3D NLS Diagnostics With Metatron 4025 Hunter Of Cholangiocarcinoma In Patients Suffering From Intrahepatic Cholangiectasis

Intrahepatic cholangiocarcinoma is diagnosed in 7-35% of all malignant hepatic neoplasms cases. Early detection of this pathology is one of the most difficult tasks in diagnostics in hepatology, because the tumor often develops against the background of chronic diseases of liver and bile-excretory ducts and disguised by symptoms of these diseases.


In recent years periodicity of cholangiocarcinoma detection increased. It is explained by introduction of modern methods of visualization, which allow to specify localization and prevalence of tumorous process more accurately. The high point of disease incidence is at the age of 50-70. The incidence of the disease in men and women is almost equal.


The main syndromes accompanying the disease are obstructive jaundice and cholestasis, which decrease greatly parenchyma’s regeneration ability. At the late stages of the disease suppurative cholangitis appears, which oftimes becomes a cause of death of a patient.


Cholangiocarcinoma has adenous structure and originates from intrahepatic bile ducts epithelium, containing keratin, which explains its density. A tumor may develop at any level of biliary tree and spread into a liver. Due to the fact that a tumor is characterized by slow infiltrating growth inside or along duct wall, it does not form clearly visualized volumetric neoplasm and has no clear borders. When a tumor squeezes bile ducts, a biliary hypertension of various intensity and dilation of superjacent parts of biliary tract (depending on a tumor spread) appear. Below the obstruction point a diameter of common bile dust and size of gall bladder decrease.


It is not always possible to reveal a reason of cholestasis analyzing clinical symptoms and biochemical indices only, especially in patients with relatively short and low hyperbilirubinemia. It is also important that the majority of patients suffering from this pathology is elderly people and is admitted to a hospital’s surgery departments with already developed complications.


The only efficient method of cholangiocellular carcinoma treatment is a surgical intervention, which emphasizes the importance of well-timed examination to reveal “lesser” tumors. In patients with small tumors 5-years survival rate reaches 85%. The main factor determining resectability of a tumor is functional possibilities of remaining part of a liver.


Methods of the highest importance for primary diagnostics of bile-excretory dusts pathologies are non-invasive methods of research (ultrasound scanning, computed tomography and magnetic resonance imaging). But these methods cannot clearly detect a localization of a focal process and its character. Basing of acquired data therapists decide about the more accurate method of invasive diagnostics: endoscopic retrograde cholangiopancreatography (ERCPG), percutaneous transhepatic cholangiography (PTCG), and in some cases - angiographic study and liver biopsy. Choosing of a method is determined by its availability, information value, safety and affordability.


Recently appeared method of non-linear diagnostics (NLS) may now become the most available method for primary diagnostics of abdominal cavity diseases. One of the most-prospective trends of NLSdiagnostics is three-dimensional NLS-graphy, which has certain technical and practical advantages in visualization of anatomic and pathological structures over other methods of hardware visualization. Data acquired after computer processing can manipulated, a plane of three-dimensional model cross-cut can be adjusted, thus allowing to investigate organs images in various projections.


NLS-researches were carried out using “Metatron”- 4025 systems equipped with high-frequency trigger sensor (4.9 GHz), a unit of continuous spiral scanning and a feature of three-dimensional rendering. Acquired data was processed with specialized software “Metapathia 4025 Hunter”.


For detailed evaluation of revealed changes we used modes of ultramicroscanning, rotation, segmentation and multi-plane imaging.


Results of three-dimensional NLS-graphy were compared to the data acquired during laboratory tests, ultrasound investigation, computed tomography, ERCPG, fibrogastroduodenoscopy and surgery interventions. SEA results were compared with results of cytological and histological studies.


Statistical analysis of acquired data was carried out by standard methods. Quantitative data is represented in form of a median, 2.5-97.5 percentile, of minimum and maximum values. Differences were considered to be relevant at р ≤ 0.05.


Nowadays the symptoms of intense intra- and extrahepatic cholangiectasis are well known: presence of volumetric intra- and periductal neoplasms obstructing patency of bile-excretory ducts; presence of dilated intra- and extrahepatic bile ducts with superjacent obstruction point, etc. But still we have no diagnostically significant criteria of biliary obstruction development reasons at the early stages, before intense clinical symptoms of jaundice appear.


Due to increased number of surgery interventions on bile-excretory ducts, number of late postsurgery complications increased. One of such complications is benign strictures of bile ducts. In 90% of cases secondary strictures of major duodenal papilla are found, the reasons of which are: constrictor fibrosis, caused by concrements migration; consequences of abdominal, operational or endoscopic trauma; duodenum ulcer; ray therapy; pancreatitis, recurrent cholangitis and other non-specific inflammatory processes, affecting excretory function of bile-excretory ducts.


Significant difficulties in differential diagnostics of intrahepatic bile ducts dilation reason appear in patients with acute or chronic cholangitis. Quite often cholangitis develop in patients suffering from choledocholithiasis. According to references, in 5-10% of patients cholecystectomy with revision of common bile duct cannot remove all concrements. Most often stones in intrahepatic bile ducts remain intact. Bile stagnation leads to its contamination with intestinal microflora. Common bile duct is dilated, desquamation and cankering of mucous tunic are registered. When cholangitis spreads to intrahepatic bile ducts, liver abscesses may be formed. Continuous stand of a concrement leads concentric cicatrization of bile-excretory ducts, resulting in development of secondary sclerosing cholangitis and biliary cirrhosis.


Application of radiological method of diagnostics (CT and MRI) at cholangiocarcinoma allows to detect a dilation of intra- and extrahepatic bile ducts, but it is much more difficult to visualize tumor itself, density of which is the same as density of liver. The advantage of these diagnostic methods is that they allow to evaluate spreading of tumorous process to surrounding tissues and organs with a greater reliability.


To evaluate level and parameters of bile-excretory ducts stricture, invasive methods of diagnostics are usually used: ERCPG, PTCG, operative cholangiography and biopsy. Still, even after these complex studies, it is not always possible to define a character of an obstruction in common hepatic or common bile ducts.


At development of cholangiocarcinoma, as well as at any other types of obstructive jaundice and accompanying cholangitis, biochemical parameters of blood prove development of cholestatic jaundice.


Levels of total and conjugated bilirubin and alkaline phosphatase may be very high. Variation of indices reflects incomplete obstruction or involvement of only one duct. At acute obstruction increased activity of transaminase may be registered. It should be noted that great compensatory abilities of a liver provide preservation of its functioning at the early stages of tumor development.


Thus application of 3D NLS-graphy with SEA allows to: reveal etiological reason of bile ducts affection more accurately; evaluate spreading and intensity of bile ducts damage; evaluate relation of pathological nidi to vessels (branches of portal vein and hepatic artery) and surrounding structures; choose treatment tactics and decide about possibility of radical or nonradical surgical intervention. High resolution at three-dimensional NLS-ultramicroscanning allows to visualize small objects accurately. Application of SEA helps to evaluate morphological character of tumorous affection of tissues and organs, which influences choosing of further treatment.

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