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11. Isobe Koichi, Uno Takashi, Hanazawa Toyoyuki, Kawakami Hiroyuki, Yamamoto Seiji, Suzuki Homare et al. Preoperative Chemotherapy and Radiation Therapy for Squamous Cell Carcinoma of the Maxillary Sinus//Japan J. Clinical Oncology. - 2005. -V. 35, № 11. - P. 633-638.
Khojitoev Sanjar Valirakhimovich, Republic Specialized center of phtisiology, Researcher, assistant of faculty urology department, Master's degree E-mail: sanjarkh@gmail.com
Tillyashaykhov Mirzagolib Nigmatovich, Director of National Cancer Research center, D. M., Professor, Urooncology department E-mail: tmirza58@mail.ru
Abdurakhmonov Doniyor Komiljonovich, Republic Specialized center of phtisiology, D. M., head of department of urology E-mail: sanjarkh@gmail.com
Comparison of modified radical cystectomy with traditional in bladder cancer patients with comorbidities
Abstract: The paper analyzed 65 cases of bladder cancer who undergone traditional and extraperitoneal radical cystectomy with ureterocutaneostomy. Patients included the study had a number of complications and comorbidities that limited volume of surgery. Radical cystectomy with extraperitoneal access objectively shorter. Postoperative rehabilitation faster, it decrease the risks associated with surgical interventions in the peritoneal cavity. Keywords: bladder cancer, radical cystectomy, comorbidity.
Introduction
In the structure of cancer pathology bladder cancer (BC) takes the 9th place. The global death rate from bladder cancer in 2008 was 4.4: 100 000 in men and 1.1: 100 000 — women. BC takes third place among urological and 2nd place among oncouro-logical pathology [1; 2; 3].
In Uzbekistan, according to Cancer Registry, in 2014 the incidence of bladder cancer has reached 1.3 : 100 000 and the mortality rate of 0.6 : 100 000.
In the world of 80 % of diagnosed cases of bladder cancer are non-invasive or T1 [1; 3]. In Uzbekistan, according to the Cancer Registry, nearly 70 % of bladder cancers are diagnosed muscular invasive. Thus 41 % of patients with stage III and 13 % identified in stage IV. According to the above-mentioned reports, at least 30 % of patients, from newly diagnosed with bladder cancer, we can perform organ-preserving treatment.
According to the literature, the incidence of postoperative complications after radical cystectomy varies very widely — from 19 % to 64 % [5].
Compared with failure of intestinal and urinary anastomoses, paresis (obstruction) of the intestine more common complication after radical cystectomy, which was observed in 23 % of patients in recent studies [6].
Ureterocutaneostomy (UCS) after radical cystectomy remains the main method of urinary diversion in our region, as in most cases of bladder cancer are diagnosed at later stages T3-T4, and somatic status of patients does not allow performing the operation. Surgical treatment takes many hours, traumatic, requires highly skilled operator and a special post-operative care.
UCS remains in the EAU guidelines and recommended a certain contingent of patients in whom it is impossible to perform a more complex and difficult operation [4; 7].
Materials and methods
We conducted analysis of 65 cases of BC in the male patients T2-4aN0-2M0 stage, treated in the department of urology of Tashkent city oncology dispensary 2010 to 2014.
1 — group of patients undergoing traditional radical cystectomy with bilateral ureterocutaneostomy (30 patients).
II — group of patients who underwent extraperitoneal radical cystectomy with bilateral ureterocutaneostomy (35 patients).
The average age of the patients was in the group I — 63 years, in the group II — 65. All patients included in the study were older than 50 years. In 50-59 in both groups of 8 patients. 60-69: I group —11 patients, II —13; 70-79: I — 10, II —12 group;
I patient in the I and 2 patients in group II were older than 80 years.
In both compared groups patients had invasion depth T2-16 in group I (53.3 %) and in II — 17 (56.6 %) patients, respectively. 9 (30 %) patients in the first and 11 (33.4 %) patients from the second group diagnosed T3 invasion. From I group 5 (16.6 %) and
II group 7 (20 %) patients had signs of germination in prostate and ureterohydronephrosis. In all cases Histological analysis showed transitional cell carcinoma.
13 % of patients in the first and 23 % in the second group had histologically proven metastases in the lymph nodes.
2 patients in group I and 4 in the II diagnosed one side ureterohydronephrosis due to the invasion to the ureter.
Patients included in the study had a number of complications and co-morbidities, which limited the long time traumatic surgery (Tab. 1).
Comparison of modified radical cystectomy with traditional in bladder cancer patients with comorbidities
Table 1. - Complications caused by tumor and comorbidities
Complications/comorbidities I group % II group %
T4 a- (hydronephrosis, invasion to neighbor organs) 5 16.6 7 20
Diabetes mellitus 3 10 2 5.7
Anemia 12 40 16 45
Cardio vascular diseases (arterial hypertension cardiac ischemia, circulatory failure) 21 70 19 54.3
Digestive system diseases 5 16.6 7 20
Operations in abdominal cavity 1 3.3 3 8.6
Hematuria 12 40 13 37.1
Note: One patient could have multiple comorbidities
As can be seen from the table, most of the patients — 21 (70 %) of the first and 19 (54 %) of the second group — had cardiovascular system diseases.
Determining perioperative risk, we used the comorbidity index of Charlson. In our view this index is convenient for use and evaluation of physical status of the patients. In our survey more than 70 % of patients had an index of 3-5. 16.6 % of patients in the first and 25.7 % in the second group are identified with the index > 6 above. It should be noted, that patients with a high index were operated due to the presence of hematuria or other complications which might worsen further results of treatment or life-threatening. Only 6.7 % of patients in the I and 2.9 % in the II group had comorbidity index < 2.
Patients in the first group performed radical cystectomy by traditional laparotomy with excision of adjacent peritoneum on the bladder.
Extraperitoneal radical cystectomy procedure is performed without access to the abdominal cavity. During the operation, after dissecting the fascia transversus abdominis opened space Rezius. On vasa deferentia level peritoneum is moved upward to visualize the common iliac vessels. The first step is performed bilateral pelvic lymph node dissection including the obturator fossa. Cystectomy begins by isolating urachus and the removal of the bladder wall from adjacent peritoneum. Subsequently, operation continues in the traditional way.
Results
Analyzing the results in the groups we noticed greater number of postoperative complications (Table 2). We associate this phenomenon with the initial state of patients before surgery, which was a predisposing factor for the development of a greater number of complications. In postoperative period in group 1 — 12 (40 %) patients and in group 2 — 8 (23 %) observed complications that required medical measures. The first group was observed more intestinal paresis — 5 (16.6 %) than in the second group — 1 (2.8 %).
Table 2. - Postoperative complications
Complication I—n ( %) II-n ( %)
Intestine Paresis 5 (16.6) 1 (2.8)
Pneumonia 1 (3.3) 1 (2.8)
Wound infection 4 (13.3) 2 (5.7)
Lymphorrheya- chylorrhea 3 (10) 2 (5.7)
Urinary tract infection 3 (10) 2 (5.7)
Lymphostasis 2 (6.6) 2 (5.7)
Note: One patient could have multiple comorbidities
Postoperative complications according to the classification of the Clavien-Dindo: I degree complications were observed in 5 patients I group and 4 in the II group; II degree complications 5 and 3, respectively. Complications were eliminated by conservative and medical treatment. 2 (6.6 %) patients in group I and 1 (2.8 %) in the II were observed III degree complications. In this cases were performed surgical treatment of infected wounds under local anesthesia (Table 3).
Table 3. - Postoperative complications according to Clavien-Dindo classification
Total patients (%) I II III IV V complications n (%)
Gr. 1 30 (100 %) 5 5 2 0 0 12 (40 %)
Gr. 2 35 (100%) 4 3 1 0 0 8 (23 %)
The duration of the operation was 1.5 hours to 3 hours 20 minutes, the average duration of the operation in group I was 143 ± 5 minutes, in II — 135 ± 5 min.
In the postoperative period, the average hospital stay was in Group I — 10 days, in II — 8 days.
Implementing extraperitoneal cystectomy, we noted the following advantages. This technique provides a reduction in the duration of the operation (2.0-2.5 hours). Integrity of peritoneum is preserved and there is no bowel contact with the atmosphere, which in turn reduces the risk of adhesive processes, reducing complications such as intestinal paresis, disruption of water and electrolyte balance in the early postoperative period. It provides easy access to revision of regional lymph nodes and perform pelvic lymphadenectomy. Immediately after surgery, the patient can start enteral nutrition. It enables early activation of patients after radical cystectomy and early rehabilitation.
Conclusion
Radical cystectomy with extraperitoneal access is shorter compared with conventional cystectomy and reduces the risks associated with the operational aggression. Postoperative rehabilitation period is shorter, compared with the group that traditionally cystectomy was performed.
Extraperitoneal cystectomy in patients with comorbidities reduces the risk of possible complications and expanding group of patients whom can be performed radical surgery.
Extraperitoneal radical cystectomy is the preferred operational method for bladder cancer with urine diversion through ureterocu-taneostomy.
References:
1. Ploeg M., Aben K. K., Kiemeney L. A. The present and future burden of urinary bladder cancer in the world//World J Urol. - 2009. -27: 289-293.
2. Parkin D. M. The global burden ofurinary bladder cancer//Scand J Urol Nephrol Suppl. - 2008. - 218: 12-20.
3. Jemal A., Siegel R., Ward E. et al. Cancer statistics, 2008//CA Cancer J Clin. - 2008. - 58(2): 71-96.
4. Kilciler M., Bedir S., Erdemir F. et al. Comparison of ileal conduit and transureteroureterostomy with ureterocutaneostomy urinary diversion//Urol Int. - 2006. - 77(3): 245-250.
5. Liedberg Fredrik. European Urology Supplements. - 2010. - Vol. 9, Issue 1. - P. 25-30.
6. Shabsigh A., Korets R., Vora K. C. et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology//Eur Urol. - 2009. - 55(1): 164-176.
7. Deliveliotis C., Papatsoris A., Chrisofos M. et al. Urinary diversion in high-risk elderly patients: modify cutaneous ureterostomy or ileal conduit?//Urology. - 2005. - 66 (2): 299-304.
Kholdarova Zulkhumorkhon Ravshanbekovna, Assistant at Tashkent Medical Academy, Department of «Oncology and radiation diagnosis», Ministry of Health of Uzbekistan, Tashkent, Uzbekistan E-mail: xoldarova.zulxumor@mail.ru
The role of digital mammography in the differential diagnosis of small form breast cancer with underlying diseases of mammary glands (Literature review)
Abstract: The article contains an overview of publications devoted to differential diagnosis of small form breast cancer with underlying diseases of mammary glands. Currently, the most common methods of differential diagnosis are clinical, X-ray and ultrasonic methods. Studying of modern diagnostic of malignant neoplasms showed the need for the early detection of the disease, before the onset of symptoms or signs, concerning which patients would subsequently applied for medical aid. The valuation of early detection of breast cancer is that, it becomes possible to detect cancer at an early stage, when it has non — invasive character and can be completely cured.
Keywords: breast cancer, screening mammography, ultrasound, digital mammography, multislice computed tomography, differential diagnosis.
Breast cancer (BC) is a serious medical and social problem in many developed countries, and in recent years — in developing countries too [6]. In 2008, in the world diagnosed 1.38 million new cases, compared to 500 000 cases in 1975, accounting for 23 % of all cancer cases in women and 16 % of deaths [20, 28]. BC in the last 8 years, In Republic of Uzbekistan consistently ranked 1st in structure of cancer deceases [4]. In 2015, the absolute number of cases of BC was 2915. From these, 1590 patients were in I - II stage, 991 patients in III stage, and 334 patients in stage IV of BC (According of the National Cancer Research Center of Uzbekistan, cancer register). In recent years, the death rate from breast cancer in Uzbekistan is leading cause of death among cancer deceases and continues to increase in absolute and relative terms (3.4; 3.9; 4.2; and 4.2 per 100 000 women in 2011; 2012; 2013 and 2015 according of the National Cancer Research Center of Uzbekistan, cancer register). Control the growth of breast cancer is not possible due to lack of effective pathways of primary prevention [15]. Accordingly, the current is early diagnosis of the disease, which may have an impact on mortality [24]. It was offered many different types screening of breast cancer: self-examination, physical breast examination, ultrasound, radiometry, electrical impedance tomography, etc. [12, 2]. Despite the variety screening methods of breast cancer, a recognized effective method in the world is X-ray mammography [14; 16]. The introduction of mammography screening contributed to a significant increase in detection of breast carcinoma in situ (CIS), accounting for one author 15-20 % of clinical cases [5], and on the other — 20-30 % [31]. According to Luke C. and Priest K. [22; 10], in Australia as a result of mammographic screening CIS increased about 7 times in the last 20 years in comparison with the increase in the incidence of invasive cancers — about 40 %.
Abduraimov A. B. et al. studied 115 women with suspected breast nodal education [3]. Age of patients ranged within 19-82 years. Depending on the morphological types of tumors examined patients was
as follows: BC — 65 (56.6 %) patients, 26 fibroadenoma (22.6 %), cyst — 10 (8.7 %), nodular breast — 9 (7.8 %) lipoma — 5 (4.4 %). The aim of this study was to explore the possibilities ofmultislice computed tomography (MSCT - mammography) in diagnosis and determining the prevalence of breast cancer. The study was conducted with absolute intravenous contrasting. During the MSCT - mammography without intravenous contrasting in majority cases densitometric indicators of glandular tissue in fibro-cystic mastitis did not differed from malignant process in the breast, which caused serious difficulties in differential diagnosis.
The study Zakharova N. A. was to evaluate the results of the implementation of mammography screening in Khanty-Mansiysk Autonomous Okrug — Ugra for the period 2007-2012 years [7]. In the region 249 106 women has been carried out of preventive breast examination. For the period the target population coverage of screening mammography was 67.5 %. In total 624 women were identified with a malignancy tumors of mammary glands. This indicates that the analog mammography ineffective in detecting the background of breast diseases.
Korzhenkova G. P. and colleagues examined for digital mam-mography, women seeking to Moscow Cancer Research Center. N. N. Blokhin [8]. During the work, they drew attention to the high possibilities of digital systems to identify nodules in women with radiographically dense breast tissue. The author believes that, due to the small sample of patients to make serious conclusions are not currently possible.
Radiology (ACR) The American College to standardize the terminology used to describe a mammogram, and further optimization tactics recommended use a BI-RADS system (the Breast Imaging Reporting And Data System — a system of interpretation and recording of breast imaging). According to requirements of the BI-RA.DS system, the protocol should include a description of the structure of the breast (I), pathologic findings (II) and conclude with setting
