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Non-Linear AnalysiS.PDF DOWNLOAD

The collection of proceedings of Institute
of Practical Psychophysics (IPP)
Volume I
Topical problems
of NLS?diagnostics
(theoretical and clinical)
Moscow – 2006
BBK
22.314 (4Ros?Moskva)
C34
The collection of proceedings of Institute of Practical Psychophysics (IPP)
“Topical problems of NLS?diagnostics (theoretical and clinical)” /Under
editorship V.I.Nesterov. — Moscow: PROSPEKT Publishing house, 2006. — 88 pages
? 5000 copies.
ISBN 5?94349?037?Х
3
CONTENTS:
Computer non?linear diagnostics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Clinic Tech Inc. — ascending into the XXI century . . . . . . . . . . . . . . . . . 7
Method of computer non?linear analysis and its role in diagnostics . . . . . 9
Potentials of NLS method in diagnosing gastric and calonic cancers . . . . . . 12
New potentials of NLS?method in colonic neoplasm diagnostics . . . . . 16
NLS?method in vascular pathology diagnosis . . . . . . . . . . . . . . . . . . . . . 22
NLS?diagnostics of lung abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
NLS?diagnostics of degenerative changes in the spine . . . . . . . . . . . . . . 27
NLS?diagnostics of diffuse infiltrative lung diseases . . . . . . . . . . . . . . . . 30
NLS?diagnostics of prostate diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
NLS diagnostics of affected regional lymph nodes at a
mammary gland cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
NLS?investigation in evaluating the condition
of knee?joint affected by osteoarthritis deformans . . . . . . . . . . . . . . . . . . 41
Potentials of NLS?investigation in the presurgical evaluation
of intramural invasion of gastric cancer . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Potentials of NLS?scopy in adrenal tumor diagnostics . . . . . . . . . . . . . . 49
Diagnosing rare instances of mammary
gland diseases using NLS?investigation . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Diagnostics of toxoplasmosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Nonlinear diagnostics of thyroid gland pathology . . . . . . . . . . . . . . . . . . 58
Nonlinear computer diagnostics and the problem of pathology
in the hepatopancreatoduodenal area . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
MECT and NLS in diagnosing myocarditis of mild or medium gravity . . . . 72
Importance of NLS?method for diagnosing timorous diseases
of the segmented intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
5
Computer non?linear diagnostics
V.I. Nesterov
The Non?linear Diagnostics Systems (NLS) have been extensively used
lately and are gaining ever growing popularity. Even in the few cases, where
the clinical symptoms look very typical the NLS diagnostics method provides
extra information about the extent of the affection and allows to consider a
prognosis. In most cases it is of vital importance for diagnostics and conse?
quently for the right choice of treatment.
In 2000 it was 20 years since Theodore Van Hoven had developed the
theory of quantum entropy logic that underlies this method. So non?linear
diagnostics appears to be the most up?to?date of all methods of the hardware?
based diagnostics. At any rate, his discovery became a significant landmark in
diagnostical medicine.
Non?linear analysis was originally employed in organic chemistry to
determine the composition of complex compounds.
Sviatoslav Pavlovich Nesterov who introduced a trigger sensor in 1988
and thus framed the concept is acceptedly considered as the originator of the
NLS?diagnostics device (metatron). Active work was immediately started to
develop and improve the NLS?diagnostical systems. Clinical testing of the
early equipment took the period from 1990 through 1995. The late 90s saw a
fast growth of commercial production of the device and a sudden surge in the
quality of the results produced.
The non?linear diagnostics method is still in its developing stage. The
diagnostical techniques are improving so fast, that the system versions have to
be updated every six months. Due to the introduction of some new devices
equipped with digital trigger sensors, the NLS?diagnostics has become not
only far more time?efficient but also quite different in terms of quality. It is
obvious that some runtime techniques, for instance three?dimensional visu?
alization of investigation results will soon become a daily practice. The vege?
tive testing is just an example of a ready implementation. The method is
employed so widely that we should rather speak about a definite range of
indications for its use than just about its popularization.
Research centers continue their quest for some new investigation meth?
ods based on the non?linear analysis systems. So far the results appear to be
quite promising.
Unlike NMR and computer tomography, the NLS?analysis does not
need strong fields. The method seems to have good prospects for metabolism
Clinic Tech Inc. — ascending
into the XXI century
D.V. Koshelenko, S.A. Letun
Head of Clinic Tech Inc. (USA)
Moscow Office
The development of a new generation of non?linear computer scanners
(metatrons) making use of multidimensional virtual imaging of the body of
interest, has allowed to substantially improve the effeciency of the NLS?
method and even expand its fields of application despite the MRT competi?
tion. The originally volumetric pattern of scanning is a distinctive feature of
the multidimensional NLS imaging. The data thus acquired are an integral
array, which facilitates reconstructing multidimensional virtual images of
anatomical structures of the body of interest. In this connection the virtual
NLS is widely used especially for angiographic investigations with a three?
dimensional reconstruction of vascular formations.
Another promissing field of application of the three?dimensional image
reconstruction based on the data acquired by means of multidimensional
NLS is the study of hollow organs with a “virtual NLS?scopy” involved. This
kind of a system was developed by Clinic Tech Inc. for their high?rate multi?
dimensional Z?series non?linear scanners, and was called Hunter. High res?
olution maintained during spiral scanning and the use of LAPP system (a sys?
tem of parallel processors with a powerful computational capability and
speed of operation) allows to implement the principle of “virtual NLS?scopy”
on a Voxel Z multimodal DICOM?compatible work station, which is the
basic system for imaging and subsequent data processing with Clinic Tech
Inc. scanners.
NLS images are made ready for visual analysis by means of the 4D
Tissue, an original company?developed method, that allows not only to
obtain virtual multidimensional images of anatomical structures but also
select a particular biological tissue of interest giving it an extra dimension,
and additionally visualize bones, soft tissues and vessels at a time.
A specific feature of representing virtual data by Hunter system is its
simultaneous vusualization of surfaces of cavatus and extramural formations
located outside the lumen of the cavity under examination (e.g. lymph nodes,
vessels). The acquired images form a natural sequence of virtual NLS shots,
while special navigation programs automatically determine the path of the
7
studies, particularly on a cellular level. The NLS?method advances along the
path not only of technical innovations but also of new applications. Some
minor surgical operations, biopsy for one, have been long monitored using
ultrasound, fluoroscopy or computer tomography. Today we have an oppor?
tunity to have biopsy monitored by NLS. By the way, many surgeons focus on
using this method to assist major surgeries.
The cost of equipment for NLS?diagnostics is still very low as compared
to some other hardware?based methods. This is supposed to promote more
extensive use of the method in countries with low living standards. Of all
methods of hardware?based diagnostics the NLS provides representations
most proximate to the pathologicoanatomic picture. This feature of the
method along with its harmlessness, promotes rapid development of the
NLS?diagnostics.
6
Method of computer non?linear analysis
and its role in diagnostics
V.D. Artyukh,
U.A. Shovkoplyas,
A.A. Gavrilov
The computer?based non?linear analysis (NLS) as a dynamic non?
invasive informative method is increasingly used to examine the status of
health affected by pathologies of different origin. The NLS can be
applied both in vivo (to acquire an NLS?spectrum of one or another part
of an organ or tissue), and in vitro (to obtain an NLS?spectrum of
extracts from tissues, biological fluids or cells); while, rather often both
approaches can be combined for a more accurate data interpretation.
The usage of NLS at a clinic requires devices producing an at least 20?30
mT eddy magnetic field. The proceedings of the latest International
Congress of Medical Doctors (2000 and 2001), that dealt with new
methods of diagnostics give evidence of a growing number of NLS?inves?
tigations used for the diagnostical purposes ? the 2000 summit heard 16
presentations on the subject, while in 2001 they were twice as many.
S.D. Tutin et al. informed of the possibility to use the NLS to diag?
nose abscesses in the encephalon. It appears, that at an abscess in the
encephalon in the NLS?spectrum, during the biochemical homeostasis
evaluation some signals from lactate and amino acids are detected, which
disappear in the course of treatment. The NLS data in vivo correlated
well with the results of abscess sample tests made by means of MRC with
a high resolution in vitro.
Using the NLS?method the dynamics of metabolic change in the
encephalon when treating epilepsy can be traced. Some data are avail?
able, that indicate a possibility to register a decline in oxidative phos?
phorylation in the lower limbs muscles with constriction of the vessels
caused by arteriosclerosis. In the course of treatment the muscle metab?
olism appears to improve. Another trend in the application of the NLS
method is detection of metabolic disturbance of phosphorergic com?
pounds at muscular atrophy related to a pathology in the musculoskele?
tal system. Some promissing prospects for myocardial infarction diagno?
sis by means of the NLS method were described by U.A. Shovkoplyas et
al., who studied the ATP exchange in the myocardium. At a myocardial
9
“virtual scanner” by center of the cavity under examination. The path of the
motion can be chosen by operator using some other settings, which allow to
detail the NLS picture by changing the view fields. A raised representation of
the cavity surface is also achievable by shaping particular artificially shaded
areas . The produced sequences of NLS shots can be easily converted into a
standard VHS video format by means of the epi?Client program and thus be
used in standard video systems, in particular for teleradiology.
The Hunter system is primarilly designed for case detection of obstruc?
tive processes in the upper respiratory passages, bulky esophageal, gastric or
colonic formations, atherosclerotic lesions of large vessels, and disorders
affecting paranasal sinuses, urinary bladder or spinal canal. The data gath?
ered by “virtual NLS?scopy” allow to pick out the optimum spot for biopsy
and define the extent of the required surgical intervention in good time.
This technique can be used both solely and as a useful linking element
between tomographic, endoscopic and NLS investigations.
The Clinic Tech Inc. latest development is its Pincers stereo tactic
manipulator integrated into a computer scanner, which is a convenient tool
for planning interventional procedures monitored by NLS. The Pincers com?
prises a controlled stereo tactic manipulator (“arm”), a flat gentry?mounted
monitor, a cable system and software. The system provides the physician with
the means of simulating and performing interventional procedures through
an interactive link between the virtual NLS and the real operational field.
8
tor the biochemical responses to treatment.
Summing up the above it can be concluded that the ever growing use
of NLS?analysis in different fields of clinical medicine, including its
combination with MRT with contrast amplification involved, increases
the efficiency and diagnostic accuracy and is indicative of a continuous
progress in the field of internal organ visualization techniques based on
the NLS?analysis phenomenon.
11
infarction its level was proven to decrease. The NLS?analysis method was
employed to study the dynamics of change in the metabolism of lipids in
the liver affected by cirrhosis. The NLS?investigation of the pancreas
affected by malignant degeneration allows to diagnose tumor progres?
sion, judge of the efficiency of radiation? or chemotherapy and also
adjust individual dosage schemes for inoperable patients.
Moreover, NLS is reported to be used to diagnose CNS disorders,
cardiovascular diseases, muscular system disorders, prostate tumors,
mammary gland tumors and in addition to monitor radiation? and
medicinal US therapies. The researchers have demonstrated the diag?
nostic  importance  of  NLS  for  arteriosclerosis,  apoplexy,
encephalomyelitis and vasculitis. NLS allows to estimate the phase of a
pathology and activity of the nidus, determine a relationship between
genetic characteristics, clinical symptoms and metabolic deviations in
the encephalon. NLS helps to differentiate between benign and malig?
nant tumors in the mammary gland. The studies of abnormal changes in
the prostate gland by means of NLS showed that the method allowed to
identify an incipient change in the gland tissue and pick out the appro?
priate therapy in good time.
K.A. Kvasov et al. presented some data about diagnosing prostate
diseases (including histologically confirmed benign hypertrophy and
Aden carcinoma) by combining NLS and dynamic MRT with artificial
“Magnevist” contrasting. According to the derived results, this kind of
combination allows to define the pattern of a prostate pathology and sub?
stantially increases the diagnostic accuracy. In the recent years special
attention has been focused on a study of liver metabolism by means of
NLS necessitated by a growing number of transplantations of the organ
(in Europe the annual number of liver transplantations is around 2000
and in the USA it is 10000) and due to this method’s noninvasive evalu?
ation of the liver function in the course of implantation. The results indi?
cate apropriateness of using the NLS?analysis in these cases since the
ATP level in the liver mirrors an integrated picture of cell homeostasis.
There is a close correlation between the disturbed metabolisms of phos?
phorergic compounds and the extent of liver decompensation.
Apart from diagnosing liver disorders in vivo, the NLS allows to
judge on the state of the transplanted liver in vitro by acquiring spectral
characteristics of the organ’s metazodes. This is based on a good correla?
tion between the pathological liver metabolism defined by means of NLS
and the disease prognosis. The authors would like to emphasize that NLS
allows not only to define pathological change in the liver but also moni?
10
According to the cancer register for 1999?2000, the values of gastric and
colonic cancer cases were 80.9 and 53.1 respectively per 100000 patients, and the
death rate according to the mortality statistics was 47.35 and 19.5%. According
to the conclusions of therapy?diagnosis unit, with around 70% of patients under
active dispensary observation, the pathologies of that kind are likely to be detect?
ed as often as in 0.4?0.8 % of cases. Therefore, the NLS screening would allow to
detect GC or CC in about every 150th?200th examinee.
Considering that the emergence of clinical signs is one of the incentives
for a patient to take medical advice and a reason for hardware?based exami?
nation, some clinical implications and their pattern were evaluated in the
cases of the above mentioned diseases. As followed from the results, in 720
patients affected by GC or CC the condition appeared to be symptom?free in
42% and 32% of cases respectively or there were some signs characteristic of
previous chronic digestive tract diseases. That was the case in 77% and 92%
for the 1st phase, 56% and 68% for the 2nd phase, 23% and 32% for the 3rd
phase, and 8% for the 4th phase of the disease. The clinical implications at a
gastric cancer were of a pain?dyspepsia syndrome nature typical for the lesion
in the upper section of the digestive tract. At a colonic cancer subgroups were
segregated with dominating signs of intestinal hemorrhage, disturbed evacu?
ation or abdominal pain. A certain interrelationship was proven between the
pattern of the clinical implications and the process localization. In more than
50% of cases the clinical implications lasted less than 3 months and in 26%
of patients the CC developed acutely within a few days. It should be noted
that the so?called “minor sign syndrome” corresponded to some later phases
of the disease. The same was true for lab examination data where the change
became evident during phases III and IV (2).
The results of NLS?diagnostics for the initial phases of gastric cancer in
a series of 104 examinations showed that in 72% of cases the physician on the
assumption of a spectral similarity to the reference standard, regarded the
lesion as benign and indicative of focal mucosa hyperplasia, polyp, an area of
local inflammation, wall deformation or a small ulcer. The probability for
detecting signs of malignant change found out in the elimination mode was
under 1%. Of 134 cases of colonic cancer in phase 1 malignant adenomas
were detected in 58% of patients. The rest of the patients were found to have
the co?called “minor” forms of cancer, like polyps, atrophic gastritis or
atrophic?hyper plastic gastritis. The endoscopic verification of GC and CC
with reference to the diacrisis of phases II, III and IV of the diseases com?
pletely confirmed the results of the NLS?investigation.
172 patients were found to have GC or CC discovered by NLS?examina?
tion conducted within a less than a year interval. Among them 62% of patients
13
Potentials of NLS method in diagnosing
gastric and calonic cancers
P.A. Svetlova, N.A. Sorokina,
T.G. Kuznetsova, V.I. Nesterova,
L.A. Yankina, N.V. Tatisohev
The non?linear diagnostics method (NLS) used in the Oberon device has
been actively practiced lately at many medical institutions. The most tangible
results were achieved by using the NLS method as a means of dispensary
observation. In the course of its development and advancement the method
has become a foremost tool of diagnostics and observation with respect to a
number of widespread digestive organs diseases; it allows to promptly collect
detailed information about a lesion and its pattern and assess the treatment
efficiency. That kind of diseases include gastrodoudenal ulcer, chronic gastri?
tis, and also benign and malignant gastric and colonic tumors. The specific
character and working conditions of the therapeutic and clinical institutions
in Russia allow to extensively employ the NLS method not only for diagnos?
ing diseases with some symptoms present but also for dispensary observation,
and what is more, practically all the patients in need of examination can be
placed under observation. So the physicians can now cover patients with the
changes that are latent and can only be verified by means of NLS. Specifically,
such patients include those having precancerous diseases or a mucous distur?
bance in the upper and/or lower sections of the digestive tract and patients
who developed a tumor, which still remains latent in a certain phase.
According to the data acquired by some medical specialists, using the
device for NLS?diagnostics, and based on annual research in thousands of
cases, the frequency of detecting focal or diffuse changes, typical for chronic
atrophic gastritis in patients over 50 years old, is within 30?40%. The analy?
sis of the spectral examinations of pattern?different sections of focal changes
in stomach mucosa shows that different symptoms of diseases including
intestinal metaplasia and epithelial dysplasia can be detected in them just as
often. During NLS analysis symptoms of gastric ulcer were recorded in about
5% of cases, polyps in stomach in 7% and polyps in colon in 45% of cases.
Thus, even the NLS analysis results alone, without other risk factors taken
into account, indicate that most of the patients in the respective age group
appear to be among those who need dynamic observation because of poten?
tial gastric cancer (GC) or colonic cancer (CC).
12
detection. The analysis of the available data allows to assume that tumor may
develop within a short time interval reaching the size of either “minor cancer”
or extensive lesion. All that confirms the idea that the tumor growth dynam?
ics in different patients and in different phases of the disease is likely to vary
and be of both continuous and discrete pattern. So a possible scenario of
tumor development could be the emergence of “early” gastric cancer against
the background of precancerous gastric diseases with a subsequent prolonged
period of existence in the initial phase which allows to diagnose it after a year
or a longer time later. At the same time, this “benign” scenario of disease
progress is not typical for some patients and because of the rapid tumor growth
we just fail to detect the initial phase of the condition in advance. The colonic
cancer development through the benign phase and then through a malignant
adenoma is not the only possible scenario it can proceed. Tumor can develop
de novo and here too, a variant of a comparatively slow or fast growth is poten?
tial. This provides an explanation for an “accidental” detection of patients with
fairly large tumors during dispensary observation and a great number of
patients with a short clinical anamnesis and late phases of the disease.
Thus, NLS can be considered as an adequate method for diagnosing gas?
tric and colonic cancers. The difficulties in dealing with NLS interpretation
largely concern the initial phases where the frequency of disease detection
depends in the long run on how keen the physicians are on performing a spec?
tral verification of any focal changes in the mucosa in the case of a chronic
gastritis and on keeping the patients under dynamic observation at the given
modes of elimination and NLS?analysis involved. The submitted results allow
to segregate two principal variants of the disease diagnosis. The first one sug?
gests “accidental” tumor detection during NLS?investigation; neither clinical
nor other familiar signs of disease are in evidence or their intensity is an insuf?
ficient reason for the patient to see a doctor. The second variant occurs when
the patients develop clinical implications which impell the physician to carry
out the respective investigations for them. The results of diacrisis of gastric and
colonic cancers indicate that for most patients the problem of early diagnosis
can not be solved, not only because of certain organizational factors but also
and primarily because of the specific pattern of the disease progress and its
manifestations. However, the actual opportunities for improving the well?
timed disease diagnosis in practical public health conditions lie, primarily, in
increasing the number of patients to be examined by means of the NLS?
method within the frameworks of a health survey and also in a timely and
complete examination of the patients who are suspected to have the disease.
15
had an initial phase of gastric cancer and 38% of the patients during previous
observation were found to have some or other signs of chronic gastritis in the
form of focal mucosa hyperplasia, local inflammation or wall deformation.
According to morphological investigation, the said sections were of a benign
nature and cancer developed therein over the last year only. In the rest of the
patients the macroscopic changes corresponding to malignant affection (spec?
tral similarity to “gastric carcinoma” reference standard D<0.425) occurred in
the span between the last two examinations. The preceding endoscopy detect?
ed atrophic gastritis free of focal changes in the area of the developed tumor.
Similar NLS data were acquired for 38 patients who during a year’s observation
were diagnosed to have developed a tumor corresponding to phases II and III.
The NLS of the colon and straight intestine was performed a year before
tumors were diagnosed in 21 patients affected by malignant polyps, of whom 17
had been under active observation because of polyposis, while no formation of
that kind was in evidence during the initial examination. In addition, within the
same time span 13 patients were examined who were diagnosed with a precan?
cerous condition (spectral similarity to straight intestine carcinoma, reference
standard D>0.7) and minor forms of cancer. In 6 of the patients the tumor
developed in the area of endoscopic polypectomy after they had a large villous
adenoma removed. Thus, in 34 (27%) of 121 patients, who were diagnosed to
have a malignant polyp condition in phase I or a small size tumor, colonic can?
cer developed within a year. 36 patients examined within the same time interval
were found to have the conditions in phase II and III just as frequently. 28 of
them were subjected to regular medical check?ups with no clinical signs of the
disease in evidence in any of them. 8 patients, within 3?7 months prior to tumor
diagnosis, began to show signs of growing anemia or progressing stool retention.
The dispensary observation data for these patients, with the NLS method
employed a year before the cancer was detected, had indicated no tumor .
There are two very essential factors known to be of paramount importance for
malignant disease diagnosis; they are the quality of clinical and diagnostic techniques
and the specific pattern of the disease progress which actually determine the dynam?
ics of the disease progression. Considering the capabilities and working conditions in
the therapeutic institutions, the presented data on gastric and colonic cancer diag?
noses may to a certain extent be regarded as optimum. It implies, that even if all the
patients were readily diagnosed with the disease during the dispensary observation
(actually it is a matter of 60%), the phase I condition could have been detected only
in 40% of them. The analysis of causes of the late diagnosis cases suggests that such
cases could be prevented by improving organizational and methodical work.
Furthermore, the focus should be placed on the specific features of the
disease progress which are of great, and possibly of vital importance for tumor
14
International Anticancer Association in 1997 (the 5th revision). Phase T1
was diagnosed in 13 patients (21%), phase T2 ? in 26 patients (43%), phase
T3 in 17 patients (28%) and phase T4 in 5 patients (8%).
According to a pathomorphological examination, metastases into
regional lymph nodes were detected in 11 of 61 cases.
All the patients underwent NLS?investigation and ultrasound colonoc?
sopy to diagnose and localize new growths, define their size, growth patterns
and approximate morphological characteristics, and also ultrasound scan?
ning of the abdominal cavity and small pelvis organs to assess the condition
of the organs adjacent to the colon and diagnose distant metastases.
The NLS?investigation used the Oberon?4011 device equipped with a
4.9 GHz nonlinear sensor manufactured by the Institute of Practical
Psychophysics (Russia) and Clinic Tech Inc. (USA). The endoscopic ultra?
sonography made use of the endoscopic ultrasonographic system UM?20
complete with the ultrasonic colonoscope CF?UM20 (Olympus, Japan). The
echographia of the abdominal cavity made use of the diagnostic unit SSD?
630 (Aloka, Japan) and Logiq?700 (General Electric, USA).
Discussion of results
We know from experience that every NLS?investigation should be pre?
ceded by diagnostic colonocsopy, which evaluates anatomic characteristics of
the colon and defines the number, localization and macroscopic characteris?
tics of the new growths, and by ultrasound scanning of the abdominal cavity
as well. A thorough transabdominal ultrasound scanning is required to assess
the condition of the organs adjacent to the colon and diagnose remote metas?
tases.
A comparison of the NLS results with those of pathomorphological
investigations was made in order to define the potentials of the NLS?method
in differential diagnostics of benign and malignant colonic new growths.
The results of the NLS?investigation coincided with the pathomorpho?
logical investigation in 87 of 91 cases. Most of the errors occured in diagnos?
ing colon adenomas. In 6 of 31 cases the patient was suspected of having can?
cer. The analysis of the observations noted that difficulties in diagnostics were
related to the deformation of intestinal wall layers due to the pressure of a
nodal villous tumor rather than to a genuine invasion. Two false?negative
results were obtained in the case of malignant adenoma and cancer diacrises.
Thus, the accuracy of the NLS method in differential diagnostics of
malignant and benign colon tumors amounted to 81.3% and sensitivity to
79.8%, while the specificity made 76.4%. The method of treatment to be
chosen for patients affected by colon cancer depends on the tumor process
17
New potentials of NLS ?method
in colonic neoplasm diagnostics
V.I. Nesterova, T.G. Kuznetsova,
V.I. Metlushko, N.L. Ogluzdina
Introduction
Colonoscopy is successfully used today to diagnose colon new growths.
Based on a number of indications endoscopic investigation allows to get reli?
able information about the colonic growth surface in order to correctly clas?
sify its pattern and take a sample for morphological identification. Yet,
colonocsopy does not give an idea of the kind of internal structure the new
growth has, nor does it allow to assess the depth of the invasion of the colon
wall by a malignant tumor, determine its proliferation to adjacent organs or
metastases to regional lymph nodes. Besides, colonocsopy does not provide
information about extra intestinal new growths unless they have already per?
meated the intestinal wall.
The NLS?investigation of the colon using a 4.9 GHz high frequency
nonlinear sensor can help clear up all of these issues.
The NLS?investigation allows to examine intestinal wall layers and the
adrectal cellular tissue.
This research aimed to define the potentials of the NLS?method in a
more specific diagnostics of straight?and segmented intestine tumors.
The matter and investigation methods
In order to achieve the set goal 87 patients were examined in whom 91
new growths were investigated by means of the NLS?method. The examinees
included 41 men and 46 women aged from 31 to 83 with most of them (82%)
aged 50 and over. All the patients affected by colon new growths were given
one or another kind of surgical treatment depending on the pattern, size and
localization of the growth. Among them in 23 cases endoscopic polypectomy
was performed, in 61 cases a resection was done on different parts of the
colon and in 3 patients transanal endomicrosurgery was performed. All of the
NLS?investigation results were verified by a pathomorphological examina?
tion of macro preparations according to which the colonic new growths were
represented by simple tumors in 30 cases and by glandular cancers with dif?
ferent degrees of differentiation in 61 cases. The stages of the malignant
process were defined according to TNM classification adopted by the
16
At this essay the greatest group were the tumours sized from 2 to 5 cm,
where the results proved to be lower, than in two first groups. The NLS data
and those of the pathomorphologic essays coincided in 66,7 % of cases. An
appreciable share of mistakes (60 %) occurred in phase Т2, where the intes?
tinal wall invasion depth was overestimated in all observations.
The great value has the fact, that according to pathomorphologic essay,
in 5 of 6 cases of hyperdiagnostics apart from the tumoral infiltration an
expressed inflammation was detected in deeper layers of the intestinal wall.
The relatively low accuracy of diagnosed depth of the intestinal wall invasion
by a tumour sized from 2 to 5 cm is due to the fact that 24 of 30 observations
of this group corresponded to phases Т2 and ТЗ. A differential diagnostics of
the tumoral infiltration depth in these phases is complex.
At the next research stage we made comparative analysis of the effect of
the form of growht of the neoplasm for accuracy of defining the phase of
tumoral invasion in the intestinal wall. All neopasms were classified into three
groups In function of the shape of the tumor growth: polypiform, saucer?
shaped and infiltrative.
The highest results were obtained when diagnosing the phase of the
saucer?shaped growth cancer process where the accuracy of defining the
tumoral invasion in the intestinal wall was 78.3 %.
It seems however impossible to fully estimate the accuracy of the NLS
method in defining the depth of a tumoral invasion at neoplasms with saucer?
shaped growth because of its dismall occurrence among other forms in
patients surveyed by us.
The polypiform of the growth was noted in 30 neoplasms. The growths
had a distinct interface with unaltered sections of the intestinal wall and did
not block the intestine lumen by more than half, which created favorable
conditions for the survey. The accuracy of NLS method in defining the depth
of tumoral invasion in the intestine wall was as high as 65 %. It has to be
noted, that half of all cases divergent with the pathomorphologic conclusions
is due to the overestimated depth of tumoral infiltration at defining the phase
Т2, which is connected with the presence of a perifocal inflammation.
This fact suggests difficulties in defining the phase of a cancer process in
cases where the tumoral invasion is compounded by the inflammatory com?
ponent penetrating deeper layers of the intestinal wall and beyond its limits.
The neoplasms with an infiltrative growth shape have proved to be most
difficult in defining the degree of the tumoral invasion into the intestinal wall.
In this this group the results of NLS method and those of the pathomorpho?
logic essays coincided only in 49,8 % of observations. It was due to the fact
that these neoplasms, as a rule, had a large size and occupied more than a half
19
phase. A comparison was made to the pathomorphological investigation data
in 61 cases in order to assess the diagnostic effeciency of the NLS?method in
classifying the colonic cancer phase.
The correct definition of the phase of tumor process was possible in
68.4% of the observations. The best results were obtained in defining phases
T3 and T4, where the diagnostic accuracy was 78.2% and 81.2% respective?
ly. It should be noted that most of the errors occurred in determining phases
T1 and T2, where the data of NLS and pathomorphological investigations
coincided only in 54.2% and 47.4% of the observations respectively.
In diagnosing phase T1 mistakes were made in 4 cases with 3 of the
errors toward overstating the phase; in one case signs of intestinal wall inva?
sion were not found and the tumor was taken for adenoma. In the analysis of
phase T2 diagnostic errors in overstated phases were noted in 7 of 9 cases; an
understatement of phase of the tumor process occurred in one case and yet in
one case no evidence of invasion proved to be found. The analysis of the post
surgical morphological conclusions made it clear that in 6 of 7 false positive
results the pathomorphological investigation of a macro preparation detect?
ed a deeper infiltration into the intestinal wall. However, according to micro?
scopic examination, the infiltration was of inflammatory rather than of a
tumorous kind. It should also be noted that in all of the cases it had to do with
an infiltrative tumorous process in the inferior ampullar section of the
straight intestine free of serous membrane while the inflammatory infiltration
area was located in adrectal cellular tissue.
To find out the causes that present difficulties for diagnosis the efficien?
cy of the NLS?method was analysed in function of the size, localization and
form of germination of neoplasms. The best results were obtained in diag?
nosing new growths sized under 2 cm and over 5 cm.
The epithelial tumour over 5 cm in size is represented by phases ТЗ and
Т4 in 12 of 17 cases. It has to be noted, that at large neoplasms the data of
NLS essay did not coincide with pathomorphologic data only in phase Т2,
where the process phase was overestimated because of the presence of inflam?
matory infiltration in deeper layers, than the layers where the tumoral inva?
sion occured. Thus, at neoplasms larger than 5 cm in size the diagnostics of
the invasion degree of the intestinal wall is feasible in 78.2 % of observations.
High results were also obtained at the estimation of depth of tumoral inva?
sion by neoplasms sized up to 2 cm. Most of them are represented by a
tumour in phases Т1 and Т2. The results of ultrasonic colonoscopy have
coincided with those of pathomorphologic conclusions in 76.7 % of the
observations. It should also be noted, that tumours sized up to 2 cm are most
convenient for examination since they have the least number of artefacts.
18
3. The diagnostic efficiency of NLS method in defining the phase of
tumoral process in the rectum is lower, than in segmented intestine.
4. The diagnostical accuracy of the cancer phase in colon depends as
much on the size as on the anatomic shape of the tumour growth. The best
results were obtained at defining depth of invasion of the intestinal walls by a
tumour sized under 2 cm and over 5 cm.
21
of the intestine wall circle. In the next investigation phase we estimated the
accuracy of the NLS method in defining the degree of the intestinal wall
invasion depending on the tumour location in the colon.
In 40 cases the tumour was localized in the rectum and in 21 cases in the
segmented intestine. The accuracy of diagnosing the phase of the tumoral
process in the colonic intestine is significantly higher, than at finding the
tumoral invasion depth with the neoplasms located in the rectum and
amounts to 71 and 62,5 % resppectively. This high result can be most likely
explained by the fact, that this department of colon contains a serous mem?
brane, which distinctly separates the muscular layer from the abenteric
organs and tissues. Also it is noted, that the serous membrane of the intestine
is less subjected to penetration of the inflammatory infiltration, than the
pararectal cellular tissue. The majority of mistakes falls on the cases of over?
estimated depth of the invasion at defining Phase Т2.
These researchers have noted, that accuracy of diagnosing the phase of
a tumoral process was higher in colonic intestine, than in rectum. The great?
est number of mistakes occures in Phase Т2, which is conditioned by the
presence of abscesses, inflammatory infiltraion or radial therapy in the neo?
plasm area. Damaged regional lymph glands are an important prognostic fac?
tor in diagnosing rectum cancer . To define the capabilities of the method in
diagnosing metastases in regional lymph glands, the results of the NLS
method were compared with those of the pathomorphologic essay. In the lat?
ter the malignant damage to the regional lymph glands was detected in 11
observations from 22 cases.
The analysis of the derrived data proved that the NLS essay had correct?
ly defined the pattern of damage to the lymph glands in 63.6 % of cases.
The metastatic pattern of damage to the lymph nodes was defined in
74.8% of cases, and in inflammatory changes the results of the ultrasonic
colonoscopy and those of the pathomorphologic essay coincided only in 45.5
% of observations. In 6 from 11 of cases the presence of metastasises in lymph
nodes was assumed (false?positive result). Such mistakes can be attributed to
oncologic vigilance of the researcher and complexity of differential diagnos?
tics of inflammatory and metastatically?altered lymph glands.
Conclusions
1. NLS diagnostics is a highly efficient method of diagnosing the neo?
plasms of the colon, allowing to diagnose neoplasms and regional lymph
glands.
2. The NLS method allows to detect the colon adenoma and cancer by
the presence or absence of the tumoral invasions in the intestinal wall.
20
because NLS does not allow to provide a vessel’s image and hence to meas?
ure the vessel’s diameter. This kind of information may be acquired with the
help of Doppler systems with 2D?imaging, that offer duplex and triplex scan?
ning (the so?called Doppler chromatic charting).
The NLS?method was developed in the mid 90?s and played an essential
role in vascular pathology diagnosis. The main advantage of the NLS?method
was that it facilitated search and locating the vessels and allowed to very quick?
ly differentiate vessels from nonvascular structures, arteries from veins and
very accurately detect signs of disturbed vascular permeability caused by
stenosis or occlusion of the vessel lumen by an atherosclerotic patch or a
thrombus which are generally not visible at scanning in B?mode alone.
In addition the NLS?method allows to diagnose portal hypertension,
the extent of its intensity, and permeability of Porto systemic bypasses. NLS
is very sensitive in defining the extent of peripancreatic vessel involvement
with pancreas cancer which is essentially important for choosing the
approach for surgical treatment.
NLS allows to detect the damaged renal vessels (both veins and arteries),
which is very important for the correct choice of a hypotensive drug at arte?
rial hypertension.
Some effecient hypotensive drugs, i.e. inhibitors of angiotensin?convert?
ing enzyme (ACE) such as capoten, enalapril, berlipril, ect., became very
popular lately, but they have counter?indications at renal artery stenosis. So
physicians should bear in mind that checking for stenosis is a must before
prescribing this kind of medicine. The NLS?method is likely to be the choice
method in such cases.
The NLS?method is indispensable for differential diagnostics of benign
and malignant hepatic diseases. Its sensitivity is comparable with the poten?
tials of conventional or digital angiography and computer?assisted amplified
tomography. In addition, the NLS?method is much cheaper, simpler and
more intelligible. It can be employed directly at the patient’s bedside if
required. The NLS?method may be used in ophthalmology to check ocular
hemodynamics before or after surgical intervention, in obstetrics to detect
the disturbed blood current in umbilical cord arteries with a view to diagnose
a retarded fetus development and predict a negative perinatal produce.
Yet another potential of NLS method lies in cranial scanning which
allows to detect intracranial hematomas, aneurisms, cysts and tumors in the
encephalon.
These are far from all potentials of the NLS method.
Summing up, the NLS?method is one of the most dynamic techniques
and within the next few years it is bound to bring some new discoveries.
23
NLS — method in vascular pathology
diagnosis
S.M. Patrushev,
A.D. Sluzky, V.M. Vagulin
Today the world faces a constant trend of a growing rate of mortality
caused by occlusive vascular diseases, especially by cerebrovascular disorders
which are in the third place among death causes. On the one hand the trend
is caused by a growing number of elderly and aged patients. On the other
hand many men even already at 45 have atherosclerotic damage of main
head arteries, causing the need for a dispensary observation.
The most simple and at the same time informative method of noninvasive
diagnosis of occlusive damage of peripheral vessels appeared to be the NLS?
method which has been used in clinical practice not long since. The first NLS
devices equipped with analog trigger sensors, operating in 1.4 GHz frequency
mode and used in clinical practice since the late 90?s have not lost their impor?
tance yet. They can help determine the condition of certain sections of the
main vessels in the lower limbs and that of the brachiocephalic vessels.
Not only the condition of the vessels but also that of the valvular system
of deep veins can be studied. 102 patients were examined in 1997?1998 to
detect valvular insufficiency of deep veins affected by varicosis. The patients
were from 21 to 67 years old. The examined patients included 25 men
(24.5%) and 77 women (75.5%). The study was carried out by means of the
Oberon device using a 1.4GHz analog trigger sensor. In 32 patients a valvu?
lar insufficiency of the femoral vein was detected, in 44 patients failure of
both femoral and popliteal veins. NLS allows to assess the condition of the
valvular system of deep veins in low limbs on a noninvasive and objective basis
which is very important point for the surgery tactics to be selected, and can
be used as an alternative to phlebography analysis.
The NLS?signal spectral analysis method has no counterindications and
in terms of informational content is comparable to angiography. It can be
used to perform screening in the course of polyclinical examination with a
view to detect early or latent forms of vascular pathology and also as a pre?
liminary method for selecting patients for angiosurgical treatment, since
according to some angiologists, angiography should only be performed on
candidates for surgery picked out after a preliminary NLS investigation.
However, this method does not allow to assess bulk index of the bloodstream,
22
The chromogenic density of the lung tissue around the nidus was some?
what higher (due to infiltration), and the folia of the visceral and parietal
pleuras were blackened in the lower sections of the right lung.
The patient was offered a further therapy in a specialized surgical
department, which he turned down. 3 weeks later, after some anti?inflamma?
tory therapy a check NLS examination was performed. During the exami?
nation the patient complained of coughing with a profuse sputum discharge.
His temperature was normal, the clinical blood analysis indicated a leukocyte
count of 8.6×109, and the differential blood count was within the standard,
and ESR grew up to 37 mm/h. The NLS?investigation visualized a rounded
formation with even outlines, increased chromogenic density and heteroge?
neous internal structure sized 47×43. The chromogenic density of the lung
tissue around the perimeter decreased (because of reduced infiltration).
At the patient’s urgent appeal he was discharged from hospital for further
outpatient treatment. Later he underwent two check examinations conducted.
Patient M., aged 63, was examined by means of the NLS?method in
order to preclude a liver or gall bladder pathology.
An NLS?investigation of the lung and pleural cavities was carried out. In
the left lung and pleural cavities it found no signs of pathology in evidence.
In the right lung in the IX, X and XI hypochondria (from the paravertebral
line to the scapular one) it parietally visualized a formation having an
increased chromogenic density and sized 85×60 mm with uneven outlines
and heterogeneous structure (due to inclusions of a decreased chromogenic
density) sized 3?4 mm. The chromogenic density of the lung tissue was not
increased. NLS conclusion: signs of abscess in the right lung?
Radiological conclusion: abscess in the lower lobe of the right lung.
The patient had check NLS?investigations conducted against the back?
ground of anti?inflammatory therapy. With the NLS?investigation performed
10 days later the formation looked rounded, had even outlines, an increased
chromogenic density (4?5 spoints) and a heterogeneous internal structure.
Around the perimeter of the nidus the lung tissue had an increased chro?
mogenic density (3?4 points) because of infiltration. The formation meas?
ured 73x50x60 mm. The NLS?investigation 2 weeks later did not detect any
positive dynamics from the administered anti?inflammatory therapy.
The submitted clinical observations once again confirm that the NLS?
investigation with lung diseases is not used in clinical practice as often as it
deserves.
Besides, the dynamic NLS?observation of the patients affected by lung
diseases allows to assess the efficiency of the employed therapy and reduce
the radiation load both on patients and on the medical personnel.
25
NLS?diagnostics of lung abscess
S.N. Makarova
A screening NLS?investigation detected two cases of lung abscess in
feverish patients who were complaining of pain in the right hypochondriac
region. The patients were subjected to echography in order to preclude an
abdominal cavity pathology.
The NLS examination was conducted by means of “Oberon?4009”
device equipped with a digital trigger sensor. (1,4GHz).
Patient N., aged 57, was admitted to the therapeutic department. He was
complaining of a week?long fever with a temperature of up to 40?C, a mod?
erate non?productive cough and pain in the right hypochondriac region as a
result of catching a cold. He came to see a doctor ten days after falling ill. The
anamnesis read a bilateral pneumonia 14 years before. The clinical blood
analysis indicated an increased leukocyte content ? up to 18.7 x 109 with a
flush left leukogram. The common urinalysis showed no deviations. Physical
examination: vesicular pulmonary respiration, weakened in the lower sec?
tions on the right with no rhonchi.
Tongue dry, white furred. Belly soft, with frank painfulness in the right
hypochondriac region. No symptoms of peritoneum irritation in evidence.
Pasternatski symptom negative on the right and left.
The NLS?investigation of the abdominal cavity did not detect any signs
of pathology in the liver, gall bladder or pancreas. On the right there are visu?
alized blackenings in the diaphragmatic pleura (4?5 points according to
Flandler’s scale) and an image of voluminous formation in the right lung was
acquired (5?6 points). On the dorsal thoracic wall there was an image of a
enhanced chromogenic formation (6 points) of a heterogeneous internal
structure, sized 80x65x54 cm. The lung tissue around the nidus had a higher
chromogenic density (4?5 points) on account of infiltration. A spectral simi?
larity to the “lung abscess” reference standard (D=0.312) was detected. The
investigation of the left lung and pleural cavities did not detect any structur?
al changes. NLS conclusion: certain signs of developing abscess in the right
lung.
The check radiological investigation arrived at the conclusion: an
abscess in the lower lobe of the right lung in progress.
A repeated NLS examination was conducted 10 days later. It visualized
a rounded hyporchromogenic formation with uneven outlines with some
hyporchromogenic zones inside, sized 81x60x51 mm.
24
did not show any changes. According to some literary evidence, in this phase
the histology detects a substitution of the fat bone marrow for the red bone
marrow often accompanied by enlarged trabeculae. This phase generally pre?
cedes an osteochondrosis development which can be diagnosed a little while
later by conventional radiographs.
The spectral similarity to the reference standard “intervertebral osteo?
chondrosis” was frank (D 0.246 to 0.360).
Degree 3, a frank hyperchromous response (6 points), which corre?
sponds to a far advanced vertebral body sclerosis, was detected in 312
patients. Some secondary symptoms, like local bulging and vertebral asteo?
phytes, were detected with a far advanced degenerative lesion of the disks and
a substantial similarity to the reference standard “osteochondrosis” (D from
0.152 to 0.218). NLS allows to differentiate between a protrusion and pro?
lapse of the disk and existence of rupture of the fibrotic ring and the condi?
tion of longitudinal and other ligaments.
A protrusion is defined as a bulging of the disk tissue beyond the poste?
rior outline of the vertebral body into the spinal canal. The fibrotic ring tissue
endures though becomes very thin and NLS only reveals a zone of slight
destructive change in the structure (3?4 points). The pulpous nucleus shifts
dorsally much farther in the disk. The protrusion has a wide base and can
spread as far as intervertebral foramina with the inferior part of the foramina
filled with disk tissue. The compression of the intraforaminal structures can
cause irritation of the nerve root. Normally, the nerve root uninvolved in the
process gives a moderate response (3?4 points). With compression it gives an
acutely frank hyperchromous response (6 points).
Protrusion may be accompanied by a slight caudal shift which is quite
often defined by means of the NLS?method at L5?S1 intervertebral disk level.
NLS detected protrusion in 729 patients.
The rupture of the fibrotic ring fibers results in the prolapse of the
pulpous nucleus on a subligamentary level and the ligament rupture results in
the prolapse inside the cerebrospinal canal. As can be seen from NLS, the
longitudinal ligaments look well delimited and are represented as hyperchro?
mous band?like structures (5?6 points) which adjoin the bones and the fibrot?
ic ring. The extraligamentary prolapse can shift either in a caudal or a cranial
direction. The extraligamentary prolapses of the disk that lost contact with
the host disk become sequesters. Occasionally, we observed some very small
extraligamentary sequesters which shifted far into the cerebrospinal canal,
which made it hard to detect them.
The NLS?investigation detected prolapse in 445 patients. In 68% of cases
the hernia of intervertebral disk was combined with other degenerative dystroph?
27
NLS?diagnostics of degenerative
changes in the spine
A.G. Brusova, P.A. Manokhin,
T.K. Puzanovskaya, T.A. Shyshkovets
Computer Nonlinear Diagnostics (NLS) is a new highly informative
method provided to examine the spine and spinal marrow. The NLS advan?
tages are noninvasiveness, scalability of the image field, a capability to obtain
sections of any orientation and virtual imaging of radicular canals and par?
avertebral zone. Undoubtedly the use of NLS in diagnostics of degenerative
spine diseases has apparent prospects.
Subject and methods
The investigation was conducted by means of “Oberon 4009” metatron
equipped with a 1.5 GHz digital trigger sensor. 1217 patients affected by
degenerative changes in the lumbar region of the spine were investigated. The
NLS of the spine and spinal marrow was performed for all patients, 112
patients had NLS and CT, and myelography was performed for 10 patients.
Analysis of results
In 87% of cases in the examinee group we found disks affected by
degenerative changes. The earliest degenerative change in intervertebral disks
(ID) was a hyperchromous lesion (6 points on Flandler’s scale) in zone
between the pulpous nucleus and the fibrous annulus. Along with the degen?
erative changes NLS has detected an increased chromogenic density of the
signal from the bone marrow in the adjacent regions of the vertebral bodies
(4?5 points according to Flandler’s scale). 3 degrees of degenerative changes
could be distinguished depending on the process intensity.
Degree 1, a hyperchromous zone appraised at 4?5 points on Flandler’s
scale, was detected in 90 patients. Conventional radiographs did not display
any changes. Formation of fibrovascular tissue followed by its penetration
into the bone marrow is believed to underlie the changes. Some authors relate
these changes to the lack of stability in this segment.
The histograms displayed a spectral similarity to the reference standard
“intervertebral osteochondrosis” (D 0.396 to 0.425)
Degree 2, a hyperchromous responce in the affected zone at 5?6 points
on Flandler’s scale was detected in 215 patients. Conventional radiographs
26
NLS ?diagnostics of diffuse
infiltrative lung diseases
V.I. Nesterova,
T.G. Kuznetsova,
N.L.Ogluzdina
Among different kinds of lung disorders special attention has been paid
over the last years to diffuse infiltrative lung diseases (DILD), which is large?
ly accounted for by some problems in their timely diagnostics and treatment.
Most diffuse lung diseases involve in the pathological process both the
interstitial tissue and the respiratory tract and alveola. In this connection this
type of pathological processes should be defined rather as diffuse infiltrative
than as interstitial diseases. Despite of the polymorphism of clinicomorpho?
logical manifestations of DILD, most of them start off with productive alve?
olitis (in contrast to the exudative alveolitis in the case of a pneumonia) with
fairly stereotyped changes in the lung interstice in the form of inflammatory
infiltration with different degrees of intensity. Subsequently a fibrosis devel?
ops that can have different rates of progression. A ‘cellular lung’ pattern is the
final phase of the development. It should be noted, that some infectious dis?
eases of certain etiology (like tuberculosis, histoplasmosis, etc.) and particu?
lar malignant tumors (lymphogenous carcinomatosis, bronchioloalveolar
cancer) do not directly belong to interstitial lung diseases but are similar to
them in terms of manifestation.
The clinical evaluation of patients with a suspected DILD is a complex
problem. Nonspecific symptoms and in some cases signs detected during
chest examination may be characteristic of a multitude of acute or chronic
lung diseases that involve the interstitial tissue, respiratory tract or alveola.
DILD are represented by an extremely heterogeneous group of diseases. The
DILDs have been described in over a hundred possible versions, however in
clinical practice only about 10 or 15 conditions are most common and it
should be noted that sarcoidosis and various cases of lung fibrosis occur in
clinical practice in 35?50% of all DILDs. Besides, acute diffuse lung process?
es in patients with reduced immunity (also in combination with HIV?infec?
tion) are likely to have a great number of infectious and non?infectious vari?
eties, which X?ray evaluation is found to be difficult.
Unfortunately, the capabilities of conventional roentgenography for
patients with a suspected DILD appear to be limited for the sensitivity and
29
ic spinal changes on this level. The hernia of the intervertebral disk was detected
at L4?5 level in 83%, at L5?S1 level in 15% and at L3?4 level in 2% of cases. A
lesion of several disks was found in 50 patients. 196 patients underwent surgery,
among them 114 had lateral hernia, 76 patients had median lateral hernia and 6
had median hernia. 5 patients had surgery for hernia recurrence. The NLS diag?
nosed extraligamentary sequestrated hernia in 38 patients, and intradural hernia
was diagnosed in 3 persons. Multiple sequesters were detected in 5 patients.
The clinical symptomatology for the prolapse of intervertebral disks was vari?
able and did not always depend on their size. In some cases we observed median
protrusions which did not result in any clinical implications. The clinical sympto?
matology for small sequestrated hernia was no less than for large sequesters.
In evaluating the NLS data not only the size of hernia but also the reserve area
of the cerebrospinal canal and their prepositions should be taken into account.
With a suspected hernia the NLS?investigation should be performed at
least in two planes, sagittal and paraxial, i. e., parallel to the disk plane, and
the sagittal investigation in T1w?SE can be combined with other sequences.
The median prolapses of intervertebral disks in sagittal shots could be
seen quite clearly. The signal content of the hernia predominantly corre?
sponded to the NLS signal content of the pulpous nucleus. The external part
of the fibrotic ring, posterior longitudinal ligament and the dura matter give
a frank hyperchromous response and do not differentiate from one another.
Thus, the NLS?method sometimes fails to present a direct proof of a rupture
in the external part of the fibrotic ring.
It is largely a lesion of the pulpous nucleus on the side of the back edge
of the vertebral body that speaks in favor of the protrusion in axial shots.
Displacement and compression of the spinal marrow can well be seen in both
sagittal and axial projections.
Sagittal shots have an advantage in deciding on the disk prolapse, the size of
intervertebral foramina and the condition of the cerebrospinal canal and bones.
These shots are not significant for detecting an intradural process with the cone
especially poorly visible in them. Frontal shots have drawbacks in determining the
condition of the pulpous nucleus and fibrotic ring. To that end paraxial virtual mod?
els are used, for they allow to differentiate the process between the pulpous nucleus
and the fibrotic ring and sometimes make it possible to differentiate between the
fibrotic ring rupture and the protrusion free of the rupture. Thanks to virtual dimen?
sional scaling sagittal shots allow to well delimit the subarachnoid space.
28
row transplant and clinical symptoms of fever of obscure genesis. The authors
demonstrated high reliability of the NLS in determining fungal infection in
20 of 24 cases. Besides, the fact that no changes were detected during NLS
lung examination allows to assume that the the fever was caused by bacterial
or fungal infection of extra pulmonary genesis.
It is also a proven fact that the sensitivity with NLS is higher than with
standard computer tomography. We examined 150 patients. Using conven?
tional CT (10 mm collimation) and NLS we found that NLS had a higher
sensitivity in recognizing pathological changes in the lung tissue.
Due to its high sensitivity, NLS should be used to define lung diseases in
patients with a normal or obscure aspect of disease who have a pulmonary
disturbance or symptoms that suggest an acute or chronic diffuse lung dis?
ease.
Even with certain clinical signs in evidence the diagnostic accuracy of
classic radiography in patients affected by DILD appears to be limited. The
reason is both superposition of the image in the radiograph and low contrast
of minute lung structures. NLS is free of these aspects, which is why it is
reputed to be a more efficient method for recognizing diffuse lesions of lung
tissue as compared to both radiographic survey and conventional computer
tomography.
Besides, having a higher sensitivity, specificity and diagnostic accuracy,
the NLS method can become a determining factor in evaluating the activity
of a pathological process in patients affected by DILD. In certain cases NLS
can be used not only to define the presence or absence of a pathological
process or the extent to which it has spread, but also to collect information
about the reversibility of changes (in an acute or active phase) as compared to
irreversible (fibrotic) changes in the lung tissue. Moreover, since NLS can
accurately identify the imponderable activity of a pathological process in the
lungs, it can be employed to evaluate the efficiently of the treatment given to
the patients.
The conventional methods for evaluating disease activity, such as trans?
bronchial lung biopsy (TBLB), bronchoalveolar lavage (BAL), chest radiog?
raphy, gallium lung scanning and functional lung tests are insufficiently reli?
able in evaluating the activity and in terms of prognostication. So the open
lung biopsy (OLB) is still the choice method for both diagnosing and evalu?
ating the process activity. We were able to prove, that signs detected in
patients by means of NLS can provide some valuable information and be sig?
nificantly important in defining the activity of a pathological process.
In terms of its prognostic value NLS is now advancing to the foreground
leaving behind some functional lung tests, BAL and even OLB, because it
31
specificity of the method prove to be insufficient. The data on 458 patients
with a histologically confirmed DILD were studied. The chest radiographs
for 10% of the cases turned out to be normal. Among 86 patients affected by
DILD no pathological change was detected in 50% of the patients with his?
tologically proven bronchiectasia and in over 20% of the patients with
emphysema shown on X?ray shots. Radiography may equally show false pos?
itive results of the investigation. We have discovered that in 10?20% of the
patients with the x?ray?confirmed signs of DILD no changes were detected
during the lung biopsy.
The computer nonlinear diagnostixs (NLS) is one of the promising
methods of diagnosing lung diseases of today. NLS appreciably improves the
communication of the fine morphological elements in the lung tissue and
opens up new opportunities for recognizing interstitial diseases of the bron?
choalveolar system. NLS has a high sensitivity in detecting fine interstitial
lesions of the parenchyma and small nodules.
The results of the investigations prove that NLS has a better sensitivity in
detecting both acute and chronic diffuse lung diseases. The sensitivity of the
NLS diagnosis in detecting lung diseases makes 85% as compared to 70% in
chest radiography.
The accumulated experience too, gives additional grounds to assert that
NLS is a highly efficient method for diagnosing a wide range of various dif?
fuse lung diseases, DILD included, and excels the ‘classic’ chest radiography
by sensitivity.
It should be noted that the high sensitivity of the NLS?method is
achieved without sacrifising the specificity and diagnostic accuracy of the
method. In patients affected by DILD the NLS specificity amounted to 86%
as opposed to 76% in radiography. In particular, the high sensitivity (87?88%)
and specificity (83?89%) of NLS were demonstrated in bronchiectasia diag?
nostics.
Although NLS is a more sensitive method as compared to chest radiog?
raphy, its sensitivity in lung disease diagnostics is not absolute and the fact
that no radiological changes were detected by NLS may lead to precluding
lung disease in patients who actually suffer from DILD. 100 patients were
examined by means of the NLS with 86 of them affected by DILD and 14
having no pathological change in the lungs.
Despite a high value of NLS sensitivity and specificity, for 4% of the
patients with biopsy?detected lung diseases the results were interpreted as
being normal. On the other hand, the NLS was proven to be a high?accura?
cy technique for precluding acute lung diseases in patients with immunode?
ficiency. Some examination data were studied for patients with a bone mar?
30
Conclusion. Radiography still remains the most accessible method for
diagnosing DILD yet its informational content appears to be not sufficient.
Making a correct diagnosis necessitates a combination of laboratory,
functional and radiological investigations as well as some invasive methods ,
each of them having its own substantial limitations.
NLS?diagnostics is a method that greatly improves identification of dif?
fuse infiltrative lung diseases and as such it should become a part and parcel
of an integrated investigation.
33
allows to assess a lesion of actually the whole lung parenchyma as compared
to a separate biopsy sample. Moreover, NLS can become an accurate nonin?
vasive method for evaluating the efficiency of the administered treatment.
Sarcoidosis is one of the most common interstitial lung diseases of
unknown etiology. In typical cases granulomas are formed in fine lymph ves?
sels or beside them, afterwards the granulomas self organize which causes
lung tissue fibrosis.
A number of researchers considered the NLS potentials in defining the
process activity in patients affected by sarcoidosis. The main activity indica?
tor is the presence of small nodules and to a lesser degree their distribution
and occurence in the lung tissue. Unfortunately, despite the difference
between reversible and irreversible changes detected by NLS for patients hav?
ing sarcoidosis, the potentials of NLS in assessing the process activity have
not been studied well enough.
Among different indications in favor of NLS application, the use of this
method in lung biopsy is probaly the most important one. Biopsy is a very
essential diagnostics technique which allows to define the nosology of a lung
disease, its activity level and phase. The diagnostic value of biopsy to a cer?
tain degree depends on its method and the type of DILD. The authors proved
that TBLB was diagnostically informative for only 20 patients of 53 (38%)
who had DILD in evidence; in 33 such patients (62%) TBLB displayed nor?
mal lung tissue or nonspecific changes.
At the same time OLB made a specific diagnosis of DILD in 92% of
cases. In DILD?affected patients TBLB proved to be most informative for
patients having sarcoidosis or lymphogenous carcinomatosis, because these
lesions have largely peribronchial tissue involved and are therefore most
accessible to TBLB. Diagnostically OLB appears to be more accurate, but it
also has certain complexities because lung tissue is sampled from a small sec?
tor of the lung which might not reflect the changes occurring in the rest of the
lung tissue. Many diffuse diseases affect lung tissue irregularly so the patho?
logically altered parts of lung parenchyma may be located among normal
lung tissue. Besides, the same lung may contain both active manifestations of
the disease and fibrotic changes of long standing. For an accurate diagnosis
and assessment of the clinical progress of the disease the right choice of a
biopsy sample is very important. During biopsy NLS helps to collect more
accurate data indicating active areas of a pathological process. By using NLS,
the areas affected by lung fibrosis in its final phase, with ‘honeycomb lung
formed, could be skipped during biopsy sampling. In addition, NLS may
prove to be vitally important for choosing the most effective technique
(TBLB, BAL or OLB) for making a histological diagnosis.
32
1) Anterior fibro muscular stoma (AFS).
2) Unstriated muscular fibers of the urethra (UMFU).
3) Preprostatic sphincter (PPS), which is an extension of the muscula?
ture of the inferior part of the urcter and prevents inverse emission of seminal
fluid.
4) Postprostatic sphincter (PPS), which is responsible for retaining
urine in the bladder and blocks incontinent micturition.
The gland can be conventionally subdivided into 2 parts:
— external part consisting of CZ, PZ, TZ and
— internal part comprising AFS, PPS and PoPS.
According to NLS?investigation, the external part looks like a structure
of normal chromogenic density (2?3 points on Flandler’s scale), and the
internal one is hypochromogenic (1?2 points). The two parts are divided by a
fibro muscular layer, the so called surgical capsule, along which an incision is
made during surgical intervention, and calcium salts deposit (calcium incrus?
tation of the gland). In the NLS investigation those formations can well be
seen as fairly hypochromogenic structures (3?4 points) of different size.
The analysis of the prostatic gland image on the NLS virtual model is
made according to the following quantity and quality characteristics:
1. Size: front to back — 2?2.5 cm, across — 3?4.5 cm, from top to bot?
tom — 2.5?4 cm;
2. Volume: up to 20 cm 3 ;
3. Symmetry. The urethra is the reference point.
If any pathological changes are detected in the NLS?graph it is recomm?
nded to:
— specify their exact location,
— perform histography of the pathological area and area of the tissue
with a normal structure.
It will be helpful for the case follow?ups. At a benign hyperplasia NLS
allows to detect the direction of the principal germination. In case of hyper?
trophic transitory zones the gland proliferates inwards. Though darkened lat?
eral zones are formed ( 4?5 points on Flandler’s scale), the nodes can still be
always visualized. The trans?rectal NLS offers the most detailed and authen?
tic information.
Enlarged lateral lobes squeeze PZ and CZ causing their atrophy. With
proliferation of the paraurethral zones a massive fibro muscular PPS layer
restricts their hyperplasia, so with this kind of pathology the gland prolifer?
ates along the urethra forming a middle darkened zone pushing back the
bladder wall. Virtual scanning makes this pathology clearly visible in longitu?
dinal sections. At the beginning of the proliferation a relationship between
35
NLS?diagnostics of prostate diseases
V.A. Toropova,
S.N. Petrenko
An ever growing number of physicians enjoy an opportunity of a screen?
ing NLS diacrisis of prostate gland and urinary bladder. This aricle attempts
to consider some particulars of morphological changes occuring in a prostate
affected by pathology, based on the results of NLS?investigations.
In the West prostate cancer makes 20% of the total cancer diseases and
ranks second to lung tumors as a death cause.
According to some autopsy findings with a histological investigation of
the prostate, 12?47% of men aged over 50 appeared to have cancerous nidi.
Clinically, cancer is diagnosed more rarely because a high percentage of that
number corresponds to ‘minor forms’ of cancer that have low invasiveness, so
the patients suffering from it die of another kind of pathology.
To enhance the quality of prostate diseases diagnostics it is important to
comprehend the specifics of topographic and zonal anatomy of a particular
organ.
The prostate gland is located in the small pelvis between the bladder and
anterior abdominal wall, anterior rectum wall and secondary urogenital
diaphragm. The gland has a chestnut shape and tightly envelops the bladder
cervix and prostatic urethra. The gland base is tightly connected with the
bladder into a coherent mass. Its anterior surface is directed to the symphysis,
and the posterior one ? to the rectum ampulla. The posterior surface of the
gland has an expressed sulcus, which allows to conventionally subdivide the
gland into the left and right lobes. Besides, there is a protruding middle
cone?shaped lobe confined anteriorly by the prostatic urethra and by the
spermatic ducts posteriorly.
According to zonal anatomy theory usually 4 glandular zones are distin?
guished in the prostate. The correct interpretation of NLS data largely
depends on the knowledge of their topical pattern. 20% of the glandular tis?
sue correspond to the central zone (CZ). The peripheral zone (PZ) occupies
75%. The intermediate (transitory) zones (TZ) make up 5% of the total
amount of the glandular tissue.
Perurethral glands (PUG) take a relatively small amount of the tissue,
however exactly this area of the gland is very important for explaining the
changes at a benign hyperplasia. Apart from the glandular area, 4 fibro mus?
cular zones can be discriminated:
34
With an oncological pathology, analysis of the gland picture helps local?
ize the process in different projections and assess the extent of prevalence and
involvement of adjacent organs. The minimum size of tumor determinable by
means of NLS?investigation is about 8?10 mm. 80% of the tumorous nodes
are represented by markedly hyperchromogenic structures (6 points on
Flandler’s scale).
Analysis of histograms of the nidi helps differentiate an oncoprocess.
The method’s sensitivity becomes higher with both ‘elimination’ and ‘NLS?
analysis’ modes in use. Peripheral zones have first place as far as cancer inci?
dence rate is concerned. Their share makes 70?80% of cases. Transitory zones
(TZ) are affected in 10?20% and CZ in less than 5% of cases. In transitory
zones a tumorous nidus should be looked for within 3?4 mm from the cap?
sule. In case of an oncological alertness the symmetry in the lobe affection is
assessed w.r.t. the sagittal axis and intensity of the black patch (4?5 points on
Flandler’s scale), in the adjacent organs, especially seminal vesicles and blad?
der because in 25% of cases metastizing occures through the gland apex and
seminiferous tracts. Considering the fact that cancer often develops with
some diffuse changes occuring on the background, for example, with chron?
ic prostatitis or adenomatosis, it is not always possible to visualize newly
formed cancerous areas. In such cases the results of PSA level definition and
digital rectal examination should be considered. The PSA level is defined
considering the patient’s age and gland volume.
Conclusions:
1. NLS?method allows to diagnose most prostate diseases and being a
screening diagnostics method, it should be supplemented by biopsy, should
any pathological changes be detected.
2. The final diagnosis should be made on the basis of the clinic lab data
and the results of digital rectal examination in combination with biopsy only.
37
the internal and external glandular parts is disturbed. Apart from some dis?
tinctions in the zones of principal proliferation, the clinical signs will be dif?
ferent as well. In the case where a globe?shaped gland is formed (TZ prolif?
eration) the gland is chiefly hyperchromogenic and the dysuric
manifestations are minimal while with a ‘middle zone’ formed the gland is
slightly darkened and dysuria appears to be frank. Sphincter decompensation
leads to the development of urinary incontinence and dilatation of the upper
urinary tract followed by the atrophy of the cortical layer of kidneys, which
gradually adds to frequent urination, nycturia, reduced pressure of the urine
or slowed?down urination occuring in the initial phase of the disease.
In case of a squeezed cervix of the bladder an NLS?graph allows to visu?
alize signs of an infravesical obstruction, that causes some morphological
and functional changes in the lower and upper urinary tracts. Specifically, in
the initial phases of benign hyperplasia a darkened wall in the bladder can be
observed. Dark patches result from compensatory hypertrophy of the detru?
sor.
These 3 phases of benign hyperplasia of the prostate can be distinguished
depending on the intensity of the changes:
1. hyperchromogenic density of the gland with no residual urine;
2. residual urine present;
3. all of the above?mentioned plus dilatation of the upper urinary tract
with the cortical layer of kidneys involved in the process.
Diagnosis of acute prostatitis is made on the basis of histograms (simi?
larity to the reference standard process “prostatitis” D<0.425).
Diagnostication should be done in combination with dactylar rectal exami?
nation (painfulness during palpation) with clinic lab data taken into account.
In the case of abscessed lesion a still higher hyperchromous area (6
points) is visible against the general dark patch (4?5 points according to
Flandler’s scale). Areas of frank blackening correspond to necrotic changes.
With an abscess in progress one can notice a reduced infiltration of the tissue
around the cavity with the dark patch gradually getting lighter in the course
of dynamic observation (up to 3?4 points). With adequate therapy employed
the postinflammatory cyst may fall into regression.
As can be seen from NLS?investigation, chronic prostatitis does not give
a common characteristic picture, however the morphological processes in
different phases of the disease are reflected in histograms. With a long?lasting
disease the chromogenic density tends to rise due to a postinflammatory sub?
stitution for the glandular component and in histograms, in the
‘organopreparations’ mode destructuring of the fibrous component starts to
predominate.
36
these days makes the NLS investigation even more important. Our own prac?
tical experience can confirm that. Patient B., 63 years old was admitted to the
clinic with regard to right mammary gland cancer in its early phase IIa after
an ischemic stroke in combination with ischemic heart disease and hyper?
tension III. Palpation did not detect any lymph node enlargement. The NLS
investigation did not detect metastasis?affected lymph nodes which allowed a
tumorectomy for this patient at a low hazard to life.
Thus, the NLS investigation of regional lymph nodes with mammary
gland cancer may become a sufficiently reliable method for assessing their
metastatic affection which allows to pick out the most efficient tactics in
treating patients with this kind of pathology.
39
NLS diagnostics of affected regional lymph
nodes at a mammary gland cancer
O.P. Dergatch, Y.A. Somov,
M.A. Kolesnikov, L.V. Chernyshov
Mammary gland cancer is one of the most common women’s oncologic
diseases. Its annual growth rate in the developed countries is about 3%. In
addition, this pathology proves to be the primary cause of mortality among
females affected by oncologic diseases. The tactics of treatment and disease
prognosis largely depend on the presence or absence of any regional metas?
tases. In this connection the problem of competent diagnosis of affected
regional lymph nodes becomes especially pertinent. With that end in view a
number of methods have been used, from physical to hardware?based exam?
inations. However, in 40% of the patients metastatic lesion of the lymph
nodes in the axillary area is not determined clinically and false positive data
were observed in 25% of cases. Instrumental diagnosis methods do not have
a rich informational content either. The NLS investigation of regional lymph
nodes has been more extensively used lately.
Subject and methods of investigation
We have examined regional lymph nodes by means of the Oberon device
using a 4.9 GHz nonlinear trigger sensor in 25 patients affected by mamma?
ry gland cancer in Phases I?III. The obtained data were compared with the
results of histological investigation of the macropreparations removed during
surgery.
Investigation results
According to the NLS investigation results, of 25 patients examined
prior to surgery as many as 1?3 affected lymph nodes were detected in 20
patients. The derrived results were practically fully confirmed by histological
investigation of the macropreparations removed during surgery. Only in one
case NLS?graphy did not detect affected nodes which we account for their
small size.
During the NLS investigation the metastatic lymph nodes were found to
have pathological changes with quite a high degree of intensity. Flandler’s
scale indicated 5?6 points in 80% of cases. The fact that organosaving surgery
and in some cases tumorectomy are being more and more extensively used
38
ed in virtual shots in sagittal planes above and below the kneecap and along the pos?
terior surface of the joint. Frontal planes along the lateral surfaces of the joint were
used to define the exact condition of menisci, articular cartilages and changes in the
synovium.
It is traditioanally believed that in the articular cartilage degenerative
changes start off with a rupture of the articular matrix and degeneration of
chondrosites. Therefore during the NLS examination special attention was
paid to changes in the articular cartilage. In the examinees of the test group
the articular cartilage looked like a hyperchromous strip (1?2 points accord?
ing to the Flandler’s scale). Two patients were found to have an articular car?
tilage of a heterogeneous chromogenic pattern, 3?5 points, in the initial
phase of the disease with small hyperchromogenic nidi (1?2 points) present.
No radiological changes in the joints were detected for this group of patients.
In 14 (28.0%) patients in the second clinical phase of the disease the
chromostructure of the cartilage was heterogeneous and some high hyper?
chromogenic structures (4?5 points) were detected as well as hyperchro?
mogenic inclusions (1?3 points) of a small diameter.
In 21 (42%) examinees in the third phase of the disease the hyaline car?
tilage looked as a hyperchromogenic strip (5?6 points).
In 10 (20.0%) patients in the same clinical phase of the disease the articu?
lar cartilage was visualized as a distinctly hyperchromogenic linear structure (6
points) with vertical fissures present (4?5 points). In three patients the higher
line cartilage was not visualized mostly in the middle departments of the joint.
Depending on the phase and duration of the disease a spectral similari?
ty (D 0.189 to 0.621) could be visualized to the reference standard process
‘osteoarthritisdeformans’.
The X?ray pictures detected a moderate constriction and deformity of
the joint space as a primary sign of the articular cartilage distraction in 22
patients and considerable constriction in 12 patients. Subcartilaginous osteo?
phyte was very important for osteoarthritis patagenesis. Formation of subcar?
tilaginous and epiphyseal sycts started off already in the initial phases of the
disease (71.0% of the patients). According to NLS?investigation, the cysts
were located subcartilaginously in the lateral regions of the bone, 1.0?3.0 mm
deep and were as many as 4 to 12?15. Standard X?ray pictures of knee joints
displayed some changes in the subcartilaginousregions of the bone, like cysts
and fibrosis, only in the second phase of the disease.
A very important role in the osteoarthrosis deformans development was
attributed to the condition of the synovium and articular capsule. With the
progress of the disease and changes in its phases, a cartilaginous detritus with
antigenicity was formed on the articular surfaces. That often led to the
41
NLS?investigation in evaluating
the condition of knee?joint affected
by osteoarthritis deformans
M.S. Petrov, L.A. Voroshilova,
V.M. Kartuzov, A.Y. Vesnin,
G.V. Derevyanko, A.P. Guglya
Introduction
Primary osteoarthritis deformans of the knee?joint is one of the most
pertinent problems in modern medicine due to its prelevance, great loss of
working time and treatment expenses. In addition, in many cases an early or
differential diagnosis of the knee?joint lesion is impeded, which complicates
selecting the most efficient therapeutical and rehabilitation measures and
evaluating the patient’s disability.
Today diagnostics of knee?joint disorders comprises conventional radiogra?
phy as well as sonographic evaluation of the joints, used to examine soft tissues of
the locomotorium. The existing techniques used to examine the knee?joint allow
to determine dominance of pathological process in the joint, including degenera?
tive ones. However, the relationship between the intensity of pathomorphological
changes and the severity and dynamics of the process have not been studied yet.
This article aims to demonstrate the efficiency of the NLS?investigation
in diagnosing osteoarthritis deformans, especially in the early (subclinical)
phase of the disease.
Subjects and methods
To define a normal relationship of the knee?joint anatomical structures
10 healthy persons aged from 25 to 55 (test group) were examined. The main
group consisted of 50 patients with clinical implications of osteoarthritis
deformans of knee joints in different phases. The average duration of the dis?
ease was 7.0±3.0 years. All patients were routinely radiologically examined in
two interperpendicular planes.
The X?ray pattern analysis took into account the joint space amount of
narrowing, existence of marginal osteophytes and deformation of osseous
structures with cysts and fibrosis areas present in the subcartilaginous bone
department. The NLS investigation was carried out using “Oberon” device
equipped with a 1.5 GHz trigger sensor. Changes in the joint capsule were evaluat?
40
Potentials of NLS?investigation
in the presurgical evaluation
of intramural invasion of gastric cancer
K.P. Vasov, S.D. Setkin,
S.A. Skvortsova, G.F. Maretskaya
Gastric cancer in Russia as well as in some other countries all over the
world reamains one of the most acute medical problems. Most researchers
engaged in the diagnostics and treatment of gastric cancer have concluded
that a timely and early diagnosis can promote cancer treatment and improve
prognostication for the patients.
For many decades radiology and endoscopy remained the principal
methods for diagnosing gastric cancer. The main shortcoming of these meth?
ods of investigation is their inability to obtain a picture of the thick layers of
the stomach wall and hence a more exact data about the extent of tumor inva?
sion into the stomach wall, i. e., the phase of the tumor process in the presur?
gical period. The first attempts to establish phase gradation in stomach tumor
were made when such investigation methods as computer tomography (CT),
transabdominal ultrasound scanning (US) and the most recent NLS investi?
gation were put into clinical practice. In today’s medicine the NLS investiga?
tion may become an essential method for diagnosing abdominal cavity dis?
ease because of its extreme simplicity, accessibility and non?invasiveness.
However, in view of the fact that this investigation method has been used in
medical practice since the late 90s, the amount of the published literature
dealing with potentials of the NLS in diagnosing parenchymal organs is still
insufficient.
Rather explicit methods of NLS stomach investigation have been
already developed and some NLS signs of cancer, benign and malignant gas?
tric ulcers have been described (V.I. Nesterova et al., 2002). An attempt was
made to establish phase gradation of gastric cancer by means of NLS investi?
gation which resulted in a fairly high accuracy (75.8%) of the diagnosis most?
ly due to diagnosing much earlier phases of the tumor process. According to
some authors, NLS offers some incontestable opportunities in defining phas?
es of gastric tumor mostly located in distal regions of stomach.
Yet, according to most researchers, until recently the NLS had been
largely used as a method for specifying the extent of cancer proliferation, for
defining metastases and malignant invasions beyond the stomach, in other
43
inflammation of the synovium and its fibrosis. As a result, the synovium pro?
duced an inadequate fluid, which in turn impaired the cartilagan nutrition
with its ensuing degeneration.
The synovium in healthy persons (test group) was visualized as a hyper?
chromogenic linear structure (1?2 points). The first and second phases of the
disease saw a steady rise in its chromogenic pattern in 14 (28%) patients (3?
4 points). In 32 (62%) patients in the third phase of the disease the chro?
mogenic density of the membrane reached 4?5 points throughout the phase
with at most 3 or 6 hyperchromogenic inclusions. In three patients with an
aggravated form of the osteoarthrosis deformans (the forth clinical phase) the
synovium looked like a distinctly hyperchromogenic structure (4 points) with
areas of a reduced entropic density (3?4 points).
Changes in the membrane structure were always concomitant with syn?
ovitis with a limited amount (mostly in the upper enstrophe in 28.0% of the
patients) or a great amount (in all regions of the joint ? in 68% of the patients)
of fluid free of sediment and additional inclusions.
Depending on the phase and extent of pathological changes in the joint
affected by osteoarthrosis a change in the joint capsule structure also took place.
Only in the first phase of the disease did the joint capsule structure remain normal.
In the second phase of the disease, especially with synovitis in evidence,
the chromostructure was assessed at 4?5 points in 14 (28%) patients and in
the third and forth phases of the disease ? up to 6 points in 34 (68%) patients.
Roentgenographic evidences of synovitis and changes in the paraarticular soft
tissues were detected in some patients only in the third and forth phases of the disease.
Thus, the analysis showed that the NLS?investigation had an advantage
over conventional roentgenologic methods in terms of early detection of
degenerative changes in the articular cartilage.
On the whole, the NLS?method sensitivity in the early phase of the dis?
ease amounted to 82%, specificity to 85% and accuracy to 86%. The sensi?
tivity of standard radiography in two projections was 68%, specificity 54%
and accuracy 78%.
Conclusion
The extensive use of NLS?investigation of knee?joints in everyday clini?
cal practice allows to diagnose osteoarthrosis deformans in its early phases.
42
patients’ posture in the course of scanning allowed to visualize all the regions
of the stomach very well. The location of the tumorous infiltrate as to the
stomach wall layers was assumed as a principal criterion whose analysis
allowed to suggest the extent of the intramural invasion of the gastric cancer
during NLS?investigation, while in computer tomography the main point
was to define the thickness and elasticity of the stomach wall at the lesion
spot.
The point is that NLS?investigation allowed to differentiate tumor quite
clearly w.r.t. the layers of the stomach wall, while in computer tomography
the most diagnostically important factor was the degree of the stomach wall
thickening at the lesion spot with respect to the neighboring unaffected areas
(thickening ratio) along with some other sings (rigidity, roughness, uneven?
ness). Based on the analysis of the results of the surgical intervention and
morphological investigation of post surgical material as well as their compar?
ison with NLS and CT data the following conclusions were reached: both
methods are quite potent in presurgical determination of the extent of intra?
mural invasion of gastric cancer, however the NLS investigation demon?
strates a higher specificity as compared to computer tomography in detecting
early phases of gastric cancer due to visualization of lesion zones in the stom?
ach wall.
The analysis of the the performed investigations allowed to discriminate
the NLS?signs that allowed to define the extent of intramural invasion of gas?
tric cancer:
1. T1 phase: presence of tumorous infiltrate within the first layer of the
stomach wall, which is accompanied by hyperchromogenic density of the
wall at the lesion spot lesion spot (5, less often 6 points on Flandler’s color
scale).
2. T2 phase: tumorous infiltrate within the first and second layers of the
stomach wall accompanied by hyperchromogenic density of the first two lay?
ers (5?6 points at the lesion spot).
3. T3 phase: a frank chromogeneity of the inner layers of the stomach
wall (6 points) except for the serous layer, which is evaluated at 4 or more
often 5 points.
4. T4 phase: lesion of all layers of the stomach wall accompanied by
chromogeneity of the serous membrane (6 points) and signs of tumorous
invasions into the neighboring anatomical structures accompanied by a frank
chromogeneity (4?5 points) of the adjacent organs.
Detection of some affected peregastric (regional) lymph nodes and dis?
tant metastases in the course of investigation allowed to analyze the N and M
criterion as well.
45
words, the NLS investigation method allows to diagnose stomach tumors
even in early phases of the disease.
Most literature dealing with the use of radiological computer tomogra?
phy to diagnose stomach tumors provides a proof that this method can poten?
tiality be used to diagnose gastric cancer, especially its endophytic forms.
However, most authors still believe that the principal role of this method lies
in acquisition of certain very important information about the extent of stom?
ach lesion and spread of the process to some adjacent organs. According to
different researchers, the early gastric cancer, that only affects the mucosa
and submucous layer can not be detected on the computer tomograms. In the
authors’ opinion, this is beyond ‘the resolution capabilities’ of this investiga?
tion method.
This work attempted to evaluate the potentials of the noninvasive radia?
tion methods of investigation (trans?abdominal ultrasound scanning and
radiological computer tomography) in detecting intramural invasion of gas?
tric cancer, and to draw their comparison characteristics.
The analyse included 72 cases of gastric cancer. All the cases were com?
pared with the surgical intervention data and the morphological studies of
post surgical evidence. According to the latest gastroenterological TNM clas?
sification of tumors (1997), the group of gastric cancer carriers in phase T1
made 9 (12.5%) cases, T2 8 (11.1%) cases, T3 22 (30.6%) cases and T4 33
(45.8%) cases. Computer nonlinear diagnostics (NLS) and radiological
computer tomography (CT) of the stomach were performed as supplemen?
tary investigation methods deliberately after a preliminary integrated
radioendoscopic investigation.
Computer tomography of the stomach was done after expanding the
stomach walls with a gas (pneumoscanning) in standard projections (lying on
the back and belly); the transabdominal NLS?investigation of the stomach
was performed using the standard procedure.
In order to more clearly comprehend the NLS and CT signs underlay?
ing the presurgical diagnosis of the T?phase of gastric cancer (i.e., invasion
degree) one needs to have a clear idea of the image of a ‘normal’ stomach wall
visualized by means of the investigation method.
Thus, in CT investigation the stomach walls (adequately expanded) were
at most 0.3 cm thick in normal conditions (test group of 50 persons) in all
regions with few exceptions in cardiac and prepiloric regions where the walls
were 0.4 cm thick, whereas at an intramural tumorous effect the stomach wall
authentically thickened over 0.6 cm (p < 0.01). In most cases it proved to be
impossible to differentiate the lamellar structure of the stomach wall by com?
puter tomography. Changing the section thickness, pitch of the table and the
44
So, an integrated approach to the use of NLS investigation and radio?
logical computer tomography has proved to be more preferable for more
accurate presurgical diagnostics of intramural invasion of gastric cancer,
however the order of priority and efficiency in their use somewhat depend on
the results of primary radioendoscopic investigation of the stomach. In addi?
tion it should be noted, that contradistinction of these methods of investiga?
tion in diagnosing and phasing of gastric cancer against each other would be
a mistake and delusion.
In conclusion, it should be emphasized that despite their subordinate
use with reference to radiological and endoscopic methods of gastric cancer
investigation, the NLS investigation and radiological computer tomography
should be brought into line with primary methods of stomach investigation.
The conclusion is based on the facts that unlike some conventional radi?
ological and endoscopic methods of investigation they allow to evaluate the
internal structure of the stomach wall, which is a master factor in the presur?
gical detection of intramural invasion.
This allows to work out the proper approach for treating patients affect?
ed by gastric cancer, and based on the well?founded data reject the explo?
rative laparatomy in case of a frank process. Considering general accessibili?
ty, lack of radiation exposure and application simplicity it appears more
apropriate to use NLS investigation as the most preferable of the above?men?
tioned methods.
47
With respect to the potentials of computer tomography in presurgical
determination of the extent of intramural invasion of gastric cancer, it should
be admitted that it had a less specific pattern and was essentially based on the
extent of the stomach wall thickening at the lesion spot.
Thus, since the CT signs are indicative of one or another degree of gas?
tric cancer invasion, they could be conditionally classified in the following
manner:
• It proved practically impossible to distinguish between tumors in T1
and T2 phases. So their diagnostics was based on the analyses of non?multi?
ple stomach wall thickenings from 0.3 to 05 cm, with the external outlines
being clear and smooth.
• The T?3 phase typically had integer multiple thickenings of the stom?
ach wall over 0.5cm not accomapanied by deformed external outlines of the
stomach wall and with no signs of the tumor spreading beyond the stomach
wall ,
• The T4?phase had multiple thickenings of the stomach wall (two,
three or more times as thick) over 0.1cm with a disturbed integrity of the
external outlines of the stomach wall at the lesion spot and with some signs
of tumorous invasion into the adjacent anatomical structures.
According to our information, the NLS?investigation proved to be the
most accurate and specific method of investigation in presurgical diagnosis of
gastric cancer in its early phases (T?1, T?2) while CT results appeared to be
more convincing in detecting later phases of tumorous lesion (T?3, T?4). It
should be noted, that, in our opinion NLS is the most accurate method of
investigation in detecting remote metastases (p > 0.05). Based on the statis?
tical analyses, the specificity of the NLS method of the investigation in
detecting the T?phase of gastric cancer (with calculations made with refer?
ence to T?1, T?1 phases) amounted to 76%, sensitivity to 74.3% and accura?
cy to 78.2%, w.r.t the computer topography the specificity, sensitivity and
accuracy were 70% each (in this case calculations were made w.r.t. T4?phase
of gastric cancer, because differentiating the lamellar structure of the stom?
ach wall was found impossible in CT investigation).
Thus, as compared to computer tomography, the NLS investigation
proved to be a more specific method for diagnosing gastric cancer in its early
phases although in a number of cases it was found difficult to differentiate
between T1?T3 phases of a tumorous lesion. In CT investigation T1?T2 phas?
es were defined conventionally based on the degree of stomach wall thicken?
ing at the lesion spot. NLS did not succeed in imaging anatomical structures
beyond the stomach wall as distinctly as CT investigation did, but NLS was
more efficient in evaluating such characteristics as M and N.
46
important, for example, for differential diagnostics. As a result of using high
frequency sensors in combination with virtual imaging equipment, a high
spatial resolution is provided which is very important for patient examina?
tion.
According to the analysis of our observations, the correct diagnosis was
made for 22 patients of 23 (95.6%). In one female patient with Itzenko?
Kusching syndrome in clinical evidence the NLS?scopy detected in the supe?
rior pole area of the right kidney a small (30?35 mm) hyperchromous growth
which had a monochromous internal structure and a spectral similarity to the
‘adrenal adenoma’ reference standard (d=0.217) and was regarded as a
benign adrenal tumor. Because of typical clinical presentation of Itzenko?
Kusching syndrome and concomitant changes in blood and urine in clinical
and lab evidence, computer tomography was not performed. The surgery
detected a focal macronodal hyperplasia of the adrenal, which was confirmed
by the histological investigation of the removed growth.
Generally a distinction is made between the diffuse and focal hyperpla?
sia. Focal hyperplasia can be subdivided into micro? and macronodal hyper?
plasia. As a matter of fact, focal hyperplasia can not be easily discriminated
from adrenal tumors by means of NLS evidence, so in this partcular case our
conclusion cannot be considered to be diagnostically wrong.
Of 23 cases computer tomography was done for 17 with its data match?
ing the NLS?investigation results. 9 patients of 23 underwent surgery to have
an adrenal tumor removed, and the NLS data were confirmed by surgery and
histological investigation results.
The size of detected tumors varied in diameter from 6 to 10 cm. All of
them had a capsule, smooth surface and rounded or oval shape. Small tumors
had a monochrome structure and in 4 cases with the tumor size over 8 cm,
the internal structure was represented by an irregular alternation of areas
having different color saturation on account of necrotic zones, degenerative
changes and decalcification, which was confirmed by a histological investi?
gation of the removed tumors.
According to the literature and our information the differential diagnos?
tication of benign and malignant adrenal tumors is an extremely difficult
process. A malignant pattern of the detected growth can be suspected only in
the presence of an irregular internal structure of the growth, restricted kidney
mobility at forced breathing, enlarged regional lymph nodes and metastases
in other organs.
Thus, diagnosis of adrenal tumors is complicated because of diverse
clinical implications in place. The potentials of the NLS?diagnostics could
scarcely be overestimated, for the simplicity of the investigation procedure,
49
Potentials of NLS?scopy
in adrenal tumor diagnostics
B.I. Lukashenko,
T.B. Georgadze
Adrenal tumors do not occur very often still they are known to be most
often hormon?active and even if small sized cause various glandular disor?
ders. However, practice knows adrenal tumors, which clinically develop with
no symptoms in evidence or are accompanied by vague complains.
Both documentary evidence and our experience show that from 6
months to two years may elapse from primary disease manifestations to form?
ing a diagnosis. Early detection of adrenal tumors has become an important
clinical problem, which is now conventionally solved by means of ultrasound
investigations (US) along with computer tomography (CT), magnetic reso?
nance tomography (MRT) and angiography (AG).
Today NLS?scopy is one of the most advanced informative hardware?
based methods of diagnostication. The NLS method will allow to substan?
tially increase the percentages of early and accurate diagnostication of adre?
nal tumors. The implementation of the latest devices equipped with digital
trigger sensors made it possible to detect any growth sized around 1 cm in
adrenals, which is comparable to computer tomography in terms of diagnos?
tical accuracy.
This our research aimed to study the NLS?scopy potentials in adrenal
tumor diagnostics and to provide an evidence that with a proper procedural
approach and advanced equipment in place, bulky growths could be diag?
nosed as successfully as if by using computer?aided and magnetic resonance
tomography.
Subject and methods
Clinical data: from June 2000 through May 2001 23 patients aged 25?64
were examined who were suspected to have developed adrenal tumors based
on careful complaint analysis and clinical and lab data. For all the patients
kidney and adrenal investigation was conducted under a regular procedure by
means of the Oberon metatron equipped with a 4.9 GHz digital sensor and
developed at the Institute of Practical Phychophysics. The device has an
automatic focusing, that can self adjust both when emitting and receiving
echo signals, and it ensures high definition of the spectrogram, which is very
48
Diagnosing rare instances of mammary gland
diseases using NLS?investigation
S.N.Okunev,
K.S. Kogan
This article deals with some clinical observations of rare cases of mam?
mary gland diseases detected by means of nonlinear diagnostics method
(NLS) during clinical diagnostic prophylactic investigations performed in
October 2001 with the purpose of an early diagnostics. In the course of the
activity the examined patients were found to have different diffuse or nodal
mammary gland diseases among which of particular interest are some rare
diseases like liposarcoma (1 case), colloidal cancer (1 case), phyllode cys?
tosarcoma (1 case), phyllode fibroadenoma (2 cases), hemangioma (1 case)
and Mondore’s syndrome (1 case).
According to some literary evidence, colloidal cancer and liposarcoma
do not occur very often among malignant tumors: colloidal cancer in 2,4%
and liposarcoma in 0.001? 0.03% of cases respectively. Among benign tumors
hemangioma occurs in 0.12%, phyllode fibroadenoma in 5.4% and phyllode
cystosarcoma in 2.5?5.4% of cases. The investigation was done using series
4011 Oberon device with a 4.9 Ghz nonlinear sensor under the program of
virtual tissular representation of panoramic scanning (Panoramic NLS
Imaging).
Mammary gland liposarcoma
Patient G., aged 28, was admitted having complaints of a nodal forma?
tion in her left mammary gland. During the examination an umbilication
symptom in the upper outside guardant of the left mammary gland was dis?
covered. The palpation detected a small?sized painless sluggish node of a
dense elastic consistency, that had a doled structure and adhered to the skin.
By means of a detailed imaging the investigation ascertained a node of 15?20
mm in diameter and detected its spectral similarity to the reference standard
‘mammary gland liposarcoma’ (D=0.204). The investigation of the regional
lymph nodes did not detect any metastatic lesion.
Based on the NLS?investigation data a surgery (radical mastectomy
according to Maden’s method) was performed. The histological diagnosis
was liposarcoma.
51
its harmlessness and rich informational content allowed us to make a correct
and promt diagnosis in 78% of cases. The conducted investigation showed
that NLS?scopy may become as efficient method of adrenal tumor examina?
tion as computer tomography and US. Patients having complaints typical for
adrenal tumors should be examined by means of the NLS?method the first.
Patients with symptoms indicative of adrenal tumor should be referred to spe?
cialized endocrine surgery departments where they would be thoroughly
investigated using US, CT and MRT which will allow to substantially reduce
the investigation time and timely provide a correct treatment.
50
were performed. The histological diagnosis was phyllode fibroadenoma.
After the plastic surgery (one month later) a repeated NLS?investigation
was carried out.
Mammary gland hemangioma
Patient C. aged 42 was admitted as having complaints of a large size
node in the right mammary gland.
During the examination it was found out that the skin over the node had
a cyanotic cast. On the border between the upper quadrants a mobile forma?
tion with a soft consistency was palpated. The graph analysis detected a sim?
ilarity to the reference standard ‘hemangioma’ (D=0.414).
The patient underwent surgery, i.e., a sectoral resection was performed.
The histological diagnosis was cavernous hemangioma.
The presented clinical observations showed that the continuous
improvement of NLS?systems and the modern technologies made it possible
to introduce a morphological picture of the neoplasm which helps devise the
optimal tactics of surgery with further morphological verification of the der?
rived results.
53
Colloidal mammary gland cancer
Patient K. aged 49 was admitted as having complaints of a node in the
left mammary gland.
The examination did not produce any visible evidence of changes in the
mammary glands. A sluggish roundish formation with a diverse consistency
and vague outlines was palpated on the border between the upper quadrants
of the left mammary gland.
The NLS?investigation detected a roundish formation (6 points accord?
ing to Flandler’s scale). The graph examination showed spectral similarity to
the reference standard ‘solid cancer’.
The patient underwent surgery; a radical mastectomy was performed
according to Moden’s technique. The histological conclusion was colloidal
cancer.
Phyllode mammary gland cystosarcoma
Patient G. aged 46 was admitted as having complaints of a slow growth
dense node in the right mammary gland.
Palpation detected in the upper outside guardant of the right mammary
gland a painless motionless formation with a diverse density and heteroge?
neous surface, that adhered to the skin.
The NLS?investigation detected an irregular 3x6x4 cm formation. A
spectral similarity to the reference standard ‘mammary gland sarcoma’
(D=0.412) was found. Its small size allowed to completely visualize the
involvement of lymph nodes.
The patient underwent surgery ? radical mastectomy according to
Moden’s techique. The histological diagnosis was phyllode cystosarcoma.
Phyllode mammary gland fibroadenoma
Patient Z. aged 43 was admitted as having complaints of a large node in
the right mammary gland.
The examination showed asymmetry of the mammary glands.
On the border between the outside quadrants of the right mammary
gland a mobile node of a large node with distinct outlines and smooth surface
and tight elastic consistency was palpated. The skin above the tumor was very
thin.
The NLS?investigation detected some hyperchromous structures corre?
sponding to intranodal vessels. The analysis of the graphs detected a similar?
ity to the reference standard ‘fibroadenoma’ (d=0.384).
On the strength of the NLS?investigation subcutaneous amputation of
the right mammary gland and omentomammoplaty on a vascular pedicle
52
with granulomatous fields which are small ? 2.0 cm or less in diameter. On
NLS image these formations look like hyperchromatic areas (6 points on
Flandler’s scale) with the central necrosis zone in ring?shaped structures
being visible as an area of lower chromogenic density (4?5 points).
Hemorrhage areas of small size are quite typical. The above?mentioned
changes are localized peri?and paraventriculary, often in the region of bor?
dering corticomedullary structures as well as in the region of basal ganglia.
Clinical observation
Patient K., born in 1974. The preliminary diagnosis when admitted into
the neurological department was acute cerebral circulation disturbance in the
spinal artery basin.
The patient complained of weakness in left limbs, speech impediment,
asthenia and loose cough. Accourding to her wording she fell ill (Feb. 06.01)
when she stopped talking, developed weakness in left limbs, diplopia and dis?
turbed swallowing. The anamnesis read a developed right?side hemiparesis,
that passed off by itself within two weeks.
The patient is in grave condition. Neurological status: conscious, under?
stands when she hears people speaking to her, but doesn’t speak. Cranial
nerves: equal palpebral fissures, nystagmus not present, the right nasolabial
fold smoothed out. Slight deviation of the tongue to the right. High tendon
and periosteal extremity reflexes, weakness in right limbs. Reduced pharyn?
geal reflex on both sides. Rigidity of occipital muscle is moderately frank.
Kering’s symptom on both sides. Babinski’s reflex on the left.
Laboratory investigation:
Clinical blood analysis: erythrocytes — 3.96×10.12/1; hemoglobin — 127
g/1; ?0.9; L — 5.6×10.9/1, ESR — 32 mm/g, — 1; — 74; — 21; — 2; — 2.
Biochemical blood test: glucose — 4.6 mm/1; urine — 6.6 mm 1/1,
bilirubin — 13.38; — 5.5; — 7.85 mmo1/1; creatinine — 0.066 mmo1/1, total
protein — 70.0m g/1; albumin — 5.5; globulins — 44.8; L2 — 4.8; L2 — 7.7,
B — 11.8; J — 20.5; — 1.24; — 0.29 mmo1/1; — 0.31 mmo1/1.
Test for toxoplasmosis detected antibodies with rising antibody titer in
dynamics (1:21 — 1:400).
Cerebrospinal — 2.5 mmo1/1; chlorides — 1.24 mmo1/1, protein —
0.2 g/1; sugar — 4.1 mmo1/1. Cellular composition: cytosis — 213, L — 1?2;
erythrocytes — 4?5.
MRT?investigation of the encephalon (of 16 Feb. 01) in T?2 picture on
both sides, detected paraventriculary and subcortically multiple unequal?
sized roundish nodi (from 0.5 to 2.0 cm) producing an unevenly increased
55
Diagnostics of toxoplasmosis (serologic
examination, CT, MRT and NLS)
T.I. Pankova,
A.S. Sosnovskaya
Toxoplasmosis is a parasitic disease whose causative agent is toxoplasma
(Tixoplasma gondii Nicolle et Manceaux), which belongs to protosa. The
disease typically has a chronic course, nervous system lesion, limphadenopa?
thy and enlarged liver and spleen. Quite often myocardium, muscles and eyes
are affected.
The infection is mostly transmitted through the alimentary tract. Yet
there are some instances recorded where contagion occurred through the
injured skin and mucous membranes. Toxoplasma is apt to form cysts in tis?
sues causing a latent infection condition. The parasite becomes active in the
conditions adverse to the macroorganism and with its immune responsive?
ness going down. In the pathogenesis of the toxoplasmodial lesion of the cen?
tral nervous system of importance are local inflammatory occurrences, dis?
circulatory disturbances related to vasculitis and blocked liquor tracts leading
to hydro? or microcephaly.
Clinically, the lesion of the central nervous system manifests itself as
meningitis, encephalitis, meningoenciphalitis and encephalomyelitis.
The most typical form of toxoplasmosis of the central nervous system is
meningoenciphalitis, which clinical picture contains general cerebral and
meningeal symptoms, paresis and limb paralyses, tonic and clonic spasms,
opticokinetic?(diplopia) and coordination disturbances. The blood test
reveals a left?shiifted leukocytosis and increased ESR; the cerebrospinal fluid
contains lymphocytic pleocytosis and a moderately increased protein con?
tent.
In diagnosing toxoplasmosis of importance are cranial radiography,
serological investigation, pneumoencephalography, CT and MRT. However,
it is the NLS?investigation of cerebral structures that plays the most impor?
tant part in the diagnosis. Of great diagnostic importance is a substantially
increased spectral similarity to the reference standard ‘toxoplasma gondii’ (D
< 0.425). The toxoplasmosis should be discriminated from viral encephalitis,
encephalomyelitis and meningitis.
In the MRT?investigations toxoplasmosis is manifested by a progressive
multifocal encephalopathy. With toxoplasmosis the typical cases have to do
54
Nonlinear diagnostics
of thyroid gland pathology
K.M. Beznogov,
L.V.Kondratyev,
S.N. Pauli
Introduction
The morphological diagnosis of thyroid gland pathology during surgery
is rightfully considered one of the most important and complicated tasks
faced by anatomist and surgeon. This research aimed to choose an optimum
surgical tactics with tumors and tumor?like lesions of the thyroid gland,
which is achieved by accurate verification of the process as well as by deter?
mining its spread in the organ and/or beyond it. The experience in the use of
nonlinear computer diagnostics (NLS) in surgical clinics covers quite a short
period of time, during which quite conflicting opinions w.r.t. its efficiency
were formed. Among the prime considerations against an extensive use of
NLS we should mention the possibility to preclude in some instances malig?
nant pattern of a new growth because of a morphological similarity of follic?
ular tumors. Without down?grading this problem and based on our own
experience in the use of NLS we have attempted to access the importance of
this method for choosing the optimum surgical tactics and working out some
methodical techniques enhancing efficiency and accuracy of the NLS inves?
tigations.
Subject and investigation methods
We analyzed the results of 682 pathohistological investigations of the
thyroid gland carried out in 2000?2001 in patients operated on for solitary
nodes, diffuse and multinodal hyperplasia and autoimmune thyroid diseases.
326 of all surgeries were accompanied by NLS. NLS data were compared
with the final results of pathohistological investigations.
Result analyses
Of 682 surgical operations of the thyroid gland, 326 (47.8%) were
accompanied by NLS?investigation. According to our information, there is
an increased demand for NLS, which has to do with a growth of surgical
operations for nodular goiter from 70% to 85% and also with a growing thy?
roid cancer incidence including hyperplastic and autoimmune lesions of the
57
MR?signal. Similar nodi were detected in the dorsal part of the pons on the
left and in the basal regions of the frontal lobes. In the frontal lobe the exam?
ination subcortically detected an ellipsoidal cyst 1.2×0.5 cm. In the T?1 pic?
ture of the field the nodi detected in the T?2 picture produced a slightly
diminished MR?signal and was clearly outlined. Upon administration of
magnevist some nodi, not visualized in the T?1 picture, manifested them?
selves by uniform amplification of the MR?signal, the others produced an
amplification in the form of a thin ring or a small amplification in the center.
The cyst did not respond to administration of the contrasting agent. The
central regions of the granulomatous fields represented by necrotic zones
were more hyperintensive in the T?2 picture and after the contrasting agent
administration did not accumulate it, a signal amplification occured in the
peripheral regions in the form of a thin ring. The lateral ventricle bodies were
not quite clearly enlarged. The median structures did not appear to be shift?
ed.
In the frontal lobe on the right NLS picture shows subcortically detect?
ed hyperchromatic areas (6 points) surrounded by a perifocal edema zone (3?
4 points) detected in the dorsal part of the encephalon on the right. A spec?
tral similarity to the standard reference process “toxoplasma gongii” (D <
0.183) was found, which allowed to confirm the diagnosis of toxoplasmosis.
56
tumors of the thyroid gland. A comparison was made considering age and
gender of patients as well as the size of the tumorous nodes in 61 cases of fol?
licular cancer and 162 cases of follicular adenoma. The study of the parame?
ters didn’t detect any difference between these two patient groups. The
male/female ratio in both groups was the same ? 1:9, the average age of the
patients operated on for adenoma was 42.36±13.76 and was not different
from that of the patients in the follicular cancer group (41.40±16.14).
Follicular cancer is known to be more common with elderly people and very
rare with children and teenagers. The latter circumstance could be a supple?
mentary reference point for investigating solitary nodes of the thyroid gland
in junior patients. The investigation analysis of 89 cases of follicular tumors
in patients operated on at the age of 30 showed that in one third of cases the
new growth was of a malignant nature.
Some differences were found in the average diameter of the tumorous
nodes: 3.05±1.45 cm for adenoma and 3.89±1.77 for follicular cancer (p <
0.05). At the same time, the coincident size limits (from 1.5 to 8 cm) in
patients in both groups made this evidence an unreliable indication in the dif?
ferential diagnosis of tumors. Both kinds of neoplasms equally often (approx.
in 80% of cases) were not accompanied by morphologically significant
changes in the thyroid gland being a solitary node. Some frank secondary
changes such as sclerosis, petrifaction, cystic changes, hemorrhages, e.t.c,
were more often observed in follicular adenomas, however these distinctions
were not authentic enough.
In our opinion the difficulties in the clinic morphological interpretation
of the follicular tumors pattern need more than anything else improvement in
the methodical techniques, which is especially important considering certain
time and hardware?related limitations of the NLS?method. When faced with
diagnostic difficulties we investigate series of nidi in every 30?60 mm.
Conducting investigation on such a large scale consumes additional time (30?
45 min) and yet in many instances it allows to specify the pattern of a follic?
ular tumor. If the investigation of some additional nidi doesn’t produce the
desirable result, the diagnostics is performed after the surgery. According to
our observations, in 65% delayed cases the tumor proved to be malignant yet
had minimal manifestations of invasive growth into the node capsule or its
individual vessels. Absence of palindromium in 95?99% of cases, following
the surgery for follicular cancer with minimal manifestations of invasive
growth into the capsule and with some individual vessels (up to 5) involved,
gives solid grounds to classify these tumors as clinical “boundary” processes
whose malignant potential remains conditional and justifies the tissue?spar?
ing amount of the thyroid resection (lobectomy with isthmectomy and subto?
59
thyroid gland. We did not succed in specification of the pattern of the process
in the course of 3.6% of all the surgical operations. In 65% of cases for which
diagnosis was postponed, a malignant process was detected in the final phase
of the investigation. An erroneous intraoperative diagnosis was made in 4.8%
of cases with hyperdiagnosis of thyroid cancer recorded in 5 cases.
Carcinoma was not identified during 38 operations; in 23 cases of the surgery
the tumor did not exceed 2.5 cm nor did it spread beyond the thyroid gland.
17 (2.3%) patients needed correction of the amount of the thyroid gland
resection, which was done on the 4?5th day after the first surgery. The NLS
sensitivity was 76.4%, specificity? 87.6% and accuracy? 78.6%.
The submitted data generalizing the experience in the use of NLS in a
specialized surgical clinic are indicative of extensive opportunities for choos?
ing the optimum surgical tactics to treat the goiter using this method, and
also of a growing recognition of NLS despite some recent publications ques?
tioning the efficiency of consultations during the surgery. Apart from some
evidence of a high efficiency rate, another advantage of NLS method is indis?
putably the low percentage of delayed diagnoses, which in our cases was
under 1.4%. The advantages of the method include quickness (10 or 15 min)
and relative technical simplicity of the investigation.
According to our research and some literary evidence, the problems in
the course of NLS?investigation are caused by differential diagnostics
between cellular follicular adenomas and minimum invasion follicular can?
cer. These very cases account for the major share of delayed and erroneous
results. In the series of our investigations in 48 cases of tumors with a micro
follicular or trabecular structure (among which 21 were benign and 27 malig?
nant) drawing a final conclusion on their pattern was impossile. In 5 cases it
was false negative. At the same time 257 follicular adenomas and 30 cases of
follicular cancer were correctly verified in the course of surgery.
It is known that the problems of differential diagnostics of follicular ade?
noma and follicular cancer are closely related to histotypical and cytotypical
similarity of the two processes, that are so much expressed that it is impossi?
ble to diagnose a carcinoma without apparent manifestations of a malignant
potential in the form of the tumor ? germinated capsule with the tumorous
invasion into its vessels. With cancer having minimum invasion the nidi of
infiltrative growth appear to be isolated. In addition, being microscopically
invisible these diagnostically important areas may escape observation in case
of a limited number and random choice of investigation targets in the course
of surgery.
We have considered a number of clinical and microscopic characteristics
in terms of their potential use in NLS differential diagnosis of follicular
58
obtained from other clinics, a tumor in excess of 0.5 cm incurs a higher risk
of potential palidromium and requires a more radical approach to its treat?
ment, than a microscopic cancer nidus. In this connection, it is recom?
mended to take a series of parallel shots of the thyroid tissue in different pro?
jections in the course of macroscopic search for cancerous nidi. According to
our observations this technique may be effective in diagnosing 52% of papil?
lary micro carcinomas sized up to 0.4 cm and 68.6% of tumors over 0.4 cm,
and in most cases will ensure the right choice of a surgical approach.
According to most pathologists, diagnostics of follicular version of pap?
illary cancer is considered to be one of the most difficult problems in NLS?
investigations. Erroneous verification or this neoplasm often leads to anoth?
er surgical operation. Among the difficulties in diagnosing this kind of tumor,
we should first mention some artificial histogram changes in tumors cells,
which hamper identifying diagnostically significant cytological criteria of
papillary cancer. In our series of observations follicular version of papillary
cancer was reported in 43 cases, in 2 of which diagnosing was postponed until
after final investigations and in 5 (3.2%) cases the diagnosis was false nega?
tive. None of the cases showed any metastatic lesions of cervical lymph
nodes. Considering the spectral similarity of follicular encapsulated version
of papillary cancer to adenomatous goiter, the cytological differences in dif?
ferential diagnosis are the decisive criterion in differential diagnosticsis. In
order to assess them in doubtful cases we have additionally investigated some
impression smears, which in most cases helped detect some changes in the
nuclei characteristics of papillary thyroid cancer, such as irregular shape,
jagged boundaries, deep nucleolemma invaginations, outlines of intranuclear
sulci and inclusions marked off by marginally condensed chromatin, fine
chromatin dispersion, etc., as well as to indirectly assess some cohesive prop?
erties of tumorous cells and the inflammatory infiltrate pattern. Among some
cancer?suspicious histological signs observed on a frozen section, we can
note polymorphism of follicles lined with high cubical epithelium with
intensely tinged colloid (if fixed in ethanol!) and/or its marginal vacuolation,
close adherence of follicles to one another owing to scarce stroma in the cen?
tral part of the node, hemorrhage in the follicle lumen at abundance of
siderophages, multinuclear cells, etc.
The recent years publications have extensively debated expediency of
NLS?investigations of the thyroid gland in the cases with the available results
of aspiration biopsy. The cytological investigation in known to be the most
extensively applicable method of presurgical diagnostics of nodular forms of
the goiter because of its accessibility, comparatively low cost, lack of trauma?
tism and most importantly, high accuracy. The progress in the diagnostics of
61
tal thyroidectomy) similar to the one recommended for surgery for follicular
adenoma.
Thus, the NLS?investigation of follicular thyroid tumors can be regard?
ed as an efficient method for choosing the optimum surgical approach,
because with sufficient experience and proper performance it allows to diag?
nose some clinically adverse forms of follicular thyroid cancer that actually
need radical surgery and post surgical treatment.
The papillary cancer is the most common form of thyroid gland carci?
noma. It was correctly diagnosed by means of the NLS?methods in 63.2% of
cases, was a diagnosis failure in 26.3% and was responsible for delayed diag?
nosis in 0.6% of the observations. Unlike follicular tumors, most versions of
papillary cancer typically have frank histotypical differences from benign
proliferate processes, clear manifestations of infiltrative germination in the
tumor?surrounding tissues and frequent metastatic lesion of the lymph nodes
by the time of surgery, which allows to diagnose a malignant process without
difficulty even with inadequate practical experience. The difficulties we con?
fronted mostly concerned papillary micro carcinoma, which made 71% of
cases nondiagnosed during the surgery, and also a follicular encapsulated ver?
sion of papillary cancer that was responsible for the rest 29% of diagnostical
errors.
The problem of NLS papillary micro carcinoma lies in a macroscopic
search for a cancer nidus in the removed fragment of the thyroid gland, which
creates difficulties because of concomitant changes in the thyroid gland at a
multinodal form of the goiter or autoimmune processes. At the same time in
45 cases microcarcina was diagnosed intraoperatively, including 15 cases,
where the tumor size was below 0.4 cm. In 23 cases of papillary micro carci?
noma unidentified by NLS, the surgery was performed for multinodal goiter
(15 cases) and autoimmune thyroiditis (8 cases), which determined the
required amount of surgical intervention (subtotal or total thyrodectomy).
The undiagnosed micro cancer nidi sized from 0.4 to 0.9 cm did not spread
beyond the thyroid gland and afterwards none of the patients affected by
latent carcinoma required another surgical operation to extend the amount of
thyroid gland resection.
Papillary micro carcinoma is known to localize quite often in the thyroid
gland, especially in elderly people and it does not always display its malignant
potential in the form of clinical implications (I.L. Avetisyan, 1999). The
progress of the great majority of such tumors is entirely favorable.
Meanwhile, a direct relationship was established between the size of a papil?
lary micro carcinoma nidus and the frequency of its metastasizing into the
cervical lymph nodes. According to our information and some evidence
60
From comparion of the FNAB and NLS results it was found that of 27
false negative results of punch biopsy 21 nidi of malignant growth were
detected during surgery among multiple benign goiter nodes. The latter,
being prevalent in clinical implication, became the object of FNAB leaving
some latent cancer nidi sized 0.2?1 cm undiagnosed before the surgery. The
insufficiently accurate cytological interpretation of the pattern of a cystic
cavity in the 111G also requires an intraoperative verification. In our series in
2 cases of encapsulated papillary cancer with cystic generation wrongly inter?
preted as a benign process during FNAB the diagnosis was rectified by means
of NLS.
Another equally important task of intraoperative investigation is leveling
possible false positive conclusions of FNAB. In our series in 497 patients hav?
ing benign new growths according to FNAB results, papillary cancer was sus?
pected in 2 cases and a malignant process was not excluded in 26 cases. The
rectification of the process pattern in the course of surgery allowed to choose
the most efficient surgical approach in all cases.
Conclusions
1. The NLS?investigation of thyroid tumors is an efficient method for
choosing surgical approach in surgery for nodal and diffuse forms of goiter.
2. The NLS performed for the patients following FNAB, considerably
enhances the accuracy of morphological investigations at the preliminary
phase, and optimizes the surgical approach in surgery for the thyroid gland.
3. This is a very important reason in favour of the appropriatness of using
NLS?investigation together with FNAB.
63
thyroid tumors using the cytological investigation technique has induced
some researchers to become result?oriented in choosing a surgical approach.
In this connection we made an attempt to define to what extent this
approach is justified after having analysed our own observations and the prac?
tical experience of specialists in a number of well?known clinics of the world.
Among some major problems of fine needle aspiration biopsy (FNAB)
performed under the control of ultrasound scanning (US) we can mention an
amount of aspirate inadequate for diagnosis as well as some situations that do
not allow to preclude a malignant process in the node under the investigation.
While in the former instance a repeated procedure may prove efficient for
30% of the patients, the other problem needs to be solved by a surgical
removal of the tumor with a subsequent histological verification of its pattern.
According to some publications, the number of tumors, which malignant
potential cannot be excluded based on FNAB results, exceeds 11%. In the
majority of cases (about 70%) this kind of diagnostic problems is caused by
follicular adenoma.
According to our information of 338 patients who had surgery after pre?
liminary FNAB the malignant process was not cytologicaly ruled out in 41
cases. In 26 of these observations follicular adenoma and in 15 thyroid can?
cer were verified (2 follicular, 3 medullary and 10 papillary carcinomas). In
all cases the NLS allowed to specify the diagnosis and avoid errors in defin?
ing the amount of resection.
The problem of FNAB accuracy is no less pertinent. According to some
recent reports, the sensitivity and specificity of thyroid FNAB has approached
100%. At the same time, it proves to be difficult to interpret the obtained data
due to different approaches to their analysis. For instance, specialists in some
clinics, where the results were highly accurate, consider only specific cytolog?
ical conclusions ignoring a category of tumors, which cytological picture gives
grounds only to suspect malignant change. In analyzing the FNAB accuracy
some researches consider follicular adenoma in the same category as malig?
nant tumors. Though this kind of approach may be justified in terms of indi?
cations for surgery, by no means it can be justified in terms of a surgical
approach to be chosen. The analysis of some publications shows, that FNAB
can ensure the right surgical approach only in 70?75% of cases. The FNAB
efficiency data evaluated after classifying cancer?suspicius conclusions as
malignant tumors and adenoma as a benign tumor, were as follows: sensitivi?
ty ? 92.1%, specificity ? 94.4%, accuracy ? 93.45. Thus, the FNAB data could
help decide on the proper amount of surgery for 90% of the patients, which in
terms of specialized clinic cannot be a sufficient reason and is an argument in
favour of supplementing FNAB with NLS?investigation.
62
up new opportunities for detecting diseases in the hepatopancreatoduodenal
region, with obstructive jaundice being one of their main clinical implica?
tions. With the development and adoption of a number of speedy programs
for obtaining NLS images, specifically NLS? cholangiopancreatography,
which allows to obtain an integrated virtual picture of the biliary system and
pancreatic ducts without administration of contrasting agents and interven?
tion into the biliary system, the method was attempted to put into active use
as an alternative to ERCPG.
Some published works dealing with NLS have some distinct trends to
pay more attention to this issue with a view of obtaining sufficiently convinc?
ing informaion, that would allow to draw a final conclusion about a new rela?
tionship between integrated X?rayendoscopic examinations, and in the first
place between ERCPG and NLS, when detecting a pathology in the
hepatopancreatoduodenal region. Some of the works suggested that NLS be
used as a method preceding endoscopic cholecystoectomy.
With all the above in view, this paper aims to present our data on the role and
significance of NLS at certain diseases in the hepatopancreatoduodenal region.
To achieve this aim the following tasks were performed:
1. examination of the test group to study different versions of a standard
NLS?picture of the biliary tract;
2. description of the principal NLS semiotics in the patients with a
pathology in the hepatopancreatoduodenal region;
3. cross?comparison of MRT, ERCPG and NLS for a more objective
assessment of the collected data;
4. definition of clinical indications and diagnostic potentials of the NLS
method for the patients with obstructed biliary ducts.
Subject and methods
The NLS investigation was performed on 54 patients, of them 19 made a
test group and 35 had different pathologies in the hepatopancreatoduodenal
region, with 89% of these patients showing signs of obstructive jaundice. The
patients were from 36 to 77 years old. There were 20 women and 15 men in the
group of 35. As a primary method of investigation all the patients had a sonog?
raphy which acted as a screening tool for performing NLS. A relative com?
parison of the results of MRT, ERCPG and NLS was made for 18 patients.
The NLS investigation was carried out using the “Oberon” metatron
jointly manufactured by the Institute of Practical Psychophysics and Clinic
Tech Inc. (USA) and equipped with a 4.9 Ghz trigger sensor.
We assessed the condition of the lymph nodes, especially in the portal
fissure projection, and the hepaticoduodenal ligament on the virtual images.
65
Nonlinear computer diagnostics
and the problem of pathology
in the hepatopancreatoduodenal area
S.P. Tokar, A.S. Davydova,
T.L. Guseva, V.I. Gusarov,
Z.F. Khabibullina, L.S. Pugacheva
The problem of pathology in the hepatopancreatoduodenal area still
remains urgent and explains why researches are keen on the search for
improved diagnosis methods, since the diagnostics proper is the starting point
for determining an approach to treatment. Today the basic methods for diag?
nosing a pathology in this region are traditionally methods of direct artificial
contrasting of the pancreatobiliary system, such as endoscopic retrograde
cholangiopancreatography (ERCPG) and percutaneous transhepatic
cholangiography (PTCG), well established in both diagnostics and treatment
of a number of diseases such as cholelithiasis, cysts and tumors in the head of
pancreas, tumorous and corrosive strictures of the biliary ducts, tumors of
Vater’s papilla, etc.
At the same time, the radioendoscopic methods of investigation of the
biliary ducts, though characterized by a rich diagnostic informational con?
tent owing to their invasiveness, still do not eliminate the danger of serious
complications, such as acute pancreatitis, hyperamylasemia, cholangitis,
sepsis, and allergic reactions, biliary flux into the abdominal cavity with
developing biliary peritonitis, hemorrhages, ect.
Their incidence rate varies from 0.8 to 36%. Besides, in the course of
ERCPG different technical problems may arise (failure in the cannulation of
Vater’s papilla, the impossibility to enter the duodenoscope at esophagus dis?
eases, such as strictures, achalasia, ect.). In addition ERCPG requires
involvement of certain specialists like radiologic diagnosticians, surgical
endoscopists and anesthelists.
The advent of new diagnostical techniques in radiology and first of all
ultrasound scanning (US) and computer tomography (CT), did not produce
a great limiting impact on the use of ERCPG so far as these methods were not
successful in solving a number of diagnostical issues related to pathologies in
the biliary system and pancreas. The development of nonlinear computer
diagnostics (NLS) as s method for diagnosing abdominal pathology, opened
64
The major NLS disadvantages in diagnosing concrements in the hepatic?
ocholledochus are associated with certain difficulties in assessing the chole?
dochus condition, when the choledochus is fully filled with concrements.
In 1 observation the concrement localized in some distal areas of the
hepaticocholledochus, and on NLS shots it looked like a hyperchromogenic
oval?shaped defect with the upper outline looking like a concave lens. The
combination of NLS?shots with conventional MR?tomograms in axial plane
allowed us to specify the spatial relationship between the choledochus and head
of pancreas and the duodenum, in other words, it allows to detail the localiza?
tion of the concrement in the ampullar region of the common biliary duct.
Papillosphincterotomy was done during ERCPG with concrement
extraction.
The genesis of benign strictures of biliary ducts was related to their sur?
gicial lesion or inflammation caused by lithiasis, chronic pancreatitis or
papillostenosis in 90?95% of cases. The number of iatrogenic lesions of the
biliary system ducts grew up with the extensive application of the laparo?
scopic cholecystectomy, because the intraoperative investigation of the com?
mon bile duct is more complicated during laparoscopy than during open sur?
gery. In this connection, in terms of preoperative preparation for endoscopic
cholecystectomy it is necessary to specify the anatomy of the pancreatobiliary
system and assess its condition in order to prevent potential iatrogenic lesions
of the biliary ducts.
So, owing to its noninvasiveness and high resolution, NLS can be a diag?
nosis?determining method for this kind of patients. Unlike ERCPG, NLS
allows to visualize the bile ducts above and below the obstruction level, which
is displayed on both MRT and NLS shots. The latter method gives a virtual
physiological picture of the condition of hepatic and pancreatic ducts as
compared to ERCPG, in which the administration of a contrasting agent
overstates the extent of duct dilatation.
In all of our observation NLS allowed to define the accurate extent of
the arctation, its length and cause. In 2 cases the arctations localized at the
cystic duct level, which was indicative of their iatrogenic genesis. In 1 case it
was an arctation hepaticocunoanastomosis. In 5 observations the arctations
from 1.5 to 2.0 cm long were located at the confluence and in the proximal
region of the hepaticocholledochus.
In assessing the arctation extent in the case where the lumen was not
visualized on NLS?shots, we always analyzed the native MRT scans and sup?
plemented the investigation with thin sections, which allowed forming a
more exact opinion about the arctation extent. At the same time, comparing
the results of nonlinear diagnosis to ERCPG one must admit that the latter
67
We used the “Metapathia IT”, a special computer program for acquisition of
a virtual image of the biliary system and Wirsung’s duct.
Analysis of results
The virtual model distinctly visualized the common bile duct, common
hepatic duct, right and left lobar ducts and gall bladder (GB). The segmen?
tary and subsegmentary intrahepatic ducts are not actually visualized even in
a polyprojection examination. The normal lumen of the common bile duct is
0.6 cm; the NLS?signal coming from it, is homogeneously normochromatic
(1?2 points according to Fandler’s chromatic scale).
The anatomical variations and abnormal developments occur very sel?
dom, yet we observed 3 cases of this kind, of them 2 contained an abnormal
drainage of the cystic duct and 1 an atypically high point of entry of the cys?
tic duct into the common hepatic duct. An insufficient detailing of the papil?
lo?sphincter region is the basic limitation of NLS in our investigation was.
Calculi are known to be the most frequent cause of the bile duct obstruction.
According to our investigations, cholecysto?choledocholithiasis made 34% of all
diagnosed pathologies in the hepatopancreatoduodenal region. Regardless of
their location, the concrements in the biliary ducts were visualized on the NLS
images as individual or multiple hyperchromogenic zones (5?6 points), rounded
or oval?shaped. The sizes of the concrements detected in the hepaticocholle?
dochus and lobar hepatic ducts varied from 5 to 20 mm. 6 patients had single
concrements, and 4 had multiple concrements, and the entire lumen of the
hepaticocholledochus “stuffed” with concrements was found in 1 patient.
The localization of the concrements was variable. In 2 observations the
concrements only localized in the gall bladder and in 5 cases they did in the
hepaticocholledochus; in 1 case the clinic laboratory evidence of obstructive
jaundice was not found, and in 2 cases the concrements were visualized in
both the choledochus and lobal biliary ducts. In 5 cases we observed a con?
currence of concrements in the gall bladder and choledochus.
In the course of our observations we arrived at a conclusion that the NLS?
diagnostics of concrements in the gall bladder depended on their size. So, as
compared to the US data, the concrements under 5 mm in diameter were
largely not visualized on NLS shots, because the signal from them was over?
lapped by a hyperchromogenic signal from the mucous membrane. Small mul?
tiple concrements in the gall bladder that produce a low entropy density signal
(3?4 points according to Fandler’s scale) on NLS?shots hamper their differen?
tial diagnosis because of sediment and putty?like bile. We agree with same
authors who consider the ultrasound scanning to be the “golden standard” in
detecting gall bladder concrements, which should not be replaced by NLS.
66
We observed 4 cases of cholangiocarcinoma with obturation of intra? or
extrahepatic ducts including 2 cases with a tumor localized at the common
hepatic duct level and 2 cases with affected intrahepatic ducts and liver parenchy?
ma. In all of the 4 cases the NLS allowed to precisely localize the lesion level and
define its length. Both cases of cholangiocarcinoma displayed a spectral similar?
ity to the reference standard process ‘liver carcinoma’ (D from 213 to 418).
Researchers observed an increased chromogenic density (5?6 points) of
intrahepatic ducts more proximal to the arctation. In one of the observation,
in the projection of the constriction of the common biliary duct, the MRT
scans displayed a soft tissue structure, up to 3 cm in diameter with a medium
intensity signal, which enveloped the duct in a sleeve?like manner at the
lesion level and was indicative of a tumorous etiology of the structure.
Another observation at stenosis of the common biliary duct with no imaging
of the tumorous tissue, detected enlarged lymph nodes in the lesser omentum
region and a single metastasis into the liver which allowed us to correctly
interpret the pattern of the lesion confirmed by histological investigation of
the biopsy material acquired during transhepatic drainage for decompressing
the biliary ducts. In 1 of the 2 observations of cholangiocarcinoma of intra?
hepatic ducts also histologically confirmed later, we drew an erroneous con?
clusion, because the pattern of MR?changes, i.e., a small ectasia of the intra?
hepatic ducts by a varicose type above the moderately constricted common
hepatic duct, and unaffected hepatic duct more distal from the structure, a
rather long anamnesis of the disease (the patient had had itching fits, occa?
sionally icteric integument, decolored feces and dark urine for ten years) and
the obscure clinical presentation were interpreted by us (and during
ERCPG) as manifestations of a primary sclerogenic cholangitis.
In all three our observations of pancreas head cancer the obstruction of
the biliary duct looked on NLS shots like a progressively growing chro?
mogenic density of the ecstatic biliary duct at the level of its intrapancreatic
area. A frank hyperchromogenic pattern of the intrahepatic ducts was con?
currently noted. The Wirsung duct was unevenly hyperchromatic too. The
standard AUTO TUNE shots allowed to evaluate the spread of the tumor to
the adjacent structures and determine some hematogenic and lymphogenous
metastases. The structure of the tumor itself could be better visualized on the
front shots. In one of the cases we also detected both metastases into the liver,
and enlarged lymph nodes in the suprapancreatic cellular tissue. The histo?
logical investigation confirmed the adencarcinoma in all three cases.
Differential diagnostics of pancreas head cancer and chronic pseudotu?
morous pancreatitis is a very complicated task and until now has been a prob?
lem yet to be solved. Integrated abdominal NLS?investigation with visual
69
method is more exact in determining the extent of duct affection.
However the essential criterion in deciding on the surgical correction
method allows not only to detect the level and length of a structure, but also clear?
ly specify the pattern of cholledochus deformation in presence of an arctation,
which also determines the surgical approach to the reconstructive operations.
The combination of conventional MRT and NLS considerably
enhances the diagnostic potential of this method as oppposed to ERCPG in
diagnosing chronic or acute pancreatitis, because it allows not only to inves?
tigate the condition of the ducts of the pancreatobiliary system, but also to
assess both the pancreas proper and the adjacent organs and structures. Of 4
our observations of chronic pancreatitis in 1 case we had a frank contraction
of the intrapancreatic part of the cholledochus caused by a chronic inflam?
matory process, in 3 patients the constriction of the distal part of the cholle?
dochus was caused by a cyst in the head of pancreas. On the NLS?shots the
obstruction of the biliary duct looked cone?shaped, and its affected part
could be visualized all the way along the head of the pancreas including
Vater’s papilla area, and was assessed at 5?6 points according to Flandler’s
chromatic scale.
In all the cases a moderate chromogenic density of dilated biliary ducts
and a heterochromous response of Wirsung duct occured. The cysts, where
existed, were depicted on MRT and NLS shots and the constricted area of
the common biliary duct had an arc?shaped route because of being forced
back by the cyst. The NLS allowed to detect a relation between the Wirsung
duct and pancreatic cysts.
The most common and well?known causes of the biliary tract obstruction
are the tumors localized in different organs: liver, biliary extra hepatic ducts,
head of pancreas, major duodenal papilla, as well as metastases into the hepa?
toduodenal ligament and portal fissure. In diagnostical department of the
clinical medicine the tumors concentrated in these locations are convention?
ally called the “tumors of the hepatopancreatoduodenal region”. The reason
for that is common clinical implications related to the obstruction of biliary
and pancreatic ducts. In patients affected by malignant tumors localized in
this area the primary symptom of the disease is generally obstructive jaundice.
So, decision on the expediency of surgery for this kind of patients necessitates
an assessment of a clinical prognosis depending on the tumor state according
to the TNM system. So, if a malignant pattern of obstructive jaundice was sus?
pected, then together with the elimination analysis, which is a special pro?
gram, we always carried out standard investigations in the AUTO TUNE
mode which allowed to localize the tumor and assess its spread to the adjacent
structures as well as to define hematogenic and lymphogenous metastases.
68
MECT and NLS in diagnosing
myocarditis of mild or medium gravity
P.S. Bortshov, K.L. Fadin,
O.P. Derkatch, P.A. Abdulov,
T.N. Timofeyefa, B.M. Nikolaev
Introduction
The diagnosis of non?reumatic myocarditis remains a complicated and
pertinent problem, which is conditioned by lack of pathognomonic clinical
signs and similarity of the semiotics of the disease to other kinds of cardiac
pathology.
The notion of myocarditis brings together inflammatory myocardium
conditions, different in terms of etiology and pathogenesis both at isolated
affects of myocardium (primary myocarditis) and at some infectious diseases
and systemic pathological processes (secondary myocarditis). The disease
may develop with a focal or diffuse lesion of the myocardium.
The clinical diagnostics of primary myocarditis presents great difficul?
ties, so because of the lack of direct signs of the inflammatory lesion of the
myocardium, the diagnosis is based on indirect clinical hardware?bsed syn?
dromes that become apparent within 2 or 3 weeks after the administered
infection. The related syndromes are as follows:
1. any newly detected pathological changes in ECG;
2. an increased level of cardio selective enzymes and proteins in blood
(troponin T and I);
3. cardiomegaly as per radiography or echocardiography data;
4. congestive heart failure;
5. changed immunologic indexes (a higher CD4/CD8 and circulating
immune complex ratio, “yes” response to inhibition of lymphocyte migra?
tion;
6. tachycardia, reduced first sound and gallop rhythm.
The needle biopsy of the myocardium is one of such diagnostic tech?
niques. Meanwhile, the basic morphological sign of the disease in this con?
text is presence of an inflammatory reaction (lymphocytic and histiocytic
infiltration) in the myocardium with damaged cardiomyocytes and capillary
endothelium. However, the endomyocardiac biopsy does not ensure an
exhaustive diagnosis because of a chance to pick up a sample from the unaf?
fected section of the myocardium and obtain a false negative result.
71
simulation of changes in the head of pancreas (not always pathognomonic for
a tumor) and its spectral similarity to blastic process (D< 0.425) allowed us
to produce a more definite opinion about the tumorous pattern of the
process. In addition, the value of the NLS consists in its capability to asses
the spreading of the tumour to the cystic duct which is very essential for mak?
ing a decision on the expediency of cholecystodigestive anastomosis.
According to some literary evidence, differential diagnostics of diseases
of the papillosphincteral region by means of NLS investigation is very diffi?
cult. In 1 of our observations of a patient with clinical lab manifestations of
obstructive jaundice the US detected a distal block of cholledochus with
dilated superjacent regions of the biliary system. The duodenoscopy detected
signs of frank papillate of the major duodenal papilla and suspected infiltra?
tion of the longitudinal fold of the duodenum. The percutaneous transhepat?
ic cholangiography (PTCG), that was performed additionally showed a pic?
ture of stenosed papillosphincteral region. The NLS displayed
hyperchromatic intrahepatic ducts and hepaticocholedochus, with the latter
traceable as far as the level of entering the duodenum. The NLS investigation
performed in a sagittal projection allowed to detect an additional structure
with a moderately chromogenic signal in the ampullar region of the cholle?
dochus. It allowed a supposition about a tumorous lesion of the major duo?
denal papilla. The patient died of DVS syndrome. In section: poorly differ?
entiated adenocarcinoma of the major duodenal papilla. We would like to use
this example to stress the importance of a correct methodic approach for car?
rying out an investigation in a specific diagnostic situation.
Thus, our results were able to show that NLS had great prospects for
diagnosing a number of diseases with such a common anatomic?functional
concept as a pathology in the hepatopancreatoduodenal region. So, thanks to
its noninvasiveness, no need for administering contrasting agents and inter?
vening into the biliary system as well as the aibility to combine with conven?
tional MRT, which substantially increases the diagnostic importance of the
method, in quite a lot of cases the NLS investigation can replace radioendo?
scopic methods of investigation (ERCPG and PTCG) as a primary diagnos?
tics method although the other methods can retain their therapeutic func?
tions. NLS may also become a method of diagnostics choice for patients who
have some counter indications to X?rayendoscopic investigation. We believe
it necessary to actively expand the use of NLS with a view of making an ulti?
mate decision on its clinical diagnostic importance.
70
underwent an NLS investigation of the heart within 2?8 months after the pri?
mary radioisotope investigation and three patients had MECT performed
repeatedly 1.5?8 months later.
Depending on the variant of the primary accumulation of leukocytes in
the myocardium, all the patients with clinic?lab signs of myocarditis were
divided into three groups. The first group included patients with a diffuse
accumulation of tagged leukocytes in the myocardium (n=16), the second
one comprised patients with a focal accumulation (n=20) and the third one
did not have any distinct accumulation of tagged autoleukocytes in the
myocardium (n=13). The groups were comparable by age and gender. The
average age of patients in the group with a diffuse accumulation of leukocytes
was 32.1 ± 1.8, in the group with a focal accumulation? 35.2±2.1 and in the
group without a distinct accumulation ? 36.6±2.2.
Result analysis
The analysis of intracardiac distribution of tagged auto leukocytes
showed that all the patients in the first group had a diffuse lesion of the car?
diac walls in at least two regions: the atril 94% of cases (n=15), left ventricle
(LV) 63% (n=10), right ventricle (RV) 63% (n=10) and interventricular par?
tition 63% (n=10). In patients of the second group with a focal accumulation
of auto leukocytes in the myocardium a lesion of the interventricular parti?
tion (IVP) was visualized most often ? in 65% of cases (n=15), and in the
other regions of the heart inflammatory infiltration was detected with cer?
tainty less often than in the first group and was less frank (atrium ? 30%, n=6,
RV?25%, n=5 and LV?20%, n=4).
One of the factors possibly related to the pattern of auto leukocyte accu?
mulation in the myocardium was an extracardiac spot of leukocyte fixation in
the nasopharynx, gall bladder and uterine appendages regions, which could
be regarded as an obscure foci of chronic infection. It was established that at
a diffuse pattern of auto leukocyte accumulation in the myocardium (which
could be interpreted as a sign of diffuse myocarditis) the extracardiac foci of
the infection were visualized in 100% of cases.
With a focal pattern of leukocyte accumulation in the myocardium the
foci of chronic infection were determined in 70% of cases. In the group of
patients without a clear accumulation of the leukocytes in the myocardium
the foci of chronic infections were only detected in 40% of cases. Extra car?
diac foci of tagged auto leukocyte fixation were more often detected in the
nasopharynx, however there were no authentic distinctions among the
groups. Another factor related to the pattern of the auto leukocyte distribu?
tion in the myocardium was the duration of the disease which consecutively
73
According to most authors, the endomyocardiac biopsy confirms the clinical
diagnosis only in 17?37% of cases.
In this connection the development and extensive use in clinical prac?
tice of noninvasive methods of diagnosis of myocarditis that allow to visual?
ize myocardium inflammation and determine its intensity and evolution in
the course of treatment, arouse active interest. We have accumulated some
experience in non?invasive diagnostics of myocarditis and dynamic control
of the myocardium condition in the course of treatment. In the integrated
diagnostics of inflammatory cardiac lesion, additionally to conventional
methods of clinical, laboratory, immunologic and ultrasound investigation,
we have used the methods of monophoton emission computer tomography of
the myocardium (OECT, tomoscintigraphy of the myocardium) with
autoleukocytes  tagged  by  ottTc?hexamethylpropyleneaminooxym
(HMPAO), and NLS?investigations of the heart.
Material and methods
The tomoscintigraphy of the myocardium was performed on the
monophoton emission computer tomograph ‘Elcinct?Apex?SP?6’ (Israel)
every 1?2 and 24 hours after the autoleukocytes reentered the bloodstream.
The leukocytic suspension was extracted from 500ml of the whole blood by
centrifugation and leukocytopheresis. The leukocyte count was 37.000?
45000 cells per 1 microliter. Before its administration the leukosuspension
was incubated in a flask with 99 tTC ?HMPAO (500) for 15 minutes at room
temperature. For better visualization of myocardium inflammation and a
perfusion study the tomoscintigraphy was performed once again using 44tTc?
tetraphosmine. During processing of the results the tomographic ‘sections’ of
the heart were drawn along the short axis every 0.8 cm from top to bottom
and the outward outlines of the aortic ventricle were encircled. Meanwhile
the inflammation areas were visualized on the scans as foci of hyperfixation
of tagged leukocytes in at least three adjacent sections.
The NLS?investigation was carried out using ‘Oberon?4099′ device
equipped with 1.4 GHz digital trigger sensor (IPP ?CLINIC TECH inc). In
analyzing the obtained virtual shots a special attention was paid to the emerg?
ing zones of the increased chromogenic value of the signal from the
myocardium (5?6 points according to Flandler’s scale). All in all 49 patients
affected by myocarditis of mild or medium gravity were examined (25 women
and 24 men aged 15?47). All the patients underwent a primary clinical hard?
ware?based investigation including MECT with tagged leukocytes. 9 patients
had check examinations of the myocardium condition carried out during the
therapy using tomoscintigraphy of the myocardium and NLS. Six patients
72
mulation had NLS carried out 6 and 8 months after MECT, and the shots did
not display any pathological changes.
Thus, the repeated investigations using tomoscintigraphy of the
myocardium and NLS proved, that a clinical improvement in the patients’
condition that could be seen 1.5?3 months after the medication, was not
indicative of recovery, because the “morphological sanitation of the
myocardium” even at a myocarditis of medium or mild gravity, arrives much
later. The tomoscintigraphy of the myocardium with tagged auto leukocytes
proved to be a more sensitive and informative method of diagnosing
myocarditis in such cases (especially during the primary investigation) than
the NLS investigation. MECT allowed to detect lesions of both ventricles and
also atrii despite their small thickness. The inflammatory tissues in thin?
walled cardiac chambers were well visualized though it proved difficult to
visualize them during NLS. In addition, rhythm disturbances rather often
occuring in myocarditis patients did not affect the quality of the MECT scan?
ning images, but they did affect the images obtained during the NLS exami?
nations. Another negative factor at MECT examination was an inevitable
admixture of erythrocytes in the leuko concentrate, which increased the gen?
eral background radiation of organs and tissues and in some cases effaced the
boundary between the organs under investigation and its background. The
NLS? investigation can be probaly used as a means of the myocardium con?
dition control during therapy, but not as a method of primary diagnostics.
As an example we would refer to the data obtained during one of the
observations. Patient K., 32 years old came to the clinic with complaints of a
persistent dull heart pain experienced at rest, irregular heartbeat and respirato?
ry distress at a moderate physical activity, pasty legs and feet in the evening,
fatiguability and general weakness. The anamnesis showed that two months
before the patient had had an acute rhinopharyngitis without confinement to
bed. For 5 days the patient had a fever with a temperature rising up to 38.5 0 C
and algors in the evenings and in addition developed herpes labialis. The
patient took biseptol, remantadinum and aspirin on her own accord, and grad?
ually started to feel better, however 3 weeks later the complaints reappeared.
When she was hospitalized her condition was satisfactory. According to
the physical examination the patient had pasty talocrural joins, moderate
tachycardia (pulse rate 90 beats per minute), and frequent extrasystole (about
5 beats per minute), muted first sound and third sound on the apex of the
heart. The blood test detected moderate leukocytosis up to 8.8×109 1, stab
cell shift within 9%, accelerated ESR within 20 mm/h slightly increased
within 12.8 U/L (with the norm being 12.5), LDG within 510 U/L (within
450), fibrinogen within 5.5 (4.0), immunoglobulin M within 4.5 g/L (2.5),
75
increased from group 1 to group 3. So, in the first group the average duration
of the disease (from the initial signs of myocarditis to MECT performance)
was 8+4 months, which is authentically shorter than in the second group,
16±7 (P,.2 < 0.05) and in the third group, 28+10 (P,. 3 < 0.05).
The initial integrated investigation of the patients affected by myocardi?
tis showed that in 75% of the patients (36 cases of 49) the accumulation of
auto leukocytes occured in the thick layers of the myocardium, either diffuse
or focal, which together with some clinical signs of myocarditis confirms the
inflammatory lesion of the cardiac muscle. Typical for a diffuse myocarditis
proved to be the moderately increased activity of cardio selective enzymes
and indexes of the cell section of immunity as well as some changes in ECG,
such as disturbed conductivity (A?V blocades of I?II degrees). Increased
diastolic size of the left atrium and left ventricle and increased indexes of the
humoral section of immunity were typical for a focal inflammatory process.
The minimum clinical implications of myocarditis were found in 25% of the
examined patients, whose tomoscintigraphy did not display a distinct accu?
mulation of leukocyte in the myocardium. All the patients were put on med?
ication based on anti?inflammatory and metabolic drugs for 6 months and
their walking regime was restricted for a month. As required, some antiarry?
thmic, antiviral or antibacterial drugs were administered. 1.5?3 months after
the medication was started actually all of the patients began to feel better and
the clinical signs that had made them call in medical aid, disappeared.
Three patients had tomoscintigraphy of the myocardium performed
repeatedly during the medication. Meanwhile, 2 patients with a diffuse pat?
tern of tagged leukocyte accumulation, 1.5?3 months later during check
tomoscans still showed some foci of auto leukocyte fixation in the myocardi?
um, though fewer than at the primary examination. One patient with fixed
accumulation of tagged leukocytes at a repeated MECT procedure 8 months
after the medication did not show any foci of intracardiac leukocyte accu?
mulation.
An NLS?investigation performed on three patients affected by diffuse
myocarditis within 1.5?5 months after the medication was started, confirmed
zones with an abnormally hyperchromatic NLS?signal, which fully corre?
sponded to the foci of tagged auto leukocyte fixation in the myocardium. Our
results are in conformity with some literary evidence on a possible noninva?
sive diagnostics of myocarditis using computer nonlinear investigation. Still
in another instance of NLS investigation we obtained a doubtful or false neg?
ative result which was accounted for by some technical problems (increased
signal deviation connected with a convulsion of ciliary arrhythmia that
occurred during the investigation). Two patients with a focal leukocyte accu?
74
Importance of NLS?method for diagnosing
timorous diseases of the segmented intestine
L.V. Shaposhnikov,
O.R. Kozshemyakin
We made use of the computer nonlinear diagnosis method (NLS) to
identify early phases of malignant growths in the colon. The obtained data
allowed to believe that this method could evaluate the infiltration depth of the
tumor within the intenstine wall and allow to diagnose malignant adenopa?
thy which was necessary to make a prognosis and determine tumor
resectability.
The average detection rate of tumors in the colon at the NLS?investiga?
tion is around 63%. The sensitivity of NLS in diagnosing malignant lym?
phadenopathy at segmented intestine disease is about 65%. It is higher for
rectal tumors because a visualizable lymph node in the adrectal region can be
regarded as a malignant one. The detection of lymph nodes during the NLS
investigation may be connected to the existence of an inflammatory process.
However, perecolonic lymph nodes can be more often diagnosed in patients
affected by colonic cancer (71%) than in cases of inflammatory lesions
(45%).
The NLS?method can be useful in evaluating the spread of tumor to
neighboring organs and tissues as well as metastatic lesions of the liver, adren?
als, lungs, etc. The NLS?investigation can be used to:
— determine resectability and need for presurgical radiation therapy;
— plan radiation field;
— detect complications caused by the tumor such as perforation at a
formed abscess or preobstructive ischemia in patients with fully tumo?
occluded intenstine lumen.
The NLS?method allows to distinguish tumor and ischemic changes in
the wall in 75% of cases (D<0.425). In most cases the ischemic area is locat?
ed beside (in closer proximity) the tumorous area, however occasionally an
intermediate zone with normal mucous membrane may be detected. The
tumor is mostly defined as an unevenly chromogenic area of the intestine wall
(from 0.8 to 4.5 cm, 2.0 cm on the average). The ischemic section is largely
detected due to a concentric zone of a higher chromogenic pattern (5?6
points according to Flandler’s scale), with the zone thickness varying from
0.6 to 1.5 cm (1.0 cm on the average). The timorous area is mostly hete?
77
immunoglobulin G within 24.2 g/l (16.0), within 96 units (66). The reaction
to inhibited lymphocyte migration made 174% (with the norm being 90%).
The ECG recorded some episodes of migration of the pacemaker and fre?
quent ventricular extrasystoles. The chest X?ray pictures detected a stronger
lung pattern due to the vascular component. The heart shadow was not
enlarged. The echocardiography did not detect any changes in the heart cav?
ities and valve system, or any disturbed systolic or diastolic functions of the
left ventricle.
Based on the clinical and instrumental investigations the patient was
diagnosed to have an infections?allergic myocarditis of medium gravity.
A performed tomoscintigraphy of the myocardium detected a diffuse accu?
mulation of tagged leucocytes in the right atrium region, posterior and lateral
walls of the left ventricle and interventricular partition. The NLS?spectral simi?
larity to the reference standard process “Infectious?allergic myocarditis”
(D=202) allowed to objectify the clinical diagnosis and determine the localiza?
tion and spread of the inflammatory process. The patient was prescribed an
antiviral, anti?inflammatory and metabolic treatment. 1.5 month later the
patient’s general condition improved: heartache, irregular heartbeat, shortness
of breath and feebleness did not trouble her any longer and her legs were not
pasty any more. The laboratory and ECG changes became smaller though did
not disappear completely. 2.5 month later a check NLS examination of the heart
was performed. Check shots displayed some areas with a higher chromogenics
of the NLS signal (4?5 points). The increased chromogenics zones completely
corresponded to the fixation areas of tagged autoleukocytes in the myocardium.
A peculiarity of this clinical example is that in this particular case the
diagnosis of myocarditis was confirmed by several noninvasive methods; the
spread of the process was determined and physical control over the
myocardium condition was set in the course of treatment. In summing up it
should be stressed that the MECT with tagged autoleukocytes and NLS are
noninvasive methods of visual diagnosis of inflammatory diseases of the
myocardium. That gives reasons to recommend using MECT and NLS for
diagnosing myocarditis, for making a differential diagnosis of some other dis?
eases of the myocardium of a non?inflammatory pattern, and also for evalu?
ating the condition of the cardiac muscle in the course of treatment.
76
In 10 cases we found some signs characteristic of segmental intestine
cancer, like unevenly chromogenic walls of the segmental intestine sized 1.5
to 3.5 cm (4?6 points on Flandler’s scale) and a spectral similarity to the ref?
erence standard process, ‘colon carcinoma’ (D<0.425). In 2 cases segment?
ed intestine cancer was accompanied by signs of ileus. In one case a massive
tumor originated from the right kidney and involved the ascending intestine.
In other case we diagnosed a tumor largely located extraorganically with
respect to the descending intenstine. In one case the dimensional scaling
imaging of the segmented intenstine gave reason to suspect a cancerous
lesion of the splenic angle of the colon. To confirm it we repeated the inves?
tigation after vegetal testing at a nosodeme ‘colon adenocarcinoma’ which
resulted in diagnosing a polyp (D=0.213). In two cases the NLS?investiga?
tion did not produce a convincing evidence of a cancerous lesion of the seg?
mented intenstine (D>0.425) although the colonoscopy data were indicative
of a cancerous disease or a malignant polyp.
Conclusions
1. Computer nonlinear diagnostics should be used in the cases where a
colon disease may be suspected or where it appears difficult to carry out par?
ticular conventional methods of colon investigation, such as irrigoscopy and
colonoscopy, and also in the cases of a massive extraorganic growth in order
to define the spread of the process, extraorganic relapses of the tumor and
complications caused by tumor or surgical intervention, which helps solve
the issue of tumor operability and therapy approach choice.
2. Using the NLS?method to diagnose single polyps does not appear
efficient, because for the most part they are hard to detect, and differentia?
tion between hyperplastic and adenomatous polyps is impossible.
79
rochromatic (4 to 6 points) whereas the ischemic area is generally found to
be homochromatic (in 70% of cases).
NLS is very important for diagnosing multiple colonic cancers and has
considerable advantages over colonoscopy because it allows to detect changes
more proximal to the tumor and exactly localize the process in the colon and
outside of it. NLS is the only method to diagnose tumor relapses external to
the colon.
It should be taken into account that colon tumor may be mimiced dur?
ing the cotonoscopy by ileocecal valve, fecal masses, respiratory artifacts or
feces?filled diverticulum, which is eliminated in the NLS?diagnostics.
Colonoscopy does not allow to find whether a soft tissue formation in the
tumor bed is a relapse, so it is very important that NLS be performed 4 month
after the surgery and be repeated every 6 months. A scar tissue, even though
it may slightly enlarge initially, should shrink some time later (about a year
after)with its outlines becoming more distinct. Enlarged scar tissue and
lymph nodes should be regarded as an indication for biopsy.
The computer NLS diagnostics method allows to judge the condition
of the mesocolon that can be found by locating mesocolon vessels as a ref?
erence point. Some pathological changes in the mesocolon are related in
the first place to organs with which the mesocolon is linked, such as colon
and pancreas.
Computer non?linear diagnostics is a very promising tool for differenti?
ating between malignant and precancerous colon diseases and some other
changes. The NLS?diagnostics method makes it very easy to detect adeno?
matous polyps over 0,7 cm in diameter. However single polyps lower than 2
mm as measured from the colon surface are hard to detect. Although NLS?
diagnostics does not allow to differentiate between hyperplastic and adeno?
matous polyps well enough, it can be very reliable in diagnosing lipomas.
In some typical cases detection of colonic cancer does not require any
special preparation, however to make the diagnostics of colon diseases more
reliable, it is advisable to evacuate the bowels by giving the patient an enema
a day before and immediately before the examination.
We performed NLS?investigation of the segmented intestine in the cases
of a suspected colon disease, where it was found difficult to carry out con?
ventional methods of colon investigation such as irrigoscopy and
colonoscopy (because of acute painfulness, enema incontinence, impossibil?
ity of investigating the right regions of the colon or some suspected early post?
surgical complications) and also in the cases of massive extraorganic growth
in order to determine the spread of the process and extraorganic relapses in
tumor.
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