RU2311132C1 - Method for differential diagnostics of gastric neoplasms' forms - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should fulfill endoscopic ultrasonography and laser Doppler flowmetry from mucosal surface in projection of intramural neoplasm. It is important to determine the thickness of organ's wall, differentiation by layers, arithmetic mean of microcirculation value (M). Moreover, at total thickness of gastric wall being 5 mm, not more that consists of 10 well-differentiated layers, M value ranged 26.3±1.2 up to 35.6±2.4 pf. U one should detect the norm. At detecting simultaneous thickening of gastric wall by more than 5 mm, affected differentiation of its layers and increased M value being above 39.9±1.6 pf. U one should diagnose malignant gastric lesion. At detecting simultaneous thickening of gastric wall by more than 5 mm, keeping distinct differentiation of its layers and M value ranged 16.5±0.9 pf. U up to 25.6±1.4 pf. U one should diagnose benign gastric neoplasm.

EFFECT: higher accuracy of differential diagnostics.

2 ex, 2 tbl

Description

The invention relates to medicine, surgery, and specifically to methods for differential diagnosis of infiltrative forms of tumors of the stomach.

Currently, the main diagnostic method for malignant neoplasms is the morphological study of biopsy material. In the case of a malignant disease of the stomach, such material is a fragment of the gastric mucosa taken during endoscopic examination. However, with a number of infiltrative (endophytic) forms of gastric malignant lesions (lymphosarcomas, leiomyosarcomas, and scirrhosis forms of cancer) in the early stages, the mucous membrane remains intact, which makes it impossible to make a timely correct diagnosis using only this method.

Closest to the proposed is the method proposed by Lemeshko Z.A. et al. [1] that conduct a transabdominal ultrasound examination of the stomach, paying particular attention to the condition of its walls, the uniformity of their thickness: in healthy individuals, the thickness is uniform, not exceeding 5 mm; unlike an unchanged stomach, when a narrow peripheral part and a wider echogenic center are visible, with one or another pathology involving the gastric wall, the above proportions are violated: the anechogenic peripheral part becomes wide, and the echogenic central part becomes or seems relatively small, with a common organ wall thickness more than 5 mm, this condition is known as a symptom of a lesion of a hollow organ (PPO).

The known method is not sufficiently accurate and informative due to the lack of differential criteria for determining the nature of the organ damage: pre-malignant or malignant. A new technical task is to increase the accuracy and information content of the differential diagnosis of infiltrative forms of gastric malignant neoplasms.

The problem is solved by a new method for differential diagnosis of infiltrative forms of gastric malignant neoplasms, which consists in carrying out ultrasound with measurement of the physical characteristics of the stomach wall in the neoplasm, and endoscopic ultrasonography and laser Doppler flowmetry from the mucosal surface are performed in the projection of the neoplasm and the organ wall thickness is determined, differentiation by layers, the arithmetic mean value of the microcirculation index (M), while with a total wall thickness of the stomach of not more than 5 mm, consisting of ten well differentiable layers, the value of M in the range from 26.3 ± 1.2 pF. units up to 35.6 ± 2.4 pF. units determine the norm, and if a simultaneous thickening of the wall of the stomach is detected more than 5 mm, a violation of the differentiation of its layers and an increase in the M value of more than 39.9 ± 1.6 pF. units diagnose malignant lesions of the stomach.

This method is as follows. A GIF-1T140 video endoscope with a tube diameter of 11 mm and an Olympus UM-3R ultrasound probe with a scanning frequency of 20 MHz, a laser analyzer of capillary blood flow LAKK-01, single-channel, with a laser in the red region of the radiation spectrum with a signal penetration depth of about 1, are used as equipment. 5 mm. Esophagogastroduodenoscopy is performed according to the standard procedure [2]: the esophagus, stomach and duodenum are examined. A detailed examination of the pathological focus. Air is evacuated from the upper gastrointestinal tract, the stomach and duodenum are filled with degassed distilled water. An ultrasound probe is brought to the pathological focus through the instrument channel of the endoscope and a scan of the targeted area is performed with constant monitoring of the position of the ultrasound probe (picture-in-picture mode). In the presence of an elastic balloon worn on an ultrasound probe, scanning is performed without removing air from the upper sections of the gastrointestinal tract, but simply filling the balloon with degassed distilled water and pressing it to the desired area. To register LDF-grams and their subsequent processing, a unified software “Lakk 2.2.0.492” was developed and used in the Windows 98 operating system. When performing gastroscopy in patients with suspected malignant lesions of the stomach wall after performing ESM, a flexible LAKK sensor is carried out through the endoscope tube -01. Microcirculation indicators are recorded for 3-5 min from the surface of the mucosa in the projection of the greatest thickening of the wall without additional drug and mechanical effects on the mucosa. The main factor in assessing microcirculation is the arithmetic mean of the microcirculation index (M), characterized by the product of the number of red blood cells in 1 mm ^{3 of} tissue and their speed and measured in perfusion units. The range of variation of this indicator is determined by the standard deviation calculated by the Lakk 2.2.0.492 program. When revealing the simultaneous thickening of the wall more than 5 mm, the violation of its differentiation by layers and an increase in the value of M more than 39.9 ± 1.6 pF. units they diagnose a malignant lesion of the stomach, followed by surgical treatment.

The effectiveness of the proposed method is demonstrated by the following clinical examples:

Example 1. Patient C., 48 years old, was admitted in a planned manner to 1 surgical department G. B. No. 2 of Seversk on January 31, 2005 with a diagnosis of

Main disease: antrum neoplasm?

Concomitant diseases: hr. autoimmune thyroiditis, compensated. Chr. stoneless cholecystitis, remission. CHD: paroxysmal ventricular extrasystole.

The diagnosis was established on the basis of complaints of dull, intense pain in the epigastrium, regardless of the meal, with radiation to the right hypochondrium; medical history and instrumental examination.

From the anamnesis of the disease: considers herself a patient since the fall of 2004, when the described complaints first appeared, the examination revealed mild anemia. In October, gastroscopy revealed the formation of a stomach wall in the antrum, 3 × 5 cm in size, and a peptic ulcer up to 1.2 cm on the opposite wall. According to histological examination, atypia was not found from the mucosa above the formation and from the edge of the ulcer. The presence of education in the wall of the stomach is confirmed by CT scan of the abdominal cavity. A course of conservative anti-ulcer therapy. With a control gastroscopy in December 2004, a submucosal formation along the lesser curvature of the antrum is visualized with dimensions of 20 × 35 mm, elastic consistency, no mucosal defects.

During the examination: FGDS dated 12/23/04: The esophagus is not changed, the cardia is closed. There is a small amount of fluid in the stomach. The proximal stomach is not changed. In the antrum along the back wall, the lumen of the stomach is deformed by a rounded formation up to 4 cm in size, covering the mucous membrane about. The gastric mucosa in all departments is pale pink; no defects are detected. Pylorus freely pass. KDP is not changed. Mucosal biopsy over education. Conclusion: volumetric formation of the antrum.

The histological conclusion No. 22506 of 12.23.04: small intestinal metaplasia of the gastric mucosa.

Ultrasound of the abdominal cavity from 1.02.05: free fluid in the abdominal cavity is not determined. In the projection of the stomach, a hypoisoechoic formation with uneven contours is determined. 4.5 × 3.5 cm. The wall thickness of the stomach is more than 5 mm. Liver: not enlarged. CWR 13.5 cm. Echogenicity is average, the structure is homogeneous. The vessels are not dilated, common bile duct 0.3 cm. Gall bladder: with inflection times. 7.5 × 2 cm. Wall 0.3 cm, compacted, uniform content. There are no calculi. Pancreas: dimensions 2 × 1 × 1.7 cm, the contours are uneven, the structure is somewhat denser. There is no effusion in the stuffing bag. Wirsung duct is not expanded. Spleen: not enlarged, uniform.

Conclusion: the formation of the stomach. Small diffuse changes in the pancreas. The department conducted a survey according to the proposed method:

Endoscopic ultrasonography of the stomach No. 268 of 02/01/05: the walls of the stomach and perigastric space were scanned using an ultrasound probe with a scanning frequency of 20 MHz. The large curvature of the body of the stomach contains multiple convoluted folds with the unchanged structure of the layers of the wall of the stomach. When scanning the antrum, a hypoechoic formation of 20 × 35 mm in size is located in the muscle layer of the stomach wall. The wall thickness of the stomach is more than 5 mm. Differentiation of the wall of the stomach by layers is not broken. The mucous and submucous layers covering the formation are not changed. Conclusion: leiomyoma? antrum. Data on laser Doppler flowmetry of the gastric mucosa from 02/01/05 are presented in the table.

Indicators KR - scan mode M (arithmetic mean value) 23.3 pf units Standard deviation (standard deviation) 1.1 pf. units Kv (coefficient of variation) 4.7%

Conclusion: the evidence suggests benign

the formation of the stomach.

02/03/05, under ETN, an operation was performed - selective proximal vagotomy, resection of 1/2 stomach according to Billroth-I with the formation of pulp and valve flap. Urgent histological conclusion during surgery - gastric leiomyoma.

The final histological conclusion No. 1715 of 02/03/05: leiomyoma of the wall of the stomach, resection of the stomach within healthy tissue.

The postoperative period was uneventful. Sutures without signs of inflammation, removed on the 9th day after surgery. A control gastroscopy was performed on day 4: there was anastomositis of the II degree of HD-anastomosis, no other pathology was detected. Discharged from the hospital on the 9th day after the operation.

Example 2. Patient L., 48 years old, was admitted as planned to 1 surgical department of GB No. 2, Seversk 02/22/06, Regarding obliterating atherosclerosis of the vessels of the lower extremities.

During a comprehensive examination of a suspected stomach disease, the patient did not subjectively complain.

During the examination: FEGDS from 02.26.06 g. The mucous membrane of the esophagus is not changed. The cardia is closed. There is a little light fluid in the stomach. The gastric mucosa is hyperemic. In the region of the angle of the stomach on the lesser curvature and the anterior wall to the greater curvature there is a section of the mucosa with hyperemia, a section of up to 4-5 cm, without clear boundaries, the mucosa is dense, it is fragmented by taking a biopsy. Biopsy taken, smear for cytology. The pylorus is closed, we pass, the duodenal bulb is deformed, on the back wall there is an ulcer up to 0.6 cm, shallow, covered with fibrin. In n / departments of the duodenum, there is no pathology. Conclusion: stomach tumor? LDPK ulcer. Bulbit. LDPK deformation. The result of the cytological conclusion: white blood cells, fibrin in large quantities. Epithelial cells are destructively altered, the cytoplasm is mostly destroyed (not evaluated). It is difficult to give a conclusion. The result of the cytological conclusion of the repeated biopsy: intestinal metaplasia of the integumentary fossa epithelium of a benign nature.

Ultrasound of the STOMACH of March 7, 2006. STOMACH: examined on an empty stomach and after taking 400 ml of fluid. Stomach wall: the affected area was found in the middle section for 27 mm, with a thickening of the wall up to 7 mm, with hypoechoicity of the layers. The peristalsis of the stomach is preserved.

CONCLUSION: Damage to the wall of the stomach was revealed in the middle section over 27 mm in the form of thickening of the wall, general hypoechoicity of the layers.

The department conducted a survey according to the proposed method:

ENDOSCOPIC ULTRASONOGRAPHY OF THE STOMACH No. 67 of March 6, 2006

The GIF-1T140 video endoscope is freely carried into the esophagus, then into the stomach and duodenum. The walls of the duodenum, stomach and perigastric space were scanned using an ultrasound probe with a scanning frequency of 20 MHz. The wall of the intestine is uniformly nine-layer throughout. Choledoch in n / a up to 7 mm, in the lumen homogeneous contents. The large duodenal papilla does not bulge, the intramural part of the choledochus is not expanded, the lumen is uniform in content. When scanning the ligament wall in the region of the angle and the anterior wall, a circular thickening of the ligament wall to 8 mm due to the mucosa (3.5-6 mm) and the submucosal layer is visualized, the differentiation between the layers is reduced, the submucosal layer is heterogeneous in structure. Liquids in br. cavity is not determined.

Conclusion: echoes of malignant lesions of the female. Data on laser Doppler flowmetry of the gastric mucosa from 03/06/06 are presented in the table.

Indicators KR - scan mode M (arithmetic mean value) 42.4 pf. units Standard deviation (standard deviation) 2.1 pf. units Kv (coefficient of variation) 5.0%

Conclusion: the findings suggest a malignant lesion of the stomach.

03/09/06, under the ETN operation was performed: sparing distal gastrectomy. A section of the tumor was excised from the preparation and sent for an urgent histological examination. The result is lymphosarcoma. The operation was expanded to gastrectomy for RU, lymphadenectomy in the volume of DZ.

The final histological conclusion No. 4451 of 03/10/06: prolymphocytic lymphasarcoma of the stomach. Tumor growth to the inner muscle layer of the stomach. Resection of the stomach within unchanged tissues. Lymph nodes No. 3, 4d, 4s, 5, 6, 12 are not changed. The gland has the usual structure.

The postoperative period was uneventful. Sutures without signs of inflammation were removed on the 11th day after surgery. Conducted symptomatic, rehabilitation therapy. At the time of discharge, according to the control FGS - anastomositis esophagoenteroanastomosis I tbsp.

The proposed method examined 21 patients with various formations of the wall of the stomach without a mucosal defect. The median age of the patients was 56 years (range, 43–72 years). The reason for seeking medical help in 17 patients was gastric dyspepsia (loss of appetite, epigastric severity, nausea, less often vomiting, heartburn). In all 17 patients, when performing a transabdominal ultrasound, a PPO symptom was detected, in another 4 patients, a PPO symptom was detected during a screening examination in the absence of clinical symptoms. An endoscopic examination of 14 patients revealed a submucosal formation of the antrum or body of the stomach (in the PPO projection) with sizes from 3 to 8 cm. In the remaining 7 patients, clearly no volumetric formations were detected, folds were smoothed, the wall in the PPO projection was rigid, pale. 21 patients took material for histological examination, in no case data for atypia were obtained, 15 patients showed intestinal metaplasia in biopsy material, and the remaining 6 showed a picture of atrophic gastritis.

All patients were examined according to the proposed method, a group of volunteers (15 people) who did not have organic changes in the stomach according to ultrasound and endoscopic examination was used as control. Based on the results, the following patient groups were identified:

1) wall thickness of 5 mm or less, maintaining a clear differentiation into 10 layers with a value of M in the range from 26.3 ± 1.2 pF. units up to 35.6 ± 2.4 pF. units observed in all 15 healthy volunteers;

2) thickening of the wall more than 5 mm (mainly due to the muscle layer), preservation of clear differentiation into 10 layers with an M value ranging from 16.5 ± 0.9 pF. units up to 25.6 ± 1.4 pF. units observed in 14 patients;

3) wall thickening of more than 5 mm with a violation of differentiation between the distinguished layers at a value of M ranging from 39.9 ± 1.6 pF. units up to 43.2 ± 1.4 pF. units observed in 7 patients.

All patients underwent surgical treatment in the amount of distal gastric resection with an urgent histological examination: all patients of the 2nd group were diagnosed with gastric leiomyoma, the operation was completed by the formation of gastroduodenoanastomosis according to Billroth-1. The final histological conclusion in all 8 patients was gastric leiomyoma.

In patients of the 3rd group, atypical cells were identified on a section of the stomach wall at the site of neoplasm. In these 7 patients, surgery was expanded to gastrectomy with lymph node dissection. The final histological examination of the surgical material: in 2 patients - lymphosarcoma of the stomach wall, in 1 patient - leiomyosarcoma, in 1 patient - skirr and 3 patients - undifferentiated cancer.

Thus, the proposed method for the differential diagnosis of infiltrative forms of gastric neoplasms is a highly accurate method that allows to differentiate their malignant and benign forms in the absence of a morphological conclusion in the preoperative period and serves as an objective indicator for clarifying the treatment option.

Bibliography

1. Lemeshko Z.A. Ultrasound examination of the stomach // Guide to gastroenterology: 3 T. T. 1. Diseases of the esophagus and stomach / Ed. Komarova F.I., Grebeneva A.L., Sheptulina A.A. M .: Medicine, 1995, p. 311-313.

2. Standard technique for endoscopic ultrasonography of the pancreatobiliary zone in the radial scan mode // Digestive Endoscopy (2004) 16 (Suppl.), S118-133.

Claims (1)

A method for differential diagnosis of forms of gastric neoplasms, characterized in that they perform endoscopic ultrasonography and laser Doppler flowmetry from the surface of the mucosa in the projection of the intramural formation and determine the organ wall thickness, layer differentiation, arithmetic mean microcirculation index (M), while the total wall thickness stomach no more than 5 mm, consisting of ten well differentiable layers, the value of M in the range from 26.3 ± 1.2 pF. units up to 35.6 ± 2.4 pF. units determine the norm, and if a simultaneous thickening of the wall of the stomach is detected more than 5 mm, a violation of the differentiation of its layers and an increase in the M value of more than 39.9 ± 1.6 pF. units they diagnose a malignant lesion of the stomach, if a simultaneous thickening of the wall of the stomach is detected more than 5 mm, maintaining a clear differentiation of its layers and the value of M in the range from 16.5 ± 0.9 pF. units up to 25.6 ± 1.4 pF. units they diagnose a benign neoplasm of the stomach.