RU2547081C1 - Diagnostic technique for tumour involvement of spinal column - Google Patents

Diagnostic technique for tumour involvement of spinal column Download PDF

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RU2547081C1
RU2547081C1 RU2014103416/14A RU2014103416A RU2547081C1 RU 2547081 C1 RU2547081 C1 RU 2547081C1 RU 2014103416/14 A RU2014103416/14 A RU 2014103416/14A RU 2014103416 A RU2014103416 A RU 2014103416A RU 2547081 C1 RU2547081 C1 RU 2547081C1
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diagnosis
ct
stage
biopsy
tumor
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Олег Иванович Кит
Игорь Викторович Балязин-Парфёнов
Артём Андреевич Барашев
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Федеральное государственное бюджетное учреждение "Ростовский научно-исследовательский онкологический институт" Министерства здравоохранения Российской Федерации
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Abstract

FIELD: medicine.
SUBSTANCE: technique involves the three-stage diagnosis of all the patients suffering tumour diseases of various localisations. The first stage involves CT-densitometry performed every 6 months; if the CT-densitometry shows sites with varying spine bone density by 30% and more, the second diagnostic stage that involves a transpedicular biopsy is initiated. If the biopsy material appears to contain no tumour material, the third diagnostic stage starts with F-18 positron-emission tomography (PET-CT).
EFFECT: improving the early diagnosis of the spinal tumours.
1 ex

Description

The invention relates to medicine, oncology and can be used for early diagnosis of vertebral tumors.

Despite the achievements in the diagnosis of spinal tumor lesions using magnetic resonance imaging (MRI), computed tomography (CT), and radionuclide scintigraphy, the early diagnosis of vertebral tumor lesions is far from perfect.

The need for timely treatment of metastatic disease of the spine also requires early diagnosis of small metastases, which can occur "in the guise" of degenerative-dystrophic changes in the spine amid systemic osteoporosis (N. V. Klimova, A. A. Gaus. Differential diagnosis of small metastases and degenerative-dystrophic spinal changes in systemic osteoporosis. Siberian Oncology Journal, 2011. Appendix No. 2, p. 38). The patient turns to a neurosurgeon only with the appearance of a neurological deficit due to a pathological fracture of the vertebra with compression of the neural structures. In these cases, the implementation of a minimally invasive method of treatment - percutaneous puncture vertebroplasty - is already impossible, and stabilization of the spine with titanium structures is acceptable for a single or two-level lesion.

The well-known "Method of X-ray diagnosis of diseases of the spine" (patent RU 2033084 C1, A61B 6/00), one of the goals of which was to increase the accuracy of X-ray diagnosis of diseases and morphometry of the spine. In this invention, spine radiography is performed using a narrow slit-like beam of rays directed perpendicular to the film and the object of study, in the process of uneven movement of the emitter along the longitudinal axis of the spine or in the process of movement of the patient and the film cassette fixed with it when the emitter is stationary, and then obtained radiographs evaluate the results of the study or morphometry. However, to date, x-ray is completely replaced by X-ray computed tomography.

The invention is known "Method for the diagnosis of diseases of the spine" (patent SU 1741312 A1, A61B 5/00), the essence of which is to receive thermal radio measurement of the spine by moving the contact antenna along it, converting the radiation into an electrical signal. The resulting temperature distribution is compared with the normal temperature distribution in healthy people and, at certain values, radicular syndrome, osteochondrosis and a tumor are diagnosed. However, when considering the temperature distribution of healthy and sick people, it is difficult to obtain reliable differences, in addition, the method itself does not have wide clinical application, and the equipment for its implementation is not accessible and is not included in the list of high-tech equipment.

The invention is known "Method for the diagnosis of tumors of the skeletal system" (RU 2454665 C1, G01N 33/49, published on June 27, 2012, bull. No. 18), the essence of which is the spectrophotometric determination in the blood serum of a patient of the quantitative value of the level of neopterin protein. With values above 2.6 ng / ml to 7.0 ng / ml, a benign tumor process is diagnosed, more than 7.1 ng / ml - malignant. The disadvantage of this method is the lack of histological verification of the process, and it does not allow the localization of the tumor itself.

In the invention, "Method for the differential diagnosis of multiple myeloma and bone cancer metastases" (RU 2210773 C1, G01N 33/52, published on 08.20.2003) from an undetected primary focus by infrared spectrophotometry of blood serum with transmission coefficients in nine sub-bands of the infrared spectrum of electromagnetic radiation within 1 minute after 1 second, the Mahanolobis criterion is calculated and, with its value of less than 20 conventional units, multiple myeloma is diagnosed. When the value is from 25.5 to 33.3 srvc. - cancer metastases from an undiagnosed primary focus. The method also has a drawback in the absence of the possibility of verification of tumor lesions of the bones, especially for cancer metastases with an undiagnosed primary focus.

The invention is known "A method for differential diagnosis between bone-forming and bone marrow sarcomas, a giant cell tumor and inflammatory diseases of long tubular bones" (RU 2215478 C2, A61B 8/00, publ. 10.11.2003), which is intended for differential diagnosis between bone-forming and bone marrow sarcomas, giant cell swelling and inflammatory diseases of the long bones. Its essence is to perform a full-length radiography of the affected limb in two mutually perpendicular planes, followed by targeted ultrasound scanning of the affected segment. This method is not applicable to determine the tumor lesion of the vertebral bodies, and even more so for the differential diagnosis of their damage, since it is impossible to perform ultrasound scanning of the vertebral bodies with reliable assessment. In addition, the subjective assessment of the ultrasound picture by each specialist reduces the accuracy of the technique, the method also does not allow the verification process.

In the invention, "A method for differential diagnosis of non-specific inflammatory and malignant tumor processes of the musculoskeletal system" (RU 2323685 C1, A61B 6/02, A61K 51/04, publ. 10.05.2008, bull. No. 13), the authors proposed to increase the accuracy and information content of the differential diagnosis of non-specific inflammatory and malignant tumor processes of the musculoskeletal system due to the expanded qualitative and quantitative assessment of the scintigraphic picture. Intravenous administration of 199 Tl-chloride is carried out, followed by planar scintigraphy in the early phase after 20 minutes, visual determination of the area of increased marker accumulation, its quantification in the early phase of the study (ER), additional scintigraphy in the delayed phase 180 minutes after 199 Tl-injection chloride, and re-visualization of the area of increased accumulation of 199 Tl-chloride, quantitatively determine the intensity of its accumulation (DR), calculate the retention index (RI) equal to DR / ER, and in the presence of two of the three signs: RI <0,047 ER + 0.979 in the early and delayed phases of the study, the greater clarity of the contours of the marker hyperfixation site in the early phase of the study compared to the delayed, the uniformity of the structure of the marker hyperfixation area in the delayed phase of the study diagnoses a non-specific inflammatory process. And if there are at least two of the three signs, such as RI> -0.047 ER + 0.979 in the early and delayed phases of the study, the clarity of the contours of the marker hyperfixation area in the early phase of the study is less clear than the delayed or substantially unchanged depending on the phase of the study, malignant tumor process. The method allows to differentiate between a non-specific inflammatory process and a tumor process, but it does not make it possible to verify the process, and even more so in the formula of this method there is no possibility of obtaining biopsy material for verification of the process.

Available diagnostic algorithms do not improve the early diagnosis of tumor lesions of the vertebrae until the patient has a neurological deficit. So, E.G. Pedachenko et al. (EG Pedachenko S.V. Kushchaev, I.L. Avetisyan. Puncture biopsy of vertebral bodies. Ukr. Medical chronicle, 5 (61) - IX / X, 2007, p. 92-96) consider that the data CT is most reliable in the differential diagnosis of small plastic metastases and degenerative-dystrophic changes in the spine, while contrast enhancement does not increase the information content of the study. And MRI data are most reliable in the differential diagnosis of small lytic metastases and foci of systemic osteoporosis in the spine, while contrast enhancement significantly increases the information content of the study. But the necessary basis for referring the patient to CT or MRI is the presence of certain complaints, namely pain in the vertebrae, decreased sensitivity (with compression of the dural sac and spinal cord).

The diagnostic algorithm for pathological vertebral fractures proposed by D.S. Astapenkov (DS Astapenkov. Diagnostic tactics for pathological vertebral fractures. Traumatology and orthopedics of Russia. 4 (54) - 2009, p. 27-30), already implies the presence of a pathological vertebral fracture. In all cases of the presence of tumor lesion of the vertebra, puncture or trepanbiopsy is performed, performed transpedicularly, parapedicularly, and in the upper thoracic spine it is advisable to perform extrapedicular lateral access to the vertebral bodies (A.V. Babkin, A.I. Voronovich, L.A. Pashkevich, S .V. Makarevich, A.M. Petrenko, A.N. Mazurenko. Modern technologies for surgery of spinal tumors. // Materials of the 3rd Congress of Oncologists and Radiologists of the CIS Minsk, 2004, Volume 2, p.267).

A puncture biopsy (trepanobiopsy) under X-ray control has been used since 1941 to verify the tumor process in the spine. The results of a percutaneous biopsy of the spine depend on the nature of the bone-destructive process. With osteoblastic lesions, negative results are obtained in 35% of patients, with lytic metastases - in 15%. This is due to the fact that with sclerotic lesions it is more difficult to obtain adequate material for verification (Martin H.E., Ellis E.V .: Biopsy by need lepuncture and aspiration AnnSurg - 1992: 139, - 19307).

Percutaneous biopsy is included in the standard for examining patients with tumor lesions of the spine; the greatest experience with percutaneous biopsy and spine and vertebroplasty is in the RONC RAMI (Aliev M.D., Teplyakov V.V., Callistov V.E., Valiev A.K., Karpenko V.Yu., Trapeznikov NN Modern approaches to surgical treatment of metastases of malignant tumors in the bone // Practical Oncology: selected lectures, St. Petersburg - 2004, p. 738-748). But despite the achievements, early diagnosis and positive results of a puncture biopsy of the vertebrae are far from always successful. And described by Babkin et al. open transpedicular or extrapedicular biopsy is a more traumatic and invasive procedure (A.V. Babkin, A.I. Voronovich, L.A. Pashkevich, S.V. Makarevich, A.M. Petrenko, A.N. Mazurenko. Modern technologies surgery of spinal tumors. // Materials of the 3rd Congress of Oncologists and Radiologists of the CIS, Minsk, 2004, Volume 2, p.267).

Authors Belykh E.V., Menshikova L.V., Mikhalevich I.M. proposed "A method for predicting bone fractures in women with rheumatoid arthritis" (RU 2261661 C1. A61B 10/00, A61B 6/00 (publ. 10.10.2006, bull. No. 28). Its essence is to determine the bone mineral density tissue in the lumbar spine, femoral neck, finding out from the medical history of life the risk factors for fractures (menopause duration, duration and severity index of the disease, systemic manifestations of rheumatoid arthritis (RA), loneliness, dose and duration of glucocorticosteroid drugs (GCS). If there is no factor Risk - feature value - "0" is - a "1" and then determines the predictive value by the formulas.

F1 = -38.72-7.27 × X1 + 9.77 × X2 + 6.30 × X3 + 4.25 × X4 + 7.41 × X5 + 9.66 × X6 + 32.97 × X7 + 3 62 × X8 + 8.96 × X9 + 38.04 × X10-0.55 × X11-0.50 × X12;

F2 = -5.41 4.32 × X1 + 3.22 × X2 + 2.91 × X3 + 3.84 × X4 + 3.24 × X5 + 3.93 × X6 + 7.43 × X7 + 1, 35 × X8 + 1,08 × X9 + 9,07 × X10-0,11 × X11-0,19 × X12, where X1 - the patient's age is more than 45 years, X2 - postmenopause more than 5 years, X3 - RA duration more than 10 years, X4 - severity index more than 5 points, X5 - systemic manifestations of RA, X6 - loneliness, X7 - taking GCS for more than 2 years, X8 - cumulative dose of GCS more than 5000 mg, X9 - bone mineral density in the lumbar spine at T- less criteria - 2.5; X10 mineral density of bone tissue in the neck of the femur according to the T-criterion is less than 2.5; X11 - bone mineral density in the femoral neck according to the T-criterion is less than 0.700 g / cm 2 , X12 - bone mineral density in the lumbar spine according to the T-criterion is less than 0.900 g / cm 2 ). For F1> F2, a high risk of fracture is predicted, and for F1 <F2, a low risk. The method improves the accuracy of the prognosis of bone fractures in women with rheumatoid arthritis. However, this method for predicting bone fractures is unsuitable for determining the degree of risk of fractures in cancer patients with spinal lesions of both primary and metastatic tumors, and moreover, their tumor lesion is not suspected.

"A method for determining osteoparetic fractures in the thoracic spine" (patent RU 2376935 C2, AB 6/03, publ. 12/27/2009, bull. No. 36) allows us to assess the degree of resorption of the cancellous bone of the vertebrae and timely conduct the necessary treatment. Mineral density is determined by quantitative computed tomography. The patient is laid horizontally, a bone-equivalent phantom is placed over the lower thoracic spine, and a direct examination is performed. The mineral density of the bodies of the thoracic vertebrae is determined, then quantitative indicators are calculated using a correction factor of 0.93. Absolute values of mineral density are obtained, they are compared with known threshold values, and with values less than 110 mg / ml calcium, an increased risk of vertebral fracture is determined, and with values less than 50 mg / ml calcium, a high risk of fracture development. This method allows you to determine the risk of fracture of the vertebral body, but does not allow to diagnose its tumor lesion.

“A method for the prevention of osteoporosis in preoperative chemotherapy in patients with stage III non-small cell lung cancer” (patent RU 2452483 C1, A61K 31/337, A61K 31/573, A61K 31/66, A61P 19/10, published on June 10, 2012, bull. No. 16) is intended for the prevention of osteoporosis in preoperative chemotherapy in patients with stage III non-small cell lung cancer. Densitometry is performed before the start of treatment and after 2-3 courses of preoperative XT according to the paclitaxel / carboplatin scheme with premedication with glucocorticoids and bone mineral density is assessed by the T-criterion. This method allows to prevent the development of osteoporosis in patients with stage III non-small cell lung cancer during preoperative chemotherapy, it is used in patients with non-small cell lung cancer, but it is not applicable in other groups of patients with primary or metastatic vertebral lesions and cannot be used for early diagnosis of metastatic lesions vertebral bodies.

"A method for predicting osteoparetic spinal fractures in women older than 50 years" (patent RU 2465832 C1, A61B 10/00, publ. 10.11.2012, bull. No. 31) can improve the effectiveness and focus of preventive measures in groups of patients with a high risk of fracture determination bone mineral density, risk factors (weight less than 50 kg, height above 160 cm, body mass index less than 25 kg / m 2 , heavy physical labor up to 25 and after 50 years; surgical menopause up to 50 years, loneliness. But this method is not allows you to diagnose and verify the tumor lesion of the vertebral bodies.

The technical result of our proposed method is to improve the early diagnosis of vertebral tumors.

The technical result is achieved by the fact that the diagnosis of tumor lesions of the spine is carried out in three stages: CT-densitometry (the first stage of diagnosis) is regularly performed every 6 months for all patients with tumor diseases of various localization, with foci with a changed bone density of the vertebra by 30 percent or more a transpedicular biopsy is shown (the second stage of diagnosis), in the absence of tumor material in the biopsy sample, a transition to the third stage of diagnosis is shown - positron emis ion imaging (PET-CT) with a 18-fluorodeoxyglucose.

The invention "A method for the diagnosis of tumor lesions of the spine" is new, since it is unknown from the prior art in the field of neurooncology. The novelty of the invention lies in the fact that the authors propose a three-stage technique for the diagnosis of tumor lesions of the spine.

The first step - for all patients receiving treatment for oncopathology (cancer of the kidney, prostate, lung, thyroid, breast, colorectal cancer, etc.), regular CT densitometry (1 time in 6 months) is indicated as a way to detect changes in density bone tissue of the vertebra. This technique is not invasive and is quickly feasible in any center of the RKT diagnostics in the presence of CT densitometry program. If CT densitometry reveals the presence of foci with a change in the density of the bone tissue of the vertebrae by 30 percent or more, which may be the result of a tumor lesion, a transition to the second stage is shown - transpedicular biopsy of this focus of the changed density for its verification. A transpedicular biopsy is minimally invasive and is proposed by us in the presence of changes in the density of the bone tissue of the vertebra. If CT densitometry did not reveal foci with changes in bone density by 30 percent or more, we continue to observe this patient and repeat the CT densitometry procedure after 6 months. If the second stage of our technique - a transpedicular biopsy of the lesion of the bone density of the vertebra - did not reveal the presence of tumor cells in the biopsy, the transition to the third stage of our diagnostic technique, positron emission tomography (PET-CT) with 18-fluorodeoxyglucose, is shown. PET / CT with 18F-FDG is a hybrid radiation diagnostic technique that includes positron emission tomography and low-dose X-ray helical computed tomography performed sequentially on a single tomographic apparatus. PET with 18F-FDG is a molecular imaging technique performed after the intravenous administration of fluorodeoxyglucose labeled with the 18F ultra-short-lived isotope. This radiopharmaceutical has biological properties that are completely similar to ordinary glucose, which allows you to quantify the metabolism of tissues and organs. The ultrashort-lived isotope provides minimal radiation load on the patient's body, comparable to low-dose x-ray studies. In most cases, PET / CT with 18F-FDG is performed from the lower edge of the orbit to the middle of the thighs. When searching for a primary tumor of unclear localization, metastasizing to the spine, or a primary tumor of the spine, which could not be verified by transpedicular biopsy, the study is carried out from the bones of the cranial vault to the toes. In order to differentiate the nature of the revealed metabolic changes, delayed scans of zones of interest are carried out, and an additional targeted CT scan with intravenous contrast enhancement is carried out to clarify the topography of metabolic changes in anatomically complex locations and the need to confirm metabolic changes with x-ray data. The total radiation dose to the patient during PET / CT of the whole body with 18F-FDG does not exceed 10 meV.

If the presence of tumor cells is detected in a biopsy at the second stage of our technique, then the optimal treatment tactics is chosen.

The invention "A method for the diagnosis of tumor lesions of the spine" is industrially applicable, as it can be used in healthcare, medical institutions of oncological profile, oncology dispensaries, research institutes, oncology centers.

A method for the diagnosis of tumor lesions of the spine is as follows.

A patient receiving treatment for oncopathology (cancer of the kidney, prostate, lung, thyroid gland, breast, colorectal cancer, etc.) is shown regular CT densitometry (once every 6 months). When foci with a changed bone density of 30% or more are detected, patients are shown a transpedicular biopsy of the identified foci. The resulting material is examined histologically and, with a positive response, the optimal treatment tactics is chosen.

If there is no tumor material in the biopsy from the spinal column, PET-CT tomography with 18-fluorodeoxyglucose is shown to patients.

Patient K., medical history 15780/6, turned to the clinic of the RNII in October 2012. Suffers from August 2012, when there were pains in the lumbar spine. Prior to this, I did not consult a doctor. The pains were chronic and debilitating, difficult to treat. During the examination at the outpatient stage, taking into account the presence of pain in the lumbar spine, an CT scan of the chest, abdominal and pelvic organs was performed, consultation of a mammologist, gynecologist, ultrasound of the retroperitoneal space, where at the time of examination only a slight change in the body structure of the third lumbar vertebra was revealed. CT densitometry of the lumbar spine determined the presence of a lesion up to 1.5 cm with a density 43% lower than the density of the rest of the bone tissue of the vertebrae. The patient performed transpedicular biospy of the L3 third third lumbar vertebra under CT control. G / a No. 61705-6 / 12 - sections of fibrous tissue. The patient was sent for PET-CT, where a tumor of the left breast 0.8 × 0.6 cm and a solitary lesion in the third lumbar vertebra were detected. In order to avoid a pathological fracture of the spine, which can lead to a gross neurological deficit due to damage to the cauda equina roots, the first stage performed transpedicular stabilization from the second to the fourth lumbar vertebrae (L2-L4) with titanium metal construction. Simultaneously, a mammectomy performed a mastectomy on the left. After 2 weeks - the second stage - from lateral access, removal of the body of the third lumbar vertebra affected by metastasis (L3), removal of L2-L3 and L3-L4 discs, anterior stabilization with a titanium nickelide prosthesis to replace the removed body of the third lumbar vertebra. The patient was consulted by a chemotherapist, receives chemotherapy courses, her condition is stable.

Noteworthy is the fact that breast cancer manifested pain in the lower back due to a solitary metastatic lesion of the third lumbar vertebra, revealed during the examination at the stage of absence of a gross neurological deficit, before the compression of the dural sac and horse tail roots appeared. The initial consultation of the mammologist and mammography did not reveal any pathology, but thanks to the use of the method of diagnosis of tumor lesions of the spine proposed by the authors, both the primary tumor metastasizing to the vertebral body was identified, and the tumor lesion of the spine was confirmed. This clinical example suggests the need for examination of patients with chronic pain in the back according to our proposed three-stage technique for the diagnosis of tumor lesions of the spine to exclude tumor pathology.

Claims (1)

  1. A method for the diagnosis of tumor lesions of the spine, including computed tomography, biopsy, characterized in that they diagnose all patients with tumor diseases of different localization, moreover, the diagnosis is carried out in three stages: at the first stage, CT densitometry is performed once every 6 months and, if foci are identified with altered with a bone density of the vertebra of 30% or more, they pass to the second stage of diagnosis - a transpedicular biopsy is performed, in the absence of tumor material in the biopsy Passing to the third stage of diagnosis - is carried out positron emission tomography (PET-CT) with a 18-fluorodeoxyglucose.
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