head editor’s introductory word · 4 №1 / january / actual aspects of nls-diagnostics...
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You are reading the first issue of medical scientific journal ACTUAL ASPECTS OF NLS-DIAGNOSTICS. Even with-out reading a single article you can see that this journal differs from traditional academic medical journals.
Firstly, it is focused and related to a new trend in medi-cal science — non-linear (NLS) diagnostics — the trend that appeared at the junction of classical and Oriental medicine, quantum mechanics and psychophysics. NLS-diagnostics, based on a new physics of quantum-entropic interaction allows to acquire maximum information about severity, maturity and intensity of functional changes in hu-man organism during medical check-up. In majority of cases application of this technology has a principle meaning for diagnosing and therefore for choosing of proper treatment course. Thereby developing of this method became an im-portant milestone in diagnostic medicine.
The first decade of the 21st century is marked by consid-erable extension of NLS-technology’s diagnostic possibilities, first of all by means of new technologies introduction and using of high-performance computers. Such concepts as 3D NLS-graphy, NLS-ultramicroscopy, spectral-entropic analysis (SEA), have become customary in many clinics. Along with development of affordable portable digital NLS-systems, scope of their application in the world has been extended also. Cost of NLS-diagnostic equipment is really low in com-parison with other methods of medical imaging, such as ultrasound, CT and MRI. It promotes wide spreading of the technology in countries of low income level. Among other methods of medical imaging the NLS gives a picture closest to the pathologicoanatomic one. This fact, as well as safety, promotes quick development of NLS-diagnostics.
More and more clinical therapists realize necessity to master NLS-diagnostic equipment. That is why a need in properly educated experts in this field is obvious.
Today, as we can see, non-linear diagnostics is one of the most prospective and fast-moving branch of medical science and practice, having all necessary institutional attributes, the main of which is formally established and active profes-sional society of non-linear diagnostics experts — the Inter-national Academy of non-linear diagnostic systems (IANDS). Until today non-linear diagnostics experts had no forum to discuss topical issues of NLS-diagnostics, which would promote wide spreading and development of this branch of medicine. Published materials are scattered among general medical and highly specialized journals and are lost in the mainstream of publications on more traditional for medical science fields.
I want to believe that this journal issued by IANDS will become a discussion forum for non-linear diagnostics ex-perts, help to ensure scientific communication, exchange of ideas and results of studies, and promote introduction of latest scientific developments into practical work of all non-linear diagnostics experts.
Secondly, this journal is electronic one and there will be no printed version of it. Today traditional paper scientific journal cannot get in line with dynamic information envi-ronment. Modern scientific periodicals seek representation in the Internet, otherwise it will probably result in absence of demand and withdrawal from professional communicative space. Creating his journal we have intentionally chosen the electronic form of publication, because it has many advan-tages over traditional paper form. Thanks to electronic form journal volume limitation are dropped, financial expenses are lowered and time for delivery to each reader is decreased — it takes seconds now. All issues of the journal will be in constant and free access for any reader.
The editorial board of the journal establishes a very am-bitious goal — to make the journal recognizable among ma-jor medical journals and to become well-know to world’s sci-entific society as the journal reflecting the latest achieve-ments of medical science in NLS-diagnostics field. Scientif-ic renown will be ensured by transparency and accessibility of published materials 24 / 7.
The journal will be issued in English four times per year. The journal adheres to standard publishing requirements. ACTUAL ASPECTS OF NLS-DIAGNOSTICS is the officially registered full length publication undergoing complete editorial and correction cycle. It publishes adequate and completed manuscripts only. To maintain high professional quality an expertise of all materials will be carried out. Well know scientists will be engaged in various official capaci-ties (authors, reviewers, members of the editorial board), which will also ensure high quality of published materials.
All materials in electronic assets (of local and remote access) of the electronic journal are considered to be pub-lished and are the subject matter of copyright.
We welcome partnership with all interested people.
Vladimir Nesterov,Head editor of ACTUAL ASPECTS OF NLS-DIAGNOSTICS,
Full member of the Academyof Medical and Technical Sciences,
President of the International Academy of non-linear diagnostic systems, Academician
HEAD EDITOR’S INTRODUCTORY WORD
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ACTUAL ASPECTS OF NLS-DIAGNOSTICS
journal is the official information unit
of the International Academy of non-linear
diagnostic systems. (Media organisation
registration certificate
El No FS77–52133 from 11.12.2012)
Publication frequency: 4 times per year
Language: English
ACTUAL ASPECTS OF NLS-DIAGNOSTICS is the professional medical
journal. Latest news about NLS-diagnostic systems market, research and
practice articles on topical question of NLS-diagnostics for general prac-
titioners, therapists, surgeons and specialized doctors. Regular columns
for scientists and medical students.
Intended readers: practicing physician of various specializations:
surgeons, endocrinologists, cardiologists, rheumatologists, psychoneu-
rologists, pulmonologists, gastroenterologists, E. N. T. specialists, derma-
tovenerologists, urino-nephrologists, gynecologists and family doctors.
Main subject: the journal has practical orientation and publishes ar-
ticles created by leading experts and opinion leaders addressing topical
issues of NLS-diagnostics of wide nosological range; modern methods and
algorithms of non-linear diagnostics of diseases and traumas.
These issues have a particular interest and practical significance for
everyday work of therapists and practicing physicians — the intended
readers of the journal.
CONTACTSEditors office:
Head editor and the project director
Dr. Nesterov Vladimir
full member of the Academy of Medical
and Technical Sciences, the President
of International Academy of non-linear
diagnostic systems, Academician.
Phone: +7-3812-31-86-97
Technical editor
Mrs. Yankina Lyudmila
Phone: +7-916-112-18-15
Marketing
Marketing manager
Mr. Zabolotskiy Vladimir
Phone: +7-495-616-66-59
Editors office address:
Bldg.6, 3-1 / 12, Obukha lane,
Moscow, 105064, Russia
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Combined NLS study of space-occupying lesions of ocular organsP. Finger, R. RozenUniversity of Texas M. D. Anderson Cancer Center
Three-dimensional non-linear disgnostics of cholangiocarcinoma in patients suffering from intrahepatic cholangiectasisA.Y. Shvack, T.G. Kuznetsova, V.I. Nesterova, G.A. LopukhovClinic of postgraduate education department of the Omsk state medical academy
Possibilities of NLS-study methods in examination of certain skin diseasesE. Gizbrecht, A. BalcevichAssuta Medical Centers LTD, Tel-Aviv
3D NLS-graphy in full-scale study ofurinary bladdertumorsA. M. Shmerkovich, K. S. KoganMoscow scientific-research oncological institute named after P. A. Gertsen
Three-dimensional NLS-graphy in diagnostics of chronic pseudo-tumor-like pancreatitisS. Mitter, K. Lehnhardt, A. ElvinsHospital Erasme Universite Libre de Bruxelles
Importance of three-dimensional reconstruction and visualization algorithms in non-linear diagnostics of knee jointV. I. Nesterov, N. L. Ogluzdina, P. A. ManokhinThe Institute of Practical Psychophysics, Clinic of postgraduate education department of the Omsk state medical academy
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INTRODUCTION
Over the last years there is a steady increase ten-dency of malignant neoplasms formation in eye tumors despite its insignificance in the structure of oncologi-cal pathology. It should be noted that the problem of an early diagnostics of oncoophthalmological pathol-ogy has its own peculiarities in the different coun-tries. Retinoblastoma in particular is the most spread congenital and acquired oncological disease. Among 450-500 thousands of examined patients there are 20-30 firstly diagnosticated cases of retinoblastoma registered every year in USA. These retinoblastoma cases differ by their aggressive growth rate and they cause metastasis, invalidity and lethality if untimely diagnosed.
There are certain difficulties in the diagnostics of malignant orbital and extra-orbital neoplasms related to the complexity of topographic-anatomic features of the head, type and growth rate of the tumor. In oph-thalmological practice it is both necessary to detect
neoplasm and also to evaluate the rate of process prevalence in surrounding tissues, change of the ves-sels that feed the tumor. It is known that many brain diseases, supramaxillary and ethmoidal cells and also endocrine diseases are accompanied by the syndrome of unilateral or bilateral exophthalmos. In many cases such syndrome rouses an assumption for oncological pathology of eyes.
Modern ophthalmoscopic and roentgenologic methods not always allow dealing with the problems of topographical diagnostics of tumors. Over the last years there were some reports concerning diagnostic capabilities of CT, MRT in case of eye and orbital cav-ity neoplasms. But the large-scale implementation of abovementioned research methods of eyes and orbital cavity depends largely on their availability.
In this regard the use of modern techniques of non-linear diagnostics (NLS) for detection, differen-tial and corrective diagnostics of eyes and extraor-bital neoplasms is closely followed by the researches. Implementation of non-linear ophthalmography into clinical practice actually reflects all the periods of tool engineering development and improvement of the technologies in this regard. There were no detailed studies of diagnostic capabilities of NLS-graphy in case of neoplasms in ocular organs.
In case of assumption of eyes neoplasms ophthal-mologists deal not only with the detection of their organ affiliation but also with rational evaluation of blood circulation. In this regard 3D NLS- angiography offers great opportunities in oncological ophthalmol-ogy.
The goal of given report is experience interchange of clinical application of 3D NLS-graphy in full assess-ment of eyes and orbital cavities neoplasms.
MATERIAL AND METHODS OF RESEARCH
Full-scale clinical NLS-graphic studies of the eyes and orbital cavities were carried out in 90 patients. Among them there were 30 patients — 18-65 years old
There are presented results of the complex NLS-research of patients with space-occupying lesions of orbital and extra-orbital genesis which were confirmed by the results of the clinical research, MRT and CT scanning and also morphologically verified in patients who had underwent surgery. It is determined that spectral-entropic analysis of tissues structure of spectral parameters of blood circulation in feeding vessels substantially helps during corrective diagnostics of the eye tumors. 3D NLS-reconstruction allows accurate stating the syntopy of a neoplasm and its relation with the surrounding tissues on a real time basis. NLS-ultramicroscanning is one of the effective methods in determination of neoplasm types. As a result of performed work the advantage of full-scale 3D study is demonstrated in comparison with traditional 2D NLS-graphy.
Combined NLS study of space-occupying lesions of ocular organs
P. Finger, R. Rozen
University of Texas M. D. Anderson Cancer Center
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volunteers (control group of patients) with no detected pathological changes of the eyes and orbital cavities. In 2010-2011 at Oncoophthalmology Department of Texas M. D. Anderson Cancer Center there were 60 pa-tients with an assumption of eyes tumor. The age of patients varied from 7 to 76 years (24 men, 36 women). Retinoblastoma was diagnosed in 40 patients, uveal melanoma was diagnosed in 14 patients and orbital cavity neoplasms were diagnosed in 6 patients after full-scale clinico-ophthalmological examination. 54 of patients were operated on in the clinic which allowed comparing the results of NLS-graphy with gross appear-ance of the removed neoplasm.
NLS-research of the eyebulb and orbital cavity was performed in M. D. Anderson Cancer Center using «METATRON» — 4027 system with «Metapathia GR Sci-entific» professional software (Clinic Tech Inc, Texas; IPP, Russia) with the use of non-linear trigger multi-frequency sensors with 9.6 GHz generator. The system is designed for 2D and 3D researches. Volumetric ultra-microscanning mode, multiplan analysis of the image, interactive 3D-rendering and spectral-entropic analysis of the tissues structure were used during the research. Overlapping mode of volumetric data received in the modes of NLS-image and MRT was used for 3D organ reconstruction procedure. Dynamic multifrequent fo-cusing, panning and scaling (high-resolution) are the parts of the research technology.
Using such methodological approach allowed studying individual eye elements from the different angles which frequently permitted to «observe» eye corners inaccessible for common ophthalmological examination. Received data archiving was performed using magnetic carriers.
The examination of both eyebulbs of the patient and comparison of their NLS-graphic image were the obligatory conditions.
Qualitative and quantitative characteristics of the eye and orbital cavity structures were studied using serial poly-projection NLS-grams.
Virtual 3D NLS-reconstruction along with relief and form determination of the neoplasm is used for correc-tion of its ratio to the eye and orbital cavity structures. The use of 3D color reconstruction of the vessels helped studying of angioarchitecture of the eye vessels and neoplasm presenting the information concerning the peculiarities of the feeding artery.
RESEARCH RESULTSAND DISCUSSION
414 patients were sent to the ophthalmology department of M. D. Anderson Cancer Center during 2010-2011 from various state medical institutions to exclude ophthalmological pathology cases. Tu-moral diseases were found in 126 patients (30.4 %),
intraocular tumors and orbital cavity neoplasms were found in 60 patients, blepharoncuses were found in 40 patients, conjunctivoma and lacrimal passages tumors were found in 26 patients. All patients were fully examined using routine clinical methods and advanced non-linear ophthalmography technologies. Given report does not include the results of non-linear diagnostics of blepharoncuses, conjunctivoma and lacrimal passages tumors which must be considered and summarized individually.
Pic.1. Two-dimensional NLS-ophthalmography. Choroid melanoma.
Pic.2. Two-dimensional NLS-ophthalmography. Retinoblastoma invading retrobulbar space.
In ophthalmological practice it is both
necessary to detect neoplasm and also to
evaluate the rate of process prevalence
in surrounding tissues, change of the
vessels that feed the tumor.
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At cancer care facility the complex of methods and techniques of NLS-diagnostics must have a sig-nificant importance in the examination system of the patients. We have developed a system conception to non-linear diagnostics of malignant neoplasms in-cluding eye and orbital cavity tumors which provides revealing of pathological process for the detection of spectral similarity with etalon process (spectral-entropic analysis) correction diagnostics of the local, regional and remote spread of the neoplasm, estima-tion of the blood circulation condition in feeding ves-sels, study of angiogenesis state in the tumor, diag-nostics of the accompanying diseases, complications and consequences of oncologic patients treatment. In this regard the use of 2D and 3D NLS-graphy and the methods of ultramicroscopic NLS-angiography substantially expands the opportunities of the cor-rective diagnostics of oncological eyes pathology.
The research began with a common 2D NLS-oph-thalmography. The structure and condition of lens
capsule, structure of vitreous body and condition of optic nerve disk were subjected for the assess-ment. In case of detection of changes of the orbital or extraorbital localization their following aspects were closely studied: type, location, sizes and dimen-sional orientation of these changes. In the mode of 3D NLS-graphy the localization of the neoplasm was confirmed, the structure of the tumor with the use of spectral-entropic analysis was studied.
It should be noted that 2D NLS-graphy (when di-agnosing volumetric intraocular formation according to the signatures of «plus-tissue» presence in either part of the eye-bulb) does not always allow perform-ing the corrective diagnostics of the pathological formation spread and studying the type of tumor and vascularization of the formation which have primary importance when choosing the remedial measures.
Retinoblastoma is the most wide spread oncologi-cal eyes pathology. This disease was found in 34 of 40 patients (age of the disease up to 1 year) who have been
Pic.4. 3D NLS- ophthalmography. Retinoblastoma.Pic.3. Spectral-entropic analysis.Melanoma (D=0,096)
Pic.5. 3D NLS- angiography. Affection of vascular branch-es at retinoblastoma
Pic.6. NLS-ultramicroscanning. Affection of eyeball wall at retinoblastoma. 7
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REFERENCES1. Fledelius H. C. Ultrasound in ophthalmology // Ultrasound Med. Biol. 1997. V. 23. № 3.
P.365-375.2. Sbields J., Sbields C. Retinoblastoma // Pediatric Ophthalmology / Ed. by Gallin P. New York:
Thieme Medical Publishers, 2005. P. 284-294.3. Lemke A. J., Hosten N., Richter M. et al. Contrastenhanced color Doppler sonography of
uveal melanomas // J. Clin. Ultrasound. 2001. V. 29. № 4. P. 205-211.4. Romero J. M., Finger P. T., Rozen R. B., Iezzi R. Three-dimensional ultrasound for the mea-
surement of choroidal melanomas // Arch. Ophthalmol. 2001. V. 119. № 9. P. 1275-1282.5. Nesterova V. I., Shaposhnikov L. V., Yankina L. A., Kozhemyakin O. R. Application of NLS-
diagnostics in oncology. New trends and prospects. // Collection of scientific papers of the Insti-tute of Practical Psychophysics «NLS-diagnostics in medicine. Prospect of development». Tome 3. Moscow. Katalog, 2010, p. 9-12
observed by us. The tumoral affection of the both eyes was registered in 11 cases.
Retinoblastoma has some characteristic features when performing 2D NLS-graphy: detachment of retina in neoplasm area (36 cases), growing multinodular tu-mor with heterogeneous structure (17 cases of exophytic growth and 23 cases of endophytic tumor growth), in-creased chromogenecy (5-6 degree according to Fleyn-dler’s scale) with torose and bizarre contours, frequently with small or grouped petrificates (21 cases) with «comet tail» effect. At the same time a common 2D NLS-research does not always allow differentiating retinoblastoma from fibrosis of vitreous body, angiomatosis and Coats disease.
Full scale 3D NLS-research in case of retinoblastoma with spectral-entropic analysis allowed detection tumors up to 3 mm. in 14 patients. In 6 of cases the neoplasm occupied quarter of the eye cavity, in 10 patients it oc-cupied half of the eye bulb, in 8 patients more than half of the eye bulb, and in 2 cases the tumor grew into sclera and filled the whole orbital cavity.
In the mode of full scale 3D reconstruction with the use of spectral-entropic analysis the accuracy of the di-agnostics in case of such pathology was 2-3 times higher than when using common 2D NLS.
Hemangioma of retrobulbar cavity which constricted ophthalmic artery and optic nerve was detected in 1 out of 6 patients who suffer from orbital formations. In the mode of a common 2D NLS-graphy it was not pos-sible to differentiate the pathology of an artery and vessels in the central parts of hemangioma. Hypo-chromogenic glioma of retrobulbar part of the visual nerve was found in 2 cases. Orbital lymphosarcoma was confirmed when 3D NLS-graphy with spectral-entropic analysis was used: along with studying of the type and
the structure of the formation a possibility for care-ful study of affected feeding artery was provided. It was possible to assess the type of vessels affection inside of the tumor using ultramicroscanning mode with spectral-entropic analysis. Formation of lacri-mal glands was detected in 2 cases. In the mode of 3D reconstruction the pathology of the feeding vessels
of suprapubic arterial system and ophthalmic artery was detected.
Performed researches indicate that the complex approach with the use of modern technologies of 3D NLS-diagnostics with spectral-entropic analysis helps improving the quality of the differential and correc-tive diagnostics of eyes and orbital cavity neoplasms.
Researches also showed that 3D virtual NLS-re-construction with spectral-entropic analysis allows the best accurate characterization of the structure, contours and the degree of involvement of surround-ing anatomical eye and orbital cavity structures into pathological process.
In the mode of full scale 3D reconstruction
with the use of spectral-entropic analysis
the accuracy of the diagnostics in case of
such pathology was 2-3 times higher than
when using common 2D NLS.
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INTRODUCTIONIntrahepatic 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 of-ten develops against the background of chronic diseases of liver and bile-excretory ducts and disguised by symp-toms 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 ac-curately. 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 origi-nates 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 cholesta-sis 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 carci-noma treatment is a surgical intervention, which empha-sizes 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 re-maining part of a liver.
Methods of the highest importance for primary diag-nostics of bile-excretory dusts pathologies are non-inva-sive 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 thera-pists decide about the more accurate method of invasive diagnostics: endoscopic retrograde cholangiopancreatog-raphy (ERCPG), percutaneous transhepatic cholangiogra-phy (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
A.Y. Shvack, T.G. Kuznetsova, V.I. Nesterova, G.A. Lopukhov
Clinic of postgraduate education department of the Omsk state medical academy
In order to evaluate informativity of a three-dimensional NLS-graphy in diagnostics of a cholangiocarcinoma, we carried out a retrospective analysis of clinical records of patients admitted to the Clinic of postgraduate education department of the Omsk state medical academy in 2009-2011. The first (control) group consisted of 30 patients treated in a hospital who had no pathologies of a gastrointestinal tract; the second group consisted of 23 patients with diagnosed benign stenosis of major duodenal papilla of the 3rd stage, complicated by cholangitis and choledocholithiasis; the third group — 21 patient with tumorous affection of hepatopancreoduodenal area organs (tumors of common bile duct, major duodenal papilla and head of pancreas); the fourth group — 12 patients with cholangiocarcinoma. We carried out a comparative analysis of a two-dimensional and a three-dimensional NLS-graphy, CT, endoscopic retrograde cholangiopancreatography.
Three-dimensional non-linear disgnostics of cholangiocarcinoma in patients suffering from intrahepatic cholangiectasis
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primary diagnostics of abdominal cavity diseases. One of the most-prospective trends of NLS-diagnostics 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.
The objective of the present study is to evaluate pos-sibilities of three-dimensional NLS-study in diagnostics of cholangiocarcinoma.
MATERIAL AND METHODS OF THE STUDYWe carried out a retrospective analysis of clinical re-
cords of patients admitted to the Clinic of postgraduate education department of the Omsk state medical acad-emy in 2009-2011. The first (control) group consisted of 30 patients treated in a hospital who had no pathologies of a gastrointestinal tract; the second group consisted of 23 patients with diagnosed benign stenosis of major duodenal papilla of the 3rd stage, complicated by cholan-gitis and choledocholithiasis; the third group — 21 pa-tient with tumorous affection of hepatopancreoduodenal area organs (tumors of common bile duct, major duodenal papilla and head of pancreas); the fourth group — 12 pa-tients with cholangiocellular carcinoma.
The majority of patients were of middle and old ages. Accompanying pathology of gastro-intestinal tract organs was in clinical history of the major part of patients of the 2-4 groups. Concrements in gall bladder at the moment of the study were in 91.3 % of patients of the second group, 57.1 % patients of the third group and 50 % — of the fourth. Biliary obstruction symptoms continuance ranged from several days till 4 months. 4 patients of the second group (17.4 %) were earlier subjected to various types of operative interventions on distal parts of a com-mon bile duct (papillosphincterotomy, pancreaticoduo-denal resection).
Most often cholangiocarcinoma developed in patients with affection of hepatic parenchyma. In 58.3 % of patients of the fourth group we detected chronic hepatitis B and C, which corresponds to information given in references. In HBsAg-positive patients risk of liver cancer development is 30 times higher. Also in 25 % of patients of this group an oncologic pathology of other organs was registered in clinical history.
All admitted patients at the first stage were subjected to ultrasound investigation of hepatopancreobiliary system organs with mandatory study of bile-excretory ducts, major duodenal papilla and head of a pancreas. Further on, in or-der to specify nosological form of a disease, we used other hardware and laboratory methods in correspondence with medical and financial standards and the three-dimensional NLS-graphy with spectral-entropic analysis (SEA), which allowed to define a character of volumetric neoplasm in a liver and bile ducts according to a spectral similarity with etalon processes.
NLS-researches were carried out using «Metatron» — 4025 systems (the IPP, Russia) equipped with high-frequen-cy trigger sensor (4.9 GHz), a unit of continuous spiral scan-ning and a feature of three-dimensional rendering. Acquired data was processed with specialized software «Metapathia GR Clinical». For detailed evaluation of revealed changes we used modes of ultramicroscanning, rotation, segmentation and multi-plane imaging.
Results of three-dimensional NLS-graphy were com-pared to the data acquired during laboratory tests, ul-trasound investigation, computed tomography, ERCPG, fibrogastroduodenoscopy and surgery interventions. SEA results were compared with results of cytological and his-tological studies.
According to SEA results in the third group there were 7 patients with adenosquamous carcinoma (cancer), 1 with non-differentiated (anaplastic) carcinoma and in 13 pa-tients — adenocarcinoma. In all 12 patients of the fourth group we diagnosed intrahepatic cholangiocarcinoma. SEA results were confirmed by cytological and histological stud-ies results in 98.3 % of cases.
Pic. 1. Patient F., 60 years old. Tumorous affection of com-mon bile duct. Three-dimensional NLS-graphy in a mode of multi-plane multidimensional rendering of a image
Pic. 2. Patient E., 58 years old. Segmented intestine cancer metastasis into a liver with growing into left lobe bile duct. Three-dimensional NLS-graphy.
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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 rel-evant at р ≤ 0.05.
RESULTS OF THE STUDY AND DISCUSSIONNowadays the symptoms of intense intra- and extrahe-
patic cholangiectasis are well known: presence of volumet-ric intra- and periductal neoplasms obstructing patency of bile-excretory ducts; presence of dilated intra- and ex-trahepatic 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 post-surgery complica-tions increased. One of such complications is benign stric-tures 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; con-sequences of abdominal, operational or endoscopic trauma; duodenum ulcer; ray therapy; pancreatitis, recurrent chol-angitis and other non-specific inflammatory processes, af-fecting 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 cholecystec-tomy 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, des-quamation and cankering of mucous tunic are registered. When cholangitis spreads to intrahepatic bile ducts, liver abscesses may be formed. Continuous stand of a concre-ment leads concentric cicatrization of bile-excretory ducts, resulting in development of secondary sclerosing cholan-gitis and biliary cirrhosis.
In majority of patients of the second group (82.6 %) we noted presence of accompanying choledocholithiasis. Adequate setting of a patient and proper methodological approach may ensure diagnosing of common bile duct distal part dilation even at scheduled ultrasound check-up. 3D NLS-diagnostics method allowed to visualize more accu-rately area of affection in common bile duct and formulate indications for ERCPG. When this pathology was confirmed, we carried out correction using endoscopic papillosphinc-terotomy. If it was not possible, a hepaticojejunostomy was applied by surgical way.
Normal values of oncomarkers and a possibility to monitor patients in dynamics after active conservative or surgical therapy can help in proper diagnosing.
Tumors of major duodenal papilla, distal parts of com-mon bile duct and pancreas head due to tumorous inva-sion, circular squeezing and growing into a duct can lead to an obstruction (the third group of patients). At the same time the following symptoms of biliary obstruction are re-vealed: dilation of proximal parts of bile ducts; enlarging of gall bladder; development of hepatic changes typical for cholestasis. At accompanying obstruction of a major pancreatic duct directly at the point of its transition into a capsule, a dilation of the duct superjacent to a point of the obstruction is detected.
A direct sign of a major duodenal papilla tumor is a volumetric neoplasm in its projection. At growing of a neoplasm into duodenum we detected constriction and tortuosity of a distal part of a common bile duct and se-vere damage of a papilla walls, chromogeneity of which was significantly heightened during NLS-research (6 points at the Fleindler’s scale). If a tumor grows towards a common bile duct, in its dilated opening in major duodenal papilla projection, NLS-study detected a neoplasm of varied chro-mogeneity, which obstructed the duct. Especially clearly advantages of three-dimensional NLS-graphy in detection of tumors in this area in comparison with ultrasound are seen if major duodenal papilla tumor’s size is less than 5 mm.
Direct signs of common bile duct tumorous affection were local thickening of duct wall with disorders of layer structure and hyperchromogenic neoplasm in duct open-
Pic.3. Patient B., 65 years old. NLS-ultramicroscanning. Cholangiocarcinoma located in major hepatic duct.
Pic.4. Patient V., 68 years old. Spectral-entropic analysis. Cholangiocarcinoma (D = 0,030)
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ing. Visualization of damaged wall improved greatly after three-dimensional NLS-ultramicroscanning was applied.
A significant NLS-sign of pancreas head tumor is a di-rect visualization of a volumetric neoplasm — a solid nidus (of increased chromogeneity, as a rule) or hypochromogenic cystic and solid neoplasm with bordering line between a tu-mor and surrounding tissues. If pancreas head tumor causes obstruction of two duct systems, a common bile duct and a major pancreatic duct may be visualized as neighboring roundish hypochromogenic structures. If a tumor is locat-ed close to vessels, signs of extravasal compression and walls invasion are visualized. A fundamental importance for proper diagnosing belongs to NLS-ultramicroscanning with SEA for sure. The best results of three-dimensional re-construction of NLS-image was achieved in diagnostics of «lesser» tumors of pancreas head (less than 5 mm). Using of three-dimensional NLS-ultramicroscanning al-lows to define more precisely size of tumors and their relation to surrounding vessels and bile ducts, extent of surrounding tissues invasion.
A dilation of intrahepatic ducts may be detected in patients with metastatic lesions of a liver. Reveal-ing of volumetric neoplasms located near the dilated duct may help in diagnosing of the dilation reasons.
As we noted before, in majority of cases cholan-giocarcinoma does not form clearly defined volumetric formation, it has no clear borders and its chromogeneity is only slightly different from healthy tissue of a liver. Often only results of SEA show presence of a tumor.
If a process is generalized (25 %) metastases into regional lymph nodes, located in projection of portal fissure, hepatopancreoduodenal ligament and pancreas are visualized.
Using of three-dimensional NLS-graphy allows to visualize more accurately a tumor itself, trace spread-ing of a tumor along bile duct and through its walls; application of SEA helps to differentiate metastatic and inflammatory character of surrounding tissues affection. Sometimes annular stricture and occlusion of intra- and extrahepatic bile-excretory ducts is de-tected. At development of accompanying cholangitis, affection of ducts walls is visualized clearly.
Size of detected by NLS-ultramicroscanning tu-mors, according to our data, is from 2.5 mm to 5 mm. The minimal detected cholangiocarcinoma was of 1.5 mm size. Localization of cholangiocarcinoma is shown in Table 1.
The fact that in this group of patients severe affec-tion of common bile duct and major pancreatic duct is
detected not so often, has a certain meaning for NLS-diagnostics of cholangiocarcinoma.
Table 2 shows indices of information value of vari-ous research methods and techniques in revealing of bile ducts affection reasons. Three-dimensional NLS-graphy improves information value of Ultrasound study and CT.
According to references, cholangiocarcinoma inva-sion into blood vessels is registered rarely. Application of NLS-ultraangiography allows to detect affection of hepatic vessels (tumorous invasion) in majority of cases (83.3 %).
It should be noted that any detected local stricture and bile ducts damage must be regarded as malignant, until opposite is proven.
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 ob-struction in common hepatic or common bile ducts.
At development of cholangiocarcinoma, as well as at any other types of obstructive jaundice and accom-panying 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 incom-plete obstruction or involvement of only one duct. At acute obstruction increased activity of transaminase may be registered. It should be noted that great com-pensatory abilities of a liver provide preservation of its functioning at the early stages of tumor development. Probably that is why in our study frequency of jaundice and acute pancreatitis revealing in patients with chol-angiocarcinoma was less that in patients of the second and the third groups.
According to our data response of СА-19-9 oncomarker level detection was above 80 % in patients of the third and the fourth groups. References say that simultaneous detection of СА-19-9 and CEA is more accurate, diagnostic precision in this case reaches 86 %.
Localization Absolute number Relative number, %
Intrahepatic ducts 2 16.7
Common hepatic duct and point of lobar hepatic ducts junction
5 41.7
Diffuse affection of common bile duct 1 8.3
Diffuse affection of biliary tract 4 33.3
Table 1. Localization of cholangiocellular carcinoma (n = 12)
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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 surround-ing structures; choose treatment tactics and decide about
possibility of radical or nonradical surgical intervention. High resolution at three-dimensional NLS-ultramicroscan-ning allows to visualize small objects accurately. Appli-cation of SEA helps to evaluate morphological character of tumorous affection of tissues and organs, which influ-ences choosing of further treatment.
Methods and techniques 2nd group(n = 21)
3rd group(n = 21)
4th group(n = 12)
Ultrasound research responce specificity accuracy
n = 2386,991,789,8
n = 2185,792,189,8
n = 1283,395,693,1
Three-dimensional NLS-graphy responce specificity accuracy
n = 2398,699,197,5
n = 2197,295,696,8
n = 1294,699,696,8
Computed tomography responce specificity accuracy
n = 1384,691,789,8
n = 2185,792,589,6
n = 1299,691,991,8
ERCPG responce specificity accuracy
n = 18100,0100,0100,0
n = 12100,0100,0100,0
n = 5100,0100,0100,0
REFERENCES1. Sherlock S., Duli J. Diseases of liver and bile ducts: Practical manual. 2006. 834 с.2. Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practice. 16th ed. / Ed. by
Townsend C. M. Jr. Philadelphia: W. B. Saunders Company, 2001. 1076 p.3. Ahrendt S. A., Pitt H. A., Nakeeb A. et al. Diagnosis and management of cholangiocarcinoma in primary
sclerosing cholangitis // J. Gastrointest. Surg. 1999. V. 3. № 4. P. 357-367.4. Ramage J. K., Donaghy A., Farrant J. M. et al. Serum tumor markers for the diagnosis of cholangiocarci-
noma in primary sclerosing cholangitis // Gastroenterology. 1995. V. 108. № 3. P. 865-869.5. Taylor H. M., Ros P. R. Hepatic imaging. An overview // Radiol. Clin. North Am. 1998. V. 36. № 2. P. 237-245.6. Vauthey J. N. Liver imaging. A surgeon’s perspective // Radiol. Clin. North Am. 1998. V. 36. № 2. P.445-457.7. Magnuson T. H., Bender J. S., Duncan M. D. et al. Utility of magnetic resonance cholangiography in the
evaluation of biliary obstruction // J. Am. Coll. Surg. 1999. V. 189. № 1. P. 63-71.8. Sanches J. M., Margues J. S. A multiscale algorithmfor three-dimensional free-hand ultrasound// Ul-
trasound Med. Biol. 2002. V. 28. № 8. Р.1029-1040.9. Lee H. J., Choi B. I., Han J. K. et al. Three dimensional ultrasonography using the minimum transpar-
ent mode in obstructive biliary diseases: early experience // J. Ultrasound Med. 2002. V. 21. № 4. P. 443-453.10. Macchi V., Floreani A., Marchesi P. et al. Imaging of primary sclerosing cholangitis: preliminary results
by two new non invasive techniques // Dig. Liver Dis. 2004. V. 36. № 9. P. 614-621.11. Saini S. Imaging of the hepatobiliary tract // N. Engl. J. Med. 1997. V. 336. № 26. P. 1889-1894.12. Campani R., Bottinelli O., Calliada F., Coscia D. The latest in ultrasound: three-dimensional imaging.
Part II // Eur. J. Radiol. 1998. V. 27. Suppl. 2. P. S183 — S187.13. Nesterov V. I. 3D NLS diagnostics. Prospect of development. Collection of scientific papers of the
Institute of Practical Psychophysics «NLS-diagnostics in medicine. Prospect of development». Tome 3. Mos-cow. Katalog, 2010, p. 5-8.
14. Nesterova V. I., Shaposhnikov L. V., Yankina L. A., Kozhemyakin O. R. Application of NLS-diagnostics in oncology. New trends and prospects. // Collection of scientific papers of the Institute of Practical Psycho-physics «NLS-diagnostics in medicine. Prospect of development». Tome 3. Moscow. Katalog, 2010, p. 9-12.
15. S. P. Tokar, A. S. Davydova, T. L. Guseva, V. I. Gusarov, Z. F. Khabibullina, L. S. Pugacheva. Non-linear computer diagnostics and pathology of hepatopancreaticoduodenal area. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 77-88.
Table 5. informativity (%)of various research methods and techniques in revealing of bile ducts affection reasons.
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Possibilities of NLS-study methods in examination of certain skin diseases
E. Gizbrecht, A. Balcevich
Assuta Medical Centers LTD, Tel-Aviv
Wide spread of skin diseases dictates a necessity in early and maximum accurate diagnostics, because severe forms of skin diseases decrease greatly quality of life of a patient and his family, promote development of a psychoso-matic disorders. Visual evaluation of symptoms and severity of a disease often has subjective nature.
From histological point of view skin consists of two layers: epidermis and derma which are closely connected. On histological cross-cuts of skin a line between epidermis and derma looks uneven due to presence of many dermal papillae divided by outgrowths of epidermis. Epidermis con-sists of several layers: basal, spinous, granular and horny. In epidermis of palms and feet, between granular and horny layers there is additional layer — stratum lucidum. Some-times the aggregate of basal, spinous and granular layers is called a malpighian layer.
Derma is a connective basis of skin, where perspiratory and sebaceous glands, blood and lymph vessels, nerves and smooth muscles are located. There are papillary and reticu-lar layers of derma. Papillary layer, located under epidermis, and a part of reticular layer conditionally form upper derma; layer of derma located at the level of pilosebaceous unit is indicated as middle derma; the underlying layer contain-ing perspiratory glands, bordering subcutaneous fat, is called a deep derma.
Blood vessels of skin form two anatomic plexuses: a deep one, located next to subcutaneous fat, and a super-ficial one, located in sub-papillary layer. They consist of microcirculatory bloodstream vessels: arterioles, venules and capillary tubes.
Total thickness of skin without subcutaneous fat var-ies from bits of a millimeter to 4 mm.
Exiting systems for NLS-diagnostics («Metatron» — 4019) are equipped with high-frequency linear generators (1.4 GHz) allowing to visualize the most superficial struc-tures, in particular skin. However to evaluate condition of ultrafine structures of skin such frequency is not enough sometimes. That is why dermatologists started to use spe-cial devices with sensors of 40 GHz operating frequency, which allow to see the finest structures of skin layers down to the level of large carbohydrate molecules and peptides. But at the same time due to significant cost of such equip-ment if becomes unaffordable for wide application in the majority of clinics. Taking into account a need in evaluation
of regional lymph nodes and tumors of soft tissues, appar-ently the optimal decision is to use devices for non-linear diagnostics equipped with non-linear sensors of 4.9 GHz operating frequency («Metatron» — 4025, the IPP, Russia).
«Metatron» — 4025 system has axial resolution of 30 µm. Application of this device allows to study epidermis on cellular and sub-cellular levels.
Nowadays objectives and limits of three-dimensional NLS-ultramicroscanning research in dermatology have be-come very broad.
The following has become real:— evaluation of treatment efficiency of diseases
characterized by skin sclerosis (localized scleroderma, gen-eralized scleroderma), edematous (lipo-dermatosclerosis) and chronic inflammatory (psoriasis) dermatosis;
— measuring skin tumors invasion extent and moni-toring after surgical interventions, cryo- and laser therapy at melanotic cancer, basal-like cancer, hemangioma, fibro-ma, seborrheic keratosis;
— study of local and system medications’ effect to skin (corticosteroids, estradiol).
In accordance with a methodology the NLS-ultrami-croscanning diagnostics of skin diseases must be carried out by comparing of affected area with healthy skin at counterlateral homological area.
At NLS-graphy with use of non-linear sensors of 4.9 GHz frequency, normal skin is represented by three layers: epidermis, derma and subcutaneous tissue. Regional and age-related peculiarities of skin thickness are conditioned by derma thickness mainly, which depends in the first place on collagen content in it.
It is considered that at NLS-study with sensor fre-quency of 1.4 GHz, normal epidermis is visualized poorly, because real thickness of epidermis is 0.02-0.5 mm, which is a limit of resolution for system of this class.
Epidermis is a moderately chromogenic structure (2-3 points at Fleindler’s scale), chromogeneity of which de-pends on thickness and desquamation rate of horny layer.
According to El Gammal S. et al. who used «Metatron» — 4025 system with non-linear sensor of 4.9 GHz operat-ing frequency, horny and malpighian layers of epidermis may be differentiated.
Super-high-frequency non-linear sensors allow to re-search more superficial papillary layer and underlying re-
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Pic.1. NLS-ultramicroscanning. Skin melanoma.
Pic.2. Melanoma.Spectral-entropic analysis (D=0,027)
ticular layer of derma, The latter is characterized by more homogeneous structure.
In a healthy skin there are small areas, which are lo-cated in derma and correspond to hair follicles, vessels and sebaceous glands. Hypoderm at NLS-grpahy is represented as hypochromogenic and achromogenic layer (1-2 points on Fleindler’s scale), because mainly it consists of relatively ho-mogeneous fat tissue. In this layer more chromogenic strips may be found, which represent connective interseptums.
Analysis of references showed that NLS-research of skin often applied at various oncologic diseases. To study skin tumors both two-dimensional and three-dimensional
NLS-graphy may be applied. In majority of cases tumors are represented as areas of increased chromogeneity, more or less separated from derma. It is impossible to define histo-logical character of a tumor on the basis of NLS-graphy only.
For differential diagnostics of such skin tumors as hemangioma or melanoma, modes of ultramicroscanning together with spectral-entropic analysis (SEA) may be successfully applied.
Using NLS-graphy makes possible to study malignant melanomas. Melanomas at NLS-research are spindle shaped, quire homogeneous in structure and clearly separated from surrounding tissues. We noted high precision in evaluation of neoplasms’ size, which were confirmed by comparison of data acquired with NLS-study of a tumor before surgi-cal intervention and by histological tests after operation. According to other data, despite good visualization of a tumor at NLS-graphic study, the major problem is to distin-guish tumor parenchyma from surrounding inflammatory infiltrate, because they look like single hyperchromogenic structure. Thus size of some tumors may be overstated at NLS-study. As studies of Ulrich J. et al. show, accuracy of
tumor size evaluation increases greatly if we exclude from analysis tumors with extensive inflammatory infiltrate or nevus-associated melanomas when we apply SEA.
At NLS-ultramicroscanning study benign nevi look like spindle-shaped structures of increased chromogeneity, which makes their differentiation from malignant mela-nomas difficult, because these neoplasms are also hyper-chromogenic. Differential diagnostics is done successfully when SEA is applied.
We studied basal-like cancer using NLS-analysis, the cancer was represented as hyperchromogenic neoplasm (5-6 points at Fleindler’s scale) of irregular shape. Addi-tional NLS-ultramicroangiographic study allows to reveal changes in vessels of a tumor.
Tumors with hyperkeratosis, such as angiokeratomas and acantholytic nevi, are characterized by moderate chromogeneity (4-5 points at Fleindler’s scale), that is why they can be easily distinguished from other tumors, for example, from malignant melanomas.
NLS-ultramicroscanning may provide accurate visu-alization of morphological damages of skin at psoriasis. Epidermis at psoriasis is thickened and moderately chro-mogenic (3-4 points at Fleindler’s scale). At the level of derma’s papillary layer a hyperchromogenic stripe of vari-ous thickness, more intense at the acute stage, is present. Thus, according to NLS-graphy data we may judge about acuity of a disease. When we use SEA — high spectral similarity with «Psoriasis» etalon (D<0,425).
NLS-study of skin of patients suffering from gener-alized scleroderma we found that acquired data varies depending on activity of the disease. When we study the acute stage of the disease we note sub-epidermal hyper-chromogenic stripe wider than in case of healthy skin, which is a result inflammatory infiltration. A structure of a thickened derma becomes heterogeneous due to pres-ence of achromogenic areas against a hyperchromogenic background. With connective tissue thickness and chro-mogeneity increasing, the difference between derma and hypoderm disappears.
Subacute stage of generalized scleroderma is charac-terized by disappearance of sub-epidermal hyperchromo-genic stripe, at the same time derma’s structure becomes homogeneous and its thickness decreases.
Moreover, to diagnose generalized scleroderma a
Pic.3. NLS-ultramicroscanning of skin of right hand index finger at generalized scleroderma.
We studied basal-like cancer using NLS-analysis, the cancer was represented as hyperchromogenic neoplasm (5-6 points at Fleindler’s scale) of irregular shape.
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Pic.4. NLS- ultramicroscanning. Epidermis at psoriasis.
Pic.5. NLS-ultramicroscanning. Scalp skin at psoriasis.
Pic.6. Spectral-entropic analysis. Psoriasis (D=0,214).
researcher should apply evaluation of spectral similarity to the etalon of this process by using of SEA, which is the basic diagnostic sign. To evaluate changes of skin at local-ized scleroderma Cosnes A. et al. used non-linear sensor of 4.9 GHz frequency.
Thus, thanks to modern NLS-technologies, more ac-curate evaluation of changes at various skin diseases be-comes possible; it allows not only to improve diagnostics and start treatment in proper time, but to ensure control of the treatment efficiency.
REFERENCES1. Paltsev М. А., Potekayev N. N., Kazantseva I. А. and others. Clinical and morphological diagnos-
tics of skin diseases. М.: Medicina, 2004. p.12-17.2. Jemec G. B., Gniadecka M., Ulrich J. Ultrasound in dermatology. Part I. High frequency ultra-
sound //Eur. J. Dermatol. 2000. V. 10. № 6. P. 492-497.3. Ulrich J., Voit C. Ultrasound in dermatology. PartII. Ultrasound of regional lymph node basins
and subcutaneous tumours // Eur. J. Dermatol. 2001. V. 11. № 1. P. 73-79.4. Cammarota T., Pinto F., Magliaro A., Sarno A. Current uses of diagnostic high frequency US in
dermatology // Eur. J. Radiol. 1998. V. 27. Suppl.2. P. S215 — S223.5. Vogt M., Kaspar K., Altmeyer P. et al. High frequency ultrasound for high resolution skin imag-
ing// Frequenz. 2000. V. 54. № 1-2. P. 12-20.6. Schmid Wendtner M. H., Burgdorf W. Ultrasound scanning in dermatology // Arch. Dermatol.
2005. V. 141. № 2. P. 217-224.7. Vogt M., Ermert H. Development and evaluation of a high frequency ultrasound based system
for in vivo strain imaging of the skin // IEEE Trans. Ultrason. Ferroelectr. Freq. Control. 2005. V. 52. № 3. P. 375-385.
8. Turnbull D. H., Starkoski B. G., Harasiewicz K. A. et al. A 40-100 MHz B scan ultrasound backscat-ter microscope for skin imaging // Ultrasound Med. Biol. 1995. V. 21. № 1. P. 79-88.
9. Marghoob A. A., Swindle L. D., Moricz C. Z. et al. Instruments and new technologies for the in vivo diagnosis of melanoma // J. Am. Acad. Dermatol. 2003. V. 49. № 5. P. 777-779.
10. El Gammal S., El Gammal C., Kaspar K. et al. Sonography of the skin at 100 MHz enables in vivo visualization of stratum corneum and viable epidermis in palmar skin and psoriatic plaques // J. In-vest. Dermatol. 1999. V. 113. № 5. P.821-829.
11. Hoffmann K., Gerbaulet U., El Gammal S., Altmeyer P. 20 MHz B mode ultrasound in monitoring the course of localized scleroderma (morphea) // Acta Derm. Venereol. Suppl. 1991. V. 164. P.3-16.
12. Nesterov. V. I. Computer nonlinear diagnostics. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 5-6.
13. Artukh V., Shovkoplyas U., Gavrilov A. Computer non-linear analysis and its role in diagnostics. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 9-12.
14. Nesterov V. I. 3D NLS diagnostics. Prospect of development. Collection of scientific papers of the Institute of Practical Psychophysics «NLS-diagnostics in medicine. Prospect of development». Tome 3. Moscow. Katalog, 2010, p. 5-8.
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3D NLS-graphy in full-scale study of urinary bladder tumors
A. M. Shmerkovich, K. S. Kogan
Moscow scientific-research oncological institute named after P.A. Gertsen.
INTRODUCTIONMalignant urinary bladder tumors fill 8th position in
male and 18th position in female patients within the struc-ture of oncological diseases. Urinary bladder tumor is in the 4th position among oncourological diseases according to the absolute rate of growth (the first three positions are: prostate cancer, renal cancer and testicular cancer). The multiplicity of rudiments and frequent recuring is charac-teristic for the tumors of urinary bladder.
In all the countries in majority of cases (90-95 %) the tumors of urinary bladder are morphologically transient cell carcinomas; the rest of cases relate to squamous cell cancer and adenocarcinoma. Non-epithelial tumors consist less than 1 %.
The main and the most reliable method of urinary blad-der cancer diagnostics in clinical practice is still cystoscopic examination with gathering of cytological or histological material. But this method does not allow estimation of tumor invasion depth into bladder wall. The depth of inva-sion is one of the essential factors when choosing surgical treatment: transurethral resection is not possible in case of
affection of wall’s muscular layer (category T2). In case of invasion of perivesical cellular tissue and tumor spread to the adjacent organs (T3-T4) the risk of regional lymphatic glands affection increases: it consists 30 % at T2 stage and it reaches 65 % at stage T4.
Computer tomography, magnetic resonance tomogra-phy and transurethral ultrasonic examination are mainly used over the last years as corrective diagnostics methods to determine the depth of urinary bladder tumor invasion. According to the information provided by Nesterova V. and others the recent method of 3D NLS-research may become crucial both when specifying the prevalence rate of blad-der cancer and when performing case monitoring. Such advantages of the method as availability, painlessness and absence of radiation exposure allow performing multiple researches when carrying out case monitoring.
Goal of the given article is to study 3D NLS-research possibilities in primary and corrective diagnostics of malig-nant urinary bladder tumors, examination of complications which develop during NLS-research of urinary bladder and also systematization, correction and supplementation of NLS-semiotics of urinary bladder tumors.
MATERIAL AND METHODS OF THE STUDYFull-scale 3D NLS-research of 365 patients (aged 26-83)
with malignant tumoral affection of urinary bladder was performed in the Institute named after Gertsen P. A. 317 patients (86.8 %) suffered from bladder cancer, 4 patients (1.1 %) had sarcoma, 6 patients (1.6 %) suffered from tumor deposits of another primary site, 2 patients (0.5 %) had ma-lignant non-Hodgkins lymphoma with bladder affection, 36 patients (9.9 %) had tumor ingrowths into bladder wall from the adjacent organs. Male patients consisted the majority — 273 patients (74.8 %) and 92 female patients (25.2 %).
All patients were examined using 3D NLS-research of urinary bladder. In all cases the microscanning of urinary bladder wall with spectral-entropy analysis of tissue struc-tures was performed to provide differential diagnostics of various cancer types. 3D NLS-research was performed us-
This article explains the possibilities of 3D NLS-graphy in full-scale study of urinary bladder tumors. 365 patients suffering from malignant tumoral affection of urinary bladder were examined. 317 patients (86.8 %) suffered from bladder cancer, 4 patients (1.1 %) suffered from sarcoma, 6 patients (1.6 %) suffered from tumor deposits of another primary site, 2 patients (0.5 %) suffered from malignant non-Hodgkins lymphoma with bladder affection, 36 patients (9.9 %) had tumor ingrowths into bladder wall from adjacent organs. Possibilities of the method in primary and differential diagnostics and also in detection of local prevalence of urinary bladder tumors depending on their localization are demonstrated in the given article. There is also a description of the difficulties when performing NLS-diagnostics of urinary bladder tumors.
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Pic. 1. 3D NLS-graphy. Bladder cancer in urinary triangle area. Tumor grows into prostate gland
Pic. 2. NLS-ultramicroscanning of urinary bladder wall. Urinary bladder cancer. Onset of invasion of muscular layer
ing «Metatron» — 4025 system (IPP, Russia) with 4.9 GHz frequency sensor.
All patients were operated on not later than 2 weeks after performance of NLS-research, the data of morpho-logical research were compared with the results of NLS-ultramicroscanning with spectral-entropy analysis.
We have carried out NLS-ultramicroscopic research of 28 patients with no urinary bladder pathologies to ex-amine NLS-ultramicroscopic features of healthy urinary bladder wall.
RESULTS AND DISCUSSION1. Ultramicro-NLS-semiotics of urinary bladder tumors. Difficulties of NLS-diagnostics of urinary bladder tumors
We have developed ultramicro-NLS-semiotics of healthy urinary bladder wall and urinary bladder wall with tumoral affection. Healthy urinary bladder wall has 2.5-8.0 mm. in thickness (depending on its filling). In majority of cases it is possible to visualize 3 layers of bladder wall:
1) inner layer corresponds to mucous membrane with submucous layer; in its normal state — moderate hypo-chromogenic (2-3 points according to Fleindler’s scale)
2) middle layer corresponds to muscular layer; in its normal state — hypochromogenic (2 points according to Fleindler’s scale);
3) outer layer corresponds to adventitious membrane; in its normal state — a-hypochromogenic (1-2 points ac-cording to Fleindler’s scale);
Most commonly urinary bladder cancer in 3D NLS-microscopic image has an appearance of exophytic forma-tion of high hyperchromogenecy (5-6 points according to Fleindler’s scale) of round or irregular-shape with uneven surface. In case of absence of infiltrating growth the line between tumor bottom and urinary bladder wall is sharply defined, even and hypochromogenic (1-2 points). In case of infiltration the line between tumor bottom and urinary bladder wall firstly becomes uneven, obscure then there appear tumor structures in the wall’s depth. In this case wall layers stop differentiating. If the tumor grows into
the whole wall’s depth then the outer contour of the wall becomes uneven, sometimes obscure.
Tumor with an endophytic component in invasion area is most frequently achromogenic, sometimes it is isochromogenic. If the tumor grows endophytically it is most frequently isochromogenic in all parts. In our opin-ion the detection of low chromogenic (1 point according to Fleindler’s scale) areas in the tumor of urinary bladder is always indicative of infiltrating growth presence.
Tumor may be singular but tumors of urinary bladder most frequently have multifocal growth type up to total affection of the whole bladder. Detailed examination of all bladder walls is necessary because of this. Sizes, shape, chromogenecy and intensity of nodules invasion into the wall may be different in case of multifocal growth.
Major problems when performing NLS-research are faced when diagnosing the invasion into the submucous layer or when diagnosing the onset of invasion into the muscular layer. Spectral-entropy analysis often allows solving of such problems.
Tumors (especially endophytic ones) which affect ma-jor part of bladder wall may cause its sharp size reduction (microcystis). Small bladder capacity in such patients and also in patients who were surgically treated (often repeated due to repeated relapses) may complicate the detection of
Рис 3. Spectral-entropy analysis.Leiomyosarcoma of urinary bladder (D=0.091)
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tumor’s invasion depth.Urinary bladder tumors (more often multifocal) in com-
bination with intravesical clots may be complicated for in-terpretation. Intravesical clots accompanied by macrohae-maturia sometimes fill the whole bladder cavity. In these cases it is always possible to differentiate the tissue of the tumor nodule from clots using spectral-entropy analysis.
Diagnostic difficulties appear when detecting the depth of tumor invasion if the nodule is located in urinary triangle (Lieutaud body) especially when it overlaps on the contour of prostate gland. Image unsharpness of wall layers may be caused by multiple surgical interferences in case of bladder tumor relapses and also intravesical immune- or chemotherapeutical treatment and layering of urinary salts.
The sensitivity of NLS-method in detection of tumor
invasion depth in such patients may be decreased.Tumors coming from urachus must be described indi-
vidually. When performing cystoscopic examination the tumors of urachus do not differ from a common bladder tu-mor. But certain difficulties may arise during NLS-research if one does not know the semiotics typical for urachus tu-mors. Urachus tumor is characterized by the location on the frontal wall in upper part of the bladder and also there is a presence of hyperchromogenic fibrotic fold (5-6 points according to Fleindler’s scale) of particular thickness that goes upwards, gradually narrows and binds the tumor with omphalus. It may seem as if tumor invasion spreads to ad-jacent tissues (however such tissues may not exist). Dop-pler sonography often detects intense blood flow both in tumor bottom and along fibrotic fold. During diagnostics of such tumor it is necessary to perform thorough examination to exclude premature metastasis in abdominal membrane, lymph glands and lungs.
Not only epithelial but also non-epithelial tumors may be found in urinary bladder. Despite the infrequency of such diseases the diagnosis may be presupposed during NLS-research based on typical ultramicroscopic picture. Preservation of complete or partial integrity of wall’s mu-cous layer is the particular feature of non-epithelial tumors. In this case the major part of the node is located in wall’s depth and beyond its borders.
Early relapse detection during case monitoring is one of the goals of NLS-research of patients who suffer from bladder tumors. Semiotics of relapsing bladder tumors in patients after organ preservation treatment does not have any fundamental differences from semiotics of primary tumors. Relapse of the tumor after cystectomy looks like nodus of increased chromogenecy of regular or irregular shape with even or uneven contour in bladder bed.
Metastatic affection of urinary bladder is possible
(though quite rarely) besides presence of its primary tu-mors. There are 2 typical variants of NLS-graphic picture for metastases that go into bladder wall. The first one is round-shape tumor located in the wall’s depth with sharp smooth contour. Such variant resembles non-epithelial tumor judging by NLS-picture. The second variant (rarer type of metastasis) is the tumor that spreads on the wall; it resembles common picture of invasive cancer of urinary bladder. Information on anamnesis and also the results of spectral-entropy analysis allow correct diagnosing.
More occasional variant of secondary affection of the bladder that sometimes cause diagnostic difficulties is the intergrowth of tumors into wall of the bladder from the ad-jacent organs (most frequently it is cancer of large bowel, neck of womb or prostate gland). When tumor ingrows into the wall of the bladder this wall interrupts on the area that adjoins to the tumor and it is replaced by the tumor. Mucous layer may be preserved or the tumor that ingrows in it may press into the lumen of the bladder. If the tumor comes from large bowel then extraorgan tumor component that ingrows into urinary bladder changes to a typical symptom of the affected hollow organ. If the formation comes from the neck of womb then the tumor which is located in uri-nary bladder directly goes into changed neck. Nonorganic extraperitoneal tumors may seldom ingrow into the wall of urinary bladder.
The ingrowth into prostate gland is typical for tumors of urinary bladder located in the area of urinary triangle; and ingrowth into urinary bladder wall is typical for prostate gland tumors. Differential diagnostics of organ affiliation of prostate gland and urinary bladder tumors in case of ul-tramicroscanning has no real difficulties in 95 % of patients. Although there may appear some diagnostic difficulties if the process is locally advanced and when urinary bladder in the area of urinary triangle and prostate gland (in rare cases when multifocal tumoral affection of both organs is present) are involved into this process.
In majority of cases the clinical picture in such pa-tients does not allow performing differential diagnostics. Regardless of primary tumor localization there is distinct ankylurethria, often chronic urine retention (especially if the tumor developed in patient with benign prostatic hy-perplasia), pain syndrome and macrohaematuria. Clinical picture does not exclude the possibility of prostate cancer and normal level of prostate-specific antigen. The increase of prostate-specific antigen is not an absolute diagnostic indicator of prostate cancer; although prostate-specific antigen is an organo-specific glycoproteid it is not Onco-Marker itself.
We have performed a full-scale study (including 3D NLS-ultramicroscanning with spectral-entropy analysis and cystoscopy with targeted biopsy) of 28 patients with advanced cancer of urinary bladder who were treated by cystprostatevesiculectomy and 17 patients with advanced cancer of prostate gland detected by biopsy.
The analysis of NLS-picture in these patients was supplemented by spectral-entropy criteria of morphologic affiliation of the primary tumor. The following signs are the most significant ones in specification of primary process localization of large-scale urinary bladder tumors that in-grow into prostate gland:
The most statistically reliable method of NLS-research in case of urinary bladder tumors is an ultramicroscopic research
with the usу of spectral-entropy analysis.
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1) localization of the maximum tumor component in urinary bladder;
2) multicentric affections of urinary bladder;3) presence of the sharp edges between tumor and pros-
tate gland contours.The absence of abovementioned signs and localization
of general tumor mass in gland itself are the most typical factors of prostate gland tumor.
Taking abovementioned signs into account allows ac-curate detection of which organ the locally advanced tumor comes out from — whether it is urinary bladder or prostate gland. The accuracy of the diagnostics of primary tumor site with consideration of these signs is 89.3 %.
After performing of histological examination the multi-focal synchronous tumoral process is found in 9 (32.1 %) out of 28 patients with locally advanced cancer who had underwent surgery. These patients also suffered from localized prostate cancer besides urinary bladder cancer. The secondary tumor was diagnosed with the use of spectral-entropy analysis only in 1 of these patients.
As can be seen from the above the incidence of prostate gland cancer in these patients was the same as in elder men of full set population. Doctor was not searching secondary tu-mor in prostate gland because he was concentrated on solu-tion of urinary bladder cancer prevalence problem. Obtained data demonstrates that prostate cancer must be excluded as much carefully than in elderly patients in general in case of advanced urinary bladder cancer.
2. The possibilities of various methods of NLS-research in case of urinary bladder tumors
The most statistically reliable method of NLS-research in case of urinary bladder tumors is an ultramicroscopic research with the usу of spectral-entropy analysis. Such method pro-vides the detection of the tumor less than 3 mm., specifies its localization and in case of its invasive form it allows specifying its proportion in relation to adjacent organs and tissues. It is possible to examine the layers of bladder wall in all patients when using 3D NLS-ultramicroscopic research. We use spectral-entropy analysis in case of any process localiza-tion in urinary bladder after performance of ultramicroscopic
research. Only endocavitary ultramicroscopic research is the most effective method for examination of all tumor aniages in case of multicentric growth.
The visualization of small sized formations (less than 4 mm.) is complicated in case of common non-scaling NLS-research; in more rarely cases the visualization of larger tumors located on the frontal urinary bladder wall is com-plicated. Performance of spectral-entropy analysis with ultramicroscanning always helps to make correct diagnosis in cases like these. The frontal urinary bladder wall which is put close to an abdominal wall is visualized with consider-able zooming in, which allows examining both wall layers and their correlation with tumor nodule.
Common 2D NLS-research (which was put high hopes on) did not obtain widespread use in our country. Such method allows good visualization of superficial formations though relatively large ones (from 6-8 mm).
In case of deep invasion it is not always possible to es-timate the exterior contour of the tumor. These peculiarities lower the effectiveness of 2D NLS-graphy method in detec-tion of invasion depth into the bladder wall.
At the present time we are able to use extensively NLS-research of urinary bladder tumors with 3D reconstruction. The method allows visually presentation of the tumor and its correlation with surrounding tissues when making deci-sion on choosing of surgical procedures type, and it allows storing the information in digital format. Information stor-ing provides the possibility for attending doctors to subse-quently review the whole 3D information block which gives more objectiveness to 3D NLS-research.
CONCLUSIONS1. Urinary bladder wall in 3D ultramicroscopic imaging
has three-layer structure.2. In case of urinary bladder cancer the common 2D NLS-
research allows visualization of the tumor if its size is more than 5 mm. When performing 3D-ultramicroscopic research the tumors less than 2 mm. can be detected, it is also pos-sible to define tumor’s growth form (exophytic, endophytic or combined one) and its invasion depth into the wall (preva-
Pic. 4. NLS-scanning.Cancer of the upper-and middle ampullar parts of straight intestine; ingrowth into urinary bladder.
Pic. 5. 3D NLS-graphy. Cervical cancer;ingrowth into urinary bladder.
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lence of invasion influence both on disease prognosis and therapy method).
3. Major problems appear when diagnosing of initial tumor invasion into muscular layer. Ultramicroscanning with spectral-entropy analysis helps defining the depth of invasion when this occurs.
4. Familiarity with typical semiotics allows making the correct diagnosis when performing NLS-research in cases of non-epithelial tumors of urinary bladder and ura-chus tumors.
5. Information recording of anamnesis and perfor-mance of spectral-entropy analysis allow presupposing the correct diagnosis in case of metastases into urinary bladder wall of tumors of another primary localization.
6. Ultramicroscopic research with the use of spectral-entropy analysis allows specifying if the tumor which had
been detected in urinary bladder emanates from the blad-der wall or it is just a part of the tumor that emanates from other organs (large bowel, neck of womb, prostate gland and etc.) and ingrows into bladder wall.
7. To perform an appropriate diagnostics it is necessary to use all available NLS-research means considering the pre-disposition of urinary bladder tumor to multifocal growth.
8. Ultramicroscopic NLS-researches are the most effective ones when performing diagnostics of urinary bladder tumors. 3D reconstruction of the image increases both the effectiveness of diagnostics and it also provides more informative presentation of detected changes and it gives the possibility for reviewing of stored information.
9. In case of urinary bladder cancer it is necessary keep in mind the possibility of synchronous prostate cancer.
REFERENCES1. Chissov V. I., Starinskiy V. V., Malignant growths in Russia in 2000 (disease and mortality rates),
Moscow: MNIOI n.a. Gertsen P. A., 2002, p. 264.2. TNM: Classification of malignant growth. 6th edition / Under the editorship of Blinov N. N., S-
Petersburg.: Eskulap, 2003. p. 244.3. Teplov A. A. Surgical and combination therapy of patients who suffer from invasive cancer of
urinary bladder. Problem state. Choosing of treatment policy. // Materials of international scientific forum Oncology at the turn of XXI century. Prospects and possibilities. Moscow, 1999, p. 382-383.
4. Beer A., Saar B., Link T. M. et al. Virtual endoscopy of the urinary tract from T2-weighted and gadolinium-enhanced T1-weighted MR urographic images// Rofo. 2001. V. 173. № 1. P. 997-1005.
5. Bernhardt T. M., Schmidl H., Philipp C. et al. Diagnostic potential of virtual cystoscopy of the bladder: MRI vs CT. Preliminary report // Eur. Radiol. 2003. V. 13. № 2. P. 305-312.
6. Scher H. I., Shipley W. U., Herr H. W. Cancer of the Bladder // Cancer, Principles and Practice of Oncology. 5th ed. / Ed by De Vita V. T., Hellman S., Rosenberg S. A. Philadelphia: Lippincott Raven Pub-lishers. 1997. P. 1300-1322.
7. Song J. H., Francis I. R., Platt J. F. et al. Bladder tumor detection at virtual cystoscopy // Radiol-ogy. 2001. V. 218. No.1. P. 95-100.
8. Yaman O., Baltaci S., Arikan N. et al. Staging with computed tomography, transrectal ultraso-nography and transurethral resection of bladder tumour: comparison with final pathological stage in invasive bladder carcinoma // Br. J. Urol. 1996. V. 78. No.2. P. 197-200.
9. Mitina L. A. Ultrasonic diagnostics of urinary bladder new growths on different treatment stages: Thesis … MD, Moscow, 1998, p.108.
10. Mitina L. A., Kazakevich V. I., Stepanov S. O. Ultrasonic oncourology / Under the editorship of Chissov V. I., Rusakov I. G, Moscow: Mediya Sfera, 2005. p. 200
11. Sitdikov E. N., Sitdikova M. E., Zubkov A. Yu. Algorithm of ultrasonic monitoring of patients with urinary bladder new growths before and after surgical treatment. Kazan: Medicina, 1996, p 168.
12. Garin A. M. The secrets of prostate cancer, disputes on treatment of these patients // Material of VII Russian oncological congress. Moscow, 2003, p.28-32.
13. V. I. Nesterov. Computer nonlinear diagnostics. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 5-6.
14. V. Artukh, U. Shovkoplyas, A. Gavrilov. Computer non-linear analysis and its role in diagnos-tics. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 9-12.
15. V. I. Nesterov. 3D NLS diagnostics. Prospect of development. Collection of scientific papers of the Institute of Practical Psychophysics «NLS-diagnostics in medicine. Prospect of development». Tome 3. Moscow. Katalog, 2010, p. 5-8.
16. Nesterova V. I., Shaposhnikov L. V., Yankina L. A., Kozhemyakin O. R. Application of NLS-diag-nostics in oncology. New trends and prospects. // Collection of scientific papers of the Institute of Practical Psychophysics «NLS-diagnostics in medicine. Prospect of development». Tome 3. Moscow. Katalog, 2010, p. 9-12
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Three-dimensional NLS-graphy in diagnostics of chronic pseudo-tumor-like pancreatitis
S. Mitter, K. Lehnhardt, A. Elvins
Hospital Erasme Universite Libre de Bruxelles
In order to evaluate informativity of a three-dimensional NLS-graphy in diagnostics of a pseudo-tumor-like pancreatitis, we carried out a retrospective analysis of clinical records of 328 patients admitted to the Erasme academic hospital in 2010-2011. The patients suffered from a hepatopancreatobiliary system organs pathologies complicated by a biliary obstruction; these patients formed a main group. A control group consisted of 30 patients treated in a hospital who had no pathologies of a gastrointestinal tract and a hepatopancreatobiliary system; the main group consisted of 30 patients with diagnosed chronic pseudo-tumor-like pancreatitis. We carried out a comparative analysis of a two-dimensional and a three-dimensional NLS-graphy in revealing of a chronic pseudo-tumor-like pancreatitis signs; evaluated informativity of a two-dimensional and a three-dimensional NLS-graphy and a multi-layer spiral CT in diagnostics of a chronic pseudo-tumor-like pancreatitis.
INTRODUCTIONTimely and accurate diagnostics of pancreatic dis-
eases, without which efficient treatment is not possible, is one of the main goals of a modern gastroenterology. It is determined by increasing of disease incidence and difficulties in a differential diagnostics due to absence of pathognomonic clinical symptoms, especially in the early stages of an illness. The difficult is differential di-agnostics between pancreas head cancer and a chronic pseudo-tumor-like pancreatitis that sometimes result in complications requiring surgical interventions. These diseases may look like stomach and duodenum ulcer, pylorus stenosis and be accompanied by gastrointes-tinal hemmorhage and acute pain in superior parts of stomach. Chronic pancreatitis is diagnosed in 0.2-6.8 % of adults. It is diagnosed in 6-8 % of all digestive or-gans diseases. Examination of patients suffering from pancreas pathologies must ensure accurate diagnos-ing allowing to choose adequate tactics of treatment in proper time.
Choosing of diagnostic method depends on its avail-ability, informativity, possibility of graphic registration of acquired data, safety and affordability. At the present moment neither method of clinical and hardware exami-nation cannot solve problems of modern diagnostics of pancreas pathologies independently.
Leading position in detection of pancreas patholo-gies is taken by radiological methods, although their accuracy is far from perfect.
Recently appeared NLS-diagnostics method allows to acquire sufficiently accurate information about pa-renchyma’s and pancreatic ducts system’s condition. But until now two-dimensional NLS-graphy leaves unsolved certain issues related to spatial relations of examined structures and character of affection; in theory this is-sues may be addressed by three-dimensional NLS-graphy with spectral-entropic analysis (SEA) of tissues.
So, one of the most prospective directions of NLS-diagnostics development is a method of three-dimen-sional reconstruction of NLS-image, allowing to visualize projections hidden for two-dimensional scanning and to carry out anatomical reconstruction of researched area. This method allows to see any projection of acquired image, select separate parts of it and operate the data interactively using rotation and scaling of researched structures.
The objective of the study is to evaluate informativ-ity of three-dimensional reconstruction of NLS-image in diagnostics of chronic pseudo-tumor-like pancreatitis.
MATERIAL AND METHODS OF THE STUDYWe carried out a retrospective analysis of clinical
records of 328 patients admitted to the Erasme academic hospital in 2010-2011. The patients suffered from a he-patopancreatobiliary system organs pathologies compli-cated by a biliary obstruction; these patients formed a main group. The first (control) group consisted of 30 patients treated in a hospital who had no pathologies of a gastrointestinal tract and a hepatopancreatobili-ary system; the second group consisted of 30 patients with diagnosed chronic pseudo-tumor-like pancreatitis.
Patients’ parameters are shown in the Table 1. Among patients of this group male patients prevailed, apparently it is related to peculiarities of male con-sumatory behavior. Patients complained about chronic long-term disease of gastrointestinal tract organs: pain in epigastrium and dyspepsia (100 %), general weakness and loss of appetite (93.3 %), loss of weight (76.6 %). Continuance of symptoms ranged from several months to 10 years. All patients of the second group had gas-
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trointestinal tract organs diseases and preceding surgi-cal interventions in their medical history. In the second group there were many cases of pancreatic secretory and excretory dysfunction. Pancreatic diabetes was diagnosed in 20 % of patients, hyperglycemia episodes (glucose level above 6.7 mmol / l) were detected in almost half of all patients (43.3 %). Signs of chronic pancreatitis complications (increasing of α-amylase) at the moment of admission were detected in every fifth patient.
At the initial stage all admitted patients were sub-jected to the usual two-dimensional NLS-study of a hepatobiliary system’s organs with evaluation of bile-excretory ducts, the major duodenal papilla and the head of pancreas. Further on we applied methods of three-dimensional reconstruction of a NLS-image with the SEA and other hardware and laboratory methods and techniques in accordance with medical and financial standards for this nosological form of a disease.
NLS-studies were carried out using the «Meta-tron»–4025 system (the IPP, Russia) equipped with a high-frequency trigger sensor of 4.9 GHz frequency.
To acquire a high-quality statistically relevant three-dimensional image we used various modes of re-construction.
— Multi-plane volumetric reconstruction (4D-Tis-sue) of NLS-image mode; it renders a cube, a cross-cut image of which can be viewed in any of three ortho-graphical projections. Thanks to this a multi-plane three-dimensional image of any anatomical structure is created at any plane section.
— Multidimensional representation of color-coded NLS-data mode; it creates an image of organ’s vessels and tissues surface in various colors. It is used to clarify spatial position of vessels and tissues of researched area.
If focal changes of the pancreas head of bile-excre-tory duct walls were found, we used adjustable trans-parency and selection of separate tissues mode (Deep-Vision), which allows to study deep structures, normally hidden by other tissues, segmentation (FastVision) and rotation of acquired three-dimensional model.
The results of the three-dimensional NLS-graphy were compared with data acquired with laboratory stud-ies of the patients, results of standard ultrasound in two-dimensional mode, fibrogastroduodenoscopy, multi-layer spiral CT (MSCT), magnetic-resonance cholengiog-raphy (MRCG), endoscopic retrograde cholangiopancrea-tography (ERCPG) and intraoperative findings (table 2).
The results of a spectral-entropic analysis were
Parameters 1st group(n = 30)
2nd group(n = 30)
Two-dimensional NLS-graphy (absolute and relative (%) amount) 30 (100) 30 (100)
Three-dimensional NLS-graphy (absolute and relative (%) amount) 30 (100) 30 (100)
Fibrogastroduodenoscopy (absolute and relative (%) amount) 30 (100) 30 (100)
MSCT (absolute and relative (%) amount) 18 (60) 30 (100)
MRCG (absolute and relative (%) amount) - 2 (6.7)
ERCPG (absolute and relative (%) amount) - 4 (13.3)
Table 2. Parameters of hardware studies.
Parameters1st group(n = 30)
2nd group(n = 30)
Age, years 42-72 29-89
Sex (male/female) 1/1 3/2
Stomach and duodenum pathologies (absolute and relative (%) amount)
– 30 (100)
Pancreatic diabetes (absolute and relative (%) amount) – 6 (20)
Chronic viral hepatitis (B or C) (absolute and relative (%) amount) – 2 (6.7)
Surgical interventions because tumors in other organs in medical history (absolute and relative (%) amount)
– 6 (20)
Cholecystectomy in medical history (absolute and relative (%) amount)
– 8 (26.7)
Surgical interventions into distal part of common bile duct in medical history (absolute and relative (%) amount)
– 4 (13.4)
Surgical interventions into stomach and duodenum in medical history (absolute and relative (%) amount)
– 4 (13.4)
Hyperbilirubinemia symptoms at admission – 12 (40)
Hyperamylasemia symptoms at admission – 6 (20)
Table 1. Parameters of studied patients
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Pic.1. 2D NLS-scanning. A calcification in pancreas head projection.
Pic.2. 3D NLS-graphy. Multiplane 3D rendering mode. Pseudo-tumor-like pancreatitis. Hypochromogenic neoplasm of 2x1.5 cm sixe in pancreas head.
compared with cytological / histological studies data acquired with a needle biopsy and during surgical inter-ventions. At the same time we received no evidence of a malignant affection of a pancreas in all cases.
Statistical analysis of acquired data was carried out by standard methods. Quantitative signs are represented in form of a median, 2.5-97.5 percentile, of minimum (min) and maximum (max) values. Differences were con-sidered to be relevant at р ≤ 0.05. Also we calculated re-sponse characteristics, specificity and accuracy of vari-ous methods of medical visualization (two-dimensional and three-dimensional NLS-graphy, MSCT) in diagnostics of chronic pseudo-tumor-like pancreatitis.
RESULTS OF THE STUDY AND DISCUSSIONRadiodiagnosing of any volumetric neoplasm of
pancreas is based on detection of a focal affection, par-tial or complete increasing of its size, changing of its form and surrounding tissues and organs. Diagnostics of chronic pseudo-tumor-like pancreatitis, in a form of a local affection of any part of pancreas along with its increasing is a very difficult task. Chronic inflammatory process, fibrosis and calcification in a parenchyma are presented in form of separate areas of increased chromo-genity. Considerable dilation of major pancreatic duct is detected quite often.
During aggravation of an inflammatory process chro-mogenity of detected neoplasms may increase greatly (up to 5-6 points on Fleindler’s scale). Depending on size of affected areas, one may detect both micro- and macrofocal affection of parenchyma.
If a process is localized in the head of pancreas its increasing and form roughness may be revealed. In this case one may observe squeezing of a distal part of a common bile duct leading to its dilation above the ob-struction point.
Long-termed clinical course of the second group pa-tients’ diseases, in comparison with the control group, resulted in more frequent diagnosing of liver parenchyma
structure changes (heterogeneity of echostructure, in-creasing of chromogenity).
Co-occurring concretion of gall-bladder were de-tected in 30 % of the second group patients (excluding patients subjected to cholecystectomy earlier). Concre-tion of a common bile duct was detected in 7 patients (23.3 %).
The size of a gall bladder was statistically equal in both studied groups. Maybe it was related to the fact that in almost a half of patients a cholelithiasis with chronic inflammation and fibrosis of a gall bladder walls was present.
Because of the fact that chronic inflammatory pro-cess was more often localized in a head of pancreas and caused squeezing of intrapancreatic part of common bile duct, in all patients of the second group we detected signs of biliary obstruction of various stages. In patients subjected to ERCPG we detected thickened uneven walls of common bile duct in distal part and aerobilia.
Presence of pseudo-tumor-like pancreatitis led to reliable increasing of pancreas head size (indirect symp-tom) in comparison with control group. Because of a pro-longed clinical course of the disease, much more often we detected uneven form and changing of a pancreas pa-renchyma’s structure (heterogeneity) (86.7 %). Diffuse-heterogeneous increasing of parenchyma’s chromogenity (5-6 points on Fleindler’s scale) was found in 73.3 % of patients. In 26.7 % of patients we detected moderate chromogenity (3-4 points) of pancreas parenchyma. In-creasing of major pancreatic duct was detected in a half of the patients. In case of significant dilation of major pancreatic duct a thickening of its walls was found.
Against the background of pancreas changed paren-chyma, in all patients (as a rule in the head and the body of the organ) neoplasms of high chromogeneity, diffuse heterogenic structure, uneven round or oval form, of 0.8-3.5 cm size were visualized. When these neoplasms were located near the edge of pancreas, a deformation of the gland’s form was detected (but without solution of capsule’s continuity). Numerous small diffuse-located
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hyperchromogenic areas (fibrosis and calcinosis) were found in these neoplasms. We faced additional difficul-ties when inflammation spread to parapancreatic cellular tissue, which may imitate tumorous invasion. Differen-tial diagnostics with blast processes was carried out using the SEA. These neoplasms were visualized in a pancreas within 2 months, gradually decreasing in size.
When we applied three-dimensional NLS-ultrami-croscanning of bloodstream to examine patients suf-fering from pseudo-tumor-like pancreatitis, in detected lumps we found signs of thrombosis without violation of angioarchitecture. This symptom was found in all (100 %) patients of the second group. In all groups we found no signs of portal vein thrombosis.
Application of superficial multidimensional re-construction with adjustable transparency improved greatly quality of visualization of both internal struc-tures of detected neoplasms and their contours. Multi-plane and multidimensional reconstruction allowed to detect more precisely localization of neoplasms in a pancreas and their edges. Using of various modes of three-dimensional reconstruction allowed to detect clear division between this neoplasm and parenchyma of pancreas in 28 patients (93.3 %).
Affection of regional lymph nodes (at superior and anterior edge of pancreas head and along hepatoduo-denal ligament) was registered in 70 % of patients of this group. As a rule lymph nodes were characterized by slightly increased chromogeneity (4-5 points at Fleindler’s scale) with distinct contours. It is very dif-ficult to tell the difference between mentioned changes of lymph nodes and tumorous affection by usual two-dimensional NLS-study. We were able to judge about character of changes in lymph nodes only by analyzing of the SEA data, which was confirmed by biopsy.
Undular clinical course of pancreas chronic disease, often resulting in biliary obstruction, was typical for major part of the second group patients. Obstruction of extrahepatic bile ducts leads to increasing of pres-sure in bile tract and hypertension in intrahepatic
bile ducts. Intrahepatic cholestasis is added to extra-hepatic cholestasis and thus the process becomes a combined one. So, hyperbilirubinemia (total bilirubin more than 25 mcM / l) was diagnosed in 40 % of patients of this group (Table 3). Due to long clinical history of the disease in every fourth patient anemia was found. Increasing of blood sedimentation rate was found in every third patient and was related to aggravation of the inflammation. In some patients we found slight increasing of tumor markers levels, which required further scheduled examination of hepatopancreobili-ary system’s organs in order to exclude development of tumorous process.
A need in application of MSCT and ERCPG appears when it is not possible to visualize clearly some areas of a pancreas by the NLS-study or when there is an as-sumption of volumetric processes in a pancreas.
MSCT was applied to all 30 patients (100 %) in order to specify a character of pancreatic disease. According to acquired data, in case of absence of pancreas size increasing, MSCT has less informativity in comparison with three-dimensional reconstruction, because it does not provide clear information about changes in its pa-renchyma, when radiologic densitometric density of pancreas tissues is close to normal values.
MSCT gives a possibility to diagnose on a stage of pancreatitis aggravation: at calcinosis, forming of pseudocysts, affection of surrounding organs or pancreas parenchyma atrophy. This method allows to evaluate affection of soft tissues beyond pancreas and surrounding structures in order to evaluate prevalence of the process and inflammatory response of parapan-creatic tissue and retroperitoneal space. But some-times fibrosis and inflammatory changes may imitate tumorous invasion.
A disadvantage of this diagnostic method is its high costs. Another disadvantage is a strict binding of acquired images to transverse plane.
MRCG was administered to 2 patients only because of common bile duct distal part stenosis and it gave
Pic. 3. NLS-ultramicroscanning. Pancreatic duct walls. Pseudo-tumor-like pancreatitis with squeezing of the duct distal part.
Pic. 4. 3D NLS-graphy. Pseudo-tumor-like pancreatitis. Multiplane 3D rendering mode. Affection of lymph nodes in pancreas head area.
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Parameters 1st group(n = 30)
2nd group(n = 30)
Total bilirubin, mcM/l11,9
(4,6-19,2)(3,9-20,6)
16,9(10,0-105,8)(6,8-320,0)
Conjugated bilirubin, mcM/l2,1
(2,0-3,6)(1,7-3,8)
5,5(2,5-72,1)
(1,5-222,0)
Unconjugated bilirubin, mcM/l10,5
(3,7-16,1)(2,9-17,5)
10,1(7,0-42,9)(5,5-98,0)
BUN, M/l4,90
(3,70-6,60)(3,00-7,50)
5,34(3,66-7,02)(2,43-7,69)
Creatinine, mcM/l 92,0
(72,0-106,0)(55,0-112,0)
67,8(63,6-82,0)(61,0-103,9)
Glucose, M/l5,2
(4,7-6,0)(4,1-6,1)
5,7(4,5-6,9)(4,1-8,4)
Alanine aminotransferase, mcM/l29,8
(11,5-39,8)(10,3-48,9)
40,9(15,9-98,0)(11,5-211,8)
Aspartate aminotransferase, mcM/l32,6
(15,7-38,1)(14,2-43,8)
40,8(28,4-105,1)(20,6-183,1)
Alkaline phosphatase, IU/l86
(51-125)(44-156)
308(208-934)(135-2582)
Amylase, U/l46
(24-71)(21-79)
54(29-109)(13-138)
Ca-19-9, U/l(normal value – up to 37 units per ml) _
14,0(8,7-47,8)
(2,5-262,0)
Ca-125 U/l(normal value – up to 35 units per ml) _
23,8(5,2-61,9)(2,3-92,7)
Ca-153 U/l(normal value – up to 38 units per ml) _
22,1(12,8-41,7)(9,2-90,7)
Carcinoembryonal antigen, ng/ml(normal value – up to 7 ng/ml)( 2.26–8.40) _
2,95(2,26-8,40)(1,19-18,73)
Table 3. Laboratory analysis of blood
no additional information about the reasons of ste-nosis development. Main disadvantages of MRCG are: high cost of a research, using of contrast, radiologic stress and impossibility of a scanner transportation to a patient.
Informativity of two-dimensional and three-di-mensional NLS-graphy and MSCT in revealing of chronic pseudo-tumor-like pancreatitis is shown in the table 4.
ERCPG allows to find changes in a duct system (di-lation, roughness, stenosis), localize an obstruction, detect intraductal calcification and protein plugs. Ex-tent of found by ERCPG changes may not correspond to intensity of functional and structural changes in a pan-creas. The disadvantage of this method is impossibility to evaluate changes of pancreas parenchyma directly.
All 4 applications of ERCPG were scheduled and carried out for treatment purposes (lythoextraction or papillosphincterotomy at stenosis of major duode-nal papilla). No complications were registered after this procedure.
Various types of surgical interventions on organs of hepatopancreatobiliary system were performed on 7 patients (23.3 %) of the second group. The majority of surgical interventions were diagnostic ones (4 op-erations — 57.1 %). But in the last 18 months (after mastering of three-dimensional NLS-graphy and devel-oping of examination and monitoring algorithm) this type of surgical interventions was never repeated. In three cases patients refused to be subjected to surgery. In the rest of cases operations were not recommended because of compensated state of patients. As we noted before, morphological study was administered to 30 patients (100 %) of the second group.
After NLS-study of 328 patients admitted to the hospital with hepatopancreatobiliary system organs pathologies complicated by biliary obstruction, we found no statistically reliable difference between two-dimensional and three-dimensional NLS-graphy in revealing of indirect symptoms of biliary obstruc-tion: changes of bile-excretory ducts and gall bladder,
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changes in liver typical for cholestasis, dilation of ma-jor pancreatic duct.
Application of various modes of three-dimensional NLS-graphy allowed to acquire data showing 1.8 times improving in revealing of biliary obstruction symptoms.
CONCLUSIONThree-dimensional image rendering improves visu-
alization in revealing of pancreas structure changes. Superficial multidimensional image reconstruction with adjustable transparency feature improves quality of vi-sualization of both internal structure of revealed neo-plasm and its shape and contours. In case of duct system (common bile duct and major pancreatic duct) dilation this mode allows to distinguish external contour of duct wall from neighboring tissues and internal surface of wall from a cavity content, to monitor structure of duct wall in the investigated area.
Multi-plane multidimensional reconstruction of an image with segmentation feature allows to localize and define size of a neoplasm in pancreas parenchyma and to evaluate borders with surrounding tissues, ducts and vessels.
Multi-plane multidimensional reconstruction of an image with color-coded methods allows to carry out
three-dimensional reconstruction of tissues and vessels that reveals convincing signs of affection.
Thus application of three-dimensional NLS-graphy with SEA allows to:
— carry out more precise differential diagnostics between benign and malignant nature of detected pan-creatic neoplasms;
— define clearly indications for extended diag-nostics (evaluation of spectral similarity with onco-logical markers) in order to exclude tumorous affection of pancreas;
— exclude in some cases duplicating radiologic methods (MSCT and MRCG), which optimizes diagnostic algorithm of patients examination;
— decrease a risk of complications development, related to using of invasive methods of diagnostics (ER-CPG, needle biopsy);
— choose treatment tactics in proper time;— ensure dynamic monitoring in a diagnostic de-
partment for patients from pancreas tumor develop-ment risk group.
In order to exclude a possibility of tumorous process development in pancreas all patients with diagnosed chronic pseudo-tumor-like pancreatitis and moderate increasing of tumor markers level are recommended for dynamic monitoring in a diagnostic department.
Diagnostic methods and techniques Response Specificity Accuracy
Two-dimensional NLS-graphy 63,3 81,5 78,1
Three-dimensional NLS-graphy 93,3 99,0 98,5
MSCT 83,3 96,3 95,0
Table 4. Informativity of various diagnostic methods (%)in revealing of chronic pseudo-tumor-like pancreatitis.
REFERENCES1. Cameron J. L. Pancreatic Cancer: Atlas of Clinical Oncology. Hamilton, London: BC Decker Inc.,
2001. 457 p.2. Sabiston Textbook of Surgery: the Biological Basis of Modern Surgical Practice. 16th ed. / Ed. By
Townsend C. M. Jr. Philadelphia: W. B. Saunders Company, 2001. 1076 p.3. Koito K., Namieno T., Nagakawa T. et al. Pancreas: imaging diagnosis with color / power Doppler
ultrasonography, endoscopic ultrasonography, and intraductal ultrasonography // Eur. J. Radiol. 2001. V.38. № 2. P. 94-104.
4. Campani R., Bottinelli O., Calliada F., Coscia D. The latest in ultrasound: threedimensional imag-ing. Part II // Eur. J. Radiol. 1998. V. 27. Suppl. 2. P. S183 — S187.
5. Rohling R. N., Gee A. N., Berman L. Automatic registration of 3D ultrasound images // Ultra-sound Med. Biol. 1998. V. 24. № 6. P. 841-854.
6. Sanches J. M., Marques J. S. A multiscale algorithm for threedimensional freehand ultrasound // Ultrasound Med. Biol. 2002. V. 28. № 8. Р.1029-1040.
7. Masci E., Mariani A., Curioni S., Testoni P. A. Risk factors for pancreatitis following endoscopic retrograde cholangiopancreatography: a metaanalysis //Endoscopy. 2003. V. 35. № 10. P. 830-834.
8. V. I. Nesterov. Computer nonlinear diagnostics. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 5-6.
9. S. P. Tokar, A. S. Davydova, T. L. Guseva, V. I. Gusarov, Z. F. Khabibullina, L. S. Pugacheva. Non-lin-ear computer diagnostics and pathology of hepatopancreaticoduodenal area. Collection of scientific papers of the Institute of Practical Psychophysics «Current problems of NLS-diagnostics». Tome 1. Moscow. Katalog, 2006, p. 77-88
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Importance of three-dimensional reconstruction and visualization algorithms in non-linear diagnostics of knee joint
V.I. Nesterov, N.L. Ogluzdina, P.A. Manokhin
The Institute of Practical Psychophysics, Clinic of postgraduate education department
of the Omsk state medical academy
INTRODUCTIONAccording to the World Health Organization in de-
veloped countries pathology of musculoskeletal system ranks No. 2 among reasons of disablement for a period of less than two weeks, trailing only to respiratory dis-eases, but it takes the first place for periods of time above two weeks. In general manifestations of arthrosis of various localizations are diagnosed in 9.6 % of men and 18 % of women above 60. In developed countries gonarthrosis prevails — symptoms of the pathology are diagnosed in 14.1 % of men and 22.8 % of women above 45. These indices have clear upward trend due to ageing of population.
We carried out 439 NLS-studies of knee joints us-ing «Metatron» — 4025 system with «Metapathia GR Clinical» software and a feature of three-dimensional visualization of knee joint.
Three-dimensional non-linear scanning getting a special importance as highly-informative method of knee joint pathology diagnosing in comparison with CT and MRI, first of all owing to lesser cost of a study, at the same time diagnostic advantages of the latter are not so evident in this field. This fact is proven by growing application of NLS system in orthopedics.
Diagnostic value of NLS-graphy in respect to knee joint pathology is extremely high for non-invasive method. It is proven that at acute trauma of knee joint NLS-graphy reliably decrease time needed for diagnosing, improves quality of life within the first 6 weeks after a trauma, decreases total expenses. Also we noted relatively high reliability of damaged menis-cus study; at the same time some authors in doubtful case recommend to trust more 3D NLS-scanning, than CT and MRI. Initial signs of degenerative changes of arthrodial cartilage in form of superficial separation of fibers are visualized rather good, because to do so a very high resolution — down to 30 microns is required and «Metatron» system has such resolution charac-
teristics. Evaluation of anterior cruciate ligament condition, which was quite difficult using systems of the previous generation («Metatron» — 4017, 4019), can be successfully fulfilled using systems with 3D-visualization feature.
We tried to improve diagnostic possibilities of NLS-scanning by wide application of three-dimensional modes of morphological structures visualization, such as 4D tissue, multiscanning in three mutually perpen-dicular planes, DeepVision, FastVision and ultrami-croscanning with spectral-entropic analysis (SEA).
For proper ultramicroscanning a resolution of NLS-systems must not exceed 30 microns, for cytological studies — less than 10 microns, so the only real way to achieve this is to use algorithms of three-dimensional visualization, such as MIP (Maximum Intensity Projec-tion, MPR (Multi-Planar Reconstruction) and DVR (Di-rect Volume Rendering).
Review of basic algorithms of multidimensional visualization of three-dimensional NLS-data and evalu-ation of their importance for knee joint pathology di-agnostics are the objectives of our study.
MATERIAL AND METHODSNLS-studies were performed using the last genera-
tion of NLS-diagnostic systems «Metatron» — 4025 (The IPP, Russia), equipped with trigger sensors and high-frequency generator of 4.9 GHz frequency.
All post-processing and analysis were carried out on a PC with Windows OS, taking into account constantly growing performance characteristics of a PCs and vari-ety and functionality of Windows-compatible software.
As a workstation we used a PC with Pentium 4 2.4Ghz processor, 1Gb DDR 400 RAM, graphic board Leadtek WinFast A6600 GТ (128Mb DDR3) with Win-dows OS.
The following Windows-compatible software was used: ImageJ 1.38e (http://rsb.info.nih.gov / ij), eFilm
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Pic.1. 3D NLS-study of knee joints. Hemarthrosis of left knee joint.
Pic.2. NLS-scanning. Cross-cut of knee joint at the level of anterior cruciate ligament by horizontal plane. Partial intrasynovinal damage of anterior
Workstation 2.1.2 (https://www.merge.com), FP Im-age 0.7 (http://www.fpimage.com), VGStudioMAX 1.0 (http://www.volumegraphics.com), 3DView 1.2 (http://www.rmrsystems.co.uk), Adobe Photoshop 9.0 (http://www.adobe.com / photoshop).
RESULTS AND DISCUSSIONIn our study we used three-dimensional visualiza-
tion modes (4D Tissue) that allows not only getting of virtual multidimensional pictures of anatomic and histological structures, but also mark with color the researched biologic tissue — «additional dimension» and visualize bones, soft tissues and vessels simultane-ously or in any desired succession. In this case maxi-mum possible for a generator of 4.9GHz resolution of 10 microns is reached.
We added the following three-dimensional modes to a routine scanning protocol:
— DeepVision — allows to visualize internal and deep structures of a body, normally hidden by other
anatomical structures. This modes can make all lay-ers of joint capsule transparent and thus visualize and evaluate intraarticular ligaments, normally hidden by joint capsule.
— FastVision — allows to study separate ana-tomical structures quickly and in more details.
— Cross-cut selection — allows to make a cross-
cut of an organ model by a plane. Cross-cut can be done in three mutually perpendicular planes: frontal, sag-gital and horizontal.
NLS-scanning allows to restore a picture in any plane from three-dimensional array. The best results are achieved at 30-microns isotropic spatial resolu-tion, which can be achieved only for 4D Tissue suc-cession. We use this mode to visualize at least in two planes of anterior cruciate ligament and lateral col-lateral ligament of knee joint. NLS-graphy in meniscus’ plane along its flexure is irreplaceable for detection of transverse (radial) rupture of the latter. We use NLS-ultramicroscanning mode for evaluation of arthrodial cartilage condition, at the same time we can visualize small (about 0.3 mm) damages of its surface, corre-sponding to chondropathy of the 1st stage.
Texture mapping method has practical value among the main algorithms of image rendering with 4D Tis-sue method. Significance of each element in the final image is calculated by the software according to a for-mula known as «volume reconstruction integral» which assumes high requirements for central processing unit performance and memory bus capacity. Texture map-ping method is realized on the level of PC’s graphic subsystem and provides interactive refresh rate of at least 15 fps, at the cost of image color depth reducing to 8 bits and absence of complex shadows. At 4D Tissue internal structure of an object is preserved and various methods are used to demonstrate it — cross-section of a model with a plane, segmentation of anatomic structures, etc. The following examples illustrate their informative features.
Thus data acquired with 4D Tissue at computed NLS-graphs in general meet the conditions of three-dimensional post-processing and Windows-compatible software in combination with processing power of modern PC allows to fulfill it quickly and efficiently.
Probably the most valuable feature of three-di-mensional visualization algorithms it their ability to
We tried to improve diagnostic possibilities of NLS-scanning by wide
application of three-dimensional modes of morphological structures visualization
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Pic.3. NLS-scanning. Cross-cut of left knee joint by saggi-tal plane. Transverse (radial) rupture of meniscus.
Pic.4. NLS-scanning. Cross-cut of right knee joint by frontal plane. Lateral collateral ligament rupture.
extract additional diagnostic information from ac-quired data, which is unavailable at usual analysis of two-dimensional NLS-graphs; in this context three-dimensional visualization is close to so-called «data mining» — a search for hidden and unexpected infor-mation in large data arrays.
We noted a certain conservatism of a software for two-dimensional visualization pre-installed to NLS-
systems and that was the reason for development of conceptually new software for systems with three-dimensional visualization of the last generation. That is why we believe that one of the most important as-pects in creation of a new generation of NLS-diagnostic equipment was the development of universal, multipur-pose and extendable Windows-compatible software for three-dimensional NLS-visualization.
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low-field-strength MR imaging — results of randomized controlled trial // Radiology. 2005. V. 236. P. 958-967.
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4. Rubenstein J., Li J., Majumdar S., Henkelman R. Image resolution and signal-to-noise ra-tio requirements for MR imaging of degenerative cartilage // Am. J. Roentgenol. 1997. V. 169. P. 1089-1096.
5. Fellner F., Fellner C. 3D imaging and virtual reality technique, applications and pitfalls// Syllabus of 9th Advanced Course of the ESNR. Vienna. 1999. P. 91-104.
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7. Brusova А. G., Manokhin P. А., Puzanovskaya Т. К., Shishkovets Т. А. NLS-diagnostics of degenerative changes of a spine//Collection of scientific papers of the Institute of Practical Psychophysics «Actual aspects of NLS-diagnostics». Tome I. Moscow. Katalog, 2006, p. 30-33.
8. Petrov М. S., Voroshilova L. А., Kartuzov V. М., Vesnin А. Y., Derevyanko G. V., Guglya А. P. NLS-study in evaluation of knee joint condition at arthropathy deformans// Collection of scien-tific papers of the Institute of Practical Psychophysics «Actual aspects of NLS-diagnostics». Tome I. Moscow. Katalog, 2006, p. 47-50.
9. V. I. Nesterov. 3D NLS diagnostics. Prospect of development. Collection of scientific papers of the Institute of Practical Psychophysics «NLS-diagnostics in medicine. Prospects of develop-ment». Tome 3. Moscow. Katalog, 2010, p. 5-8.
