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Khudaiberdiyeva Mashkhura Shavkatovna, Djuraev Mirjalol Dehkonovich, Khudoyorov Sanjar Sarvarovich, Juraev Farrux Mirjalolovich, National Cancer Research Center of Ministry of Health of the Republic of Uzbekistan E-mail: Dr.Mashhura@mail.ru
The impact of prognostic factors on the recurrence of stomach cancer
Abstract: The study included the results of retrospective studies conducted in 128 patients with recurrent gastric cancer. Retrospective analysis of prognostic factors on the recurrence of stomach cancer showed that non-adherence of one factor during the operation was observed in 6 (4.7 %), 2-factors in 72 (56.2 %) of 3 or more in 50 (39.1 %) patients. In terms of resection, in 114 (89.1 %) patients relapsed gastric cancer was determined after distal subtotal resection in 8 (6.3 %) after the proximal subtotal resection in 6 (4.7 %). The most important prognostic factor of treatment of SC is a radicalism of performed surgery. Based on the above mentioned data it can be concluded convincingly that, the reasons for recurrence was non-compliance with the principles of radicalism in the main group, in comparison with the control group, where was a low rate of recurrence (3.8 %), duration of recurrence-free period 22.4 + 0.4 months and in more than 47 % cases late relapse was diagnosed. This demonstrates the importance of minimization of negative prognostic factors affecting the abidance of the principles of radicalism. Keywords: prognostic factors, stomach cancer, recurrence, surgery.
Actuality
Stomach cancer (SC) has taken a crucial position in the structure of cancer incidence and mortality [4]. Furthermore, an aggressive forms predominant amongst the morphological forms of SC, that are characterized by infiltrative growth, early lymphatic dissemination and low resectability [5].
A high qualified level of surgical technique as well as the development of combined and expanded operations with maximum compliance of oncologic principles will abet to improve significantly the survival of patients with SC, but even after the overextended surgical interventions, tumor recurrence takes leading position in case of main cause of death [1; 2]. The prognosis of survival of patients
The impact of prognostic factors on the recurrence of stomach cancer
with gastric cancer is primarily determined by the ability to perform radical surgery. Only a few numbers of non-radical operated patients have one year survival [9].
According to the literature the frequency of recurrence after surgery for gastric cancer composed at 20-48 % [5; 7]. Amongst the patients, who have been undergoing to radical surgery, the most important criterions of the prognostic components are degree of tumor differentiation, localization, process stage, growth form, adequacy of dissection, resection and type of reconstruction. With regard to literature there is the concept of the time of recurrence: up to 3 years — early, and after 3 — later [3].
Analysis of modern literature over last 10 years has shown that, in general, there has been very few works devoted to the problems of diagnosis, treatment and prevention of gastric cancer recurrence. As Blokhin N. N. pointed out (1981), recurrent gastric cancer, unlike the primary tumor characterized by a high biological activity, expressed a tendency to infiltrative growth, high level of invasive growth and frequent attaching to the adjacent organs. For many years the question of the necessity and appropriateness of the recurring surgery for relapsed gastric cancer has maintained its actuality among scientist [6; 8].
Nowadays, feasibility of re-interventions for recurrent gastric cancer that develops in the remaining part of the tumor has been already determined. Undoubtedly, it should be removed, but still it has not been clearly explored the possibility of a surgical method for recurrent gastric cancer with esophageal-intestinal anastomosis after gastrectomy [3].
Thus, providing surgical care to patients with recurrent gastric cancer remains unsolved, another word, here is no consensus on surgical tactics with recurrent gastric cancer, what caused our interest to this issue. The aim of this study is to determine the role of the main prognostic factors in the development of gastric cancer recurrence, and to improve methods of early diagnosis.
Materials and methods
The study included the results of retrospective studies conducted in 128 patients with recurrent gastric cancer who were treated at abdominal surgery departmentof the National Cancer Research Center (NCRC), in the period from 2002 to 2014.
From 128, in 79 (61.7 %) patients with the primary tumor process, surgery was performed in the general treatment hospitals, in 40 (31.3 %) cases surgery was performed in regional oncologic dispensaries, in 9 (7.0 %) occasions was were performed in the clinic of NCRC. In terms ofresection, in 114 (89.1 %) patients relapsed gastric cancer was determined after distal subtotal resection in 8 (6.3 %) after the proximal subtotal resection in 6 (4.7 %).
A retrospective analysis with aim of identifying the causes of recurrence of gastric cancer conducted by the following criteria:
1. Familiarization with the records of diseases from the hospital, where surgery was performed.
2. Familiarization with the protocol of operations (on request).
3. Carrying out repeated clinical-laboratory and endoscopic studies to clarify the location of the tumor, tumor resection volume and type of reconstruction.
4. Re-examination of the pathomorphologic materials.
5. Re-biopsy and morphological examination.
6. Exploring the results of research methods before and after the operation. The data shows, that all of these operations were carried out without complying the principles of radicalism or principles were complied partially
In order to determine whether these prognostic factors are important for the development of gastric cancer recurrence there
was included a control group withradically operated 448 patients. These patients underwent surgery at the abdominal department of NCRC, in the period from 2009 to 2011. The entire volume of operations in these years, we have specially to trace a possible relapse within the next 5 years.
The study included 2 groups: the first group (n = 128) major surgery carried out without basic principles of radicalism; the second control group (n = 448) surgical intervention was conducted with keeping all principles of radicalism. In the second group the volume of operations were as follows:
1. Standard radical distal subtotal resection in 112 (25.0 %) cases;
2. Standard radical proximal subtotal resection in 31 (6.9 %) occasions;
3. Standard radical gastrectomy in 295 (65.8 %) patients were performed.
Results of the study
Analysis of the results of a retrospective study in themain group showed:
1. Ofthe 114 patients who underwent distal subtotal resection in 58 (50.9 %) cases a tumor spread on the body of the stomach, which is required the implementation of a standard radical gastrectomy.
2. Inadequate resection and reconstruction by Billroth I were performed in 34 (24.8 %) patients. This type of reconstruction in oncology practice has not been applicable due to the inadequacy of the volume of resection. In many case, for the formation of gastro-duodena-anastomosis without tension, surgeons deviate from the recommended amount of resection with ligation of the left ventricular artery and vein. Unfortunately, recurrence appeared after reconstruction in the area of the anastomosis Billroth-1, resectability has not exceed 10 % as the intergrowth of the tumor in the head of the pancreas and liver gate.
3. We have established metastatic lymph nodes in almost all patients of the main group, who were performed inadequate N2 lymph node dissection, which was confirmed by ultrasound examination, carried out before and after the operation.Enlarged metastatic lymph nodes weredeterminedalong the celiac trunk, common hepatic and splenic artery. The main reason for inadequate lymph node dissection was the lack of experience and practical skills of the surgeons performing the operation in this volume.
4. Low differentiation tumor was verified in 68 (53.1 %) patients, in which according to the standard of treatment, regardless of localization, approved performing total gastrectomy, except for the first stage of the process.
5. Prognostic unfavorable type of tumors, endophytic and infiltrative growth, occurred in 79 (61.7 %) patients.
6. The third stage of the process, according to the protocol, was determined in 109 (85.2 %) cases, stage 4 in 19 (14.8 %) patients.
Retrospective analysis of prognostic factors on the recurrence showed that non-adherence of one factor during the operation was observed in 6 (4.7 %), 2-factors in 72 (56.2 %) of 3 or more in 50 (39.1 %) patients.
According to modern surgery strategies of SC, in 92 (71.8 %) cases, in order to ensure radicalism there was necessary to perform a standard radical gastrectomy. The analysis reveals that, indications for distal subtotal resection has not exceed in 28.2 % (36) patients. Unfortunately in these cases there was not performed an adequate lymph node dissection, and in 14 (38.8 %) cases Billroth I reconstruction was implemented.
Summarizing the retrospective analysis, it might be concluded that in the case of 71.8 %was made inadequate resection without
considering location, form of growth, grade of the tumor, and lymph node dissection. Despite the fact that, in 28.2 % cases the volume of operation has been selected correctly, lymphadenectomy volume D2 has not been carried out, as required by the standard. As a consequences, in38.3 % cases the result was inadequate. A retrospective analysis represents that, early relapse was observed in all 128 cases, disease-free survival was 5.4 ± 0.4 months.
A retrospective analysis ofpatients in the control group (n=448) illustrates that, patients that have been carried out operations in compliance with all principles ofradicalism showed recurrences appeared only in 17 (3.8 %) cases within 5 years. Therefore, after subtotal resection the distal recurrence was detected in 7 (7.1 %) patients with gastric remnant, after proximal subtotal resection in 3 (9.7 %) and total gastrectomy in 7 (2.4 %) occasions. In 9 (52.9 %) cases, there was an early, and 8 (47.1 %) late recurrence.
As can be seen from the data presented the lowest rate of recurrence was observed after standard radical gastrectomy, which is 3 times less than distal subtotal resection and 4 times than proximal subtotal resection.
Consequently, we cannot exclude the adequacy of compliance with all the principles of radicalism in the performance of surgery in
this study. In spite of fact that most relapses occur on leaving a certain part of the stomach after distal and proximal subtotal resection, does not exclude the possibility of recurrence due to multicentric growth of SC, which is not always can be possible to determine. It has been proven thatthe duration of recurrence-free period was 22.4 ± 0.4 months in the control group, which isfour times more than in the main group.
Conclusion
It should be admitted that, the most important prognostic fac-toroftreatment of SC is a radicalism ofperformed surgery. Based on the above mentioned data it can be concluded convincingly that, the reasons for recurrence was non-compliance with the principles of radicalismin the main group, in comparison with the control group, wherewas a low rate of recurrence (3.8 %), duration of recurrence-free period 22.4 + 0.4months and in more than 47 % cases late relapse was diagnosed. This demonstrates the importance of minimization of negative prognostic factors affecting the abidance of the principles of radicalism. These comparisons has been proven absolutely, the main causes of recurrence of SC has been surgery, which was performed without taking into consideration factors that defines the significant role in the manifestation of early recurrent SC.
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Khudaykulova Gulnara Karimovna, Tashkent Medical Academy, Associate Professor, Department of Infectious and Pediatric Infectious Diseases E-mail: gulechkauz@rambler.ru
Dynamics of immunologic and virological indicators in HIV natural course in perinatally infected children
Abstract: The perinatal infection initiation route was revealed to be characterized by higher rates of immunodeficiency progression. It seems to be due to prenatal infection as well as early damage to the immature immune system of child by HIV. The virus concentration in perinatally infected children from the supervision start and by month 30 from the infection manifestation has been, accordingly, 5 and 2 times higher than in parenterally infected children that suggests a more adverse course of the disease when the child was infected vertically.
Keywords: HIV, children, perinatal transmission, CD4 Lymphocytes, viral load.
Background: The epidemic of HIV/AIDS is relatively recent in According to literature, in the absence of antiretroviral therapy
comparison with other countries with known history ofthe disease. (ART), the HIV-infection in perinatally infected children devel-The presented research of dynamics of immunologic and virologi- ops in one of the two variants: in 10-25 % of children, the infec-cal parameters in HIV-positive children depending on the route of tion quickly progresses with development ofAIDS and lethal com-transmission is the first for the time being [1; 3]. plications at the first year of their life, and in 75-90 % of children
