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Pulatova Iroda Zakirkhodjaevna, Institute of Postgraduate Medical Education assistant of Department of Oncology with the course of ultrasound diagnosis
E-mail: iroda1979@mail.ru Isamukhamedova Mukharam Akhatovna, Institute of Postgraduate Medical Education dokt. of med. scie., professor, Head of the course of ultrasound diagnosis
Diagnostic role of a Dopplergraphy and multispiral computer angiography in the assessment of prevalence of a tumoral invasion of a stomach cancer
Abstract: The analysis of results of research of 32 patients with gastric cancer in the age of 37-82 years has demonstrated the role of non-invasive methods of radio diagnosis (transabdominal, contrast echography, a Doppler sonography, and also a multispiral computer tomography) in the assessment of the gastric carcinoma prevalence. The control group has engaged thirty healthy persons of the same age. In all patients the diagnosis has been verified morphologically. The results of the research demonstrate that providing high quality diagnosing of the gastric carcinoma requires creating the optimum diagnostic regimens including the use of modern hi-tech methods of the stomach investigations, such as a Dopplergraphy and a multispiral computer angiography.
Keywords: gastric carcinoma, ultrasonic research, Doppler sonography, multispiral computer tomography.
In the last decades the tendency for the gastric carcinoma prevalence do decline was outlined, however this condition continues to take a leading place in structure of oncologic diseases in many countries of the world [1, 4-9; 2, 9-29]. Unsatisfactory results of treatment of tumoral and cancers of a stomach are substantially related to the late diagnosing, local spread of the malignant process and existence of the remote metastases [3, 51-56; 4, 69-90; 5, 8611-8618].
In recent years experts pay the increasing attention to presur-gical diagnosing of local-regional spread of the gastric carcinoma that is important for the choice of the best strategy for the treatment.
One of the factors defining operability of patients with gastric cancer is the lesion a tumor of surgically significant vessels of an abdominal cavity, and also degree of its invasion. Modern technologies of ultrasonic investigations (color Doppler mapping, a power Doppler) allow to survey with a larger accuracy not only a condition of organs and tissues, but also vessels of an abdominal cavity and a stomach that considerably expand possibilities of diagnostics and forecasting of a tumoral lesion. Modern ultrasonic Doppler techniques allow performing dynamic investigation of a vessel to define character and rate of a blood flow in a research zone, to estimate vessel geometry, deformation of contours and narrowing of a vascular lumen that in turn supplement methods of two dimensional echographies. However, the preoperative assessment of a condition ofves-sels at a carcinoma of the stomach causes certain difficulties that is bound to bad technical readiness of the patient, existence of the artifacts, inadequate visualization of vessels, owing to local prevalence of tumoral process [6, 207-209; 7, 42].
Along with an ultrasonic angiography the great value is got also by a multispiral computer tomography which became one of highinformative methods of non-invasive diagnostics, taking a leading place in presurgical diagnostics of many oncologic diseases [8; 9, 514-620]. According to Chen C. Y. Wu D. C. et al. the greatest possible resolving power allows to tap the minimum changes of an internal invisible at ultrasonic research, a computer tomography, a magnetic and resonant tomography that is caused by possibility of construction of informative two — and three-dimensional images of an internal, vessels, bones and joints. Emergence of a dynamic volume multispiral computer tomography considerably raised
diagnostic opportunities of a method in identification of a tumor of a stomach, in establishment of local and regional prevalence of tumoral process, and also in identification of carcinomatosis [10, 472-482]. The method of a multispiral computer tomography is applied not only to primary identification of a neoplasm of a stomach, but also to an assessment of prevalence, depth and extent of a lesion, communication with adjacent anatomic educations and existence of metastasizes. At the same time, appreciable reduction of time of research allows to study as fast as possible interesting anatomic area, and application of contrast agents opens new possibilities of studying of a carcinoma ofthe stomach [11, 40-47; 12, 102-107].
Aim of the research: To study diagnostic efficiency of a Dopple-rography and a multispiral computer angiography in an assessment of prevalence of a tumoral invasion at patients with cancer of a stomach at a presurgical stage.
Materials and methods: Research was conducted at 32 patients with gastric cancer of different localization. Among the surveyed patients there were twenty (65,5%) men and twelve (37,5%) women aged from 37 to 82 years. Average age of the surveyed was sixty years. The control group contained thirty healthy persons of the similar age. All patients were investigated histologically for existence of an adenocarcinoma of various extent of differentiation. Five (15,6%) patients were directed to chemotherapy unit for further treatment without carrying out an operative measure, in connection with local prevalence of malignant process, existence of the remote metastasises, an ascites. Operative intervention in various volume was carried out to 27 (84,4%) patients, from them to 9 patients — an exploratory laparotomy.
To all patients at a presurgical stage there were carried out clinical-laboratory, morphological, endoscopic, radiological methods of research, and also transabdominal ultrasonic echography of abdominal organs and a stomach in a sulphur-scaled regimen (B-regime before and after a contrast study of stomach the decontaminated liquid), a Doppler sonography ofvessels of an abdominal cavity and stomach walls on the Mindray DC-7 device (China), SonoAce X8 (Samsung Medison, Korea) by the convex sensor of 3,5-5,0 MHz. Carrying out survey transabdominal echography of abdominal organs and retroperitoneal space allowed to tap existence of metastasises in a liver, a lesion
of lymph nodes, to define their quantity, the sizes, ascites existence. The ultrasonic angiography was carried out in a regimen spectral, the color Doppler mapping (CDM) and the power Doppler sonography (PD) with an assessment of indicators of a blood flow in the main vessels of an abdominal cavity (a celiac trunk, the top mesenteric artery, the left gastric artery and a splenic vein) and gastric walls. At duplex echography (B-regime and a spectral regime) the blood flow analysis with an assessment of density of walls, perm abilities and echogenecity of a lumen, extent of available visible department of a vessel was carried out. Also the main quantitative indices of a blood flow were studied: peak systolic rate (Vmax), final diastolic rate (Vmin), and also corner-independent indicator — a resistance index (RI). Existence or lack of involvement of vessels in tumoral process (invasion) was estimated. At CDM there were taped signs of neovascularization of a tumor and estimated the following indicators: sharpness of vascular drawing, vascularization type, extent, sizes, color characteristic of a stream, quantitative indices of a blood flow. Application of a power Doppler gave the chance to receive additional information on a he-modynamic of a wall of a stomach, recording blood streams in the vessels invisible at scanning in a duplex regime.
The method of a multispiral computer angiography was carried out on the multidetector computer tomograph Brilliance-64 of PHILLIPS company from Netherlands. To all patients research was conducted on an empty stomach, lying on a back, in the axial plane scanning by means of programs on a breath holding with the further use of multiplanar reconstruction. Stomach previously perorally contrasted contrast water-soluble agent «Trazograf» before hard filling. The technique consisted in obtaining tomograms section of 1 mm thick from level ofproximal part of a stomach to a crest of an ileal bone. All patient entered into an ulnar vein 50 ml of a contrast agent «Omnipak
Table 1. - Doppler metric indicators of a blood flow
350» with rate of 3,5-4,0 ml/sec. by means of an automatic injector. This research includes studying oforgans and vessels of an abdominal cavity in various phases of scanning: native, arterial and venous. At native research conditions of lymph nodes, parenchymatous organs, and also thickness of a gastric wall throughout, gastroesophagal and gastroduodenal transitions, sharpness and flatness of internal contours of a gastric wall, integrity of contours mucous, intensity and homogeneity of a signal from a stomach and lumen wall were estimated. At existence of a tumoral infiltrate its extent, localization on an organ, nature ofprevalence, and also anatomic-topographical relationship of a tumor and an organ with surrounding structures were estimated. In 15 seconds after the beginning of infusion defined an arterial phase, after 50-60 seconds — a venous phase of scanning. The contrasted vessels in arterial and venous phases become well visible that allows tapping the following signs ofa tumoral invasion ofvessels: the existence of volume education adjoining on a vessel; narrowing and stricture formation ofvessel; change of its diameter; existence of an occlusion or aneurysmal expansions, illegibility of contours of walls of a vessel.
Results of the research: The analysis of results of transabdominal echography showed that at two dimensional sulphur-scaled echography at all healthy persons in a projection of a body of a stomach echographically the acoustic shadow from a gas bubble was visualized, and in the field of pyloroantral department the symptom of a physiological cockarde became perceptible. At research of indicators of microcirculation of not changed stomach in the CDM (PD) regime for identification of low-speed streams of a blood in the thickness of a gastric wall and intra mucous vessels single color locuses were registered, or practically weren't defined. High-speed indicators of a blood flow in the main vessels in norm are presented in table 1. in the main vessels of an abdominal cavity in norm
Name ofvessel Vmax., m/c Vmin., m/c RI
Celiac artery 1,23±0,15 0,53±0,04 0,69±0,04
Superior mesenteric artery 1,41±0,13 0,20±0,02 0,81±0,06
Left gastric artery 0,58±0,11 0,16±0,02 0,72±0,03
Splenic vein 0,23±0,02 0,17±0,02 —
Our researches showed that for a gastric carcinoma echographi-cal signs are stomach visualization in a look of "a pathological cockarde" (a symptom of a lesion of a hollow organ) that was observed at 100% of patients, with a thickening of walls from 15 to 24 mm. Transabdominal ultrasonic research taped at 28 (87,5%) patients a
lesion the of the regional lymph nodes, at 12 (37,5%) — a metastatic lesion of a liver, at 4 (12,5%) — a splenomegaly, at 8 (25,0%) — an ascites. Germination in the left share of a liver and a body of a pancreas was observed at 6 (18,8%) patients (fig.1a, 1b).
b
Figure 1a. Patient S. 63 years. The display shows the body of the stomach with thick walls and deformation of the middle M-echo and germination in the body of the pancreas
Figure 1b. Patient O. 42 years. The display shows a metastatic lesion of a liver
a
At 22 (68,8%) patients the existence of volume education adjoining on a celiac trunk, at 13 (40,6%) — with the top mesenteric artery, at 15 (46,9%) — with the left gastric artery was accurately visualized. At 17 (53,1%) patients the left gastric artery wasn't visualized. Illegibility of contours of walls of a celiac trunk
was defined at 3 (9,4%) patients, the left gastric artery — at 7 (21,9%) patients. At the same time, narrowing and a stenosis of a lumen of a celiac trunk was observed at 5 (15,6%) patients, the top mesenteric artery — at 4 (12,5%) and the left gastric artery — at 4 (12,5%) patients (fig.2a, 2b).
Fig. 2a. Dopplerografiya mode CDM patient M. 72 years. The display shows a violation patency left gastric artery and the presence of a turbulent nature of blood flow
Figure 2b. Dopplerografiya mode CDM patient K. 58 years. The display shows a stenosis of the celiac trunk
Characteristic symptoms of a cancer of a stomach were atypi- of walls of a stomach was observed and in 7 (21,9%) — single color cal vascularization of various intensity in stomach and tumor walls loci were noted (fig.3). at CDM (PD). In 10 (31,3%) patients the moderate vascularization
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Figure 3. Doppler mode CDM patient A. 68 years. The display shows the presence of a moderate atypical vascularization in the walls of the stomach
Our researches showed that at a cancer of a stomach the increase in speed of a blood-groove in a celiac artery by 2,5 times in 23 (71,9%) patients, in the superior mesenteric artery by 2,0 times — in 18 (56,3%) patients, in the left gastric artery by 1,7 times — in 15 (46,9%) patients in comparison with norm that was accompanied by a tendency to decrease of RI (tab. 2) is noted. At the same time, at 15 (46,9%) of patients the strengthened hypervascularization of a wall of the affected stomach with involvement in process of all layers of body with simultaneous decrease in speed of a blood-groove in the main vessels was visualized that indirectly speaks about germination of tumoral process in surrounding structures.
Table 2. - Doppler metric indicators of a blood-groove in the main vessels of an abdominal cavity at a cancer of a stomach
a
Name ofvessel Vmax., m/c Vmin., m/c RI
Celiac artery 3,15±0,71* 0,79±0,12* 0,49 ± 0,19**
Superior mesenteric artery 2,81±0,56* 1,09±0,33* 0,51 ± 0,11**
Left gastric artery 0,98±0,05** 0,29±0,06* 0,59 ± 0,06*
Splenic vein 0,31±0,04 0,23±0,03 -
Note: * — reliable difference from control P<0,05 ** — reliable difference from control P<0,01
At a multispiral computer angiography at persons of control In the main group at a multispiral computer tomography the
group it was revealed that studied vessels are passable, without signs native phase allowed to reveal a circular uneven thickening of walls
of occlusion, a stricture formation and the aneurismal expansions. of a stomach, in various departments in places to 18-27 mm that
was noted at all patients (fig.4), and also existence of the multiple increased lymph nodes of an abdominal cavity (paragastrically, para-aortally, paracavally, in a mesenterium) was observed at 30 (93,8%)
patients. Metastatic damage of a liver is revealed at 13 (40,6%) patients, bodies of vertebras in 3 (9,4%) patients, ascites existence in 8 (25,0%) patients.
Figure 4. MSCTA patient M. 53 years old. Native phase. The display shows a circular irregular thickening of the walls of the stomach, with invasion into the body of the pancreas
In an arterial phase the existence ofvolume formation adjoining of contours of walls of celiac artery it was observed in 2 (6,3%) paon a celiac artery at 28 (87,5%) patients, with superior mesenteric tients, the left gastric artery — in 3 (9,4%), other vessels were visual-artery — in 18 (56,3%), with the left gastric artery — 30 (93,8%), ized with accurate contours throughout (fig.5). with a splenic vein — in 2 (6,3%) patients was revealed. Illegibility
Figure 5 MSCTA patient F. 59 years. Arterial phase. The display marked network of collateral right and the left gastric artery, having a tortuous course
However, narrowing and a stricture formation of a gleam of a celiac artery in 7 (21,9%) patients, the superior mesenteric artery — at 5 (15,6%), the left gastric artery — in 8 (25,0%), a splenic vein — in 1 (3,1%) patients was distinctly noted. In 1 (3,1%) patient aneurismal expansion of a gleam of the superior mesenteric artery was revealed.
In a portal phase the line of demarcation between muscular and mucous layers was accurately differentiated at 18 (56,3%) patients. In other cases, revealing of a clear boundary between muscular and mucous layers, presented considerable difficulties.
Indicators of Doppler sonography and multispiral computer angiography were compared with operational data. By intraoperative way existence of a tumoral invasion in surgically significant vessels was revealed at 9 patients, that was the reason to carrying out an exploratory laparotomy. From them, at 7 patients at a presurgical stage after carrying out Doppler sonography and a multispiral computer angiography, germination of tumoral process in vessels of a celiac trunk was revealed.
Table 3. - Sensitivity of Doppler sonography and multispiral computer angiography in an assessment of a condition of the main vessels at a cancer of a stomach
Symptom Doppler sonography MSCA Doppler sonography + MSCA
Sensitivity 78% 95% 98%
Conclusion: Our researches showed that the Dopplerometria has to be included in complex ultrasonic research at a cancer of a stomach and is one of important methods of monitoring of a condition of surgically significant vessels at a cancer of the stomach, influencing assessment local and general prevalence of tumoral process.
Complex application of a duplex and triplex echography, and also multispiral computer angiography allows to increase diagnostic efficiency of methods of research, to estimate operability of a cancer of a stomach and to plan medical tactics.
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Pupelyte Ague,
student of Lithuanian University of Health Sciences
Kleinauskiene Rita, student of Lithuanian University of Health Sciences
Rakickas Julius,
student of Lithuanian University of Health Sciences E-mail: agneep@gmail.com
HDL, LDL, age and gender factors impact on cardiovascular disorders
Abstract: The aim of this research is to identify the factors eliciting coronary artery disease (CAD) among Lithuanian citizens, and to find out the influence of age and sex. Cardiovascular (CV) disease like CAD is one of the main factors of adults' death in developed countries. It is important to understand the causes of their origin and influence, in order to reduce mortality and morbidity of cardiovascular diseases.
Keywords: cardiovascular, CAD, HDL, LDL, TG.
Introduction: In scientific researches it has been found that [1] according to the latest World Health Organization data, Coronary heart disease has reached 38.26% of total deaths in Lithuania. [2] In 2012, mortality from cardiovascular diseases in Lithuania was 775.5 cases of 100 000 population, while in 2013 — already 789.5 to 100,000 ofpop-ulation. The number of deaths from cardiovascular disease is not only higher than the European average, but also it is obviously increasing every year [3]. Coronary artery disease is often caused by atherosclerotic occlusion of the coronary arteries. Atherosclerosis is the buildup of cholesterol and fatty deposits (called plaque) on the inner walls of the arteries that restricts blood flow to the heart [4].
The risk factors for atherosclerosis and CAD are basically the same. These risk factors include high blood cholesterol level, high level of LDL and TG, low level of HDL, hypertension, diabetes, smoking, obesity, and physical inactivity [5]. In some studies, TG levels do not independently predict CAD mortality after adjustment
of other cardiac risk factors, whereas others suggest an independent effect [20]. Also CAD is a fairly common problem associated with aging. The majority of cardiovascular disease cases and deaths occur in the elderly people (>65 years).
The increase in aging population and predominant Western lifestyles, which are also being adopted in developing countries, combines to produce higher population levels of cholesterol and atherogenic dyslipidemia; the result is growing in the incidence of cardiovascular disease and death [7]. According to the University of Maryland Medical Center, 80 to 90 percent of individuals over the age of 30 have some degree of atherosclerosis [8]. Also, menopause is the major risk factor for females with CAD [18]. Menopause is a risk factor for CAD because estrogen withdrawal has a detrimental effect for cardiovascular function and metabolism. The menopause contributes to blood pressure, the increases of sympathetic tone, endothelial dysfunction and vascular inflammation [19].
