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DOI: http://dx.doi.org/10.20534/ESR-16-11.12-52-54
Djuraev Mirjalol Dehkanovich, Egamberdiev Dilshod Makhmudovich, Djuraev Farrukh Mirjalolovich, National Cancer Research Center Ministry of Health of the Republic of Uzbekistan Tashkent Medical Academy E-mail: ndjuraev_tma@mail.ru
Choice of treatment tactics in cases of gastric cancer with liver metastases
Abstract: Currently one of the urgent problems of modern oncology is the treatment of gastric cancer with liver metastases. In this regard, the purpose of this study was to develop the optimal treatment strategy by means of evaluating different treatment approaches in gastric cancer with liver metastasis.
The study included analysis of the immediate and distant results of 74 patients with gastric cancer with liver metastases in the period from 2004 to 2016. The study included only those patients who according to investigations were diagnosed gastric cancer stage T4aN2 Ml, and metastatic lesions of one or two segments of one lobe of the liver, the number of metastases 1 to 5 knots. Primary lesions of all patients were resectable, affected regional lymph nodes N2 group.
Finally, in cases of resectable gastric cancer with isolated liver metastases patients require combined surgical treatment, as only surgery increases one-year and three-year survival rates significantly, however, in the absence of possibility of surgical intervention it is recommended to conduct long term endoaortic chemotherapy, which significantly increases the average life expectancy from 8.2 to 11.3 months.
Keywords: gastric cancer, liver metastases, surgical treatment, endoaortic chemotherapy.
Gastric cancer remains one of the most common types of human malignancies. According to Axel E. M. (2012) in 2010, were diagnosed more than 1 million cases. This disease has a high mortality rate (more than 700.000 per year), making it the second cause of death in the structure of cancer mortality after lung cancer [1].
In the Republic of Uzbekistan, gastric cancer occupies the second place after breast cancer. The ratio of men to women is 2:1.
At the present time, the diagnosis and treatment of gastric cancer, as well as tumors of other organs are not unsolvable problem, but the early metastasis of gastric cancer via the lymphogenic and hematogenic ways almost complicates the problem to an unsolv-able extent.
According to D. V. Podluzhny up to 87.3% (2002) metastasis in gastric cancer occurs in 80-90% of patients [6]. The most frequent localization of metastases through hematogenous via the portal system, is observed in the liver, more than 42% [3].
Currently one of the urgent problems of modern oncology is the treatment of gastric cancer with liver metastases.
Assessing the forecast, many authors identify the following factors affecting life expectancy: gender, stage of primary tumor, number of liver metastases, the distance from the resection margin
to the tumor and the stage of liver metastases [2].
Surgical treatment of liver metastases of gastric cancer still remains the preserve of a small number of surgeons, especially in view of the fact that surgery is associated with massive traumatism, the risk of complications and a high risk of fatality [5].
However, over the past 10-15 years, indications for liver resection regarding metastatic lesions has extended significantly. However, up today there are no clear indications, contra-indications to perform other method of treatment of metastatic lesion of gastric cancer. Still most of the physicians in primary general medical network and even oncologists treat patients as incurable.
Reports devoted to this subject are mostly fragmented, sparse and often controversial.
In this regard, the purpose of this study was to develop the optimal treatment strategy by means of evaluating different treatment approaches in gastric cancer with liver metastasis.
Materials and methods
The study analyzed the immediate and distant results of 74 patients with gastric cancer with liver metastases in the period from 2004 to 2016. The study included only those patients who according to investigations were diagnosed gastric cancer stage
Choice of treatment tactics in cases of gastric cancer with liver metastases
T4aN2 Ml, and metastatic lesions of one or two segments of one lobe of the liver, the number of metastases 1 to 5 knots. Primary lesions of all patients were resectable, affected regional lymph nodes N2 group.
To ensure the reliability of the study, patients with multiple and bilateral liver metastases were not included.
Men 49 (66,2%), women 25 (33.8%). Ages ranged from 33 to 74 years. Diagnosis was based on the data of complex investigations including: endoscopic, ultrasound, x-ray, CT, MRI, laparoscopic, clinical, laboratory and morphological data.
By TNM staging VII edition (2010) all patients were recorded T4aN2 Ml. The lesions of the left lobe was found in 28 (37.8%) and the lesions of the right lobe in 46 (62,2%) patients. Lesion of one segment in 21 (28,4%) patients, and the metastatic lesion of the two segments in 53 (71,6%) patients. Metastatic nodes with diameters from 0.7 to 2.0 cm were detected in 31 (41,9%) patients and from 2.0 to 3.0 cm in 43 (58,1%) patients.
The diagnosis was morphologically verified in all 74 patients prior to treatment. Of them:
Adenocarcinoma of various differentiation was verified in 59 (79.7%);
Glandular-squamous cell carcinoma in 8 (10,8%);
Squamous cell carcinoma in 3 (4.7%);
Undifferentiated carcinoma in 4 (5.4%).
Depending on the conducted treatment methods the patients were divided as follows:
I. Systemic chemotherapy n=29 (39,2%).
II. Long term endoaortic chemotherapy — 22 (29,7%).
III. Surgerical intervention — 23 (31,1%).
For chemotherapy in the first and second group, was selected DCF scheme, (Docetaxel+ Cisplatin+ Doxorubicin). The dosages of the drugs were prescribed according to instructions. In II group Docetaxel was administered during 4 hours intravenously other drugs 100 mg Cisplatin and Fluorouracil 3 gr. was administered within 72 hours endo-aortic continuously.
In all cases, regardless of the treatment methods prior to administration of Docetaxel were done appropriate premedication with Dexamethasone, and before the introduction of Cisplatin was performed hydrotation up to 1.5-2 liters.
In III group, simultaneously was carried out surgical treatment in the volume of gastrectomy with anatomical resection of the affected segments in 14 (60,8%) patients, and distal subtotal resection with anatomic resection of the affected segments in 9 (39,2%) patients. 3 weeks later after the surgery with a break of 21 day were performed 2 cycles of adjuvant chemotherapy according to the DCF scheme.
The anatomical forms of the growth, localization, histological structure, volume of liver metastases in all 3 groups were practically the same.
To assess the immediate results of I and II groups, where patients got systemic and long term endoaortic chemotherapy, were used WHO recommendations (1970) according to which can be observed one of the following:
Full response — the disappearance of the tumor 100%.
Partial response—reduction of the tumor from 25 to 50% or more.
Stabilization of the process — reducing tumors to 25%.
The progression -increase in tumor more than 75%.
Objective assessment of tumor and metastatic lesions is carried out using modern methods of research.
Criterion for evaluating the immediate results of surgical treatment was the analysis ofpostoperative complications. Evaluation of the results of groups I and II were carried out after 2 weeks following 2 cycles of treatment.
Results
Conducted research in 3 weeks after a cycle of systemic chemotherapy in group I showed that full response has not occurred in any patient. A partial clinical effect was observed in 41.4 percent (12) patients. Stabilization of the process occurred in 51.7% (15) patients. Progression of disease was diagnosed in 6.2% and (2) patients.
In group II after long term endoaortic chemotherapy as well as in the I group full effect was not observed, partial clinical effect in 63.6% (14) patients, stabilization in 8 (36,4%) cases. The progression was not observed in any patient.
In group III, after carrying out the combined surgery postoperative complications appeared in 26.1% (6) patients. Of these, in 3 cases these were therapeutic complications, failure of the cardiovascular and pulmonary system and in 3 patients surgical complications, namely, bile outflow was — 1, resistant anastomositis of the gastroenteroanastomo-sis — 1, and a partial wound discrepancy, incomplete eventration — 1. And1 patient died of massive pulmonary embolism. Mortality was 4.3%.
In group I, in cases of partial clinical effect was recommended to continue the DCF for 2 more cycles, and in cases of stabilization and progression was recommended to change the scheme into Xelox (Xeloda + Oxaliplatin).
In group II also recommended the same scheme, only systematically.
Remission period — increase of the primary tumor or metastatic nodes from the initial state or to the appearance of new metastatic nodes in group I was 1.2+0.3 months in group II 1,6+0,4 months, and in group III, before the onset of new metastatic nodes after resection of the liver was on average 4.2+0.4 months.
In the period of observation for the I and II groups 7 patients, respectively 4 and 3 were also observed severe complications like gastrointestinal bleeding, pyloric stenosis and perforation of a tumor that required urgent surgery.
One-year survival among patients ofgroup I was not observed. The average life expectancy (ALE) of patients was 8.2+0.3 months. In group II one-year survival rate was 4.5%, i. e. only 1 patient lived for 15.5 months. Overall survival rate was 11.3+0.4 months (P1-2< 0,05). In group III one-year survival was 78.3%. During 1 year, 3 died of progression of liver metastases.
Three-year survival rate constituted 17.4%. Five-year survival was not observed.
Conclusions: In cases of resectable gastric cancer with isolated liver metastases patients require combined surgical treatment, as only surgery increases one-year survival rate up to78.3% and a three-year survival to 17.4%.
In the absence of the possibility of surgical intervention it is recommended to conduct long term endoaortic chemotherapy, which significantly increases the average life expectancy from 8.2 to 11.3 months.
References:
1. Aksel E. M. Gastric cancer mortality rate among the population of Russia and CIS countries//II periodical National Cancer Institute by Blokhin, Russia - 2011. - T 22. - No 39.
2. Vashakmadze L. A., Butenko A. V., Savinov V. A. Possibilities of multivisceral resection in cases of regional recurrence of gastric cancel/Russian Oncology Magazine. - 1998. - No 4. - P. 53-54.
3. Gromov M. S., Aleksandrov D. A., Kulakov N. A. Diagnostics and treatment of locally advanced gastric cancer//Surgery periodical. -2003. - № 4. - P. 20-24.
4. Skorohod VYU., Bordov B. A., Hicheva G. A., Gastric cancer: Comparative analysis of surgical and combined treatment//Problems of Oncology. - 2004. - T. 50. - No 1. - P. 86-90.
5. Podlujniy D. V., Abstract of PhD Theses - 2002.
6. Hornas S. S., and coauthors. Gastric cancer, clinical manifestation, diagnostics and treatment// - Tomsk - 2013.
DOI: http://dx.doi.org/10.20534/ESR-16-11.12-54-57
Dusmukhamedov Dilshod Makhmudjanovich, Tashkent State dental institute, Assistant teacher of surgical stomatology and dental implantology department E-mail: dr.dilshod-88@mail.ru Amanullaev Rustam Azimjanovich, DMD, Professor Tashkent State dental institute Head of pediatric maxillofacial surgery department E-mail: dr.rustam@mail.ru Dusmukhamedov Makhmud Zakirovich, DMD, Professor Tashkent State dental institute Professor of pediatric maxillofacial surgery department E-mail: dr.mahmud@rambler.ru Yuldashev Abduazim Abduvalievich, Assistantof professor Tashkent State dental institute, Scientific and Practical Center of Dentistry and Maxillofacial Surgery E-mail: dr.abduazim@gmail.com
Method of surgical treatment of children with unilateral congenital cleft lip and palate
Abstract: The congenital cleft lip and palate (CCLP) is one of the most common malformations of the face and j aws, and it is among the most severe defects in terms of the severity of the anatomical and functional disorders. Keywords: congenital cleft lip and palate, primary cheilo-palatoplasty
Introduction
Regardless of the age of a child suffering from the congenital cleft lip and palate (CCLP), the main task of the surgeon is to restore anatomic form of the lip and its adequate functioning. Nowadays there are a lot of methods which provide only underwhelming aesthetic and functional results, but still need some improvement [2; 4; 5; 7; 10; 13; 15 and 19].
According to different authors the number of individuals with the postoperative complications and the poor long-term results after cheilo- and palatoplasty ranges from 16 to 52%. In domestic and foreign literature inadequate attention is paid to the primary cheiloplasty with the most optimal methods taking into account the degree and a form of the cleft. A high percentage of unsatisfactory results points to a lot of unresolved issues and the relevancy of this problem. The most debated issue is the determination of the optimal age and methods for surgical treatment of children with the congenital malformations of the face and jaws [3; 6; 9; 16; 19; 20].
The urgency of this problem is determined not only by the high fertility rate of children suffering from this disorder, but also with
the difficulties in selection ofthe surgical treatment [4; 10; 14]. We think that the main cause of unacceptable functional and cosmetic results could be also the imperfection of the traditional treatment methods, unreasonable choice of those methods of surgical correction and the age approaches to its implementation. Also the important cause of failure is the lack of sufficiently clear and complete picture of the problems which are inherent to these patients, and the effects of the implementation of certain surgical procedures in remote postoperative period [1; 12; 18].
The global experience on treating patients with CCLP caused the possibility of good results of surgical correction of the primary defects and secondary deformities [2; 5; 17; 19]. At the same time, the existence of such issues as the optimal age of the child for the primary surgical correction, choice of the optimal functional and less traumatic method, the cumulative effect of these factors on the subsequent state of the sense of hearing, the speech, the growth of the maxilla and the middle zone of the face and the general development of a child, remains controversial and widely discussed in the domestic and foreign literature. However, it is obvious that timely
