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Analysis of the surgical treatment of the pulmonary metastatic lesions
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Usmanov Bekzod Baymatovich, Doctor of oncology, Department of Thoracic Oncology, National Cancer Research Center, Republic of Uzbekistan E-mail: usmanov-83@mail.ru Yusupbekov Abrorbek Axmedjanovich, MD, deputy director of the National Cancer Research Center Khairutdinov Rafik Vakhidovich, MD, Senior Researcher, of ThoracicOncology, National Cancer Research Center Ismailova Umida Abdullaevna, Postgraduate Student, Department of General Oncology and Radiation Diagnosis, Tashkent Medical Academy
Analysis of the surgical treatment of the pulmonary metastatic lesions
Abstract: In he department of thoracic oncosurgery of the Republican Oncological Research Center of the Ministry of Health of the Republic of Uzbekistan from 2000 to 2013 the surgical treatment at metastatic pulmonary lesions was performed in 45 patients. The surgeries were performed by thoracotomic approach in 29 (64.4 %) and with videothoracoscopic method — in 16 (35.6 %) patients. The volume of surgeries depended on the character of metastatic pulmonary lesions (size, number of metastases located in the zones in the lungs). There were performed atypical resections — 39 (86.7 %), lobectomies — 4 (8.9 %), bilobectomies — 1 (2.2 %), pulmonectomies — 1 (2.2 %). The patients were made analysis of the postoperative development in thoracotomic and thoracoscopic approaches in the patients with similar volume of operation. On the basis of this there were made conclusions that thoracoscopy seemed to be more preferable, than thoracotomy due to less traumaticity and more favourable postoperative development. The role of videothoracoscopy was determined as diagnostic and therapeutic method at solitary character of the metastatic pulmonary lesion.
Keywords: metastases in the lungs, videothoracoscopy, toracotomy, lung atypical resection.
Introduction
According to the data of literature the morbidity of high level of patients due to result of progressing looking-like metastazing of the malignant tumors is one of the most important problem of the modern oncology [1].
The term "metastasis" was introduced, for the first time, by Recamier in 1829. Metastazing (from the Greeth metastasis -transmission of the malignant tumors into the lungs depended on the common rules, being studied in details in experiment and oncological clinic and together with autonomic growth and invasiveness appeared to be sign of the tumor progression. It is well known that hematogenous way appeared to be the main way of metastazing into the lungs [2; 3; 4].
Metastases in the lungs were defined at the primary examination or in the different time after treatment of malignant neoplasms in 6-30 % of patients with tumors of any localization [4; 5; 6].
According to the autopsies, intrapulmonary metastases were revealed in 20-54 % of patients, having extrapulmonary tumors [7; 8].
Frequency of the metastazing of the malignant tumors into the lungs, according to the data of various authors, varied from 1.6 to 55.4 %, dependently on the localization and histological structure of the primary tumor. Mostly of all metastatic lung lesions occurred in trophoblast disease (55.4 %), of the malignant kidney neoplasms (37.7 %), of the locomotor apparatus (18.6 %), the colon (16.8 %), mammary gland (15.7 %), more rarely — in uterine cancer and sarcoma (4.2 %), gastric cancer (1.6 %) [9; 10; 11]. In 70-90 % of
Section 5. Medical science
cases metastases located in the "raincoat" zone of the lungs [1; 12]. Approximately, in 70 % of patients disease progressing asymptomati-cally, so the neoplasm in the lung is revealed occasionally at roentgenological examination or in the process of dynamic observation. Only at involvement of the visceral pleura, thoracic wall or bronchus the clinical symptoms appear such as cough, thoracic pains, hemoptysis, dyspnea, increase in body temperature [3; 5].
Metastases in the lungs are divided [1; 13] in relation to the quality — solitary (1), single (2-3), multiple (more than 3); in relation to localization — unilateral, bilateral. Accordingly to the efficacy of the presenting methods of treatment of the primary malignant tumors the pulmonary metastases are divided into 3 groups:
• Group 1 — metastases sensitive to chemotherapy and radiation therapy (testicle cancer, osteogenic sarcoma, trophoblast disease, ovarian cancer;
• Group 2 — metastases, practically resistant to effect of chemopreparations (hypernefroma, melanoma, highly differential glandular cancer of the colon and endometrium, uterine cervix squamous cell carcinoma;
• Group 3 — metastases of the tumors, which partially sensitive to effect of the conservative methods of treatment (mammary gland cancer, pulmonary cancer) [1; 13; 14].
At metastases of the tumors of groups 1 and 3 the treatment are advisability to begin with chemohormono-immunotherapy, and at metastases of the second group the method of choice — is operative intervention.
The operative interventions in intrapulmonary metastases are relatively divided into the following types:
1) "radical", when there is possible the complete removal of all metastatic focuses;
2) palliative, with purpose ofprevention or elimination of the complications of the tumor process (hemorrhage, pneumothorax, bronchostenosis, abscess formation in the zone of atelectasis, destruction in the tumor node), as well as for reduction of the tumor mass with purpose of preparation of the favourable conditions for performance of the following conservative antitumor treatment.
3) exploratory [3; 4].
The first information about successful result of the surgical treatment of metastases. In the Soviet Union the first resection of the lung due to metastases of the extrapulmonary malignant tumor was performed by B. E. Linberg in 1948 [13].
At present time there have been formulated criteria for selection of patients, in whom the surgical treatment of intrapulmonary metastases is possible: absence of the recurrence of the primary tumor by the data of complex examination of isolated metastatic lesions of the lungs, technical possibility of the metastases removal, functional operability of the patient [2; 6; 15].
Introduction into the clinical practice of the endoscopic methods, particularly of videotheracoscopy, significantly extended potentiality of the surgical treatment of the metastases. Association of the high informativity and small invasiveness of the intervention allowed increase in the contingent ofpatients undergoing the surgical treatment [5; 6].
Material and methods
In he department of thoracic oncosurgery of the Republican oncological research center of the Ministry of Health of the Republic of Uzbekistan from 2000 to 2013 the surgical treatment at metastatic pulmonary lesions was performed in 45 patients. Among them there were 23 women (53.33 %). Distribution of the patients according to the age categories were following: the number of women at the age of 10-19, 30-39, 50-59 years were 3 (6.67 %) while at the age
groups of20-29, 40-49 and 60-69 years the number ofwomen were 4 (8.89 %), 6 (13.33 %) and 2 (4.44 %), respectively. The number of men at the age of 10-19 and 30-39 years was 4 (8.89 %) patients; in the group of 20-29 years — 6 (13.33 %) patients, as well as in the category of 40-49, 50-59, 60-69 years — 5 (11.11 %), 2 (4.44 %) and 3 (6.67 %) patients, respectively. Thus, the most number of the patients were treated in the age groups of40-49 years — 11 (24.44 %) and 20-29 years — 10 (22.22 %) patients. At the age of 10-19 and 30-39 years there were operated 7 (15.56 %) in the each group, and in the categories of50-59 and 60-69 — by 5 (11.11 %) patients.
All the patients received specific treatment (surgical, chemotherapy, immunotherapy, DLT, their combinations) due to malignant neoplasms of various localizations.
The patient distributions according to the histology structure and localization of the primary tumor there were following: sarcoma of the soft tissues was diagnosed in 16 (35.6 %) patients, breast cancer and kidney cancer — in 8 (17.8 %), testicle cancer — in 5 (11.11 %), rectum cancer lymphoid thymoma, testicle chorionepithelioma in
2 (4.4 %) patients, as well as there was revealed one case (2.2 %) of osteosarcoma and malignant thyroid tumor. In relation to number of pulmonary metastasis the patients were divided into: solitary (1 focus), the focuses of metastatic disease were observed in 25 (57.8 %) patients. Single (2-3 focuses — in 10 (22.2 %) cases, as well as multiple focuses (> 3) focuses — in 9 (20 %) patients.
Distribution of metastases by lobi was different in the right and left lungs. In the right lung the metastases in the upper lobe were observed in 10 (22.2 %) patients, while in the middle lobe — in
3 (6.7 %), in the lower lobe — in 7 (15.5 %), and in different lobi — in 3 (6.7 %) patients. In the left lung in 12 (26.7 %) cases there were diagnosed metastases in the upper dole, in 8 (17.8 %) patients in the lower lobe, and in 2 (4.4 %) patients in the different lung lobi.
The surgeries were carried out by two approaches: thoracotomy and thoracoscopy. Videothoracoscopy (VTS) surgeries were performed under the general anesthesia with separate bronchi intubation. The operation was finished by drainage of pleural cavity with 1-2 drainages which were removed on 1-4 day.
Thoracotomy were use in 29 (64.4 %) patients, of them atypical resection of the lung were performed in 24 (82.8 %) patients, lobectomy — in 3 (10.3 %) patients. Bilobectomy was performed in 1 (3.45 %) patient and the other patient underwent pulmonectomy. Videothoracoscopy was used in 16 (35.6 %) cases, among which in 15 (93.8 %) patients there was carried out surgery looking-like atypical resection, in one case (6.2 %) — as lobectomy.
Thus, atypical resection was performed in 39 (86.7 %) patients, lobectomy — in 4 (8.9 %), bilobectomy — in 1 (2.2 %) and pulmonectomy — in 1 (2.2 %) patients.
Results and discussion
The most frequent surgeries performed in metastatic lung damage in relation to volume appeared to be atypical resections. There were made 39 (86.7 %) from 45 operations. Thoracotomy approach was used in 29 (64.4 %) patients, thoracoscopy way — in 16 (35.6 %) patients. For resolving ofthe question about advantages ofvideotho-racoscopic operations in comparison with traditional thoracotomy we compared duration of operation, development of the postoperative period. The duration of surgery at performance of videothora-coscopic (main group) atypical resection of the lung fluctuated from 25 to 80 minutes while the control group (patients operated with thoracotomy) surgery duration was from 35 to 110 minutes. There was noted reliable shortening of the time of operation in the main group (on the average, 49.53 ± 3.09 minutes) in comparison with control group (on the average, 64.25 ± 2.97 minutes) in P < 0.01.
Neurocorrection of the spina bifida complicate
As appears from the above, in comparison with thoracotomy atypical resection, videothoracoscopic operations have been preferred. Exudation from the pleural cavity and terms of drainage appeared to be significantly higher after atypical resections of the lung, performed by thoracotomy approach in comparison with videotho-racoscopy. On the average the terms of drainage of the pleural cavity after videothoracoscopic atypical lung resection appeared to be reliably shorter (3.16 ± 0.15 days) in comparison with thoracotomy operations (4.30 ± 0.31 days) in P < 0.01.
Conclusions
1. Introduction of videothoracoscopy into the clinical practice widens possibilities of the surgical treatment
of metastases. Association of the high informativity and small invasiveness of the intervention allowed to increase in the contingent of patients undergone to surgical treatment.
2. The long-term results of the surgical treatment of the solitary metastasis are satisfactory — 5-year survival are observed in the third of cases.
3. The active surgical tactics in single and multiple metastases is also confirmed in the complex treatment allowing achievement of 3- and 5-year survival in this group of patients. In the selective contingent of patients it is possible videothoracoscopic lung resection.
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Usmankhanov Odilkhon Auybhanovish, Assistant at the Neurosurgery department of Tashkent Pediatric Medical Republican Scientific Center of Neurosurgery
E-mail: odilkhon@list.ru
Neurocorrection of the spina bifida complicate
Abstract: Of 25 patients with lipomyelocele underwent the surgical treatment. The essence of the operation was to conduct an additional laminocktomi with deficsation of a spinal cord. Keywords: lipomyelocele, spine bifida, tetring hord.
Congenital spinal hernia of the lumbosacral localization in children in mind a variety of morphological forms and severity of clinical manifestations is a complex problem of pediatric neurosurgery. The spina bifida complicate consist of 35 % of all the lumbosacral malformations [1; 3], and the fifth part of them belongs to lipomyelo-meningocele. Many aspects of the surgical treatment of spinal neural tube defects are well established. There are different opinions regards the tactics of the surgical treatment of lipomatous processes. Some authors believe it is necessary to undertake the surgery on the progression of the neurological symptoms; other researchers adhere to the earlier surgery [2; 4; 6]. In a standard situation the examination and surgical treatment algorithm of spina bifida is usually carried at the
average age of 6-7 years, and in some cases patients are operated in the age of 20-30 years old. In addition, the volume of surgical intervention is often limited to removal of only the part of extravertebral and extradural lipomas just with changing only the cosmetic appearance of the patient. In such cases the spinal cord is maintained to be fixed, and after the surgery the neurological symptoms progresses due to the growth and development of a child [5; 7; 8; 9; 10]. The aim of our work was to improve the results of surgical treatment of spina bifida complicate, by improving the diagnostic process and a rational, reasonable pathogenetic surgical tactics.
Material and methods. Our clinical observations are presented in 25 patients (17.8 %) of all patients with spina bifida complicated
