Method of intraoperative fluorescent diagnositcs of metastatic affection of lymph nodes

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to oncology, and can be applied for fluorescent diagnostics of malignant neoplasms. By means of light source with wavelength 385-469 nm boundaries and character of fluorescent nidus of lymph nodes are estimated after I level lymphadenectomy. If bright red glow of entire volume of lymph node or fluorescence in form of nidus inside lymph node is present, its metastatic affection is diagnosed. Fluorescence in form of "scalloped" rim on the border of lymph node indicates absence of metastatic affection.

EFFECT: invention makes it possible to prevent total lymphadenectomy due to intraoperative detection of metastatic affection of lymph nodes.

2 ex

 

The invention relates to medicine, namely to methods of fluorescent diagnostics (FD) malignant neoplasms, and may be used for intraoperative determination of metastatic lymph nodes (LU).

Currently in Oncology there is a tendency to reduce the volume of lymphadenectomy, since at early stages of tumor lymph node dissection process performed preventively, which leads to the development of a wide range of postoperative complications. Therefore, when the surgical treatment of malignant tumors of different localization oncologists tend to reduce the scope of lymphadenectomy, and in the absence of lesions in LOU of the first level, is considered inappropriate execution of lymphadenectomy subsequent levels (total lymphadenectomy). Using known non-invasive methods of diagnosis of metastatic lesions LU (ultrasound, CT, MRI) is not possible with enough reliability to assess the state of the lymphatic collector. In this regard, it is important to develop a method of intraoperative determination of metastatic lesions LU I level.

There is a method of determining the volume of lymphadenectomy by biopsy signal (sentinel) lymph node (SLU) (Veronesi u, Paganelli g, Galimberti V et al. Sentinel node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph nodes // ancet. - 1997. - Vol.349. - P.1864-1867). Biopsy CASES is based on the use of two imaging techniques: radioisotope (introduction colloidal radioisotope and the subsequent search for "hot" nodule using Radiodetection) and mapping of regional LU using different types of soluble dyes.). To identify CASE patients the night before surgery on the perimeter of the tumor was injected labeled TS the preparation of colloid Nanocis - TJC-17". Blue dye was injected 1.5 hours before surgery also at 4 points around the perimeter of the tumor. During the operation, search CASES was performed using Radiodetection. This CASE is characterized by increased accumulation of the radiopharmaceutical and colored in blue. After determining the last CASE was removed and did urgent morphological study. In the absence of metastatic lesions in the case of the amount of lymphadectomy not increased. However, this technique is difficult to implement from a technical point of view and may not be used in medical institutions that do not have a Department of nuclear diagnostics, a rotating gamma camera, and other equipment to perform local testing using gamma probe. In centers that use the technique of biopsy CASES, 10% of patients do not appear "hot" nodes in the armpit, i.e. CASES impossible to detect. In addition, it is possible inaccurate whom I identify SLU - delete adjacent not adjacent guard LOU. The application of this method requires urgent morphological studies of the remote LU. The number of false-negative results urgent morphological studies SLU can reach 5-15%. In addition, in this method, remove 1-2 CASES, but there are still other LU I, which may be a metastatic lesion.

There is also known a method of detecting the OCCURRENCE in patients with breast cancer (Frei KA, Bonel HM, H Frick, Walt H and RA Steiner in "Photodynamic detection of axillary sentinel lymph node after oral application of aminolevulinic acid in patients with breast cancer" British Journal of Cancer (2004) 90, 805-809). The authors of this method was investigated the possibility of identifying CASES with the use of the radiopharmaceutical, dye and 5-aminolevulinic acid. The study included 11 patients who were planned conservative surgical treatment for invasive breast cancer. Before surgery patients peritumoral have introduced Nanocolor, 3 hours before the operation, patients received 5-aminolevulinate acid at a dose of 30 mg/kg of body weight, intraoperative peritumoral introduced the blueprint. Search CASES was carried out according to standard methods: preoperative conducted mapping CASES using the drug Nanocolor. In addition, during surgery (intraoperative) operations the TES field was examined in blue light with the use of the laparoscopic system (Karl Storz GmbH, Tuttlingen, Gemany). Taken as a prototype.

During the inspection of the surgical field in the mode of fluorescence detected by the fluorescence 6 LU, while according to morphological studies only 3 revealed a metastatic lesion. A total of 11 patients removed and examined 21 LU. Each patient was removed 1-2 LOU, there remains a high probability of presence is not detected amazed LU I level.

According to morphological studies 9 LU revealed metastatic lesion. Thus, 6 metastatic LU fluorescence intraoperative could not be detected.

In this work, LOU looked at the wound with the use of laparoscopic equipment, however, it is known that the blood absorbs blue light, thereby increasing the number of false-negative results and significantly reduces the usefulness of the methodology. In addition, the use of laparoscopic equipment for imaging fluorescence significantly limits the angle, which also negatively affects the results of the application of the method.

After removal of LU were not examined in the fluorescence mode macroscopically, there was no search of the lesion in LU at the incision site, were not studied the accumulation and distribution of the drug inside LOU, have not been defined fluorescent signs of metastatic porazeni the LU. In addition, in one method for the combined staining of the blue, the use of radioisotope preparation and fluorescence studies using 5-aminolevulinic acid, which could reduce the effectiveness of PD.

The claimed invention is directed to solving the problem of intraoperative determination of metastatic disease, LOU.

Use in clinical practice, the proposed method allows to achieve several technical (diagnostic and/or therapeutic) results:

intraoperative detection of metastatic lesions LU first level;

- improving the reliability of intraoperative FD;

- reduction of the duration of the diagnostic study;

- individualization volume lymphadenectomy: the rejection of total lymphadenectomy in the absence of metastatic disease, LOU first level or performing total lymphadenectomy in the presence of fluorescent signs of defeat LU.

These technical and therapeutic results by carrying out the invention are achieved due to the fact that as in the known method of intraoperative FD metastatic lesions LOU performed by systemic injections of a solution of 5-aminolevulinic acid and intraoperative visual inspection of the LU with the help of special equipment.

The feature is allaamah method is after lymphadenectomy level I, from the fibre remote drug allocate LU, assessing the presence of fluorescence, boundaries and nature of the fluorescent foci using a light source with a wavelength of 385-460 nm, in the presence of bright red glow of the total volume LU or fluorescence in the form of a hearth inside the LU diagnosed metastatic lesion of the LU. Fluorescence in the form of a "scalloped" rim around the edge LU indicates the absence of metastatic disease, LOU.

The invention consists in the following.

The inventive method is based on the phenomenon of differential accumulation of the photosensitizer, and 5-ALA-induced PH in LU discovered by the inventors as a result of experimental studies. Found that when exposed to LU light source with a wavelength of 385-460 nm the presence of a bright red glow of the total volume LU or fluorescence in the form of fire that may be located in any part of the inside LU, indicates metastatic lesions LU. Fluorescence in the form of a "scalloped" rim around the edge LU indicates the absence of metastatic disease, LOU.

The accuracy of the above research results confirmed in 50 patients with malignant tumors. Just was studied 408 LU. At this focal fluorescence was detected in LU, of these 34 LU according to morphological studies revealed metastatic lesions, 45 LU detected fluorescence in the form of a "scalloped" rim, while in none of the cases revealed no metastatic lesion. Thus, the sensitivity of the method was 87,2%, a specificity of 94.8%, diagnostic accuracy of 94.6%.

The method is as follows.

The first stage is realized by the introduction of a photosensitizer drug Alasense (5-aminolevulinate acid) at a dose of 30 mg/kg of body weight. Welcome photosensitizer carried out for 2-2 .5 hours before the operation in the volume of 100 ml with dilution in boiled water. Solution of the drug the patient is taking inside immediately after cooking.

After a period of exposure of the drug should surgical stage, which is performed in the conditions of an operating room, under General anesthesia. After lymphadenectomy level I LU stand out from the fiber remote drug. All LOU visually examined under white light, assess the presence of macroscopic changes.

After exploring in white light conducting a thorough inspection in the fluorescence mode, while the search for red fluorescence. For excitation of fluorescence using a diode light source (wavelength 385-460 nm). The fluorescence recorded visually with the use of special glasses with what metafilter.

When viewed assess the presence of fluorescence, boundaries and nature of the fluorescent foci.

Fluorescence in the form of fire that may be located in any part of the site, is a sign of metastatic disease, LOU. When the detection of focal fluorescence necessary expansion lymphadenectomy up to the total.

Fluorescence in the form of a "scalloped" rim around the border of the LU is not a sign of metastatic disease, LOU. The detection in LU fluorescence in the form of a "scalloped" rim or in the absence of a fluorescence scope of lymphadenectomy does not change.

The entire procedure takes no more than 3-5 minutes.

If necessary, you can perform urgent intraoperative cytological or immunocytochemical study.

Clinical examples

1. Patient DLI, 57 years, 19.04.2010, of Moscow hospitalized in them. PageRank for cancer of the left breast stage I. According to the ultrasound, in the left breast in the upper outer quadrant of the hypoechoic education 7.8×5.4×7.1 mm In regional areas without pathology.

23.04.2010 made radical resection of the left breast with intraoperative FD-drug Alasens.

From the tissue of the axillary region was isolated and removed 6 LOU. When viewed in white light neoplastic lesions LU is not revealed, however, when viewed in the mode Fluor is stantsii in one of LOU revealed a single fluorescence lesion diameter up to 2 mm, located subcapsular. In connection with detection of fluorescent signs of metastatic lesions LU level I volume of transactions increased - made total lymphadenectomy.

As a result of emergency cytological study of scraping with fluorescense plot - sinus histiocytosis with education epitheliopathy structures. Spent fluorescent immunocytokine with epithelial marker Ber Ep4. Positive expression. Immunocytochemical reaction shows the metastasis of cancer in LU.

The results of the standard morphological studies in this LOU had metastasis of ductal cancer without invasion beyond the capsule of the node.

2. Patient I., 67 years, 27.01.2010 of Moscow hospitalized in them. PageRank for cancer of the right breast stage I T1N0M0. According to ultrasound in regional areas increased LU not defined. 3 hours prior to surgical treatment the patient received 1.8 g of Albenza dissolved in 100 ml of distilled water immediately before use.

01.02.2010 made radical resection of the right breast with intraoperative FD.

From fiber armpit selected 4 LU. All LOU were numbered and carefully researched. When viewed in white light macroscopically the tumor LU is not revealed. When viewed in the fluorescence mode in which Mr. LU had fluorescence in the form of a rim.

According to the urgent Cytology - gitosis sinuses. Given data FD, the lad II-III level was not performed. For a more thorough study was made plucked a biopsy of the area of fluorescence for histological examination. The results of the standard morphological studies in LU without metastasis, biopsy LOU No. 1 proliferation of histiocytes in the marginal sinus.

Use in clinical practice, the proposed method allows to intraoperatively identify metastatic lesion of the LU. The consequence of this is the ability to avoid unnecessary total lymphadenectomy and to prevent the development of a number of serious postoperative complications, such as prolonged lymphorrhea, education lymphocele, failure of lymphatic drainage from the limb, etc.

The way intraoperative fluorescence diagnosis of metastatic lymph nodes, including systemic injection of a solution of 5-aminolevulinic acid, intraoperative visual inspection, characterized in that after lymphadenectomy level I of the fiber remote drug secrete lymph nodes, assessing the presence of fluorescence, boundaries and nature of the fluorescent foci using a light source with a wavelength of 385-460 nm, in the presence of bright red glow of the entire volume of the mA lymph node or fluorescence in the form of a hearth inside the lymph node, diagnose metastatic lymph node, fluorescence in the form of a "scalloped" rim around the edge of the lymph node indicates the absence of metastatic lymph node.



 

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