RU2626676C1 - Method for rapid hysteromyoma development prediction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention is a method for rapid hysteromyoma development risk prediction, which consists in examination of uterus ultrasound parameters with calculation of the myomatous nodes number, the method of marginal dehydration of menstrual flow (MF) is used to determine the presence of parallel and fibrous structures and coefficient P is calculated:

, where z is calculated by the formula: z=b₁×x₁+b₂×x₂+b₃×x₃+a, where b₁ is the coefficient equal to 2.172; x₁ are fibrous structures in MF: presence is "2"; absence is "1"; b₂ is the coefficient equal to 2.238; x₂ are parallel structures in MF: presence is "2"; absence is "1"; b₃ is the coefficient equal to 1.568; x₃ is the number of nodes; a is the constant equal to -10.915; and at a value of P>0.5, the levels of APRIL and TRAIL ligands are additionally investigated by the enzyme immunoassay method, and at APRIL value of more than 11.1 ng/ml, TRAIL value of less than 22.5 pg/ml a risk of rapid hysteromyoma development is predicted.

EFFECT: higher prediction accuracy.

2 tbl, 2 ex

Description

The invention relates to medicine, namely to a laboratory-statistical research method, and can be used to predict the risk of developing rapidly growing uterine fibroids (BrMM).

The relevance of the diagnosis of uterine fibroids (uterine fibroids) is that it is the most common benign genital tumor. Recent large-scale pathological studies indicate that its prevalence can reach 85% (Tikhomirov A.L., 2010).

A special place is occupied by the problem of detecting BrMM, which is due to the high probability of its development in all age periods, the possibility of combination with endometrial hyperplasia, precancer and endometrial cancer, ovarian tumors, as well as transformation into leiomyosarcoma (Called LF, 2000; Sidorova I.S., Mioma uterus, MIA, Moscow, 2003; Lazareva NI et al., 2003; Dikareva LV, Uterus hyperplastic processes: clinical diagnostic value of markers of biological fluids, abstract of dissertation for the degree of Doctor of Medical Sciences, Volgog hell, 2009; Dikareva L.V., Shvarev E.G., Shramkova I.A., Shvarev G.E. Patent of the Russian Federation for invention No. 2332167 dated 08.28.2008, “Method for the diagnosis of rapidly growing uterine fibroids.” Patent service for intellectual property, patents and trademarks, description of the invention to a patent; L. Dikareva, Clinical and diagnostic features of patients with rapidly growing uterine fibroids // Journal of Obstetrics and Women's Diseases. - St. Petersburg, 2008. - T. LVII. - Issue 2. - S. 74-81; Dikareva L.V., Shvarev E.G., Shvarev G. E. Clinical meaning of rapid growth hysteromyoma, approaches to the diagnostics // European journal of natural history. - 2008. - No. 4. - P. 44-48; Dikareva L.V., Shvarev E.G., Ayupova A.K. Clinical and prognostic value of fast-growing uterine fibroids // Successes in modern science. - 2008. - No. 8. - S. 102-105).

The urgency of the problem of early diagnosis of BrMM is also associated with the tendency to “rejuvenate” this contingent of patients in recent years, late pregnancy planning (after 35 years), when MM is the cause of reproductive failures (Benecke S., Kruger TF, Siebert TI, Merwe JPvan der, Steyn DW Effect of fibroids on fertility in patients undergoing assisted reproduction. A structured literature review // Gynecol. Obstet. Invest. 2005. Vol. 59 (4). P. 225-230); Sidorova I.S., Unanyan A.L., Kogan E.A., Guriev T.D. Uterine fibroids in young patients: clinical and pathogenetic features // Obstetrics, gynecology and reproduction, 2010; N1: p. 16-20).

Several methods are used to predict the risk of developing BrMM in practical medicine.

A known method for predicting the growth of MM is that it is proposed to determine the density and intensity of staining of progesterone receptors by the immunohistochemical method in tissue samples of myomatous nodes obtained by transcervical puncture biopsy, and with an increase in these parameters, fibroid growth is predicted for 12 months (Ichimura T ., Kawamura N., Ito F., Shibata S., Minakuchi K., Tsujimura A., Umesaki N., Ogita S. Correlation between the growth of uterine leiomyomata and estrogen and progesterone receptors in needle biopsy speciments // Fertil. Steril . - 1998. - V.70. - P. 967-971).

This method has several disadvantages:

- poor reproducibility of the results due to errors in the preparation of slices, heterogeneous staining of tissues, features of microscopy (Immunological methods [edited by H. Frimel] // M .: Mir. - 1979. - 518 p.);

- invasiveness and invasiveness.

A known method for predicting the rapid growth of MM, based on the determination of the relative content of CD38-positive peripheral blood lymphocytes. With their values equal to or greater than 23%, rapid growth of MM is predicted during the year (RF patent No. 2236684 "Method for predicting the growth of uterine leiomyoma" dated 09/20/2004 / Posiseeva LV, Malyshkina AI, Sotnikova N.Yu. ., Antsiferova Yu.S., Suvorkina E.E., Arevadze I.E.).

The disadvantage of this method is its invasiveness.

The claimed method for predicting BrMM has no analogues.

The invention is aimed at simplifying and improving the accuracy of predicting the risk of developing rapidly growing uterine fibroids.

The specified technical result is achieved by examining the ultrasonic parameters of the uterus with the calculation of the number of myomatous nodes, then using the method of edge dehydration of menstrual flow to determine the presence of parallel and fibrous structures in the analytical cell and using the formula obtained by binary logistic regression, calculating the prediction coefficient for the risk of developing rapidly growing uterine fibroids :

where P is the coefficient for predicting the risk of developing rapidly growing uterine fibroids;

e is a constant, the base of the natural logarithm, equal to 2.72;

z is the degree of the inverse logarithm, which is calculated by the formula:

z = b1 × x1 + b2 × x2 + b3 × x3 + a,

where b1 is the regression coefficient equal to 2.172;

x1 - value of an independent variable, risk factor: morphological element - fibrous structures in MB: presence of "2"; lack of "1";

b2 is the regression coefficient equal to 2.238;

x2 - value of an independent variable, risk factor: morphological element - parallel structures in MB: presence of "2"; lack of "1";

b3 is the regression coefficient equal to 1.568;

x3 - value of an independent variable, risk factor: number of nodes;

and - some constant equal to -10.915,

and at a value of P> 0.5, there is a likelihood of developing rapidly growing uterine fibroids, and additionally, by the method of enzyme-linked immunosorbent assay, the levels of ligands that induce proliferation — APRIL, and apoptosis — are studied by TRAIL, and when APRIL is more than 11.1 ng / ml, TRAIL is less than 22, 5 pg / ml predict the risk of developing rapidly growing uterine fibroids.

To achieve the result, a drop of menstrual flow supernatant (MB) with a volume of 10-20 μl is applied using a pipette microdoser on a clean glass slide and covered with a coverslip, thereby forming an analytical cell. Over the next 48-72 hours, the droplet is slowly dried at room temperature, after which the formed crystals are microscopic in ordinary light in order to identify parallel structures - markers of tissue proliferation, and fibrous structures - markers of hypoxia, the detection frequency of which increases significantly with BrMM.

The choice of MB as a test substrate in women is due to the fact that a number of enzymes and enzymes can accumulate in the apical portions of glandular cells, secrete in the endometrial mucus and uterine cavity (Shvarev E.G. Tumor markers in the diagnosis and evaluation of hormone therapy for endometrial cancer, abstract of the dissertation for the degree of Doctor of Medical Sciences, St. Petersburg, 1993; Dikareva L.V., Shvaryov E.G., Ukhanova Yu.Yu., Abzhalilova AR, Tishkova OG Diagnostic value of menstrual flow with gynecological pathology // Astrakhan Medical Journal, 2013; No. 3, p. 12-17).

The evidence base of the proposed formula is as follows: we calculated the diagnostic sensitivity (Se, sensitivity) of the proposed algorithm (the ability of the diagnostic method to give the correct result, which was determined as the share of truly positive results among all tests performed) using the formula:

where TP is the truly positive results of the study;

- количество всех заболевших,

- the number of all sick,

where TP are truly positive results;

FN - false negative results.

The diagnostic specificity (Sp, specificity) of the algorithm was also calculated (the ability of the diagnostic method to not give false positive results in the absence of the disease, which is defined as the proportion of truly negative results among individuals in the group of subjects) by the formulas:

where TN are true negative cases;

D - healthy patients.

where TN is the number of truly negative results;

FP is the number of false positive results.

The accuracy of the algorithm (Ac, accuracy) is the percentage of correct test results (i.e., the sum of truly positive and truly negative results) among all examined patients is determined by the formulas:

where TP are truly positive results;

TN - true negative results;

D - all healthy patients;

- все пациенты с БрММ,

- all patients with BrMM,

where TP is the number of truly positive results;

TN is the number of truly negative results;

FP is the number of false positive results;

FN is the number of false negative results.

Positive predictive value (PVP) is the proportion of true positive results among all positive test values. This indicator is determined by the formula:

where TP are truly positive results;

FN - false negative results.

Negative predictive value (PVN) is the proportion of true negative test results among all negative values. The indicator was determined by the formula:

where TN - true negative cases;

FP - false positive cases.

The significance of the developed model was evaluated using the Omnibus Test. The results indicate the statistical significance of the model (χ ² = 62.185; df = 3; p <0.001).

The following is classification table 1, in which the observed indicators of belonging to the BrMM group are contrasted with those predicted on the basis of the calculated model.

From table 1 we can conclude that of the total number of patients selected for the prognosis (70 people), “strictly positive” results were obtained in 37 (53%) patients, false-negative (recognized as healthy by the test, although they are sick) results - in 3 (4%) patients. “Strictly negative” results were obtained in 26 (37%) patients, false-positive (recognized as patients, although they are healthy) results were obtained in 4 (6%) patients. In general, 63 cases were correctly recognized, which is 90%.

The significance of the coefficients was verified using Wald statistics. The level of statistical significance of the coefficients is <0.05, which allows the use of these indicators in the specified prognostic model (table 2).

The diagnostic sensitivity of the developed prognostic model was 93%, the diagnostic specificity of the test was 87%.

The accuracy (diagnostic effectiveness of the test) was at 90%, the predictive value of a positive result was 92.5%, and the predictive value of a negative result was 86.7%.

The predictive categorical validity of the test was calculated. Validity coefficient r = 0.79.

We offer a two-stage BrMM forecasting algorithm.

Stage 1 - determination using the developed mathematical model of risk of developing BrMM according to the proposed formula. With a value of P> 0.5, there is a likelihood of developing this pathology. All patients with P> 0.5 are included in the risk group.

Stage 2 - determination of APRIL and TRAIL ligands in MB in patients with P> 0.5. With an APRIL of more than 11.1 ng / ml and a TRAIL of less than 22.5 pg / ml and P> 0.5, the prognosis of the risk of developing BrMM approaches 100%.

Thus, the absolute risk (EER) of developing BrMM in the group of patients with an APRIL ligand of more than 11.1 ng / ml and TRAIL MB of less than 22.5 pg / ml was 97%, and in the group of patients with an APRIL of less than 11.1 ng / ml and TRAIL more than 22.5 pg / ml did not exceed 3%. The increase in EER of development of BrMM in patients with APRIL levels of more than 11.1 ng / ml and TRAIL of less than 22.5 pg / ml corresponded to 0.94 [0.86; 1.02] or 94%.

The relative risk (RR) of the development of BrMM in the group of patients with an APRIL ligand level of more than 11.1 ng / ml and TRAIL less than 22.5 pg / ml was 38.7 [35.7; 281.5]. Since the RR exceeded 2.5, this allowed us to regard the risk as very high.

The odds ratio (OR) of the development of BrMM in the group of patients with an APRIL level of more than 11.1 ng / ml and a TRAIL of less than 22.5 pg / ml was at the level of 1131 [17.29; 1234.7], which also indicated a very high risk of developing this pathology.

The proposed method was successfully tested in the gynecological department of the City budgetary institution of health care of the Astrakhan region "Clinical Maternity Hospital", City budgetary institution of health care of the Astrakhan region "City Polyclinic No. 1" in Astrakhan.

111 women aged 18 to 55 years were examined. All of them were divided by nosological basis (control group, MRMM, BrMM).

Below are the results of testing.

Example 1. Patient Z., 49 years old. It was observed in the antenatal clinic for uterine fibroids of small sizes - 6-7 weeks - for 2 years. A history of 1 timely delivery without complications. The method of contraception is barrier.

03/09/2013, MB was aspirated from the posterior vaginal fornix with a Paypel probe on day 2 of the menstrual cycle in an amount of 5 ml. MB was centrifuged for 5 min at a speed of 3000 rpm and for the study used a supernatant (supernatant). Morphological study of MB supernatant (study of analytical cells by the method of regional dehydration): parallel (proliferation marker) ("2") and fibrous ("2") structures were detected.

According to the ultrasound scan (ultrasound scan): the body of the uterus is 60 × 55 × 50 mm in size with an inhomogeneous structure. 2 intramural-subserous nodes emanate from the anterior wall on a wide base with dimensions of 10 × 7 mm, 6 × 4 mm, reduced echogenicity, heterogeneous structure, an intramural node with dimensions of 8 × 4 mm, decreased echogenicity, heterogeneous structure, emanates from the uterus intramural-subserous node 3 × 3 mm, reduced echogenicity, heterogeneous structure. The uterine cavity is not deformed. M-echo 5 mm. The right ovary is 31 × 29 mm, normal structure, the left ovary is 34 × 30 mm, normal structure. Substituting the specified parameters in the formula

Where

z = 2.172 × Fibrous structures (MB) +2.238 × Parallel structures (MB) +1.568

The number of nodes -10.915,

got:

z = 2.172 × 2 + 2.238 × 2 + 1.568 × 4-10.915 = 4.177, then

P = 1 / (1 + ^2.72-4.177 ) = 0.98.

Since the probability of occurrence of the event is P> 0.5, the second stage determined the level of APRIL and TRAIL in MB, and since the level of APRIL in MB was 12.72 ng / ml, TRAIL in MB was 21.7 pg / ml, the patient was suggested to develop BrMM with a probability of 0.985 or 98.5%.

Upon repeated treatment after 12 months, it was noted that during the last year, menstruation became more abundant, there was an increase in MM up to 12 weeks (rapid growth) according to the US data and bimanual examination. When a vaginal examination: the neck is cylindrical, pale pink, without mucosal defects, the uterus is enlarged up to 12 weeks of pregnancy, tight on palpation, limited mobility, painless, the appendages are not palpable, the arches are free.

According to the USG: the uterine body is 70 × 77 × 63 mm in size with an inhomogeneous structure. 2 intramural-subserous nodes emanate from the anterior wall on a wide base with dimensions of 32 × 34 mm, 30 × 27 mm, reduced echogenicity, heterogeneous structure, an intramural node with dimensions of 24 × 24 mm, decreased echogenicity, heterogeneous structure, from the uterine fundus intramural-subserous node 30 × 31 mm, reduced echogenicity, heterogeneous structure. The uterine cavity is not deformed. M-echo 11 mm. The right ovary is 31 × 28 mm, normal structure, the left ovary is 34 × 29 mm, normal structure.

The risk of developing rapidly growing uterine fibroids was high.

Example 2. Patient X., 31 years old. It was observed in the antenatal clinic for uterine fibroids of small sizes - 7-8 weeks - for 4 years. A history of 2 urgent births without complications. The method of contraception is barrier.

03/29/2013, the menstrual discharge was aspirated from the posterior vaginal fornix with a Paypel probe (material sampling is described in Example No. 1).

Morphological study of the supernatant of menstrual flow: revealed parallel ("2") and fibrous ("2") structures.

Level in MB: APRIL 12.8 ng / ml, TRAIL 21.0 pg / ml.

Substituting the specified parameters in the formula, where

z (development of fast-growing fibroids) = 2,172 × Fibrous structures (MB) + 2,238 × Parallel structures (MB) + 1,568 × Number of nodes-10,915, received:

z = 2.172 × 2 + 2.238 × 2 + 1.568 × 4-10.915 = 4.177, then

P = 1 / (1 + ^2.72-4.177 ) = 0.985.

Since the probability of occurrence of the event is P> 0.5, the second stage determined the level of APRIL and TRAIL in MB, and since the level of APRIL in MB was 12.72 ng / ml, TRAIL in MB was 21.7 pg / ml, the patient was suggested to develop BrMM with a probability of 0.985 or 98.5%.

Upon repeated treatment, he notes that during the last year menstruation became more abundant, there is an increase in MM up to 13 weeks (rapid growth) according to the US data and bimanual examination. When a vaginal examination: the neck is cylindrical, pale pink, without mucosal defects, the uterus is enlarged up to 13 weeks of pregnancy, tight on palpation, limited mobility, painless, the appendages are not palpable, the arches are free.

According to the USG: the uterus is 110 × 85 × 98 mm in size with an inhomogeneous structure. 2 intramural nodes with dimensions of 65 × 50 mm, 40 × 40 mm, of reduced echogenicity, heterogeneous structure emanate from the front wall, an intramural-subserous node with dimensions of 30 × 20 mm, reduced echogenicity, heterogeneous structure, intramural-subserous from the uterine fundus node 10 × 10 mm, reduced echogenicity, heterogeneous structure. The uterine cavity is not deformed. M-echo 12 mm. The right ovary is 30 × 30 mm, normal structure, the left ovary is 28 × 25 mm, normal structure.

The risk of developing rapidly growing uterine fibroids was high.

Statistical data processing was carried out using licensed packages Statistica 8.0, Microsoft Excel 2010.

The application of the proposed method allows to simplify and improve the accuracy of predicting the risk of developing BrMM, prevent the increase in the severity of genital pathology and timely resolve the issue of the adequacy of therapy, and in patients of reproductive age, organ-preserving surgical treatment and the required number of courses of hormonal pre- and postoperative therapy. The sampling of the test material is technically simple, easily tolerated by patients, eliminates the risk of developing frequent and severe complications caused by trauma during diagnostic curettage. Atraumatic sampling of the material opens up a wide possibility of repeated analyzes, which is a prerequisite for a dynamic assessment of the development of MM on the background of the treatment.

Claims (14)

A method for predicting the risk of developing rapidly growing uterine fibroids, which consists in examining the ultrasonic parameters of the uterus with the number of myomatous nodes counted, then using the method of edge dehydration of menstrual flow to determine the presence of parallel and fibrous structures in the analytical cell, and using the formula obtained by binary logistic regression, calculate the coefficient predicting the risk of developing rapidly growing uterine fibroids:

where P is the coefficient for predicting the risk of developing rapidly growing uterine fibroids; e is a constant, the base of the natural logarithm, equal to 2.72; z is the degree of the inverse logarithm, which is calculated by the formula: z = b ₁ × x ₁ + b ₂ × x ₂ + b ₃ × x ₃ + a, where b ₁ is the regression coefficient equal to 2.172; x ₁ - value of an independent variable, risk factor: morphological element - fibrous structures in MB: presence of "2"; lack of "1"; b ₂ - regression coefficient equal to 2.238; x ₂ - value of an independent variable, risk factor: morphological element - parallel structures in MB: presence of "2"; lack of "1"; b ₃ - regression coefficient equal to 1,568; x ₃ - value of an independent variable, risk factor: number of nodes; and - some constant equal to -10.915, and at a value of P> 0.5, there is a likelihood of developing rapidly growing uterine fibroids, and additionally, by the method of enzyme-linked immunosorbent assay, the levels of ligands that induce proliferation — APRIL, and apoptosis — are studied by TRAIL, and when APRIL is more than 11.1 ng / ml, TRAIL is less than 22, 5 pg / ml predict the risk of developing rapidly growing uterine fibroids.