M. Covalini，P. Benedetti
Agostino Gemelli University综合医院

介绍

近年来计算机技术的迅猛发展及其对医学可视化方法的积极引入导致了新方法的出现，为获取研究对象的三维图像提供了可能。提到的趋势*先适用于非线性（NLS）计算的诊断。现代三维模式在NLS图像中的应用，例如多平面重建，对象的详细重建（快速视觉），透明度控制（深度视觉），伪伦琴模式以及使用特殊程序自动重建各种形状的对象（4D组织）提供了创建各种器官的高度有用的虚拟多维图像的可能性。

研究的材料和方法

为了研究现代NLS方法在确定子宫内膜癌（EC）诊断中的可能性，作者对64例经形态学验证的EC患者进行了NLS研究。患者的平均年龄为61.2。

表1显示了患者子宫内膜癌各个阶段的结构。

表2显示了EC患者的形态学形式及其频率。

NLS研究使用Metatron-4025系统（俄罗斯IPP）进行。NLS研究是通过能够以4.9 GHz频率以自动模式收集多维数据的高频触发传感器来完成的。

表1.受检患者的子宫内膜癌分期。

表2。子宫内膜癌的形态学形式。

为了研究子宫和子宫内膜的结构特点，我们使用了标准的二维模式和三维NLS摄影的方法，以及各种图像重建方法。

多维数据收集的时间取决于扫描速度，范围在2到5秒之间。

为了执行获取的数据数组的处理，我们使用了多种三维重构模式：旋转模式（对象旋转）和平移模式（旋转中心沿直接横切线的移动）；以及 图像表面重建的一种模式，可以获取被研究对象内表面的多维（三维）图像。

三维NLS血管造影模式完成了子宫内膜癌局部血流的血管和血流动力学特性的研究，这有助于获得肿瘤血流血管结构的多维图像。

研究和讨论的结果

在我们的NLS研究中，为了研究EC处肿瘤病变的形态特征，我们使用了三维NLS图像和光谱熵分析（SEA）方法。同时，在图像浅表重建模式下，可以实现子宫正面横切面的渲染，这在应用传统的二维NLS图形时是不可能的。

在T1a阶段，可以看到****的子宫腔具有清晰而平滑的轮廓。在58.8％的病例中，子宫腔的内容物具有均匀的中等发色结构，在子宫角之一的投影中，我们检测到了一种肿瘤病灶，呈圆形包涵体形式，轮廓清晰而光滑，发色性增强（5-6分以弗林德勒的规模）。

在T1b阶段，在71.4％的病例中，我们记录了子宫壁之一的病变，同时发现了明显且不均匀的轮廓。内部结构主要是高发色的（5-6点），表面呈结节状。在31.8％的病例中，我们在子宫腔内发现了肿瘤。呈子宫角的投影形式，呈圆形的赘生物，具有明显和不均匀的轮廓，具有高色度结构。

图片 1. NLS*微扫描。子宫内膜癌，Т1а期。

图片 2.三维NLS-gram（具有子宫正面横切面的多平面模式）。子宫内膜癌，Т1b期。

在T1c阶段，有30％的结构是均质的，高色度的（在Fleindler量表上为5-6分）–在20％的情况下是-均匀，中度发色的（3-4分），在50％的情况下–是异质的，等色的（2 -5分）。

在大多数情况下（73.3％），T2期的特征是内部os区域和子宫颈部上三分之一（轮廓不均和轮廓不均）的中线结构受影响。

因此，如上述数据所示，子宫内膜病变的增加和侵袭性生长指数的降低伴随着肿瘤向子宫肌层的侵袭。

图片 3. NLS-gram。子宫的横切面。子宫内膜癌，Т1c期。

图片 4.光谱熵分析。子宫内膜癌（D = 0,033）。

在15.6％的研究中，我们发现子宫组织受到了显着影响（在Fleindler量表中为6分）。同时，在7例患者中，子宫腔充满了均质的*色结构，在3例患者中–由于细小的悬浮物而导致了异质的同色结构。在这种情况下，使用带有SEA的三维NLS图像可以**评估子宫内膜未受影响的状况，形态特征，肿瘤的位置，其转移到子宫腔中，生长形式，侵袭程度和进入子宫内膜的程度。

98.6％的子宫内膜癌病例可见瘤内血流。肿瘤血管形成的分析有助于找出NLS血管造影图案的各种变体，并在此基础上鉴定出四种类型的NLS血管造影图。

**种类型（占病例的31.3％）的特征是由于固定点数量的局部增加而导致子宫内膜内血流的不均匀增强。同时，我们没有在内皮下区域记录到增色固定点的增加。

第二类（32.8％）的特征是由于大量随机放置的等色固定点而使子宫内膜内血流完全增强，同时内皮下区域的高发色点数量同时增加（57.2％）或总数（42.8％）增加。

第三种类型（占病例的15.6％）的特征是在子宫内膜内血流略微增强的背景下，在内皮下区域的中等发色点数目显着增加。

第四类型（占20.3％的病例）与三个第三类型的不同之处在于子宫中线结构投影中存在大量随机放置的等色固定点。

NLS图像模式与内膜癌肿瘤生长的阶段和形式的比较表明，**类NLS-grams对应于T1a期（88.2％）。在T1b阶段，有23.8％的我们注册了**种类型，分别为47.6％–第二种类型，在28.6％–第三类中。T1c分期以第二类型为特征（81.8％）。在内皮内膜癌的TII期的86.7％中，我们注册了第四类NLS-gram。外生型生长的特征是**类NLS血管造影照片（88％），内生型生长–第三类（92.5％），综合型–第二类（90％）。

为了研究瘤内血流及其适当的视觉评估，我们使用了三维NLS成像方法，结合了血管的*微扫描和3D重建获取的图像。三维NLS血管造影照片的分析显示出杂乱无章的血流类型，具有以下显着特征：肿瘤内血管病变的不规则性，血管壁的随机性和多方向性病变。

结论

因此，结合频谱熵分析的三维NLS图形结合现代NLS图形方法的广泛频谱，已增强了NLS方法在子宫内膜癌的鼻内病学诊断中的地位，从而实现了广泛的目标：

–在子宫腔内**定位肿瘤；

–原发性肿瘤病菌的特征；

–侵入子宫肌层的深度；

–肿瘤突入宫颈管。

参考文献

1. Balen FG，Allen CM，Gardener JE等人。子宫腔*声图像的三维重建// Br。J. Radiol。1993。№66。第588–591页。
2. Barry CD，Waterton JC，Thomson DS等。三维徒手*声：图像重建和体积分析// Ultrasound Med。生物学 1997. V. 23.№8. P. 1209-1224。
3. Coute M.，Guariglia L.，Benedetti PL等。子宫内膜癌：经阴道*声检查评估子宫内膜浸润//*声检查。Gynecol。1991. V. 1. Supp.1。第27页
。4. Feichtinger W.阴道三维三维成像// J. Ultrasound Obstet。Gynecol。1993. V. 3. P. 375-378。
5. Karpov NS，Lemeshenko IV比较NLS和MRI对宫颈癌浸润性形式的诊断价值的比较评价// 3D计算NLS图像：科学作品集/编辑VI Nesterov。–М.：Prospekt出版社，2012年，第2页。43-47

M. Covalini, P. Benedetti
Agostino Gemelli University Polyclinic

Introduction

Rampant development of computer technologies of recent years and their active introduction into methods of medical visualization resulted in appearance of new methods, offering a possibility to acquire three-dimensional image of a researched object. The mentioned trend, first of all, applies to non-linear (NLS) computed diagnostics. Application of modern three-dimensional modes in NLS-graphy, such as multiplanar reconstruction, detailed reconstruction of an object (Fast Vision), transparency control (Deep Vision), pseudo-roentgen mode and using of special programs for automatic reconstruction of variously shaped objects (4D Tissue) provided a possibility to create highly informative virtual multidimensional images of various organs. Using of three-dimensional NLS-graphy for evaluation of uterine cavity condition and for study of pathological processes in endometrium, according to a number of authors, is more informative than ultrasound research and CT.

Material and methods of the study

In order to study possibilities of modern NLS-methods in specifying diagnostics of endometrium cancer (EC) authors carried out NLS-study of 64 patients with morphologically verified EC; average age of patients was 61.2.

Structure of various stages of endometrium cancer in patients is shown in Table 1.

Morphological forms and their frequency in EC patients is shown in Table 2.

NLS-research was carried out with Metatron-4025 system (IPP, Russia). NLS-research was fulfilled by high-frequency trigger sensors capable of multidimensional data gathering in an automatic mode, with 4.9 GHz frequency.

Table 1. Endometrium cancer stages in examined patients.

Table 2. Morphological forms of endometrium cancer.

To study structural peculiarities of uterus and endometrium we used standard two-dimensional mode and method of three-dimensional NLS-graphy with various variants of image reconstruction.

Time of multidimensional data gathering depended on scanning speed and was in the range of 2 – 5 seconds.

To carry out processing of acquired data array we used various modes of three-dimensional reconstruction: rotation mode (rotation of an object) and translation mode (moving of rotation centre along direct crosscuts); mode of superficial reconstruction of an image, allowing to get multidimensional (three-dimensional) image of internal surfaces of a researched object.

Study of vascular and haemodynamic peculiarities of regional blood flow at endometrium cancer was fulfilled with three-dimensional NLS-angiography mode, which helped to get a multidimensional image of tumorous blood flow angioarchitecture.

Results of the study and discussion

In our NLS-research to study morphological peculiarities of tumorous lesion at EC we used method of three-dimensional NLS-graphy with spectral-entropic analysis (SEA). At the same time, in image superficial reconstruction mode, rendering of uterus frontal crosscuts was fulfilled, which was impossible when traditional two-dimensional NLS-graphy was applied.

At T1a stage in **** of cases uterine cavity was visualized with distinct and smooth contours. In 58.8% of cases a content of uterine cavity had homogeneous moderately chromogenic structure, in a projection of one of uterine angles we detected a tumorous lesion in a form of roundish inclusion with sufficiently distinct and smooth contours, of increased chromogeneity (5-6 points at Fleindler’s scale).

At T1b stage in 71.4% of cases we registered lesion of one of uterine walls, at the same time distinct and uneven contours were detected. Internal structure was mainly hyperchromogenic (5-6 points), with nodulated surface. In 31.8% of cases we registered a tumor in uterine cavity. In projection of one of uterine angles, in a form of roundish neoplasm, with distinct and uneven contours, of hyperchromogenic structure.

Pic. 1. NLS-ultramicroscanning. Endometrium cancer, Т1а stage.

Pic. 2. Three-dimensional NLS-gram (multiplanar mode with rendering of frontal crosscut of an uterus). Endometrium cancer, Т1b stage.

At T1c stage in 30% a structure was homogeneous, hyperchromogenic (5-6 points at Fleindler’s scale), in 20% of cases – homogeneous, moderately chromogenic (3-4 points), in 50% of cases – heterogeneous, isochromogenic (2-5 points).

T2 stage is characterized in majority of cases (73.3%) by affection of midline structures in internal os area and in superior third of uterine neck (distinct and uneven contours).

So, as the above mentioned data shows, increasing of endometrium affection and invasive growth indices decreasing accompany tumorous invasion into myometrium.

Pic. 3. NLS-gram. Transverse section of an uterus. Endometrium cancer, Т1c stage.

Pic. 4. Spectral-entropic analysis. Endometrium cancer (D=0,033).

In 15.6% of studies we registered a significant affection of uterine tissues (6 points at Fleindler’s scale). At the same time in 7 patients uterine cavity was filled with a content of homogeneous hyperchromogenic structure, in 3 patients – of heterogeneous isochromogenic structure due to fine suspended matter. Application of three-dimensional NLS-graphy with SEA in this case allowed to evaluate accurately a condition of unaffected endometrium, morphological character, localization of a tumor, its metastasis into uterine cavity, form of growth, place and degree of invasion into myometrium.

Intratumoral blood flow was visualized in 98.6% of endometrium cancer cases. Analysis of tumor vascularization helped to single out various variants of NLS-angiographic pattern, basing on which four types of NLS-angiograms were identified.

1st type (31.3% of cases) was characterized by non-uniform strengthening of intraendometrial blood flow due to local increasing of fixed points number. At the same time we did not register increasing of hyperchromatic fixed points in subendothelial area.

2nd type (32.8% of cases) was characterized by total strengthening of intraendometrial blood flow due to large amount of randomly placed isochromogenic fixed points with simultaneous local (57.2%) or total (42.8%) increasing of hyperchromogenic points number in subendothelial area.

3rd type (15.6% of cases) was characterized by significant increasing of moderately chromogenic points number in in subendothelial area against the background of minor strengthening of intraendometrial blood flow.

4th type (20.3% of cases) differed from the three first types by presence of large amount of randomly placed isochromogenic fixed point in a projection of midline structures of uterine cervix.

Comparison of NLS-graphic pattern with stages and forms of tumorous growth at endomentium cancer revealed that 1st type of NLS-grams corresponded to T1a stage (88.2%). At T1b stage in 23.8% we registered 1st type, in 47.6% – 2nd type, in 28.6% – 3rd type. T1c stage was characterized by 2nd type (81.8% of cases). In 86.7% of TII stage of endomentium cancer we registered 4th type of NLS-grams. Exophytic form of growth is characterized by 1st type of NLS-angiograms (88%), endophytic form of growth – 3rd type (92.5%), combined form – 2nd type (90%).

In order to study intratumorous blood flow and its proper visual evaluation we used a method of three-dimensional NLS-graphy in combination with ultramicroscanning of vessels and following 3D-reconstruction of acquired image. Analysis of three-dimensional NLS-angiograms allowed to reveal disorganized type of blood flow, having the following distinguishing characteristics: irregularity of vessels affection inside a tumor, random and multidirectional lesion of vessels walls.

Conclusion

Therefore three-dimensional NLS-graphy with spectral-entropic analysis in combination with broad spectrum of modern NLS-graphic methods have strengthened positions of NLS-method in intranosological diagnostics of endometrium cancer, sovling a wide range of objectives:

– accurate localization of a tumor in an uterine cavity;

– character of primary tumorous nidus;

– depth of invasion into myometrium;

– presence of tumorous process transition into cervical canal.

References

1. Balen F.G., Allen C.M., Gardener J.E. et al. 3-Dimensional reconstruction of ultrasound images of the uterine cavity // Br. J. Radiol. 1993. № 66. P. 588–591.
2. Barry C.D., Waterton J.C., Thomson D.S. et al. Three-dimensional freehand ultrasound: image reconstruction and volume analysis // Ultrasound Med. Biol. 1997. V. 23. № 8. P. 1209–1224.
3. Coute M., Guariglia L., Benedetti P.L. et al. Endometrial cancer: transvaginal sonographic evaluation of miometrial invasion // Ultrasound Obstet. Gynecol. 1991. V. 1. Supp.1. P. 27.
4. Feichtinger W. Transvaginal three-dimensional imaging // J. Ultrasound Obstet. Gynecol. 1993. V. 3. P. 375–378.
5. Karpov N.S., Lemeshenko I.V. Comparative evaluation of diagnostic value of NLS and MRI at invasive forms of cervical cancer // 3D computed NLS-graphy: Collection of scientific works / Editor V.I. Nesterov. – М.: Publishing house Prospekt, 2012, p. 43-47