的切除范围。切缘阳性是肿瘤治疗失败的主要原因之一。熟练掌握肿瘤的浸润范围不仅是精确界定手术切缘的前提,而且是减少切缘阳性的有效手段,精确的手术切缘决定了喉癌患者术后生存率、解剖结构的保留和喉功能重建。本研究采用基于3D-Doctor 3.5软件的三维重建技术,实验一对正常人喉标本连续组织切片,国内首次建立了全喉连续组织切片数据库,确保了对正常人喉标本形态结构的正确认识；实验二通过组织切片与MSCT及其三维重建的比较,为喉部的影像学检查提供解剖学依据,指导MSCT在喉部的临床应用；实验三通过成人喉癌切除标本连续组织切片及三维重建,观察喉癌三维空间形态结构和生长浸润特征,将人体器官可视化应用在喉癌形态学研究中,通过对喉癌的空间结构特征的全面了解,熟悉喉癌的生长浸润特征,确定喉癌手术的立体切缘,使喉部分切除手术的更加合理,指导临床喉癌的手术治疗。
方法
1.制作华北地区正常人喉30例(男21,女9)连续切片,片厚5-15μm,间隔300μm取片,常规HE染色。专业微距照相系统获取切片图像。建立正常喉标本的连续组织切片数据集。在专业图形工作站INTEL XEON 5472(双路)上用3D-Doctor 3.5软件三维重建,对喉大体标本与重建虚拟标本的进行形态学研究；选取四组临床上喉癌常见浸润途径的参照径线,测量相应形态参数。
2.采集山西省正常志愿者30名(男12,女18)喉MSCT薄层扫描图像,用3D-Doctor 3.5软件三维重建,比较连续组织切片与MSCT三维重建虚拟标本的喉的形态学测量数据,相关测量参数同实验一。
3.收集喉癌患者的整块手术切除标本3例(声门上型、声门型和跨声门型,T3,T4),沿肿瘤长轴切开标本并制作连续切片,专业微距照相系统获取喉癌病理切片图像,在专业图形工作站INTEL XEON 5472(双路)上用3D-Doctor 3.5软件三维重建喉癌的虚拟模型,与术前MSCT及其重建图像比较,熟悉喉癌的连续切片病理组织学特点及其浸润特征。
4. SPSS16.0统计软件处理数据,以P<0.05为显著性标准。
结果
1.1与之前测量研究不同的是,甲状软骨声带附着处位于其前缘中点以上0.718mm±0.487,95%可信区间为0.369mm-1.066mm。甲状软骨声带附着处至甲状软骨上下切迹的距离和距离之比无性别上的统计学差异(P>0.05),除此以外,喉部其他结构的形态学测量数据都有性别差异(P<0.05)。
1.2甲状软骨和环状软骨大体标本实测值比连续切片三维重建虚拟标本实测值偏大,但无统计学差异(P>0.05)。
1.3杓状软骨位于甲状软骨后上1/2-2/3。除了声带附着深度(在声带末端至声带附着边缘的距离)为1.665mm-1.736mm,肌突至甲状软骨内膜距离为3.651mm-3.715mm以外,其余的指标均有性别差异(P<0.05)
1.4喉的会厌前间隙和声门旁间隙的测量：会厌前间隙在正中矢状面上的面积80.930mm2±8.911,在旁正中矢状面上的面积为84.757 mm2±15.482。声门旁间隙在经声带的水平切面上的面积为172.400 mm2±6.968,在经声带膜部中点冠状切面上的面积为248.751 mm2±5.543,在杓状软骨后缘冠状切面上的面积为221.893 mm2±9.473,在杓间切迹处冠状切面上的面积为186.678 mm2±13.249。喉间隙在不同切面上的面积测量为临床医师对喉癌的间隙浸润情况的估计提供了解剖学数据参考。
1.5喉癌常见浸润途径上选定的四组参照径线的测量：会厌软骨茎末端至前联合的距离男为5.122mm±1.031,女为4.051mm±0.944；舌骨会厌韧带会厌端至室带的距离男为23.807±3.747,女为20.638mm±2.748；杓会厌襞中点至室带的距离男为21.708mm±4.724,女为18.423mm±4.245；声带水平至甲杓肌外缘距离男为3.322±0.724,女为2.371mm±1.032；声带水平至甲状软骨板内膜的距离男为7.245±1.524,女为6.833mm±1.425。所有测量参数均有性别差异(P<0.05)。
1.6声带突离断的位置：由于声带突末端至声韧带附着边缘距离为1.665mm-1.736mm,声带突长男为5.194mm,女为4.092mm。因此,在声带突前1/3和1/2之间离断声带突较为合适。
1.7甲状软骨开窗术改良,要点：(1)确定开窗圆心：先以甲状软骨后缘中点为圆心,以甲状软骨后缘中点至杓状软骨肌突投影点距离为半径,在甲状软骨板上做第一条弧线标记；以肌突投影点为圆心,以顶底间距的一半为半径在甲状软骨板上做第二条弧线；两条弧线的交点即为开窗圆心；。(2)从外向内逐层去除窗口内的甲状软骨,用力要适度,可避免开窗后软骨断裂；(3)沿窗后下缘向内或以环杓后肌可确定肌突。术中注意事项：(1)避免损伤喉上神经外支。(2)避免损伤梨状窝粘膜。
2 MSCT图像中甲状软骨、会厌软骨和环状软骨显示清晰,杓状软骨显示不全,喉间隙内容结构无法显示。MSCT重建模型的喉软骨测量数据与组织切片相比无显著性差异(P>0.05)。用3D-Doctor 3.5软件切割MSCT三维重建图形,得到6个与组织切片同一层次的分割图像,MSCT重建切割平面与组织切片上的会厌前间隙和声门旁间隙面积进行比较,结果无显著性差异(P>0.05)。喉癌常见间隙浸润途径上,四组参照径线的组织切片与MSCT测量比较,结果显示：声带水平至甲状软骨板内膜的距离MSCT组测量结果较组织切片组小,其他参数的MSCT组测量结果较组织切片组大,但均无统计学差异(P>0.05)。
3喉癌连续切片的断面观察,较清晰分辨肿瘤与正常组织的界限。在断面切面中肿瘤呈类圆形、不规则形等,肿瘤部分色泽较正常灰暗,且肿瘤实质部分呈现不均质性,有些区域较致密,有些区域疏松,色泽呈现差异,而且肿瘤越大这种不均质现象越明显。喉癌三维重建喉癌的空间形态是不规则的,肿瘤生长是空间性三维生长,无方向性,可以向周围任何组织浸润生长。
结论
1建立了全喉连续组织切片的数据集。三维重建得到的虚拟喉标本与真实大体标本基本一致,与正常中国人体喉部解剖学数值基本一致。三维重建的虚拟喉可以作为作教学科研的辅助工具,为临床应用提供解剖学指导。
2 MSCT对超过其分辨率的细微结构显示欠佳,其三维重建的细节效果不如组织切片的完整、清晰。MSCT及其三维重建适合临床应用,可以作为临床医疗诊断和影像学检查的辅助工具。
3喉癌切除标本连续切片三维重建的虚拟图形提供了直观、形象的肿瘤立体图形,有助于临床医师熟悉喉癌的空间形态结构和生长浸润特征,提高喉癌诊治水平。
创新点：
1.完成了国内首次喉部的连续组织切片的制作,建立了喉的组织切片数据库。
2.利用专业图形工作站处理组织切片数据,实现虚拟喉组织切片的三维重建,从多角度、多层面直观显示喉的组织结构形态特征,显示效果优于MSCT三维重建的虚拟喉,更有效地指导临床,有助于确定喉癌手术的立体切缘。
Objective
Laryngeal cancer is one of the common malignant tumors in Otolaryngology-Head and Neck Surgery, surgical operation is the primary measurement of laryngeal carcinoma at present. As the irregular morphous, the complex structure and 3D feature of the growth of tumor infiltration, surgical eradication of the primary laryngeal lesion called for an accurate grasp of the scope of tumor infiltration, spatial 3D structure and the scientifical surgical resectional scope. Positive margin is one of the major surgical operation failures. Master of carcinoma infiltration is not only the premise of precisely defined scope of surgical margin, but also the effective means of reducing positive margin. Precise surgical margin determines the survival rate of laryngeal cancer patients, the preserve retention of anatomical structure and reconstruction of laryngeal function. In this study, based on 3D-Doctor 3.5 software and 3D reconstruction techniques, serial slice of the normal 3D reconstruction of laryngeal specimens were produced in the experiment one, to establish a whole database of serial tissue sections of normal larynx, to ensure the normal throat samples of correct understanding of morphological structure; experiment 2 by the comparison between serial slices and MSCT and 3D reconstruction for laryngeal imaging provide anatomical basis for guiding the clinical application of MSCT in the throat; serial slices of laryngeal biopsy specimens and 3D reconstruction were completed. Observation of 3D morphology of laryngeal cancer invasion and growth characteristics were finished, visualization of human organs was used in laryngeal morphology study on laryngeal cancer through a comprehensive understanding of spatial structure, familiarity with the invasive growth of laryngeal features and determination of the laryngeal operation of 3D cutting margin, so that partial laryngectomy will be more reasonable to guide the clinical treatment of laryngeal cancer surgery.
Methods:
1. Serial slices of 30 (21male,9female) normal whole laryngeal specimen from the north region of China were produced, thickness of slice is 5-15μm, the slice was selected every 300μm, HE stained. The photos of serial slices were acquired by professional miscrospur photograph system. A whole database of serial tissue sections of normal larynx was established. Comparative study was executed between general specimens and the virtual specimens after 3D reconstructions with 3D-Doctor 3.5 software in the graphic workstation of INTEL XEON 5472 (double route). Four reference diameters of clinical laryngeal invasion pathways were selected and the corresponding morphological parameters were measured.
2. MSCT images of 30 volunteers (12male,18female) normal necks were acquired and 3D reconstruction of MSCT images were accomplished by 3D-Doctor 3.5 software in the professional graphics workstation of INTEL XEON 5472 (double route), and measurement data of the serial slices and MSCT images were compared with the 3D reconstruction of serial sections, which the measurements parameters are same to that of experiment one.
3.3 specimens with en bloc surgical resection in laryngeal carcinoma patients were collected, which including supraglottic type, glottic type and straddled glottic type, T3, T4) were cut along the long axis of tumor specimens so as to produce serial sections, slice images were obtained by professional microspur photograph system, and virtual model of 3D reconstruction of laryngeal carcinoma were accomplished by 3D-Doctor 3.5 software in the professional graphics workstation of INTEL XEON 5472 (double route). Compared with the image of preoperative MSCT, the serial sections of laryngeal cancer and its histological features of infiltration characteristics were grasped.
Results:
1.1 Difference with the previous measurements studies, the attachment of vocal cord is above 0.718mm±0.487,95%confidence interval for the 0.369mm-1.066mm. The distances from the attachment of vocal cord in thyroid carrlage to the superior notch and the distance to inferior notch and their rate of the gender are no significant difference (P>0.05), except that, the other measurements data are significant difference on the gender (P<0.05).
1.2 The measuring data of general specimens are more than that of the virtual specimens of serial slices, but the difference is not significant (P>0.05).
1.3 Arytenoid cartilage lie in the posterior 1/2-2/3 of thyroid cartilage. In addition to the depth of vocal cord attached (in the vocal cords vocal cords attached to the edge of the end of the distance) to 1.665mm-1.736mm, muscular process to the thyroid cartilage endosteum distance 3.651mm-3.715mm, the rest of the indicators are gender differences (P<0.05).
1.4 Measurements of pre-epiglottic and paraglottic space:pre-epiglottic space in the sagittal plane of the area 80.930mm2±8.911, in the adjacent area of the median sagittal plane 84.757 mm2±15.482. Paraglottic space after vocal cord level in the area of section 172.400 mm2±6.968, the middle point in the film by the vocal cord on coronal section area of 248.751 mm2±5.543, in the arytenoid cartilage posterior coronal section area of 221.893 mm2±9.473, notch between the ladle Department coronal section area of 186.678 mm2±13.249.The area measurements of laryngeal spaces in the different section provide an anatomic reference data for clinicians on the infiltration of laryngeal cancer.
1.5 Measurements of four reference diameters on common infiltration paths of laryngeal cancer: the distance of the stem end of the epiglottis to the anterior commissure was males 5.122mm±1.031, females 4.051mm±0.944; the distance of the epiglottic end of hyoepiglottic ligament to ventricular bands was male 23.807±3.747, female 20.638mm±2.748; the distance of midpoint of aryepiglottic fold to ventricular bands was male 21.708mm±4.724, female to 18.423mm±4.245; the distance of vocal cord to the outer edge of thyroarytenoid muscle was male 3.322±0.724, female 2.371mm±1.032; the distance of vocal cord to endosteum of thyroid carlilage lamina was male 7.245±1.524, female 6.833mm±1.425. Gender differences in all measured parameters were significant (P<0.05).
1.6 Transection position of vocal process:Because the distance of the posterior end of vocal process to the attachment edge of vocal cord was 1.665mm-1.736mm, the length of vocal process was male 5.194mm, female 4.092mm. Therefore, transaction position at the anterior 1/3 and 1/2 of vocal process is more appropriate.
1.7 Thyroid cartilage fenestration improvements, main points:(1) determine the window center of a circle:Using the midpoint of the posterior border of thyroid cartilage center of the circle to the midpoint of posterior margin of the thyroid cartilage to the muscular process of arytenoid cartilage from the projection point for the radius, the thyroid cartilage marker board to do the first arc; muscle process as center of a circle, with half of the distance between top and bottom radius of the thyroid cartilage board to do the second arc; two windows shall be centered on the intersection curve;. (2) from the outside layer to remove the thyroid cartilage window, hard to be modest, avoid cartilage fracture; (3) along the lower edge of the windows or cricoarytenoid muscle to determine muscle process. Operation Notes:(1) to avoid the external branch of superior laryngeal nerve injury. (2) to avoid injury pyriform sinus mucosa.
2. MSCT image of the thyroid cartilage, epiglottic cartilage and cricoid cartilage showed clearly, arytenoid cartilage showed incomplete, the structure in the laryngeal space can not be displayed. The virtual model of MSCT reconstruction were measured and compared with serial slices of the laryngeal cartilage was no significant difference (P> 0.05). Using 3D-Doctor 3.5 software, cutting 3D reconstruction of MSCT virtual model,6 cutting plane were obtained as the same level of serial slices, the area of pre-epiglottic space and paraglottic space were compared between MSCT and serial slices, the results there was no significant difference (P>0.05). In the common ways of laryngeal cancer infiltration, four reference diameters measurements were compared between tissue sections and MSCT, the results showed:the distance of vocal cords to the thyroid cartilage endosteum of MSCT less than that of serial slices, the other parameters of MSCT are more than serial slices, but there were all no significant difference (P>0.05).
3. Serial sections of the cross-section observation of laryngeal carcinoma were observed, boundaries were distinguished clearly between tumor and normal tissue. In the cross-section aspect, type of tumor was round, irregular-shaped and so on, the color of the tumor is darker than the normal, and the tumor showed substantial part of the heterogeneity, with some regions more dense in some regions, loose, color rendering differences, but the larger is the tumor,the more obvious kinds of phenomena are not homogeneous. Laryngeal space shape is irregular, tumor growth is the spatial 3D growth and no direction, which can be invasivetowords the growth of any organization around in the 3D reconstruction model of laryngeal carcinoma.
Conclusion
1. The data sets of serial slices of whole normal larynx were established. The virtual specimens of 3D reconstruction are identified with the real general specimen basically, and provided the anatomical data fo clinical applications and imaging.
2. MSCT in excess of its fine structure shows poor resolution, the details of serial slices are more full and clear than MSCT 3D reconstruction. Based on the human laryngeal serial slices,3D reconstruction is apt to medical teaching and research. MSCT and its 3D reconstruction is apt to clinical applications and can be used as clinical diagnosis and imaging examination of the auxiliary tool.
3. The virtual model of Laryngeal resection specimens of 3D reconstruction of serial sections provide a visual image of the tumor 3D graphics, help clinicians are familiar with the spatial laryngeal morphology and growth characteristics of infiltration, improve diagnosis and treatment of laryngeal carcinoma.
Creative point:
1. Complete firstly the serial slices of larynx, and establish the database of tissue slices of larynx.
2. Using professional graphics workstation processing tissue slices, to accomplish virtual 3D reconstruction of laryngeal tissue sections. From multiple perspectives, multiple levels, visually display morphological characteristics of the organizational structure of larynx, which is better than the 3D reconstruction of MSCT, is more effective in guiding the clinics, and is helpful to determine the 3D cutting edge of laryngeal surgery.
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