本文關(guān)鍵詞：放射外科治療后星形膠質(zhì)細胞瘤的病理、超微結(jié)構(gòu)對比研究，由筆耕文化傳播整理發(fā)布。

        目的觀察放射外科治療后星形膠質(zhì)細胞瘤的病理組織學、超微結(jié)構(gòu)變化,探討放射治療的生物學機制,探尋膠質(zhì)瘤綜合治療的新方法。方法回顧性對比分析25例原發(fā)腦星形膠質(zhì)瘤(放射治療前)與25例放射外科治療后腦星形膠質(zhì)瘤的常規(guī)病理、免疫組化和放射治療前后各8例星形膠質(zhì)瘤患者不同部位(腫瘤中心、腫瘤邊緣、瘤周水腫腦組織)電鏡超微結(jié)構(gòu)改變,并就對其結(jié)果進行統(tǒng)計分析客觀評判。結(jié)果1.病理(光學顯微鏡)1)對照組:根據(jù)腫瘤細胞形態(tài)多形性,核分裂像,瘤細胞密度,血管內(nèi)皮增生程度以及瘤組織壞死情況,光鏡下將星形膠質(zhì)細胞瘤分為高級別和低級別膠質(zhì)瘤。低級別膠質(zhì)瘤分化較好,瘤細胞之間可見紅染的原纖維性背景,包括纖維型、原漿型、肥胖型和混合細胞等亞型。高級別膠質(zhì)瘤主要包括間變性星形細胞瘤和膠質(zhì)母細胞瘤,前者主要表現(xiàn)為瘤細胞密度增加,核異型性明顯,核深染可見核分裂像,血管內(nèi)皮細胞增生;后者主要表現(xiàn)為瘤細胞密集,有明顯異型性,可見異型的單核或多核瘤巨細胞,出血壞死明顯。2)治療組:(1)放射治療后低級別膠質(zhì)瘤:可見瘤細胞呈點狀或灶狀壞死。微血管壁腫脹,管腔變窄,管壁呈透明樣變性。(2)放射治療后高級別膠質(zhì)瘤:腫瘤細胞多成片狀壞死,并見多個出血灶。有的微血管管腔閉塞,管壁透明樣變性,周圍有炎細胞浸潤,呈套袖樣改變。放射治療后壞死面積與程度,與膠質(zhì)瘤的分級呈正相關(guān)(P＜0.05)。2.電子顯微鏡1)對照組:(1)腫瘤中心:低級別膠質(zhì)細胞瘤瘤細胞核異型性不大,核膜、胞膜完整,胞漿均勻,細胞器明顯較多,腫脹不明顯,血管內(nèi)皮細胞無腫脹,基膜結(jié)構(gòu)完整;高級別膠質(zhì)瘤瘤細胞核大小和形狀不一致,核不規(guī)則伴分裂,核周質(zhì)內(nèi)見膠質(zhì)絲,細胞小器稀少,胞漿內(nèi)線粒體輕度腫脹、內(nèi)質(zhì)網(wǎng)擴張,可見部分毛細血管的外形輪廓基本正常,一些內(nèi)皮細胞間的緊密連接仍呈關(guān)閉狀態(tài),內(nèi)皮細胞有線粒體腫脹,內(nèi)質(zhì)網(wǎng)擴張,基底膜厚薄不均。(2)腫瘤邊緣:瘤細胞形態(tài)與中心相似,毛細血管內(nèi)皮的變化與瘤體中內(nèi)皮的變化無明顯差異,但內(nèi)皮基膜厚薄不均,膠質(zhì)膜局部缺損,內(nèi)皮外周組織間有滲出液。(3)瘤周水腫腦組織:可見瘤細胞。毛細血管內(nèi)皮細胞無腫脹,無內(nèi)皮孔,腔面無絨毛樣突起;胞質(zhì)內(nèi)胞飲泡少,有線粒體和粗面內(nèi)質(zhì)網(wǎng),緊密連接無增長,細胞間連接無明顯彎曲,內(nèi)皮基膜厚薄均勻、完整,膠質(zhì)膜無缺損。2)治療組:(1)腫瘤中心:治療組中均見到腫瘤細胞的壞死,表現(xiàn)為包膜不完整或消失,胞漿內(nèi)線粒體腫脹、內(nèi)質(zhì)網(wǎng)擴張呈空泡樣改變,胞核內(nèi)染色質(zhì)濃聚,常染色體減少或消失,甚至有的出現(xiàn)細胞核碎裂溶解。血管內(nèi)皮細胞崩解、脫落,血管壁各層細胞結(jié)構(gòu)消失,基底膜斷裂或皺縮,有較多的片狀出血灶。部分標本發(fā)現(xiàn)凋亡細胞。(2)腫瘤邊緣:腫瘤細胞變化與中心相似,但完整的瘤細胞較多,主要表現(xiàn)為細胞器的腫脹。瘤細胞胞漿線粒體、高爾基體明顯腫脹,胞漿中可見大量空泡,細胞膜不完整或消失,細胞核極不規(guī)則,呈鋸齒狀凹陷,形成胞漿假包含體,異染色質(zhì)趨邊濃染。部分位于腫瘤邊緣區(qū)域的瘤細胞胞漿中可見少量空泡,細胞核完整,但核間隙增寬。有捌亡細胞出現(xiàn)。(3)瘤周水腫腦組織:有瘤細胞存在,變化較輕,可見神經(jīng)元部分細胞腫脹,核異染色質(zhì)增多,呈斑塊狀分布,核緣彎曲,核周間隙增寬,核仁易見,胞質(zhì)內(nèi)脂褐素明顯增多。線粒體腫脹,高爾基體、粗面內(nèi)質(zhì)網(wǎng)及糖原顆粒減少,膠質(zhì)細胞核異染色質(zhì)增多,胞質(zhì)內(nèi)有單個或多個空泡,部分髓鞘呈脫髓鞘改變。3.免疫組織化學(1)對照組中高級別星形膠質(zhì)細胞瘤Ki-67、VEGF、MVD明顯高于低級別星形膠質(zhì)細胞瘤,與腫瘤的分級呈顯著正相關(guān)。對照組中Ki-67與VEGF的表達、MVD呈正相關(guān)。VEGF與MVD無顯著相關(guān)性。(2)治療組中高級別星形膠質(zhì)細胞瘤Ki-67、VEGF、MVD明顯高于低級別星形膠質(zhì)細胞瘤,與腫瘤的分級呈顯著正相關(guān)。治療組中Ki-67與VEGF的表達、MVD呈正相關(guān)。VEGF與MVD呈顯著正關(guān)性。(3)治療組與對照組同級別的膠質(zhì)瘤比較Ki-67與MVD存在明顯性差異,提示放射治療后Ki-67、MVD降低;而放射治療前后VEGF表達的變化無統(tǒng)計學意義。結(jié)論1.接受放射外科治療腫瘤細胞均呈現(xiàn)不同程度的變性、壞死改變,在腫瘤中心、高級別腫瘤其變性、壞死改變更為明顯。提示放射治療根據(jù)治療劑量不同可直接誘導(dǎo)腫瘤細胞變性、壞死,治愈和控制腫瘤。2.放射治療可誘導(dǎo)細胞凋亡,促進細胞凋亡可能是提高膠質(zhì)瘤遠期治療效果的重要治療手段,具有很高的潛在臨床意義。3.微血管內(nèi)皮細胞對射線的敏感程度較高,管壁呈透明樣變性,管壁明顯增厚,管腔狹窄,甚至閉塞,血管周圍有明顯的腫瘤細胞的壞死和炎性細胞的浸潤,放射治療導(dǎo)致微血管損傷是放射治療晚反應(yīng)組織的主要作用之一。4.電離輻射導(dǎo)致血腦屏障三層超微結(jié)構(gòu)的破壞,通透性增加,為膠質(zhì)瘤放療后聯(lián)合化療以及生物治療等綜合治療提供了重要理論依據(jù)。5.放射性腦病及頑固性腦水腫是腫瘤細胞壞死、神經(jīng)膠質(zhì)細胞的損傷、微血管透明變性、血腦屏障破壞以及髓鞘不同程度的損傷共同作用的結(jié)果。6.推薦針對不同膠質(zhì)瘤采用個體化綜合治療措施:①立體定向放射治療代替?zhèn)鹘y(tǒng)放射治療;②惡性膠質(zhì)瘤,擴大野適形放射治療+放射外科/低分次立體定向放射治療;③惡性膠質(zhì)瘤放射治療聯(lián)合抗腫瘤化療;④惡性膠質(zhì)瘤放化療聯(lián)合VEGF靶向治療;⑤低級別復(fù)發(fā)、殘留膠質(zhì)瘤,單次大劑量放射外科/低分次立體定向放射治療;⑥有占位效應(yīng)、診斷不明確的腦原發(fā)占位病變,宜開顱手術(shù)治療。

    ObjectiveTo study the radiobiological mechanism of radiotherapy on brain gliomas via observation of the histopathological change and ultrastracture features of human gliomas treated with stereotactic radiosurgery (SRS) and stereotactic radiotherapy (SRT). And we also collect data to explore the new therapeutics for the integrated management of gliomas.MethodsA comparative, retrospective study of pathological change and immunohistochemistry of 25 glioma specimens without radiotherapy and 25 cases with SRS and SRT, and the ultrastructure of 8 glioma specimens without radiotherapy and 8 with SRS and SRT, were carried out. All the specimens were taken from their tumor center, tumor margin and peripheral edema brain tissues in each case. And the findings were statistically analyzed as to get an objective assessment.Results1. Traditional pathological observation1) Control groupAccording to the multiformity of tumor cells, the nuclear fission, the density of tumor cells, vascular endothelial proliferation and the extent of tumor necrosis, gliomas are divided into LGG and HGG group under optical microscope. The LGG is well differentiated, including subtypes of fibrillary, protoplasmic, gemistocytic and mixed astrocytoma. The HGG includes anaplastic astrocytoma and glioblastoma. The former was mainly expressed in significant increase of tumor cell density, nuclear atypia, deeply stained nuclear, mitotic nuclear, vascular endothelial cell proliferation. In glioblastoma, there was tumor cell congeries, obvious unclear atypia, different types of single-core or multi-core giant tumor cell as well as substantial necrosis and blooding. 2) Treatment groupSimilar radiation injury characteristics with different degrees were observed in all cases of the study. The structure of tumor cells at the tumor center disappeared. Whereas lots of cell fragments remained at the edge of the center areas. Some tumor cells died and hyperemia as well as hyaline degeneration could be seen. The structure of blood vessels looked like coats of onions. Swelled cells, enlarged cells, puffed endocylema and hyaline degeneration of the vessel wall can also be found. The walls of blood vessel were thickened and lumen narrowed. Some inflammatory cell infiltrated. Some small blood vessels around the brain tumor tissues dilated and became hyperemia.The square and extent of tumor necrosis and liquation were positively correlated with the tumor grade significantly (P<0.05).2. Electron microscopic observation1) Control group①Central tumor: In the tissue of LGG, tumor cells were observed with uniform nuclear atypia, vascular endothelial cells evenly. There are great many organelles without edema. And vessel endothelial cell without edema yet with integrated basement membrane were also easy found. In the tissue of HGG, tumor cells with large, irregular, multiform nuclear, mild swelling of mitochondria in the cytoplasm and expansion in endoplasmic reticulum were observed. The normal appearance of capillaries exist, the tight junctions between endothelial cell are still closed, mitochondria and endoplasmic reticulum expansion, the thickness of basement membrane is uneven.②Tumor edge: The morphology of tumor cells is similar to that in tumor center. And there was no significant difference between vascular endothelial cells in tumor edge and in tumor center. Yet there were apertures or openings on colloidal membrane of vascular endothelial cells as well as the extra-membrane extravasate in the tumor edge.③Peripheral edema cortex: The tumor cells can also be observed. The capillary endothelial cells are not swelling. In cytoplasm small pinocytic vesicles, mitochondria and rough endoplasmic reticulum are existed, the thickness of basement membrane is even and integrity.2) Treatment group①Central tumor: The tumor necrosis could be found in the center of all the specimen tissues. It was revealed as follows: the cellular membrane was incomplete or disappeared, chondriosomes of astrocytes swelled, cristae decreased or disappeard, and expansion of endoplasmic reticulum was vacuolated. In cellular nucleus, the chromatin was concentrated, autosomel was reduced or disappeared, and even some cellular nucleus were disrupted and dissolved. Some of vascular endothelial cells were disrupted and shedding. The structure of vessel wall was disappeared. The basement membrane was ruptured and a larger number of hemorrhagic foci were appeared. And the apoptosis cells could be found in some tissues. ②Tumor edge: The appearances of tumor cells in tumor edge were similar with that in the central field, yet more tumor cells were shown completed. The swelling organelle was the primary features. The cellular membrane was incomplete or disappeared. The chondriosomes, golgiosome of astrocytes were swelled obviously and expansion of endoplasmic reticulum was often vacuolated. The cellular nucleus was irregular and appeared serrate depression. The pseudo inclusion bodies could be found. And heterochromatin was concentrated peripherally. Only a little of vacuoles appeared in the peripheral enchylema in some specimens. Their cellular nucleus was revealed completely with the increased nucleus gap. And the apoptosis cells could also be found in some tissues.③Peripheral edema cortex: Some tumor cells could be found in most cases. But they varied much less in appearance. We could find some of the neuron cells were swelling, heterochromatin were increased and collected. The nucleus margin was abnormal, the nucleus gap was increased, and nucleolus could be revealed easily. And the lipofuscin was also increased. The hondriosomes of astrocytes were swelling, golgi apparatus, rough endoplasmic reticulum and glycogen granules reduced. The heterochromatin in glial cell nucleus was increased. There were single or multiple vacuoles also. And some of myelin was demyelinated.3. Immunohistochemistry examination1) Control group: The expression of Ki-67, VEGF protein and the MVD in HGG group were significant higher than those in LGG. And they were positively correlated with the glioma grade. And the Ki-67 protein expression was positively correlated with the VEGF protein expression and the MVD. Yet the VEGF protein expression was not significantly correlated with the MVD.2) Treatment group: The expression of Ki-67, VEGF protein and the MVD in HGG group were significant higher than those in LGG. And they were positively correlated with the glioma grade. And the Ki-67 protein expression was positively correlated with the VEGF protein expression and the MVD. The VEGF protein expression was also positively correlated with the MVD.3) Deference between the gliomas with and without SRS/SRT: The Ki-67 protein expression and the MVD in treatment group were significant lower than those of the control group in both LGG and HGG. Yet there was no significant difference of expression of VEGF between treatment group and control group.ConclusionThe radiotherapy plays an important role in the suppression and destruction of the glioma cells directly. Both degeneration and necrosis of glioma cells were found in the pathological and ultrastracture observation. The radiation efficacy not only depends on the intensity of radiation, the time of fraction, the way of irradiation, but also on the tumor grade and the proliferation phase in the cell cycle.Radiotherapy can also induce apoptosis. How to promote or induce tumor apoptosis is great important in clinical application which would improve the long-term outcome of gliomas.Microvascular endothelial cells have high sensitivity to SRS and SRT. After irradiation, the endothelial cells underwent swelling, loss, compensatory proliferation and increasing of fibrous stroma was observed. The fibrous thickening of the vascular walls was observed, following with marked lymphocyte infiltration and hemorrhages. The radiation injury of microvascular endothelial cells is one of the major radiotherapeutic radiobiological mechanisms of SRS and SRT.Ionizing radiation induced the destruction of ultrastructure in blood-brain barrier and increased permeability. It provided a theoretical basis to the comprehensive treatment of radiotherapy combined chemotherapy and biotherapy.Stubborn brain radiation necrosis and brain edema is the common result of the necrosis of tumor cells, the injury of glial cells, angiohyalinosis, the destroied blood-brain barrier and the myelin of different cellular necrosis.Seeking for personalized unique therapeutics for different glioma patients is promoted up to date.①To promote substitute traditional radiotherapy for SRT.②The extended-field conformal radiotherapy combined with SRS or hypofractionated SRT are recommended for the malignant gliomas.③The combination therapy of radiotherapy and chemotherapy are also promoted for the malignant gliomas.④The VEGF targeted therapy is also recommended with the combination of radiotherapy and chemotherapy.⑤The high single dose SRS and hypofractionated SRT are suitable for both postoperative residual LGG and recurrent LGG.⑥The primary undiagnosed cerebral tumors with mass effects are feasible for direct operation as to get the diagnosis and decompression.

放射外科治療后星形膠質(zhì)細胞瘤的病理、超微結(jié)構(gòu)對比研究

1 放射外科治療后星形膠質(zhì)細胞瘤的病理、超微結(jié)構(gòu)對比研究5-39    1.1 英漢縮略詞對照表5-6    1.2 中文摘要6-9    1.3 英文摘要9-12    1.4 引言13-14    1.5 材料與方法14-16    1.6 結(jié)果16-19    1.7 討論19-25    1.8 結(jié)論25-26    1.9 參考文獻26-29    1.10 附圖29-392 立體定向放射治療后星形膠質(zhì)細胞瘤的超顯微結(jié)構(gòu)變化(綜述1)39-483 電子顯微鏡技術(shù)在腦膠質(zhì)瘤研究中的應(yīng)用(綜述2)48-544 致謝54

  本文關(guān)鍵詞：放射外科治療后星形膠質(zhì)細胞瘤的病理、超微結(jié)構(gòu)對比研究，由筆耕文化傳播整理發(fā)布。