RU2537213C1 - Method of pre-operation diagnostics of parathyroid gland adenoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, diagnostics of adenoma of parathyroid glands (PTG), and can be applied in radiodiagnostics, endocrinology, surgery. Multi-phase multispiral computed tomography (MSCT) with X-ray contrast preparation (RC) is carried out at arterial and venous phases of analysis - respectively at 25 and 50 seconds after RC introduction. reading of parameters, analysis of obtained images and pre-operation diagnostics of patient's state are performed. RC is introduced single time, after its introduction physiological solution is introduced intravenously, with introduction of preparations through catheter at rate 4±1 ml/s. Visual and densitometric analysis of obtained images are performed in analysis of obtained images. As analysis parameters determined are: coefficient of radiation attenuation in all formation of the area under examination, suspicious of PTG adenoma. Presence of adenoma is diagnosed with fixation of X-ray radiation attenuation coefficient to +180+200 HU at early arterial phase and detection of not less than 80 HU density reduction at venous stage.

EFFECT: method provides improvement, high quality of diagnostics of PTG adenomas due to more accurate fixation of neoplasm location, optimal distribution and retention of contrast substance in the zone of examination in healthy and pathogenic zones, which makes it possible to reduce operation time to 15 minutes instead of 60 minutes, reduce post-operation period from 5 days to 1 day.

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Description

The invention relates to medicine, in particular to methods for diagnosing parathyroid adenoma (OSH), and may find application in radiation diagnostics, endocrinology, surgery.

Currently, the prevention and treatment of diseases of the parathyroid glands are becoming quite important due to their wide prevalence among the able-bodied population, mainly middle-aged and elderly people. Diagnosis of such diseases, as a rule, is based on the use of ultrasound, radioisotope and X-ray methods for studying the body. (Methods of imaging parathyroid glands and parathyroid surgery: a guide for doctors / edited by A.P. Kalinin. - Moscow: Vidar_M Publishing House, 2010. - 311 p .; Suliburk JW, Perrier ND / Primary Hyperparathyroidism // TheOncologist. - 2007. - Vol.12. - P.644-653; HB Karlovich. Parathyroid imaging options / Medical news. - 2009. - No. 3. - C.12-16; RandallGJ, ZaldPB, CohenJI, HamiltonBE. Contrast-enhanced MDCT characteristics of parathyroid adenomas. AJR Am J Roentgenol 2009; 193 (2): W139-W14; Vu TH, Guha-Thakurta N, Harrell RK, et al. Imaging characteristics of hyperfunctioning parathyroid adenomas using multiphase multidectector computed tomography: a quantitative and qualitative approach .J Comput. Assist Tomogr. 2011; 35 (5): 560-567; Multispira te a computed tomography / Ed Thorn SK -.. M .: GEOTAR Media, 2009. - 112).

In particular, the ultrasound method is known, including duplex scanning, which allows for preoperative topical diagnosis of thyroid lesions (imaging methods of the parathyroid glands and parathyroid surgery, a guide for doctors / edited by A.P. Kalinin. - Moscow: Vidar_M Publishing House, 2010. - 311 pp .; N.V. Karlovich, Parathyroid Gland Imaging Capabilities / Medical News. - 2009. - No. 3. - P.12-16) by means of ultrasound examination of the neck organs. However, this method does not allow highly reliable diagnosis of tumors in ectopic, dystopian glands (Randall GJ, Zald PB, Cohen JI, Hamilton BE. Contrast-enhanced MDCT characteristics of parathyroid adenomas. AJR Am J Roentgenol 2009; 193 (2): W139- W14; Vu TH, Guha-Thakurta N, Harrell RK, et al. Imaging characteristics of hyperfunctioning parathyroid adenomas using multiphase multidectector computed tomography: a quantitative and qualitative approach. J ComputAssistTomogr 2011; 35 (5): 560-567), and Ultrasound diagnosis is complicated by concomitant thyroid lesions (N.V. Karlovich. Possibilities for visualization of the parathyroid glands. / Medical News. - 2009. - No. 3. - S.12-16). In addition, when using it, the subjective characteristics of the researcher have a significant impact on the results.

It is known to use scintigraphy methods (two-isotope or two-phase scintigraphy with Tc-sestamibi) for the diagnosis of thyroid cancer, which allow the detection of large adenomas of the parathyroid glands with high sensitivity (Suliburk JW, Perrier ND / Primary Hyperparathyroidism // The Oncologist. - 2007. - Vol.12. - P.644-653 .; Multispiral computed tomography / Edited by S.K. Ternovoy. - M.: GEOTAR-Media, 2009. - 112 p.). However, the sensitivity of these methods directly depends on the mass of the tumor. In particular, the detection of adenomas weighing less than 100 mg is 10 times lower than that of 600 mg, and the sensitivity of scintigraphy is significantly reduced (up to 15-59%) with multiple lesions, when it is possible to visualize only one, the largest gland (imaging Methods of the parathyroid glands and parathyroid surgery: a guide for doctors / edited by A.P. Kalinin. - Moscow: Vidar_M Publishing House, 2010. - 311 p.).

The closest in technical essence and the achieved effect to the claimed invention is a method for detecting the presence of parathyroid adenomas by multispiral computed tomography of the neck (Multispiral computed tomography / Ed. By S.K. Ternovoy. - M .: GEOTAR-Media, 2009. - 112 p. ) The method includes computed tomography with two-phase contrasting by introducing into the body 50 ml of an iodine-containing radiopaque drug (RCP) at a rate of 2 ml / s (arterial phase of the study), and then re-administering the drug after 5 min at 50 ml at a speed of 2 ml / s (delayed venous phase of the study) and tomography with a delay of 35 s after the second phase of drug administration, image analysis and diagnosis of the presence of adenoma by the presence of a pathological formation.

The disadvantages of this method are the insufficiently high accuracy of the diagnosis, the possibility of incorrect diagnosis of the neoplasm, and the inability to determine the exact location of the parathyroid adenoma due to the low contrast of the parathyroid gland formations due to the low rate of administration of contrast medium and residual contrast of soft tissues and lymph nodes in the second phase of the study .

The task to be solved by the authors is to improve the quality of diagnosis of thyroid adenomas with the help of X-ray computed tomography (CT), in particular, due to a more accurate fixation of the location of tumors of the parathyroid gland.

The technical problem was solved by creating conditions for the optimal distribution of contrast medium in the research area and using the differences established by the authors in the retention of RCP in healthy and pathogenic zones when exposed to a contrast drug.

The indicated problem was solved by performing computed tomography of the neck and mediastinum first without administration of RCP, after which RCP was administered once and then saline sequentially, twice CT was performed at 25 and 50 seconds after the start of RCP administration, followed by analysis of the obtained images, during which visual and densitometric analyzes of the obtained images, reveal the neoplasms available in the study area with registration of their location and determine the attenuation coefficient of the radiation in pathologically altered tissues and adjacent tissues when scanned before intravenous administration of contrast and after intravenous administration, the possibility of an adenoma in the neoplasm is suggested when the attenuation coefficient of x-ray radiation is fixed to + 180 + 200 HU in the early arterial phase and this formation is diagnosed as an adenoma in if the indicated value decreased by at least 80 HU at the venous stage.

Optimum results are achieved with the introduction of a contrast medium and physiological saline at an increased rate of 4.0 ± 1.0 ml / s, however, the specific mode of administration is selected based on the characteristics of the physiological state of the patient.

The method is as follows. At the first stage, a non-contrast CT examination of the organs of the neck and mediastinum is performed in the range from the base of the skull to the diaphragm.

The study is carried out on a multispiral tomograph with the following parameters - 0.5 mm collimation, craniocaudal scanning direction.

At the second stage, a CT study is performed after intravenous administration of the contrast medium, 60 ml of a non-ionic water-soluble X-ray contrast drug (iodine content 350-370) are injected through a catheter at a speed of 4 ml / s, and then 40 ml of physiological saline and scanning at 25 and 50 seconds from the beginning of I / O contrast with the same scan settings.

In the course of the analysis of the obtained images, a comparative densitometric study of the morphostructure is carried out with an non-contrast study and in the study in the arterial phase by measuring the attenuation coefficient of x-ray radiation (in Hounsfield units - HU) in all formations that are suspected of having an ASC. The assumption of the possible presence of thyroid adenoma is made on the basis of the detection of highly contrasting (up to 180-200 HU) neoplasms in the arterial phase in comparison with less contrasting surrounding tissues and neoplasms.

Then the density of neoplasms suspected of adenoma is analyzed on images obtained during the venous phase of contrast, and if a sharp decrease in density (not less than 80 HU) is detected, the presence of adenoma is diagnosed.

The applicability of the method is illustrated by graphic materials.

Figures 1 and 2 show the images obtained at different stages of the study, where A is the native phase, B is the arterial phase, C is the venous phase (Fig. 1), and the results of a densimetric study of a tumor suspicious of adenoma in b-M (example 1).

Figures 3 and 4 show images taken at different stages of the study, where A is the native phase, B is the arterial phase, C is the venous phase (Fig. 1), and the results of a densimetric study of a tumor suspicious of adenoma in b-P (example 2).

Figures 5 and 6 show photographs taken at different stages of the study, where A is the native phase, B is the arterial phase, C is the venous phase (Fig. 1), and the results of a densimetric study of a tumor suspicious of adenoma in b-C (example 3).

The essence and industrial applicability of the proposed method are illustrated by the following examples.

EXAMPLE 1. Patient M., 28 years old, turned to the NMHTs im. N.I. Pirogov in 2012 with complaints of recurrent lower back pain.

Parathyroid hormone - 45.7 (reference limits 2.35-11.54).

Diagnosis: primary hyperparathyroidism, renal form.

Ultrasound of the neck: no pathological neoplasms were detected. Ultrasound of the kidneys: a coral calculus in the right side of the kidney, calculi up to 0.7 cm in the left kidney.

Subtraction scintigraphy of the neck and mediastinum: no foci of hyperfixation of the radiopharmaceutical were detected.

CT of the neck and mediastinum with contrast. Scanning from the base of the skull to the diaphragm to the introduction of contrast medium, after 25 and 50 seconds from the beginning of the on / in contrast. 60 ml of a nonionic water-soluble X-ray contrast drug (iodine content 350) were injected intravenously through a catheter at a rate of 4 ml / s, and then 40 ml of physiological saline at a speed of 4 ml / s.

CT results (Figs. 1, 2): in the mediastinum, in the region of the aortic window, a neoplasm 1.2 × 0.5 × 0.5 cm in size is detected (parathyroid adenoma?). Paratracheal lymph nodes are detected.

Densitometry of the lymph nodes and the formation suspicious of adenoma of the parathyroid gland was performed.

The density of the formation, suspicious of adenoma, in the native phase is + 32 HU, the accumulation of contrast medium in the arterial phase of the study is up to 180 HU. In the venous phase, a characteristic leaching of contrast medium up to 90 HU is observed. Based on a characteristic increase in density in the arterial phase and a sharp decrease in density in the venous phase, a diagnosis is suggested: ectopic parathyroid adenoma in the aortic window.

When measuring the density of the lymph node, a moderate accumulation of contrast is detected: native study - +40 HU, arterial phase - +72 HU, venous - +78 HU.

The operation was performed: sternotomy, selective parathyroidectomy.

Histological examination: parathyroid adenoma.

EXAMPLE 2. Patient P., 62 years old, turned to the NMHTs im. N.I. Pirogov in 2012 with complaints of bone pain, weakness, excessive sweating, increased blood pressure to 200/100 mm Hg

Parathyroid hormone - 18.8 (reference limits 2.35-11.54).

Diagnosis: primary hyperparathyroidism, mixed form.

Ultrasound: diffuse changes in both lobes of the thyroid gland. The node 15.0 mm in the left lobe. Neoplasms of the parathyroid glands were not detected.

Subtraction scintigraphy of the neck: no foci of hyperfixation of the radiopharmaceutical were detected.

CT of the neck and mediastinum with contrast:

Scanning from the base of the skull to the diaphragm to the introduction of contrast medium, after 25 and 50 seconds from the beginning of the on / in contrast. Introduced 60 ml of a non-ionic water-soluble X-ray contrast drug (iodine content 350) intravenously, by autoinjector through a catheter at a speed of 4 ml / s, followed by 40 ml of physiological solution at a speed of 3.5 ml / s.

CT results (Figs. 3, 4): in the posterior mediastinum, paraesophageally on the left, along the anterior surface of the Th2 vertebral body, a neoplasm of 0.7 × 0.8 × 1.0 cm in size, suspicious for parathyroid adenoma, and lymph nodes of the neck are detected. Densitometry of the lymph nodes and the formation suspicious of adenoma of the parathyroid gland was performed.

The density of formation in the native phase is +37 HU, the accumulation of contrast in the arterial phase of the study is up to 194 HU. In the venous phase, the characteristic leaching of the contrast medium to 96 HU is determined.

Based on a characteristic increase in the density of formation in the arterial phase and a sharp decrease in density in the venous phase, a diagnosis is suggested: ectopic parathyroid adenoma.

Performed operation: selective parathyroidectomy. Histological examination: adenoma of the left lower parathyroid gland.

EXAMPLE 3. Patient S., 61 years old, turned to the NMHTs im. N.I. Pirogov in 2012 with complaints of bone pain, increased blood pressure to 200/100 mm Hg A history of peptic ulcer, chronic gastritis, urolithiasis.

Parathyroid hormone - 42.7 (reference limits 2.35-11.54).

Diagnosis: primary hyperparathyroidism, mixed form (bone, visceral).

Ultrasound: diffuse changes in both lobes of the thyroid gland. Neoplasms of the parathyroid glands were not detected.

Subtraction scintigraphy of the neck: no foci of hyperfixation of the radiopharmaceutical were detected.

CT of the neck and mediastinum with contrast:

Scanning from the base of the skull to the diaphragm to the introduction of contrast medium, after 25 and 50 seconds from the beginning of the on / in contrast. Introduced 60 ml of a non-ionic water-soluble X-ray contrast drug (iodine content 350) intravenously, by autoinjector through a catheter at a speed of 3.5 ml / s, followed by 40 ml of physiological solution at a speed of 3.5 ml / s.

CT results (Figs. 5, 6): along the posterior surface of the right lobe of the thyroid gland, retrotracheally, paraesophageally, a neoplasm 1.0 × 1.2 × 1.3 cm in size is detected, which is suspicious of parathyroid adenoma.

Densitometry of the thyroid gland, lymph nodes and formation suspicious of adenoma of the parathyroid gland was performed.

The density of education in the native study +30 HU, the accumulation of contrast in the arterial phase of the study up to 200 HU. In the venous phase, the characteristic leaching of the contrast medium to 120 HU is determined. Based on a characteristic increase in the density of formation in the arterial phase and a sharp decrease in density in the venous phase, a diagnosis of adenoma of the parathyroid gland is suggested.

Lymph node densitometry: in the native phase +40 HU, in the arterial +70 HU, in the venous +80 HU.

Thyroid densitometry: in the native phase +80 HU, in the arterial +170 HU, in the venous +160 HU.

Performed operation: selective parathyroidectomy. Histological examination: adenoma of the right upper parathyroid gland.

EXAMPLE 4. In the period from November 2010 to July 2013 in the NMHC them N.I. Pirogov examined 160 patients with a clinical and laboratory diagnosis of primary hyperparathyroidism. Among the patients were 143 women - (89%) and 27 men (11%). The age of patients is from 17 to 80 years. Average - 52.6 years. The studies were performed on a Toshiba Aquilion-64 computer tomograph. Studies were performed with a bolus of non-ionic contrast medium with a content of 350-370 mg iodine / ml. The amount of contrast medium introduced is 60 ml, the injection rate is 4 ± 1 ml / s, followed by iv administration of physiological saline in an amount of 40 ml. Scanning was performed before administration of the contrast medium, 25 and 50 seconds after the start of administration of the contrast medium. The slice thickness was 0.5 mm. Scanning area - from the base of the skull to the diaphragm.

When MSCT according to the proposed method revealed 172 neoplasms of the parathyroid glands in 158 patients with primary hyperparathyroidism. 11 patients had multiple adenomas, 26 patients revealed adenomas in ectopic (dystopian) glands. In 3 patients with MSCT, neoplasms were not determined, however, adenomas up to 4 mm in diameter were detected during surgical intervention. All undiagnosed adenomas were located in ectopic glands. One patient did not have one of the two existing adenomas. In 3 patients, a false assumption was made about the presence of 2 adenomas. The diagnostic accuracy of the study was 96.3%.

The proposed method made it possible to conduct preoperative diagnosis of the morphological structures of the neck and mediastinum and to determine with high accuracy the localization of the thyroid lesion in the analysis of data of multiphase multispiral computed tomography, which reduced the time and invasiveness of the operation. Using this method of topical diagnosis of parathyroid adenomas allowed to reduce the operation time to 15 minutes instead of 60 minutes. The postoperative period was reduced from 5 to 1 day.

Claims (1)

A method for preoperative diagnosis of parathyroid adenoma by multiphase multispiral computed tomography, which includes the introduction of a radiopaque agent, computed tomography in the arterial and venous phases of the study - respectively 25 and 50 seconds after the introduction of an radiopaque agent, taking parameters, analyzing the images and diagnosing the patient's condition characterized in that the radiopaque agent is administered once, after it is administered intravenously physiological saline is taken, during the analysis of the obtained images, visual and densitometric analyzes of the obtained images are carried out, the attenuation coefficient of radiation in all formations of the study area suspected of parathyroid adenoma is determined as the study parameters, while the presence of adenoma is diagnosed when the x-ray attenuation coefficient is fixed to +180 +200 HU in the early arterial phase and the detection of a decrease in density of not less than 80 HU in the venous stage, with X-ray the contrast agent and physiological saline are injected through the catheter at a rate of 4 ± 1 ml / s.

Images