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26.1 ± 1.2%, in the group of patients after PCT without immunotherapy - 22.8 ± 1.19%, in the group of patients after EIPHT - 21.2 ± 0.98% , in the group after EIPHT + PPh - 18.1 ± 1.1%, in the group of practically healthy persons - 16.8 ± 1.2%. Consequently, the greatest expression of CD16 + was observed in the groups of patients with cervical cancer before and after PCT without immunotherapy. As you can see, immunotherapy has a beneficial effect on the immune system, reducing its tension. Thus, the analysis of the results obtained revealed 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 cervical cancer after EIPHT + PPh, where activation of T-cell immunity 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 immune system cells, as well as a violation of the function of the T-cells themselves. Thus, the detected T-cell lymphopenia is often characteristic of the background or after PCT. Suppression of IRI indicates the presence of T-cell immunodeficiency, as mentioned above, mainly due to a decrease in the number of T-helpers / inducers, which play an important role in the implementation of the immune response. Increase in T-cytotoxic lymphocytes, which indicates the suppression of T-cell immunity and the presence of cytotoxic action at the cellular level. Positive clinical efficacy of the combination of immunotherapy has been established.
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THE EVALUATION OF PROVECTORAL CYTOKINS OF THE IMMUNE SYSTEM DEPENDING ON THE VARIANTS OF COHERENT IMMUNOTHERAPY IN PATIENTS WITH UTERINE CERVICAL CANCER. ОЦЕНКА ПРОВОСПАЛИТЕЛЬНЫХ ЦИТОКИНОВ ИММУННОЙ СИСТЕМЫ
В ЗАВИСИМОСТИ ОТ ВАРИАНТОВ СОПРОВОДИТЕЛЬНОЙ _ИММУНОТЕРАПИИ У БОЛЬНЫХ РАКОМ ШЕЙКИ МАТКИ._
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.
Камышов Сергей Викторович, к.м.н., старший научный сотрудник отдела химиотерапии Республиканский специализированный научно-практический медицинский центр онкологии и радиологии Министерства здравоохранения Республики Узбекистан, Ташкент
АННОТАЦИЯ.
Изучено состояние основных цитокинов иммунной системы у больных раком шейки матки II-III стадии в комплексной сопроводительной иммунотерапии. Установлено повышение провоспалительных цитокинов в сыворотке периферической крови больных РШМ. Цитокиновый спектр при РШМ характеризовался повышенным содержанием основных провоспалительных цитокинов и IL-6. Включение в комплекс сопроводительного лечения ЭИФТ и ЭИФТ+ПФ, является одним из путей уменьшения эндогенной интоксикации при проведении противоопухолевой лекарственной терапии. Следовательно, проведенные исследования показали, что наибольшей эффективностью в плане снижения побочных эффектов химиотерапии в комплексном лечении больных РШМ II-III стадий, а также в улучшении субъективного состояния больных и качества их жизни обладают схемы иммунотерапии, включающие применение ЭИФТ и ЭИФТ+ПФ, которые снижают основные клинические проявления токсичности химиотерапии, улучшает субъективное состояние пациента. Методика ЭИФТ в комплексной терапии онкогинекологических заболеваний позволяет повысить показатели пятилетней общей и безрецидивной выживаемости пациенток.
Ключевые слова: рак шейки матки, цитокины, интерлейкины, провоспалительные цитокины, имму-нитет,иммунотерапия.
Annotation.The effect of cytokines is considered as an important mechanism for the development of many pathological processes, including cancer. It is known that in malignant growth with cytokines two systems interact: "neoplasm-cytokines" and "immune system-cytokines" [1,-P. 433; 2,-P. 169; 7,-P. 5896]. As is known, all the components of modern complex treatment for patients with malignant processes, in particular cervical cancer, are the factors that initiate immunosuppression mainly by the cellular type, which is extremely dangerous, since the tumor also uses suppression mechanisms to reduce the body's response to its availability. The mortality from cervical cancer exceeds the mortality from ovarian and uterus cancer combined, despite the advances in diagnosis and treatment. The asymptomatic course of the disease in the early stages, leading to late treatment to the doctor, and, consequently, to detectability with already widespread stages of the disease (up to 70%) leads to a high mortality of patients. The course of the tumor process, in particular, with cervical cancer is accompanied by the formation of endotoxicosis and secondary immune deficiency. Endotoxicosis, in turn, is a complex, multicomponent process that is caused by the accumulation in the tissues and biological fluids of endotoxic substances in conditions of a decrease in the physiological processes of detoxification. Carrying out chemotherapy contributes to the further growth of endogenous intoxication, suppression of the body's immunocompetence, which complicates the course of the main oncological disease, and sometimes, in the development of organ and systemic disorders, limits the possibilities for an adequate course of antitumor treatment [6,-P. 4275; 7,-P. 5896]. Despite the high sensitivity of the tumor for cervical cancer to the effects of modern cytotoxic drugs, the possibilities of antitumor treatment are often limited, which is associated with their high toxicity and the severity of metabolic abnormalities at the level of the whole organism [1, -P.433; 3,-P. 1934]. To increase the possibility of timely chemotherapy, great importance is attached to methods leading to a decrease in endogenous intoxication and an increase in the body's immunore-fense. Such methods include plasmapheresis and extracorporeal immunopharmacotherapy. As is known, the use of plasmapheresis in the complex treatment of cancer patients with the presence of tumor intoxication should be considered as one of the leading methods of detoxification, based on the mechanisms and effects of its effect on the body. The detoxification effect of plasmapheresis is not only the direct removal of toxins, xenobiotics, biologically active substances and other various pathological substances from the bloodstream, but also in the active drainage action on the intercellular space, the deprotection of the cellular receptors of organs and the systems of physiological detoxification, which lead to an intensification of toxin elimination mechanisms. Thus, the main objective of the study is to study the state of cytokines of the immune system in patients with cervical cancer, in particular the main serum cytokines of the immune system against the background of extracorporeal immunophar-macotherapy and plasmapheresis in complex treatment. In connection with the foregoing, immunotherapy for cervical cancer is a relatively new direction, in which approaches to its implementation, specific methods, timing, the possibility of combining with other methods of treatment remain insufficiently studied and developed, and naturally insufficiently described in the literature.
Key words: cervical cancer, cytokines, interleukins, proinflammatory cytokines, immunity, immunotherapy.
The aim of the study. To assess the state of the main cytokines of the immune system in patients with cervical cancer II-III stage in complex accompanying immunotherapy. Material and methods. The study included patients with cervical cancer (CC) T2-3N0-1M0 stages (II-III clinical stages). In accordance with the objectives of the study, patients with cervical cancer were randomized to the following groups to assess the effect of immunotherapy on the spectrum of the main cyto-kines in the complex treatment: the 1 group - 42 practically healthy individuals; the 2 group - 38 patients with cervical cancer before PCT; the 3 group - 45 patients
with cervical cancer after PCT without immunotherapy; the 4 group - 48 patients with cervical cancer after PCT in combination with extracorporeal immunophar-macotherapy (EIPHT); the 5 group - 52 patients with cervical cancer after PCT in combination with extracor-poreal immunopharmacotherapy and plasmapheresis (EIPHT + PPh). At the stage of clinical examination, in all patients with cervical cancer, a history of the disease, anamnestic data, and a general examination were collected. All patients underwent clinic-laboratory blood tests, which included the study of a general analysis of blood and urine, biochemical parameters, and blood coagulation. Cervical cancer patients underwent
combined therapy in adjuvant or neoadjuvant mode, including polychemotherapy with a cisplatin regimen of 75 mg / m2 + cyclophosphamide 1000 mg / m2 for 1 day for 4-6 courses 1 time every 3 weeks and surgical treatment in the volume of a radical operation. Chemotherapy was performed in both adjuvant and neoadjuvant regimens. EIPHT and EIPHT + PPh in patients with OC using immunomodulators were carried out during the period of radiotherapy and chemotherapy in the hospital. The method of extracorporeal immunopharma-cotherapy (EIPHT) was carried out with the aim of reducing the toxic manifestations after carrying out poly-chemotherapy and increasing the immunorefense of the organism. EIPHT was performed by exfusion of 5001000 ml of autoblood in sterile containers "Gemakon" or "Terumo" and its centrifugation at 3000 rpm for 30 minutes. 50-80 ml of the supernatant of the blood plasma were removed. Then the obtained leukotrombo-mass and erythrocytic mass were incubated with an im-munotropic drug in a total dose of 30 mg at 37 ° C for 60-100 min, with the subsequent return of the conjugate to the circulatory system of the patients. To stimulate the cell link of immunity, an immunotropic preparation of thymic origin, thymalin (thymus extract), was used. Produced by Samson-Med LTD, Russia. Immunological studies included a serum evaluation of the main cy-tokines of the immune system. Serum levels of cyto-kines (IL-6, IFN-y) were determined by ELISA using the test systems of the firm "Human" (Germany) in the dynamics of complex treatment. 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 obtained results of the study and their discussion. Great achievements in the field of molecular research stimulated a broad study of the possibilities of immunotherapeutic methods for the treatment of cancer patients. As shown in the literature, the use of immuno-therapy is aimed at the induction of both innate and adaptive immunity of the organism for the realization of antitumor activity. As a result of the conducted studies, a significant and reliable increase in the level of all the cytokines studied was found in comparison with the values of a healthy group of people. However, the issues concerning the cytokine regulation of immunity in malignant processes, in particular the identification of the features of the course of the disease and its prediction remain open. As is known, the system of interferons is an integral part of the immune system, which ensures coordination of proliferation, differentiation and activation of effector cells of immunity. An evaluation of the functional state of the interferon system is the study of the content of the interferons themselves [8,-P. 3591; 9,-P. 3399; 10, -P. 501]. We studied IFN-y, which refers to the cytokines produced by the TX1-type. IFN-Y has antiviral and tumorigenic activity, activates mon-ocytes and macrophages, natural killers (cytotoxicity), proliferation and differentiation of T-lymphocytes, suppresses tumor growth, proliferation, proliferation of B-
lymphocytes. By its nature, IFN-y is a potent im-munostimulant and inducer of nonspecific body defense [7,8,]. The study of IFN-y revealed a statistically significant increase in its content in all groups of patients with cervical cancer compared with the 1st group of healthy individuals. The analysis showed that serum IFN-y levels were statistically increased in all groups of patients when compared with each other. Moreover, the authenticity of the differences was absent between the 4th and 5th groups of patients, where variants of immunotherapy were used. The analysis showed that IFN-y was increased by 6.2 times in the 2nd group of patients to PCT in comparison with group 1, in the third group after PCT without immunotherapy - by 36 times, in the 4th group after PCT in the complex EIPHT - 9 times and in the 5 th group of patients after PCT in the complex EIPHT + PPh - 10 times. Consequently, the highest level of IFN-y in the serum of peripheral blood was detected in the group of patients after PCT in the complex EIPHT + PPh. Obviously, the use of EIPHT + PPh complex has a positive effect on the immune system, which is expressed in the immunomodulatory effect of IFN-y, which is an immune cytokine. The data obtained by us agree with the literature data, where the positive effect of the EIPHT in the PPh complex is quite clearly represented, and the use of thymalin, which is an im-munomodulating drug that effectively affects cellular immunity, has proved to be important. As shown above, carrying out PCT increases the content of proin-flammatory cytokines in the blood. It should be noted that this process occurs against the background of increasing concentrations of IFN-y, which inhibits tumor angiogenesis. According to our data, it can be seen that with the inclusion of immunotherapy methods in the PCT complex of patients with cervical cancer, a significant increase in the serum concentration of IFN-y is observed. Consequently, in the process of progressing, neoplasm is integrated into the main homeostatic processes of the macroorganism due to the use of regional and systemic functions of cytokines. Cytokines with systemic effects - IL-10, TNF-a and IFN-y - play a key role in the entire spectrum of cytokines, including those secreted by the tumor. The study of IL-6 revealed a statistically significant increase in all groups of patients with cervical cancer compared with group 1 of healthy individuals. Analysis of the studies showed that serum IL-6 levels were statistically increased in all groups of patients when compared with each other. A comparative analysis of the levels of IL-6 between the groups revealed that, when compared with group 1, the level of IL-6 was increased in the second group of patients to PCT by 7.5 times, in the third group after pCt without immunotherapy - in 10 times, in the 4th group after PCT in the complex EIPHT - 5 times and in the 5th group of patients after PCT in the complex EIPHT + PPh - 2.5 times. Evidently, the highest level of IL-6 in the serum of peripheral blood was detected in the group of patients after PCT without the use of immunotherapy options. It has been shown that after PCT without the use of immunotherapy in the complex it is manifested by increased values of IL-6. It is known that IL-6 is an important diagnostic index of malignancy of the oncological process. Moreover, the best effect of complex treatment is observed in the group of patients who were immunotherapy methods. Clinically, in such patients there is an improvement in the state of health, absence
of signs of intoxication, in this regard, the dose intensity of chemotherapy has been preserved and the time of hospital stay has not increased. The data obtained by us agree with the literature data. As is known, a high level of IL-6 can interfere with effective immunotherapy. There was an imbalance in the content of the main cytokines, which manifested itself in the significant production of IL-ip and IL-6, which can be attributed to intermediate cytokines between pro- and anti-inflammatory cytokines, which in turn indicates the dominance of the production of cytokines of the TX2 type. IL-6 is a pleiotropic cytokine with a wide range of biological activity, which is produced by both lymphoid and non-lymphoid cells of the organism. Thus, the EIPHT and EIPHT + PPh in the PCT complex in patients with cervical cancer with the presence of tumor intoxication causes a positive dynamics of the main parameters of the immune system, as well as a decrease in the level of serum pro-inflammatory cytokines, some of which have a growth-stimulating effect, for example, IL-6 [8,]. It should be noted that carrying out PCT aggravated the existing deviations from the average level of cytokines of a group of practically healthy persons and patients to PCT. A feature of patients with cervical cancer in the background of PCT was the progressive suppression of the mechanisms of cytokine regulation during chemotherapy.
Thus, we found an increase in proinflammatory cytokines in the serum of peripheral blood of patients with cervical cancer. The cytokine spectrum in cervical cancer was characterized by an increased content of the main pro-inflammatory cytokines and IL-6. Inclusion in the complex of accompanying treatment of EIPHT and EIPHT + PPh, is one of the ways to reduce endogenous intoxication during antitumor drug therapy. The use of the above immunotherapy methods, according to modern literature, can serve as a modifier of chemo-therapeutic treatment, since its tolerance directly depends on the functional state of the organs and systems of physiological detoxication of the body, and, not least, the immune system. Consequently, the conducted studies showed that the most effective in reducing the side effects of chemotherapy in the integrated treatment of cervical cancer II-III stages, as well as in improving the subjective state of patients and their quality of life, immunotherapy schemes including the use of EIPHT and EIPHT + PPh, which reduce the main clinical manifestations of the toxicity of chemotherapy, improves the subjective state of the patient. In addition, the use of the EIPHT technique in the complex therapy of on-cogynecologic diseases makes it possible to increase the five-year general and disease-free survival rates of patients. The EIPHT method developed by us has great prospects in oncological practice in connection with the possibility to remove the consequences of cancer and chemoradiation intoxication, and also to activate our own system of antitumor protection of the body, which should positively affect the outcome of the disease and lead to an increase in the quality and life span of the patient.
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