RU2258222C2 - Method for differential diagnostics of quickly metastasing uterine leiomyoma - Google Patents

Abstract

FIELD: medicine, gynecology.

SUBSTANCE: one should study biological material and, moreover, detect the content of epidermal growth factor (EGF) in endometrial bioptates. At its value being equal to 6 ng/ml and lower one should diagnose "false" myomatous growth, and at its value of above 6 ng/ml - "true" myomatous growth. The present innovation enables to conduct pre-operational diagnostics of quickly metastasing uterine leiomyoma by applying the above-mentioned technique.

EFFECT: higher accuracy of differential diagnostics.

3 ex, 1 tbl

Description

The invention relates to medicine, namely to gynecology, and can be used as a differential preoperative diagnosis of fast-growing uterine leiomyoma.

The relevance of the invention is determined by the high incidence of leiomyomas (hereinafter referred to as uterine fibroids) in women older than 30 years: 15-17%. Up to 80% of all cases of the disease are observed in women of reproductive age [7]. 50% of patients have a rapid growth of uterine fibroids, which is an indication for surgery, although some of them could be treated conservatively using hormonal drugs.

In practice, there are two options for the growth of rapidly growing uterine fibroids - “false” and “true” [6].

With "true" growth of uterine fibroids, there is proliferation of myogenic elements, which can successfully respond to hormonal treatment [2].

The “false” growth of fibroids at the base has a malnutrition of the node, swelling, degenerative changes in the tumor, due to which there is an increase in the size of the myomatous node, which requires mainly surgical treatment [1; 2; 6].

Currently, there are no reliable criteria for differential diagnosis of the nature of the rapid growth of uterine fibroids without histological examination of a distant organ, which does not allow the doctor to choose the optimal tactics for managing the patient.

A known method for the diagnosis of the morphological type of uterine fibroids by conducting color Doppler mapping (CDC), which consists in the fact that the sarcoma of the myomatous node, in contrast to other forms, has an intense neovascularization, with a central and peripheral, chaotic arrangement of blood vessels, a low level of blood flow resistance [ 4].

The disadvantages of the method:

1) the method is based on the differential diagnosis of sarcoma and uterine leiomyoma, while the frequency of malignancy of uterine fibroids is not more than 0.8% [9];

2) the method is not informative in terms of the differential diagnosis of "true" and "false" growth of fibroids;

3) the method is nonspecific, because the nature of the intratumoral blood flow in sarcomas and proliferating myoma is identical;

4) there is no data on the accuracy of the method.

The closest technical solution to the claimed method is a method for predicting the growth of uterine fibroids, which consists in the fact that in the tissues of myomatous nodes obtained by transcervical puncture biopsy, it is proposed to determine the density and intensity of staining of progesterone receptors by immunohistochemical method, and with an increase in these indicators, growth is predicted fibroids within 12 months [11].

This method was chosen by us as the closest analogue. However, it has several disadvantages:

1) poor reproducibility of the results due to errors in the preparation of sections, inhomogeneous staining of tissues, features of microscopy [3];

2) the need to use expensive equipment (a hysteroscope or an ultrasound diagnostic apparatus with the need to use a transvaginal sensor) and to attract highly qualified personnel to obtain and process tissue of myomatous nodes);

3) high invasiveness and invasiveness;

4) the authors do not indicate the accuracy, sensitivity and specificity of the method.

These disadvantages are proposed to eliminate in the present method.

The claimed technical result is achieved by the fact that in the endometrial biopsy of women with rapidly growing uterine fibroids, the content of epidermal growth factor (EGF) is determined, and with values of this indicator equal to 6 ng / ml or less, “false” growth of uterine leiomyoma is diagnosed, and with values more 6 ng / ml - “true”, with an accuracy of 82.1%.

The novelty of the proposed method lies in the fact that for the first time a differential preoperative diagnosis of fast-growing uterine leiomyoma is proposed for determining the content of epidermal growth factor (EGF) in endometrial biopsies.

EGF is a globular protein that acts as a strong mitogen in cells of various types. EGF is found in blood, cerebrospinal fluid, milk, saliva, gastric and pancreatic juices [5]. EGF was studied with the aim of possible participation in the pathogenesis of the appearance and growth of uterine fibroids. It was previously found that EGF induces mitotic activity in unchanged myometrium and directly in the node [8]. There is no data on the content of EGF in the endometrium in women with rapidly growing uterine fibroids and for this purpose its determination is carried out for the first time.

The method is carried out according to the standard method as follows: to study the production of EGF by mononuclear cells (MNCs) of the endometrium, an enriched fraction of the endometrial MNCs is isolated by the standard non-enzymatic mechanical method [10]. Endometrial biopsies are placed in cold physiological saline buffered with phosphates, washed twice in Medium 199, mechanically ground and filtered through 6 layers of gauze. The thus obtained suspension of endometrial cells reflects the actual content of cells in the endometrium. The enriched population of endometrial lymphocytes is isolated by the standard method of high-speed centrifugation in the density gradient of ficoll-verographin (d = 1,078). Mononuclear cells are collected in the medium 199 phase - ficoll-verographin interphase and washed twice in medium 199 for 10 minutes. Cell viability is determined by trypan blue staining, and it was at least 95%. For cultivation, the obtained endometrial MNC fraction was used at a concentration of 2 × 10 ⁶ cells / ml. Cells were cultured for 24 hours at 37 ° C in RPMI 1640 medium with 2 mM glutamine without stimulation. After the cultivation period, the supernatant (CH) is removed, centrifuged, frozen and stored at - 20 ° C.

Determination of the concentration of epidermal growth factor in the supernatants of endometrial MNCs is carried out by enzyme-linked immunosorbent assay (ELISA) using commercial ACCU-CYTE test systems manufactured by CYTIMMUNE (Maryland, USA). The sensitivity limit of the test system is 0.195 ng / ml. The measurement is carried out on a Multiscan EX microplate reader (Labsystems, Finland) at a wavelength of 490 nm. Calculation of concentration is made in ng / ml.

Using the proposed method allows with high accuracy (82.1%) to conduct differential diagnosis of the type of growth of uterine fibroids.

Distinctive features of the method are:

- a differential diagnostic parameter was established for the content of epidermal growth factor (EGF) in women with rapidly growing uterine myoma in the endometrium, with quantitative values of 6 ng / ml or less, “false” growth of fibroids is diagnosed, and with values of more than 6 ng / ml - “true” ".

The essence of the proposed method is illustrated by the following examples:

Example 1. Patient I., 30 years old, was admitted to planned surgical treatment. It was observed in the antenatal clinic for uterine fibroids of small sizes (6 weeks) for 3 years. During the last year of observation, she began to complain about an increase in the volume of the abdomen, heavy and prolonged menstruation, and frequent urination. A history of 1 timely delivery, there were no medical abortions, the contraceptive method was a barrier.

When a vaginal examination: the cervix without defects in the mucosa, the uterus is enlarged up to 16 weeks of pregnancy, with an uneven surface, dense, mobile, painless, the appendages are not detected, the vaults are free.

According to ultrasound scanning (US): uterine body with dimensions 78 × 52 × 61 mm of heterogeneous structure. From the right rib comes the intermuscular-subperitoneal node 132 × 92 × 120 mm on a wide base, reduced echogenicity, heterogeneous structure. M-echo 12 mm. The right ovary is 41 × 26 mm, the left ovary is 44 × 26 mm, normal structure.

Blood test: Hb - 110 g / l, red blood cells - 4.3 T / l, color indicator - 0.9, white blood cells - 6.7 G / l, eosinophils - 2, segmented neutrophils - 62, monocytes - 8, lymphocytes - 26, ESR - 11 mm / h.

Clinical diagnosis: intermuscular-subperitoneal uterine fibroids, rapid growth, dysuric phenomena.

According to the immunological examination according to the claimed method, it was found that the EGF content in the endometrium is within 2.39 ng / ml, which is lower than the claimed parameter (6 ng / ml) and indicates a "false" growth of fibroids.

Conclusion: "false" growth of fibroids is diagnosed.

The operation was performed: conservative myomectomy.

A histological examination of the surgical material yielded the following result: "uterine leiomyoma with severe edema and focal hyalinosis of the stroma." Thus, the diagnosis of “false” growth of uterine fibroids associated with secondary changes in the tumor was confirmed.

Example 2. Patient S., 32 years old, was admitted for planned surgical treatment. It was observed in the antenatal clinic for uterine fibroids of small sizes (4-5 weeks). On examination, three months after the first treatment, a rapid growth of the myomatous node was noted. The patient did not present complaints. From the anamnesis: a woman who had not given birth, there were no medical abortions, the method of contraception was a barrier. Further plans pregnancy.

On examination: the cervix without defects in the mucosa, the body of the uterus is enlarged to 11 weeks of pregnancy due to a node coming from the left side wall, is dense, mobile, painless, the appendages are not changed.

USG data: uterine body of heterogeneous structure, together with a node 115 × 70 × 110 mm in size. On the front wall is an intermuscular-subperitoneal node with a diameter of up to 70 mm. M-echo 4 mm. The right ovary is 36 × 18 mm. The left ovary is 33 × 11 mm. Both ovaries are of normal structure.

Blood test: Hb - 120 g / l, red blood cells - 4.2 T / l, color indicator - 0.9, white blood cells - 8 G / l, stab neutrophils - 1, segmented neutrophils - 55, monocytes - 8, lymphocytes - 35 , ESR - 6 mm / h.

Clinical diagnosis: intermuscular-peritoneal uterine fibroids. Fast growth.

A survey according to the claimed method showed that the EGF content in the endometrium was 15.04 ng / ml, which is higher than the claimed parameter (more than 6 ng / ml) and indicates a "true" growth of fibroids.

Conclusion: the "true" growth of fibroids is diagnosed, not associated with its secondary changes.

The operation was performed: conservative myomectomy.

A histological examination of the surgical material yielded the answer “proliferating uterine leiomyoma with a large number of vessels of different caliber”, i.e. Signs of “true” growth were revealed.

Example 3. Patient K., 30 years old. It was observed in the antenatal clinic for uterine fibroids of small sizes (6 weeks) for 3 years. During the last six months of observation, she began to complain of heavy and prolonged menstruation. A history of 1 timely delivery, there was no medical abortion, the method of contraception was an intrauterine device (IUD) for 5 years. When a vaginal examination: the cervix without defects in the mucosa, the uterus is enlarged to 11 weeks of pregnancy, with an uneven surface, dense, mobile, painless, the appendages are not detected, the vaults are free.

According to ultrasound scanning (US): the uterine body is 67 × 93 × 100 mm in size with an inhomogeneous structure. On the front wall, on the left, the intramuscularly-subperitoneal node is 80 × 65 × 81 mm with secondary changes. M-echo 11 mm. The right ovary is 40 × 24 mm, the left ovary is 32 × 27 mm, normal structure.

Blood test: Hb - 120 g / l, red blood cells - 4.34 T / l, color indicator - 0.81, white blood cells - 4.4 G / l, eosinophils - 2, segmented neutrophils - 64, monocytes - 11.2, lymphocytes - 40.2, ESR - 10 mm / h.

Clinical diagnosis: intermuscular-subperitoneal uterine fibroids, rapid growth.

According to the immunological examination according to the claimed method, it was shown that the EGF content in the endometrium was 6.2 ng / ml, which is slightly higher than the claimed parameter (6 ng / ml) and indicates a "true" growth of fibroids.

Conclusion: "true" growth of fibroids is diagnosed.

The operation was performed: conservative myomectomy.

A histological examination of the surgical material yielded the following result: "uterine leiomyoma with a moderate number of vessels and stromal fibrosis." Thus, signs of not only “true”, but also “false” growth of uterine fibroids were revealed.

The advantages of the proposed method:

1. The use of differential preoperative diagnosis of rapidly growing uterine fibroids as a screening examination method with an accuracy of 82.1%, sensitivity of 94.4%, specificity of 60% (table 1).

2. Examination of women is possible on an outpatient basis, does not require the involvement of numerous personnel and does not lead to temporary disability of a woman.

3. The ability to choose patient management tactics.

Table 1 Indicator The number of examined total women 28 true positive result 17 false positive 4 true negative result 6 false negative 1 Total: the accuracy of the proposed method is 82.1% the sensitivity of the proposed method is 94.4% the specificity of the proposed method is 60%

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Claims (1)

A method for differential diagnosis of rapidly growing uterine leiomyoma by examining biological material, characterized in that the content of the epidermal growth factor is determined in the endometrial biopsy and, with its value of 6 ng / ml or less, “false” growth of fibroids is diagnosed, and with a value of more than 6 ng / ml - true "growth of fibroids.