Протонная лучевая терапия рака прямой кишки: литературный обзор

Colorectal cancer is a significant group of malignant neoplasms that dominates the morbidity and mortality patterns in the world. for patients with colorectal cancer, a multidisciplinary approach is required when choosing treatment tactics involving surgeons, radiotherapists and chemotherapists. At present, it is impossible to overestimate the role of radiotherapy in the treatment of locally advanced rectal cancer. The purpose of this review is to summarize current data on proton beam therapy and its role in the treatment of rectal cancer.Колоректальный рак представляет собой значительную группу злокачественных новообразований, занимает лидирующую позицию в структуре заболеваемости и смертности в мире. Для пациентов с колоректальным раком требуется мультидисциплинарный подход при выборе тактики лечения с привлечением хирургов, радиотерапевтов и химиотерапевтов. В настоящее время невозможно переоценить роль лучевой терапии в лечении местно-распространенного рака прямой кишки. Целью данного обзора является обобщение современных данных о протонной лучевой терапии и ее роли в лечении рака прямой кишки

Modem look at etiology, pathogenesis, treatment of Peyronie's disease (literature review)

Article reviewed global data on the etiology, epidemiology, clinical manifestations, diagnosis, staging, complications encountered, as well as available in the arsenal of methods of surgical and conservative treatment of Peyronie's disease. Details covered etiological factors pathophysiological processes of the disease. According to statistics, Peyronie's disease is quite rare in the world. However, in the world's scientific literature there are many works devoted to Peyronie's disease, in particular the methods of its treatment and control of disease complications. But to date, there is no consensus in regard to the etiology, pathogenesis and treatment of this disease. That is why further research is needed in this area to improve the detection and awareness of both men and doctors. Consequently, there is a clear need for further research of Peyronie's disease, as well as the creation of new, more effective treatments. These treatments have to be introduced into clinical practice physicians.В статье проведен обзор мировых данных по этиологии, эпидемиологии, клиническим проявлениям, диагностике, стадированию, встречающимся осложнениям, а также имеющихся в арсенале методов хирургического и консервативного лечения болезни Пейрони. Подробно освещены этиологические факторы, патофизиологические процессы данного заболевания. По статистике, болезнь Пейрони достаточно редко встречается в мире. Однако в мировой научной литературе имеется множество работ, посвящённых болезни Пейрони, в особенности методов ее лечения и борьбы с осложнениями заболевания. Но на сегодняшний день, нет единого мнения в том, что касается этиологии, патогенеза, лечения этого недуга. Именно поэтому необходимы дальнейшие исследования в этой области для улучшения выявляемости и информированности как мужчин, так и врачей. Следовательно, имеется четкая потребность в дальнейших исследованиях болезни Пейрони, а также в создании новых, более эффективных методов лечения. Эти методы лечения должны быт

Возможность снижения лучевой нагрузки на пациентов за счет оптимизации протокола компьютерной томографии органов брюшной полости и забрюшинного пространства в зависимости от нозологии злокачественного процесса

Reducing radiation exposure in computed tomography is a relevant medical task due to the growing number of studies and the lack of generally accepted approaches to their conduct in the radiological community. One way to reduce the effective dose in contrast-enhanced computed tomography of the abdomen is to optimize the protocol of examination, which can include four scans: in the native, arterial, venous and delayed phases. However while providing repeated studies in patients with oncological diseases, it is possible to confine one or two phases, which will allow the radiologist to visualize observed pathological changes and to evaluate the response to the treatment, as well as detect the recurrence in case of the monitoring of the patients. In the present study, two groups were formed on the basis of a sample of 514 patients. In group 1 (control), CTB was performed according to a three- or four-phase protocol. In group 2, the same patients with an interval from 1 to 5.5 months were performed with computed tomography -OBP according to a single or two-phase protocol depending on the degree of vascularization of the tumor tissue and the clinical situation. At the same time, a decrease in the average effective dose in patients in group 2 compared with group 1 was demonstrated by 63% (p<0.05). In all cases, the various pathological changes that characterize the oncological process and were diagnosed with a three- or four-phase protocol were visualized with a single- or two-phase protocol. Thus, the informative value of computed tomography examination did not decrease.Снижение лучевой нагрузки при компьютерной томографии является актуальной медицинской задачей в связи с ростом количества исследований и отсутствием общепринятых подходов при повторных исследованиях у онкологических пациентов. В работах различных авторов продемонстрирована целесообразность ограничения протокола компьютерной томографии одной или двумя фазами сканирования при повторных исследованиях у пациентов с онкологическими заболеваниями без потери диагностической информации. В настоящей работе на основе выборки из 514 пациентов были сформированы две группы. В 1 группе (контрольная) пациентам проводилась компьютерная томография органов брюшной полости по трех- или четырехфазному протоколу. Во 2 группе этим же пациентам с интервалом от 1 до 5,5 месяцев проводилась компьютерная томография органов брюшной полости по одноили двухфазному протоколу в зависимости от степени васкуляризации опухолевой ткани и клинической ситуации. При этом было продемонстрировано снижение средней эффективной дозы у пациентов в группе 2 по сравнению с группой 1 на 63% (p<0,05). Во всех случаях различные патологические изменения, характеризующие онкологический процесс и диагностированные при трех- или четырехфазном протоколе, были визуализированы и при одно- или двухфазном протоколе. Таким образом, информативность компьютерной томографии не снижалась

Пресепсин в диагностике нозокомиальной инфекции центральной нервной системы

ABSTRACT Introduction Nosocomial infection of the central nervous system (NI-CNS) is a serious complication in neurocritical patients that leads to deterioration of patient’s condition, worsening of outcomes and increased cost of treatment. The timely diagnosis of NI-CNS is a relevant problem and the search for new reliable markers of NI-CNS is an important issue.MATERIAL AND METHODS The prospective observational study consisted of two parts. The aim of the frst part was to defne normal ranges of cerebral spinal presepsin (CSF PSP). The aim of the second part was investigation of CSF PSP in neurocritical patients. We studied CSF sampling obtained during spinal anesthesia for elective urologic surgery in order to defne the normal CSF PSP. The following data was collected in neurocritical patients: CSF cell count, glucose, lactate, PSP, microbiological tests, polymerase chain reaction (PCR), when it was possible. Blood tests included complete blood count, C-reactive protein (CRP), procalcitonin (PCT), PSP. IBM SPSS Statistics (version 23.0) was used for statistical analysis.RESULTS Fifteen CSF samplings were obtained for investigation of normal CSF PSP ranges, which was 50–100 pg/ml. Nineteen neurocritical patients were included. Sixty-three pairs of CSF and blood samplings were obtained. All pairs were divided into the 4 groups in accordance with presence/absence of NI-CNS or systemic infection. In cases without both NI-CNS and systemic infection (group 4) CSF PSP was 406±203.1 pg/ml. In cases without NI-CNS and with systemic infection (group 2) CSF PSP was 614.9±315 pg/ml. In cases with NI-CNS and without systemic infection (group 3) CSF PSP was 547.8±264.3 pg/ml. In cases with both NI-CNS and systemic infection (group 1) CSF PSP was 731.1±389.7 pg/ml. The ROC analysis showed that in neurocritical patients without systemic infection CSF PSP 537 pg/ml meant NI-CNS with sensitivity 68.8% and specifcity 85.7%.CONCLUSION The normal value of the CSF PSP is 50-100 pg/ml. CSF PSP more than 537 pg/ml in neurocritical patients without systemic infection meant NI-CNS with 688% sensitivity and 857% specifcity. CSF PSP may be used for diagnosing NI-CNS in neurocritical patients as an additional marker only. CSF may be used as an additional diagnostic criterion, but further research is needed.ВВЕДЕНИЕ Нозокомиальная инфекция центральной нервной системы (НИ ЦНС) является тяжелым осложнением, приводящим к ухудшению состояния, удлинению продолжительности лечения и ухудшению исходов заболевания у нейрореанимационных пациентов. Ранняя диагностика НИ ЦНС является актуальной клинической задачей, а поиск новых надежных маркеров НИ ЦНС — важной научной целью.МАТЕРИАЛ И МЕТОДЫ Представленное исследование было проспективным и состояло из двух частей. Целью первой части было определить нормальный уровень пресепсина (ПСП) в спинномозговой жидкости (СМЖ). Для определения нормального уровня ПСП в СМЖ исследовались образцы ликвора, полученные при спинномозговой анестезии во время плановых урологических и общехирургических операций. Целью второй части было изучение динамики ПСП в СМЖ у различных групп нейрореанимационных пациентов в зависимости от наличия НИ ЦНС и системной инфекции. Вместе с ПСП в ликворе исследовали цитоз, уровень глюкозы, лактата, проводили его микробиологическое исследование и полимеразную цепную реакцию (ПЦР), когда это было возможно. Исследование крови включало в себя ее клинический анализ, определение содержания в ней С-реактивного белка (СРБ), прокальцитонина (PCT) и ПСП. Статистический анализ проводился с использованием IBM SPSS версии 23.0.РЕЗУЛЬТАТЫ В первой части исследования для получения нормального уровня ПСП в СМЖ были исследованы 15 проб СМЖ у пациентов урологического или общехирургического профиля без поражения нервной системы. Уровень ПСП в СМЖ составил 50–100 пг/мл. Эти значения были приняты в качестве референсных для уровня ПСП в СМЖ в норме. Во второй части исследования были проанализированы 63 пары проб ликвора и крови у 19 нейрореанимационных пациентов. Все пары были разделены на 4 группы в соответствии с наличием в момент забора ликвора и крови НИ ЦНС и системной инфекции. При наличии НИ ЦНС и системной инфекции (группа 1) уровень ПСП в СМЖ составил 731,1±389,7 пг/мл. При отсутствии НИ ЦНС и наличии системной инфекции (группа 2) уровень ПСП в СМЖ составил 614,9±315 пг/мл. При наличии НИ ЦНС и отсутствии системной инфекции (группа 3) уровень ПСП в СМЖ составил 547,8±264,3 пг/мл. При отсутствии НИ ЦНС и системной инфекции (группа 4) уровень ПСП в СМЖ составил 406±203,1 пг/мл. ROC-анализ показал, что уровень ПСП в СМЖ выше 537 пг/мл у нейрореанимационных пациентов без системной инфекции означает наличие НИ ЦНС с чувствительностью 68,8% и специфичностью 85,7%.ВЫВОДЫ В норме уровень пресепсина в ликворе составляет 50–100 пг/мл. Уровень пресепсина в ликворе выше 537 пг/мл у нейрореанимационного пациента без системной инфекции статистически значимо означает наличие у него НИ ЦНС. При диагностике НИ ЦНС определение уровня пресепсина в ликворе должно подлежать анализу вместе с традиционными маркерами инфекции ЦНС в качестве дополнительного маркера. Необходимо проведение дальнейших исследований

BURKITT’S LYMPHOMA WITH A PRIMARY LESION OF THE STOMACH (CLINICAL OBSERVATION)

The article describes the case of the primary stomach lymphoma of the stomach in a 29-year-old man. The literature data on the etiology, diagnosis and morphological characteristics of the primary lymphomas of the stomach are presented, the questions of treatment tactics, variants of cytostatic therapy schemes are touched upon.In the described clinical example, the patient’s medical history is given: from the age of 16 the chronic gastroduodenitis is diagnosed, the patient periodically took omeprazole with a positive effect, there is no evidence of infection with Hp and there is no eradication. In April 2016, he noted the deterioration of health in the form of the appearance of discomfort in the epigastric region. In April 2016, an EHDS was performed at the outpatient stage, where an antral tumor of the stomach was detected, and a biopsy of the formation was taken. Histological examination of atypical cells was not revealed, and in connection with this, in May 2016, he was hospitalized at the A.M. Burnazyan for additional examination.The article presents  data  of laboratory  and instrumental examination,  the  results  of EGDS, CT of thoracic  and abdominal  cavities, cytological, immunohistochemical,  and cytogenetic studies.The patient  was given three courses of cytostatic  therapy. The first course of cytostatic  therapy was started  in June 2016, the patient  transferred it satisfactorily, in the post-cytostatic period there was a leukopenia of 2,5 thousand  cells/μl, against which the viral lesion of the tongue mucosa developed, and the therapy with virolex was performed with positive dynamics.The EGD control showed marked positive dynamics. The second and third courses were conducted in July-August 2016, treatment was satisfactory. In September 2016 he was discharged for dynamic observation by a hematologist.The article draws the attention of medical practitioners  to the fact that, in the absence of specific clinical manifestations, the basis for the diagnosis of lymphoma in this clinical example is the timely conduct of an endoscopic study with histological, immunohistochemical and cytogenetic  study of the biopsy

Clinical and morphological characteristics of type 1 and 2 autoimmune pancreatitis

Rationale: In the recent years, an increased interest to autoimmune pancreatitis (AIP) has been seen, related to growing diagnostic potential. In its turn, this leads to an increase in numbers of diagnosed AIP cases. At present, two types of AIP have been described with diverse clinical manifestation and morphology of the pancreas. However, the reproducibility of the differential diagnosis between AIP type 1 and 2 is low even among pancreatic pathologists.Aim: To identify criteria for the morphologic diagnosis of AIP type 1 and 2.Materials and methods: A morphological study of biopsy and surgical specimens from 26 patients with AIP was performed. There were 22 cases of AIP type 1 and 4 cases of AIP type 2. In addition to hematoxylin eosin staining of the specimens, immunohistochemistry was used with counting of CD138+ absolute numbers, determination of IgG+ and IgG4+ cells in the inflammatory infiltrates, as well as the ratios of IgG4+/IgG+ and IgG4+/CD138+ cells.Results: AIP type 1 was characterized by storiform fibrosis of the pancreatic tissue (81.8% cases), involving the parapancreatic fat tissue, by moderateto-severe lymphoplasmocytic infiltration and signs of obliterative/non-obliterative phlebitis. Type 2 AIP was characterized by severe fibrosis with predominantly periductal (centrilobular) fibrosis and mild chronic inflammatory infiltration of the pancreas, while there was no extension of fibrosis and inflammatory infiltration to the parapancreatic tissues in any case. The mean number of CD138+ cell in AIP type 1 was 101.2 ± 27.9 per 1 high-power field (HPF), and in AIP type 2, it was 42.8 ± 20.9 per 1 HPF. The mean absolute number of IgG+ cells in AIP type 1 was 99.6 ± 25.7 per 1 HPF, whereas in AIP type 2, 42.1 ± 20.8 per 1 HPF. In AIP type 1, the mean number of IgG4+ plasmatic cells in the infiltrates was 74.5 ± 27.2 per 1 HPF, whereas in AIP type 2, it was 3.4 ± 2.7 per 1 HPF. The IgG4+/IgG+ ratio was 75 ± 12.6% vs. 8.4 ± 6.2%, and the IgG4+/CD138+ ratio was 72.4 ± 12.3% vs. 8.3 ± 5.9% in AIP type 1 and type 2, respectively.Conclusion: For the differential diagnosis of type 1 and 2 AIP, it is necessary to take into consideration not only typical histological abnormalities, but also the numbers of CD138+, IgG+ and IgG4+ cells within the inflammatory infiltrate, as well as the IgG4+/IgG+ and IgG4+/CD138+ ratios

Clinical and morphological characteristics IgG4-associated retroperitoneal fibrosis

Background: Retroperitoneal fibrosis (RF) is a rare disease with inflammation and fibrosis of the retroperitoneal soft tissues and adjacent organ involvement. At present, a proportion of RF cases are believed to be IgG4-associated. Aim: Clinical and morphological comparison of the IgG4-associated and idiopathic (non-IgG-associated) RF. Materials and methods: The study was based on a comprehensive morphological assessment of surgical and biopsy samples taken from 12 RF patients. In addition to hematoxylin eosin stained specimens, we performed immunohistochemistry (IHC) with determination of absolute CD138+ counts, IgG+ and IgG4+ cells in the inflammatory infiltration, as well as IgG4/IgG and IgG4+/CD138+ ratios. Results: The proportion the IgG4-associated RF was 66.7% (8/12). The majority of IgG4-associated RF patients were men, with the mean age of 54.9 ± 10.3 years. Idiopathic RF was found without any gender imbalance in the younger patients. In all cases of IgG4-associated RF, the adjacent organs were also involved, whereas in those with idiopathic RF the aortic wall was involved in only half of the cases. Morphological specimen investigation in IgG4-associated RF showed signs characteristic for an IgG4-associated disorder, such as advanced lymphoplasmocytic infiltration, storiform fibrosis, and obliterating phlebitis. IgG4+ plasma cells numbers in the infiltrates was at least 25 per high-power field, and the IgG4+/IgG+ and IgG4+/CD138+ ratios exceeded 50% in all cases. No signs of an IgG4-associated disease were found in idiopathic RF, with significantly lower numbers of IgG+ and IgG4+ plasma cells in the infiltrations and the IgG4+/IgG+ ratio below 10%. Conclusion: A big proportion of RF is IgG4-associated, being an intrinsic feature of a systemic autoimmune IgG4-associated disease. The differential diagnosis should be based on the morphological assessment and immunohistochemistry results with obligatory identification of CD138, IgG, and IgG4 expression in the involved tissues. In some cases, it allows for avoidance of an unnecessary surgery. Reliable and accurate diagnosis would determine the subsequent treatment strategy of these patients

Psychoemotional stress in somatically burdened oncological surgery patients as one of the factors of postoperative complications

Planned surgical interven ons account for more than half of all opera ons in the Russian Federa on, of which more than 20–30% are performed for oncological diseases. Characteris c is an increase in the number of operated pa ents in older age groups with severe concomitant pathology and a high percentage of postopera ve complica ons, including due to psychoemo onal pathology, which can be excluded or adjusted at the preopera ve stage.Purpose. Evalua on of the infl uence of the psychoemo onal state of the oncochirical soma cally burdened patient on the lethality and revealing the possibility of correc on of the psychoemo onal state at the preopera ve stage.Paents and methods. In the period from 2006 to 2016 in the departments of therapy and oncology of the Regional Clinical Hospital of the City Clinical Hospital No. 40 of the Moscow City Health Department, AI.Burnazyan The FMBA of Russia analyzed the treatment of 958 soma cally burdened pa ents with various oncopathology who underwent opera ve interven on in a planned manner. An analysis of the psychoemo onal state of pa ents before and aft er surgery was performed using Hamilton diagnos c scales.Results. After a retrospec ve evalua on, it was determined that prac cally all patients of the oncosurgical profi le undergo various psychoemo onal strains of varying strength and dura on, both before and after surgery. This can disrupt the blood fl ow in the organs andssues, and lead to various complica ons, which manifests itself in the form of hypoxia and ischemia, which, in turn, jus fy the development of postopera ve delirium and myocardial infarc on.Conclusions. Clear distinctions between the anxiety severity in groups on outcomes of hospitaliza on of the oncosurgical patient were determined, and the tendency of the rela onship between the level of the anxiety state and the postopera ve complica ons that had been ridden in the early postopera ve period in soma cally burdened pa ents was determined. Patients of the oncosurgical profi le without fail are shown psychopharmacotherapy in the pre- and postopera ve periods, depending on the revealed pathology

THE DEPENDENCE OF DIRECT RESULTS OF DISTAL PANCREATECTOMIES ON DIFFERENT PANCREATIC STUMP CLOSURE TECHNIQUES

The  OBJECTIVE  is  to  study  the  effect  of application of different  pancreatic stump  closure techniques to  the  postoperative period,  the frequency and  severity  of postoperative complications including postoperative pancreatic fistulas  after distal pancreatectomies. MATERIAL AND METHODS.  The  clinical  material  consisted of 126  patients who  underwent distal  pancreatectomies  (isolated or  in  combination  with  surgical   interventions  on  the  adjacent organs of  the  abdominal cavity  and retroperitoneal space).  The  patients  were   divided  into  4  groups  depending  on  the  pancreatic  stump   closure  techniques (isolated suturing  of the  main  pancreatic duct  of the  pancreatic stump  with its omentization by gastrocolic omentum or local sealing its  by  hemostatic sponge  (control  group);  using  a  local  biological  glue  2-octylcyanoacrylate; using  the  Endoscopic Linear  Cutter  Echelon; external transduodenal  transnasal  drainage of the  enlarged main  pancreatic duct  of the  pancreatic stump). We  evaluated the  influence   of  different  pancreatic stump   closure techniques  after  distal  pancreatectomies on  the postoperative period  as well the  frequency and  severity  of postoperative pancreatic fistulas  depending on the  diameter of the main  pancreatic duct  of pancreatic stump.   RESULTS.  The  overall  rate  of postoperative  complications in the  control  group of patients was  45.8  %, and  was  due  to an  increase in the  frequency of specific  complications (35.4  %). The  most  frequent complication  in  the  control  group   of  patients  was   postoperative  pancreatic  fistulas   –  29.2   %.  The  statistically   significant decrease  of  frequency  and   severity   of  postoperative  complications,  frequency  and   severity   of  postoperative  pancreatic fistulas and decrease of postoperative hospital-stay after the application of the proposed different pancreatic stump closure techniques were  revealed in comparison with the  control  group  of patients. There  was  no  hospital  mortality.  CONCLUSION. Distal  pancreatectomy with  «standard»  pancreatic stump   closure techniques  accompanied by  high  frequency and  severity of postoperative complications, as well as postoperative pancreatic fistulas. The use of the proposed pancreatic stump closure techniques after  distal  pancreatectomy led  to  a  decrease of  the  frequency and  severity   of  postoperative  complications, a decrease of the  frequency and  severity  of postoperative pancreatic fistulas,  and  a decrease of the  postoperative hospital-stay