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Евразийский Союз Ученых (ЕСУ) # 5 (50), 2018
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ESTIMATION OF THE USE OF IMMUNOTROPIC PREPARATIONS IN PATIENTS WITH UTERINE CERVICAL CANCER ON THE BACKGROUND OF _COHERENT IMMUNOTHERAPY_
Kamishov Sergey Viktorovich
MD, PhD, senior researcher, chemotherapeutist Republican Specialized Scientific and Practical Medical Center of Oncology and Radiology of the Ministry
of Health of the Republic of Uzbekistan, Tashkent, Uzbekistan
ОЦЕНКА ПРИМЕНЕНИЯ ИММУНОТРОПНЫХ ПРЕПАРАТОВ У БОЛЬНЫХ РАКОМ ШЕЙКИ МАТКИ НА ФОНЕ СОПРОВОДИТЕЛЬНОЙ ИММУНОТЕРАПИИ
Камышов Сергей Викторович
кандидат медицинских наук, старший научный сотрудник отдела химиотерапии Республиканского специализированного научно-практического медицинского центра онкологии и радиологии Министерства Здравоохранения Республики Узбекистан, Ташкент
АННОТАЦИЯ.Основными причинами неэффективности химиотерапии и отдаленных результатов лечения больных раком шейки матки (РШМ) является иммуносупрессия клеточных факторов адаптивного иммунитета, которые играют важную роль в формировании и прогрессировании злокачественных процессов [4,12,13]. Несмотря на полученные результаты улучшения эффективности лечения при онкогинеколо-гических заболеваниях, до сих пор активно ведутся исследования и активно внедряются иммунологические методы лечения. Результаты таких исследований позволяют предположить, что оценка иммунного профиля опухоли может иметь значение в условиях персонализированной медицины. Как известно, что терапевтические подходы противоопухолевой иммунотерапии основаны на стимуляции противоопухолевого иммунитета в результате воздействия на неспецифическое или адаптивное эффекторное звено иммунной системы [1,4,6,7,11,13]. Однако, до сих пора в литературе отсутствуют или недостаточно описаны данные об эффективности применения иммунотерапии в качестве сопроводительной иммунотерапии при РШМ. Следует сказать, что у онкологических больных выявлены дисфункции клеточного звена иммунной системы, в частности, нарушение эффекторной функции Т-лимфоцитов и баланса «проопухолевых», «противоопухолевых» и «регуляторных» медиаторов [5,11,15,17]. При этом выраженность и механизмы развития иммунодепрессии, свойственной любому онкологическому заболеванию, различны на различных этапах прогрессирования опухоли [5,10,18]. В связи с этим, исследования, проводимые в области изучения различных вариантов иммунотерапии при РШМ является важным и актуальным направлением, используемым в медицине, и оставляющим большие надежды [9]. Подходы к её осуществлению, описанные методики, сроки реализации, возможность комбинирования с другими методами консервативного и оперативного лечения остаются недостаточно изученными и разработанными. Согласно данным литературы, недостаточно раскрыты механизмы иммунного дисбаланса, которые влияют на эффективность лечения и прогнозирование течения заболевания. Важно отметить, что большие достижения в области молекулярно-генетических исследований стимулировали широкое изучение возможностей иммунотерапевтических методов для лечения онкологических больных. В литературе показано, что применение иммунотерапии направлено на индукцию как врожденного, так и адаптивного иммунитета организма для реализации противоопухолевой активности.
Ключевые слова: рак шейки матки, адаптивный клеточный иммунитет, Т-хелперы/индукторы, Т-цитотоксические лимфоциты, Т-киллеры, иммунотерапия.
ANNOTATION.The main causes of ineffectiveness of chemotherapy and long-term results of treatment of cervical cancer (CC) are immunosuppression of cellular factors of adaptive immunity, which play an important role in the formation and progression of malignant processes [4, P. 3360]. Despite the obtained results of improving the effectiveness of treatment for oncogynecological diseases, studies are still actively conducted and immunological methods of treatment are being actively introduced. The results of such studies suggest that the evaluation of the immune profile of the tumor can make a difference in the conditions of personalized medicine. It is known that the therapeutic approaches of antitumor immunotherapy are based on the stimulation of antitumor immunity as a result of action on the nonspecific or adaptive effector link of the immune system [1, P.227; 4, 3360; 6, P. 925; 7, P. 2884]. However, up to now, data on the effectiveness of immunotherapy as an accompanying immunotherapy for CC have not been adequately described or described in the literature. It should be said that cancer patients have dysfunctions of the cellular system of the immune system, in particular, a violation of the effector function of T-lymphocytes and the balance of "pro-tumor", "antitumoral" and "regulatory" mediators [5, http://dx.doi. org/10.1155/2014/150845]. At the same time, the severity and mechanisms of the development of immunosuppression inherent in any oncological disease are different at different stages of tumor progression [5, http://dx.doi. org/10.1155/2014/150845;10, P. 18538]. In this connection, the studies conducted in the field of studying various variants of immunotherapy in CC are an important and topical direction used in medicine, and leaves much hope [9, P. 18538]. Approaches to its implementation, the described methods, the timing of implementation, the possibility of combining with other methods of conservative and surgical treatment remain insufficiently studied and
developed. According to the literature, the mechanisms of immune imbalance that affect the effectiveness of treatment and the prognosis of the course of the disease are not sufficiently disclosed. It is important to note that great achievements in the field of molecular genetic studies stimulated a broad study of the possibilities of immunother-apeutic methods for the treatment of cancer patients. In the literature it is shown that the use of immunotherapy is aimed at the induction of both innate and adaptive immunity of the organism for the realization of antitumor activity.
Key words: cervical cancer, adaptive cellular immunity, T-helpers / inducers, T-cytotoxic lymphocytes, T-killers, immunotherapy.
The aim of the study was to evaluate the choice of immunotropic drugs in the process of accompanying immunotherapy in patients with cervical cancer.
Material and methods of research. In the study included patients with cervical cancer T2-3N0-1M0 stages (II-III clinical stages), who were in the departments of oncogynecology and chemotherapy of the Republican Specialized Scientific and Practical Medical Center of Oncology and Radiology of the Ministry of Health of the Republic of Uzbekistan
. Patients with cervical cancer are divided into the following groups: the 1st group - 34 practically healthy individuals; the 2nd group - 38 patients with cervical cancer before treatment; the 3rd group - 32 patients with cervical cancer who received immunotherapy in the form of extracorporeal immunopharmacotherapy (EIPHT); the 4th group - 36 patients with cervical cancer who received immunotherapy in the form of extra-corporeal immunopharmacotherapy and plasmaphere-sis (EIPHT + PPh); the 5th group (control) - 49 patients with cervical cancer without immunotherapy. Immuno-therapy was performed in the hospital, when patients were admitted to chemotherapy. In total, patients received 2 EIPHT sessions at the beginning of admission to hospital and before discharge from the hospital. As a preparation of the immunostimulant, polyoxidonium (azoxime bromide) and thymalin (thymus preparation), was used. Both drugs have pronounced immunotropic properties. Immunological studies included the study of cellular and humoral parameters of the immune system in patients with ovarian cancer. Determination of cellular immunity (CD3 +, CD3 + CD4 +, CD3 + CD8 +, CD16 +, CD20 +), and identification of activation markers of lymphocytes (CD38 + and CD95 +) was performed by flow cytometry on Accuri C6 (USA) using MCAT. During the statistical analysis of the data presented in the work, the results of the research were entered into databases prepared in Microsoft Excel XP. Numerical (continuous) values were presented as mean arithmetic mean values and mean error (M ± m). A comparison of the quantitative traits was carried out with the help of the Student's test, for continuous variables - the paired Student test. As a boundary comparative criterion for the statistical significance of reliability, p <0.05 was assumed.
The results and discussion. The study of the state of T-cell immunity in patients with cervical cancer is an important factor in determining the depth of immunodeficiency, predicting the disease and, most importantly, identifying the most radical ways of therapy, including immunotropic therapy. We evaluated T-cell immunity in female cervical cancer, depending on the use of different approaches to immunotherapy in the
scheme of accompanying therapy in stationary conditions. It is known that phenotypic markers of T-lym-phocytes include such markers as CD3 +, CD3 + CD4 +, CD3 + CD8 +. In the literature, the information that the activation and regulation of the effectiveness of the immune response is largely determined by the specific antigen of T lymphocytes is widely reported. Responsible for this function are antigen-recognizing receptors - TCR. It is known that the degree of surface expression of CD3 + receptors on the T-lymphocyte membrane reflects its transmissive function and allows the total number of T-lymphocytes to be identified [3,P. 1064]. Thus, the analysis of the expression of CD3 + T-lym-phocytes in patients with cervical cancer, depending on the type of immunotherapy, showed that the presence of significant suppression of CD3 + expression on T-lymphocytes is observed in all groups of patients with cervical cancer, compared with the control group, and there are significant differences between groups of patients p <0.05). The lowest value of CD3 + expression was observed in the group of cervical cancer patients after PCT without immunotherapy. Moreover, reliable suppression of CD3 + expression in the group of patients after PCT without immunotherapy is observed in comparison with the values of patients with cervical cancer in groups where EIPHT and EIPHT + PPh were used. Consequently, in the group of patients after PCT without immunotherapy, a decrease in CD3 + expression was noted, which is due to the toxic and depressive effect of PCT on factors of cellular immunity. Reduction of the total pool of T-lymphocytes (CD3 +) was noted by suppressing the expression of CD3 + CD4 + T-helper / inducers. The study of expression of CD3 + CD4 + on T-lymphocytes, which are the main regulatory cells of immunity, showed that the lowest value of T-helpers / inducers was observed in groups of patients with cervical cancer without immunotherapy and before the initiation of therapy (p <0.05). It has been shown that CD4 + T-cell response to tumor proteins is an important cellular mechanism for protecting the macroorganism, since CD4 + T-helpers stimulate the production of antibodies by B lymphocytes and activate CD8 + T lymphocytes specific for tumor cells [4, P. 3360; 8, P. 66; 9, 18538]. Analysis showed that in the group of patients with cervical cancer without immu-notherapy, CD3 + CD4 + expression was 22.6 ± 1.2%, while in the groups of patients after EIPHT - 26.6 ± 1.3%, after EIPHT + PPh - 27.9 ± 0.84%, and in the group of patients before the start of therapy - 21.5 ± 1.4%, in the group of practically healthy persons - 36.8 ± 1.2%. It is known that cytotoxic CD3 + CD8 + T-lymphocytes play an important role in the pathogenesis of cancer [2,P. 942 ; 3,P. 1072; 7,P. 2884 ;10 P. 18538]. The biological role of this activation is the removal of
mutant cells. Analysis of the expression of CD3 + CD8 + on T-lymphocytes revealed a significant increase in all groups of patients with cervical cancer compared with the value of a group of practically healthy individuals. The maximum increase in CD3 + CD8 + was detected in the group of patients before and after PCT therapy without immunotherapy (p <0.05). When analyzing the expression of CD3 + CD8 + on T-lympho-cytes between the investigated groups of cervical cancer patients, it was seen that before the treatment, the expression of CD3 + CD8 + was significantly increased and amounted to 35.6 ± 2.52%, in the group of patients after PCT without immunotherapy was on the average 31,8 ± 1,6%, and in the groups of patients after the application of EIPHT and EIPHT + PPh a significant decrease in the number of cytotoxic T-lymphocytes and approximation to the values of the regulatory group is observed. Immunoregulatory index (IRI), which is the ratio of CD3 + CD4 + / CD3 + CD8 + values, is of significant importance in secondary immunodeficiency states. It is known that, in healthy IRI, an average of 1.52 ± 0.02. Obviously, suppression of CD3 + CD4 + expression against the background of increased expression of CD3 + CD8 + leads to a decrease in IRI. The least decrease in IRI is observed in the group of patients before and after treatment without the use of immunotherapy. It was noted that in the group of patients with cervical cancer who underwent EIPHT after PCT too, there was a decreased IRI in comparison with the data of patients receiving EIPHT + PPh. Thus, the lowest value of IRI in the group of patients after PCT without immunotherapy was 0.71 ± 0.03, and the highest value was noted in the group of patients after EIPHT + PPh and amounted to 1.32 ± 0.02 (p <0.05 ). The expressed immunosuppression was characteristic of patients with cervical cancer in the groups of patients before the treatment and after PCT without immunotherapy. Thus, the reduction of IRI is an important criterion for the depth of the T-cell immunodeficiency state, especially against the background of the evaluation of the effectiveness of treatment in cervical cancer. The study of expression of CD16 + on killer cells showed that killer lymphocytes belong to the category of main effectors of natural or innate immunity, which are able to lyse target cells or to perform antibody-dependent cellular cytotoxicity. It is their inherent performance of the functions of the first line of defense before the emergence of immune T-lymphocytes and specific antibodies. A significant increase in CD16 + expression was revealed in all groups of patients with cervical cancer. It was shown that the greatest expression of CD16 + was observed in the group of patients with CC before and after PCT without immunotherapy, which was significantly increased in comparison with other groups of patients (p <0.05). Thus, in the group of patients before treatment, expression of CD16 + was 26.1 ± 1.2%, in the group of patients after PCT without immunotherapy - 22.6 ± 1.14%, in the group of patients after EIPHT -22.1 ± 0.88% , in the group after EIPHT + PPh - 18,4 ± 1,2%, in the group of practically healthy persons - 16,9 ± 1,4%. The greatest expression of CD16 + was noted in the groups of patients with CC before and after PCT without immunotherapy.
Immunotherapy has a beneficial effect on the immune system, reducing its tension. It is important that with the use of polyoxidonium not only activation of cellular immunity is observed, but also a decrease in the killer activity of cells. And after the application of thy-maline, pronounced activation of T-lymphocytes is observed. The analysis of the obtained results made it possible to reveal pronounced changes in the cell link of immunity, which are manifested by suppression of the expression of CD3 +, CD3 + CD4 +, IRI, increased expression of CD3 + CD8 + and CD16 +. As can be seen, the best situation is typical for patients with CC after EIPHT + PPh, where activation of T-cell immunity against the background of thymaline is observed. There is a marked imbalance in cellular immunity. Moreover, the imbalance in the cell link of immunity is expressed in the suppression of IRI by reducing the number of T-helpers / inducers and increasing T-cytotoxic lymphocytes. Obviously, with this pathology T - the cellular immune response is substantially weak and directed against a smaller number of epitopes, which suggests that clonal depletion of T lymphocytes is possible. In turn, the decreased immunoreactivity of the T-cell link can be considered as a result of a violation of the antigen presentation to the cells of the immune system, as well as a violation of the function of the T cells themselves [8, P.66; 9, P.18538; 10, P.18538]. The detected T-cell immunodeficiency is expressed by lymphopenia and is most often characterized in the background or after PCT. A positive clinical efficacy of accompanying immunotherapy with the use of polyoxidonium and thymalin was established.
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THE CONTRIBUTION TO THE STUDY OF MAIN MOLECULAR _BIOLOGICAL MARKERS IN CERVICAL CANCER_
Kamishov Sergey Viktorovich
MD, PhD, senior researcher, chemotherapeutist
Republican Specialized Scientific and Practical Medical Center of Oncology and Radiology of the Ministry
of Health of the Republic of Uzbekistan, Tashkent, Uzbekistan
ВКЛАД В ИЗУЧЕНИЕ ОСНОВНЫХ МОЛЕКУЛЯРНО-БИОЛОГИЧЕСКИХ МАРКЕРОВ
ПРИ РАКЕ ШЕЙКИ МАТКИ
Камышов Сергей Викторович,
кандидат медицинских наук, старший научный сотрудник отдела химиотерапии Республиканского специализированного научно-практического медицинского центра онкологии и радиологии Министерства Здравоохранения Республики Узбекистан, Ташкент
АННОТАЦИЯ
Целью исследования явилось изучение экспрессии молекулярно-биологических маркеров опухоли у больных раком шейки матки, и их влияние на течение сопроводительной терапии. Материал и методы: Наибольший эффект в увеличении 5-летней выживаемости больных РШМ оказывала схема сопроводительной иммунотерапии, включающая ЭИФТ с плазмаферезом: такое влияние данного метода проявлялось как при положительных, так и при отрицательных уровнях, рассмотренных онкомаркеров. Результаты и обсуждение. Проведённый анализ корреляции уровня онкомаркеров и 5-летней выживаемости больных, позволяет сделать вывод о том, что положительный уровень p53, VEGF и Ki-67 у больных РШМ, наряду с высокой пролиферативной активностью опухоли, может служить основанием для проведения данной категории пациенток сопроводительной иммунотерапии с ЭИФТ, что может существенно увеличить эффективность стандартных схем противоопухолевого лечения. Вывод: При положительном уровне данных окомаркеров, наряду с высокой пролиферативной активностью опухоли, можно рекомендовать проведение сопроводительной иммунотерапии с ЭИФТ с плазмаферезом.
Ключевые слова: рак шейки матки, адаптивный клеточный иммунитет, молекулярно-биологические маркеры, иммунотерапия
ANNOTATION
The aim of the study was to study the expression of molecular-biological tumor markers in patients with cervical cancer, and their effect on the course of accompanying therapy. Material and methods: The greatest effect in increasing the 5 -year survival of patients with cervical cancer was provided by a scheme of accompanying immunotherapy, including EIPHT with plasmapheresis: this effect of the method manifested itself in both positive and negative levels of oncomarkers. Results and discussion. The analysis of the correlation of the tumor markers level and 5-year survival of patients allows us to conclude that the positive level of p53, VEGF and Ki-67 in patients with cervical cancer, along with high proliferative activity of the tumor, may serve as a basis for conducting this category of patients of accompanying immunotherapy with EIPHT, which can significantly increase the effectiveness of standard antitumor treatment regimens. Conclusion: In case of a positive level of these markers, along with high proliferative activity of the tumor, it is possible to recommend carrying out accompanying immu-notherapy with EIPHT with plasmapheresis.
Key words: cervical cancer, adaptive cellular immunity, molecular-biological markers, immunotherapy.
Topicality. Discoveries in the field of cell biology and experimental oncology have determined the development of a new section of oncology. Many mechanisms for controlling cell division and apoptosis, maintaining genetic stability, ways of signal transmission from receptors to the nucleus, etc. have become known [2, P.3999; 3, P.357; 8, P.33; 10, P.395]. At present, various genes, proteins and other compounds have been
identified, which are considered as additional prognostic factors in patients with malignant tumors, including those with oncogynecological diseases. They are designated as immunological and molecular-biological markers. Much attention is paid to the study of molecular-biological markers that characterize apoptosis, cell proliferation and angiogenesis [1, P.4385; 4, P.1; 5, P.1597; 6, P. 242; 7, 765]. These include p53, B1-2,
