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drug use 35.5 % ofwomen. At the same time receiving the original drug continued to 10.2 % of patients switched from opiate use to cannabinoids — 3.6 %, for alcoholic beverages — 19.3 %, to drugs (sedative-hypnotic group) — 2.4 %. In 2014, 4.8 % of women, who at the time of the study were in the prisons have been convicted.
The remaining 64.5 % of women completely stopped taking psychoactive substances. Moreover, remission occurred in 3.6 % up to 1 year over 1 year to 2 years — in 12.2 %, more than 2 years — from 48.7 % (p < 0.05) patients. By the time of the study, 19.5 % of women diagnosed HIV-positive, 1.2 % — in the period of drug transferred sexually transmitted diseases.
The study of the social characteristics showed that the never married 39.1 % ofpatients were in married or cohabiting — 43.9 %, divorced — 14.6 %. Widows were 2.4 % of patients. 52.4 % ofwomen did not work, preferring in remission do housework, 3.6 % — drawn up on the old-age pension. Compared with the premorbid phase proportion of women (30.5 %) at the time of the study was reduced by only 2.4 %.
Thus, the study of the socio-demographic characteristics of the female contingent of addicts in Tashkent showed that before the drug most women were influenced by a variety of adverse social factors that impede full coping and creating conditions for the initiation of drug abuse as the most easy way of avoiding life's difficulties. These factors include the lack of a specific profession
and occupation, unsettled personal life, the negative impact mik-rosotsialnogo environment.
The study of the chronology of initiation to drugs showed that the highest number ofwomen was involved in drug use at a time when the spread of drug abuse in the Republic of Uzbekistan was of epidemic with the rapid increase of the primary indicators and the overall incidence of drug abuse among the general population. More frequent involvement in drug use residents of Tashkent city as compared to other regions could contribute to their multi-ethnic composition, reducing the positive role of the patriarchal family order and features of education, characteristic of the indigenous population of the republic.
Mostly young age of initiation of drug abuse, the use of opioids with the highest narcogene (heroin), initially inject able route of administration contributed to the rapid development of drug dependence.
Identifying drug at a relatively early stage of the disease, timeliness and regularity of therapeutic intervention had a significant impact on the effectiveness of drug treatment to women, providing a fairly high percentage of stable remission and preventing the reduction of social adaptation of patients. The lack of a significant influx of young women drug addicts, "aging" of patients, the tendency to change their behavior towards the discontinuation of opioids suggest a further decline in the proportion of women among the total number of drug addicts registered in Tashkent.
References:
1. Анохина И. П., Кибитов А. О., Шамакина И. Ю. Генетика зависимости от психоактивных веществ//Наркология: национальное руководство/под ред. Н. Н. Иванца, И. П. Анохиной, М. А. Винниковой. - М.: ГЭОТАР-Медиа, 2008. - С. 56 -58.
2. Рохлина М. Л. Наркомании. Токсикомании. Психические расстройства и расстройства поведения, связанные с употреблением психоактивных веществ. - М.: Литтерра, 2010. - С. 22 -26.
3. Юлдашев В. Л. Социально-психологические и биологические факторы формирования аддиктивного поведения подростков: автореф. дис. ... д-ра мед наук. - М., 1997. - C. 41 -45.
4. Moise R., Reed B., Ryan V. Issues in the Treatment of Heroin-addicted women: A Comparison of Men and Women entering Two Types of drug Abuse Programs//Int.J. Addict. - 2002. - № 1. - P. 109 -139.
5. Shigakova F. A. Gender peculiarities of mechanisms of formation, progression and course of opium addiction, and development of rehabilitation measures: abstract of doctoral dissertation. - Tashkent, 2016. - P. 57 -76.
6. Warner L. A., Alegría M., Canino G. Remission from drug dependence symptoms and drug use cessation among women drug users in Puertorico//Arch Gen Psychiatry. - 2004. - Vol. 61, № 10. - P. 1034 -1036.
Bekmirzayev Rahimjon Melikuziyevich, Senior Researcher, Department of tumors of the head and neck, National Research Center of Oncology, Ministry of Health of the Republic of Uzbekistan, Tashkent E-mail: bekmirzaev_1980@mail.ru Khasanov Akbar Ibragimovich, D. m. s., Scientific leader Head and Neck tumors department, National Research Center of Oncology E-mail: akbarkhasanov@mail.ru
Non-epithelial malignant tumors neck, features of clinical current and treatment
Abstract: In this article were studied features of clinical current and treatment results of malignant non-epithelial tumors of the neck. During the 2003-2012 yy. We treated 28 patients with malignant non-epithelial tumors of the neck. Of the 28 patients, complex treatment were 14 (50 %) patients, combined treatment carried 8 (28.5 %) patients, of whom 6 (21.4 %) patients received chemo-radiation therapy and in 2 (7.1 %) patients underwent surgery and radiation therapy, 4 (14.3 %) patients received chemotherapy, and 2 (7.1 %) patients underwent symptomatic treatment. Results: The immediate results of neoadjuvant chemo-radiation therapy were partial response was observed in 11 (39.2 %) patients, stabilization in 2 (7.1 %)
patients, tumor progression observed — in 2 (7.1 %) patients. Surgical treatment is among the complex and combined treatment was performed in 16 (57.1 %) patients, while in 6 (21.4 %) patients with cervical limfodisektsiya was performed, Crile surgery in 2 (7.1 %) patients, the removal of soft tissue tumors of the neck in 8 (28.5 %) patients. Conclusion: Effective treatment is required in defining the histological nature of the tumor and on the basis of neoadjuvant chemo radiotherapy and surgery.
Keywords: non-epithelial malignant tumors of neck, surgery, sarcoma, chemotherapy.
Introduction
Sarcomas are malignant neoplasms originating from mesodermal tissues that consist connective tissues of the body [1]. They are rare group of malignancies that consist less than 1 % of body's tumors, including the head and neck region [2-5; 16]. 5-15 % of adult sarcomas are in the head and neck region, while 20 % of them arise from bones and cartilages and 80 % arise in soft tissues [3; 6-9; 18]. Of soft tissues sarcomas, 80-90 % affect adults and 10-20 % are seen in children [6]. In head and neck region, based on histological subtyping 50 % of sarcomas are: osteosarcoma, rhabdomyosarcoma, malignant fibrous histiocytoma, fibro-
sarcoma and angiosarcoma [6].
Staging
Staging conducted by the American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC). At the same time it puts the TNM system for soft tissue sarcomas based on tumor size, lymph node involvement and distant metastases [11].
Clinical presentation
Soft tissue sarcomas, as a group, show a biphasic age distribution —80 % to 90 % affect adults, whereas 10 % to 20 % are seen in the pediatric age group. Age is an important determinant of histological type of soft tissue sarcoma [10].
More than 80 % ofpatients with major and the only initial sign of the disease is the presence of a clinically defined tumor. When neuromas may be a neurological disorder associated with compression or irritation of the nerves, of which the tumor develops.
Pain could be present occasionally and it is the most common presenting symptom in bone sarcomas [12]. Carotid chemodec-toma occurs at the site of the carotid glomus location (bifurcation of the carotid artery). The development of tumors can sometimes cause headaches, dizziness, short collaptoid state when pressed. Auscultation over the tumor vascular sometimes the noise can be determined.Sarcomas neck characterized by more rapid growth, lymphogenous (neurogenic sarcoma, malignant Sinovioma and chemodectoma) and hematogenous (neuroblastoma, poorly differentiated liposarcoma) metastasis.
Тable
We can see in from the table on the frequency of occurrence of the most in 14 (50 %) patients with histologically is confirmed fibrosarcoma, followed by the occurrence detected neurogenic tumor and angiosarcoma.
Duration history before the first visit to a doctor oncologist is from 1 to 15 months. The average time from the onset of the disease up to 1 visit to a doctor of the patients was 3.5 months. Duration history before entering the RCRC average period was 8 months.
Treatment of head and neck sarcomas
The classical treatment modalities employed in head and neck sarcoma are: surgery, radiotherapy and/or chemotherapy. Treatment of sarcomas is dictated by tumor type, stage, location, size and patient age [13]. Due to the anatomical complexity and surrounding vital structures in the head and neck region, wide excision with adequate margin is not possible in all cases. Resection of gross tumor with post-operative adjuvant therapy is the treatment in most cases [14; 16].
Surgery
Adequate surgical excision is not applied in some sarcomas of the head and neck because of the complex anatomy and close proximity to major structures vital to the primary tumor.
When the surgical margins are not adequately free, post-operative radiotherapy and/or chemotherapy should be considered [10]. Lymph node metastasis from primary sarcoma in head and neck is more with embryonic rhabdomyosarcoma, epithelioid sarcoma, clear cell sarcoma, synovial cell sarcoma and vascular sarcoma [14]. The presence of nodal metastasis is a clear signal of distant micro-metastasis [10].
Chemotherapy
Soft tissue sarcoma in head and neck region responds very well to chemotherapy as their counterparts in other parts in the body [15]. It provides improved local control especially if combined with radiation therapy where wide excision is not possible. It is also indicated for high-grade soft tissue sarcomas along with radiation therapy and surgery [14]. Pre-operative chemo-radiotherapy has been tried to shrink large soft tissue sarcomas specially those near vital structures prior to surgery [15].
The purpose of our work: the analysis of the clinical picture and treatment of non-epithelial malignant tumors of the neck.
Materials and methods
We in the department of the National Cancer Research Center of head and neck tumors (RCRC) Ministry of Health of Uzbekistan for the period 2003-2012 yy treated 28 patients with malignant non-epithelial tumors of the neck. The age ofpatients fluctuated from 14 to 79 years, the average age is 40 years, ofwhich 17 men (61 %), 11 women (39 %). According to the morphological structure, see table 1. 1.
When patients are treated in the Cancer Research Center in 17 (60.7 %) had a primary, in 11 (39.2 %) patients had recurrent tumor, which are mainly treated in local Regional Oncology Center and other medical institutions.
The rate of tumor growth in the last 10-15 days increased in 1 (3.5 %) patient in the last month in 10 (35.7 %), over the last 2-3 months in 6 (21.4 %), over the last year 6 (21.4 %). At the others 5 (17.8 %) patients with tumor growth observed over
№ Morphology The number of patients n = 28 %
1 Fibrosarcoma 14 50
2 Neurogenic tumors (5) Neyrosarkomy 3 10.7
Malignant paraganglioma 2 7.1
3 Angiosarcoma 5 17.8
4 Rhabdomyosarcoma 2 7.1
5 Synovial sarcoma 1 3.5
6 Giant cell tumor with malignant course 1 3.5
long periods. The onset of the history in 1 (3.5 %) patients after injury, in 4 (14.2 %) patients the disease started after a cold island of respiratory viral infections and the others tumor appeared independently.
In the history of conservatively treated: a neurologist 1 (3.5 %) patient, the therapist 3 (10.7 %) patients witch doctor — (folk healers) 1 (3.5 %) patients, several experts 4 (14, 2 %) patients with maxillofacial surgeon 2 (7.1 %) patients, in 2 (7.1 %) patients underwent physiotherapy. From history to appeal to the RCRC were carried operations in 7 (25 %) patients in the regional oncological dispensaries, clinics, maxillofacial surgery in 1 (3.5 %) patients.
Tumor size at admission to treatment was 18 (64.2 %) patients from 5 x 4 up to 12h13 see average tumor size was 6.1h7.8 cm.
On palpation of the tumor in 19 (67.8 %) patients had pain, pain the others patients did not notice it. In 2 (7.1 %) patients with palpation tumor was mobile, in 7 (25 %) patients the tumor was inactive in 12 (42.8 %) patients the tumor was fixed. The consistency of the tumor: in 17 (60.7) patients with tumor palpation was a the dense consistency in 3 (10.7 %) patients had an elastic, 8 (28.5 %) patients had a tightly-elastic. The boundaries of the tumor in 6 (21.4 %) patients were clear in 15 (53.5 %) patients had no clear boundaries.
Status of regional lymph nodes palpation in 13 (46.4 %) patients were increased, of whom 10 (35.7 %) patients with regional metastases were confirmed by the instrumental and morphological examinations. Moreover metastases from 10 patients detected in the submandibular region in 2 (20 %) patients, the upper deep cervical lymph nodes 6 (60 %) patients and 2 (20 %) patients with other parts of the neck. In 9 (90 %) patients with metastases in the neck were unilateral, bilateral metastases were in 1 (10 %) patients.
The average size of metastases to the neck was 1.5 cm. Single metastases in 3 (30 %) patients with multiple metastases in 7 (70 %) patients were found. Distant metastases appeared after the initial treatment in the liver in 1 (3.5 %) patients (28 patients). The lungs in 2 (7.1 %) patients (28 patients) in the spine 1 (3.5 %) patients (28 patients).
Considering the complexity determining the differentiation of soft tissue sarcomas of the neck we could not classify these tumors at stages of the process and the TNM system. However, depending on the tumor size of more than 50 % of patients had locally advanced tumor process in nature.
Instrumental examination of MSCT and MRI in 19 (67.8) patients, UTT all patients were conducted. For cytology needle biopsy was performed in 18 (64.2 %) patients, the smear imprints tumor was taken in 4 (22 %) patients, which was ulcerated tumor surface. When cytology were found in 8 (44 %) patients with malignant cells of origin, in 2 (11 %) patients with malignant cell sarcomatous character in 1 (5.5 %) patient cells with dysplasia grade 3.
A biopsy was performed in 19 (67.8 %) patients, of whom 16 (84 %) patients underwent incisional, in 2 (10.5 %) patients ekt-sizion in 1 (5.3 %) patient trephine biopsy, and 9 (47 %) patients underwent removal of the tumor to the residence.
Results
Of the 28 patients, complex treatment were 14 (50 %) patients, combined treatment carried 8 (28.5 %) patients, of whom 6 (21.4 %) patients received chemo-radiotherapy and 2 (7, 1 %) patients underwent surgery and radiation therapy, 4 (14.3 %) patients received chemotherapy, and 2 (7.1 %) patients underwent symptomatic treatment.
Surgical treatment is among the complex and combined treatment was performed in 16 (57.1 %) patients, while in 6 (21.4 %)
patients with cervical limfodisektsiya was performed, Crile surgery in 2 (7.1 %) patients, the removal of soft tissue tumors of the neck 8 (28.5 %) patients. At the same time the internal jugular vein resection was performed in 3 (10.7 %) patients. Before contacting our center in the regional oncological dispensaries and other medical facilities in 6 (21.4 %) of patients with non-radical treatment is performed.
Time of recurrence of the tumor after surgery, which was carried out on a residence the average time is about 2-3 months after surgical treatment in RCRC average time of recurrence of the tumor consisted of 30 months.
In 3 (10.7 %) patients for disease recurrence was on average 2-3 times. With continued growth or recurrence of the tumor, if the tumor was resectable state performed surgical removal of tumors, chemoradiotherapy was performed at unresectable state.
The reason for not carrying out surgery on patients with primary focus was the refusal of the operation and because of of elderly, concomitant disease, unresectable disease and other causes.
Chemotherapy held in the neoadjuvant mode RCRC in 9 (32.1 %) patients in the CCCs in 4 (14.2 %) patients. Adjuvant chemotherapy was performed in 5 (17.8 %) patients.
Chemotherapy scheme was different depending on the histology of the tumor in this scheme — CAP + Cisplatin Doxorubicin, Cyclophosphamide + intravenous chemotherapy was performed in 4 (14.2 %) patients, according to the scheme Doxorubicin + cyclophosphamide + vincristine + prednisone in 14 (50 %) patients, according to the scheme + doxorubicin + ifos-famide Mesna in 1 (3.5 %) patients, gemcitabine + docetaxel in 5 (17.8 %) patients.
Radiation therapy was performed in 22 (78.5 %) patients in various combinations. Simultaneously, tumor metastasis and neck held in 2 (7.1 %) patients. Adjuvant radiotherapy was performed in 7 (25 %) patients. Radiation therapy to tumor recurrence was performed in 4 (14.2 %) patients, relapse metastasis in
1 (3.5 %) patients.
Neoadjuvant radiotherapy remote gamma therapy single dose
3 cGY, total dose — 40 cGY. average fraction was performed in 7 (25 %) patients, remote gamma therapy single dose — 2, total dose — 30-40 cGY. Fractionally extended performed in 2 (7.1 %) patients, remote gamma therapy — single dose 2.5 Gy, total dose — 40 cGY. Fractionally extended performed in 3 (10.7 %) patients. Adjuvant radiation therapy was performed before 40 cGY in 4 (14.2 %) patients. In combination with other techniques in
4 (14.2 %) patients.
The immediate results of neoadjuvant chemo-radiation therapy were partial response was observed in 11 (39.2 %) patients, stabilization in 2 (7.1 %) patients, tumor progression observed — in
2 (7.1 %) patients, the remaining patients received chemo-radiotherapy in the community, and in our center surgery was performed and some received chemo-radiation therapy after the surgery, so the immediate results of the treatment was impossible to define.
When studying the characteristics of the operations, radical surgery was performed in 10 (35.7 %) patients, relatively radical surgery was performed in 1 (3.5 %) patients. In 5 (17.8 %) patients underwent surgery in the regional oncologic dispensary or in other clinics. Surgery for recurrent tumor — the primary locus (after treatment) was performed in 6 (21.4 %) patients.
The general condition of the patient at discharge by ECOG scale in 21 (75 %) patients had score 1, 5 (17.8 %) patients had ECOG scale 2 points in 2 (7.1 %) patients had ECOG status of the scale 3 score.
The wound healed in the primary hearth ofwas traced in 16 patients without complications, and 1 (3.5 %) patients with local complications, failure of the wound edges in 1 (3.5 %) patients. In 3 (10.7 %) patients after operation was observed regional recurrence of the primary tumor. The treatment was carried out under the CRC on the tumor recurrence in 6 (21.4 %) patients who were initially operated at Regional Oncology Center.
Discussions
Neck sarcomas are characterized by a rapid pace of growth of the tumor, and according to our data for the last 1-3 months in 51.1 % patients had relapses These findings are consistent with data Podvy-aznikova in which malignant non-epithelial tumors of the head and neck is characterized by high relapse rate (64.8 % and 45.4 % respectively). Metastases to regional lymph nodes in the localization of tumors in the head totaled 29.4 %, while localization in the neck region — 12.0 %.
Distant metastases were detected more frequently in the localization of tumors in the neck than in the head region (21.3 % and 17.6 %, respectively) [1].
According to the morphological structure of the most commonly diagnosed fibrosarcoma in 14 (50 %) patients.. Two factors that play an important role in the survival in sarcomas, head and neck, it is locally advanced tumor and the presence of distant metastases. The size of the primary tumor is not correlated with the local outcome. Light is the most common site of distant metastases of sarcomas of the head and neck. Prognosis: The 5 years survival rate for head and neck sarcoma is between 49 and 55 % [14; 15].
Conclusion
To be effective, treatment should determine the histological nature of the tumor and on the basis of is expedient conducts neoadjuvant chemo-radiation therapy and surgery.
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