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9
Том 18. N 5-6 2014 р.
тальних лiмфатичних вузлiв. Даний метод 4iTKO Bi3ya-лiзye розповсюдження пухлинного процесу на суммж-Hi органи та тканини, що надзвичайно важливо для встановлення стадп поширеностi пухлинного процесу та вибору оптимального методу лкування. За нашими данними, чутливють методу при дiагностицi МПРПК склала 94,8%, специфiчнiсть - 85,8%.
Отриман данi пiдтверджyють можливiсть застосу-вання ТРУЗД для оцшки ефективностi проведеного неоад'ювантного лiкyвання хворих на МПРПК.
Л^ература
1. Федоренко З.П. Бюлетень нацiонального канцер-реестру УкраТни № J4. „Рак в УкраТы, 2011-2012". / [З.П. Федоренко, Ю.Й. Михайлович, Л.О. Гулак та ш.].-КиТв, 2013.- 120с.
2. Анализ выживаемости больных раком прямой кишки после специализированного лечения / Д. В. Мясников, А. В. Нестеров, Д. В. Никишин [и др.] // Известия высших учебных заведений. Поволжский регион. Медицинские науки. - 2014. - № 2 (30). - С. 84-95.
3. Чорнобай А. В. Ендолiмфатична тератя в комплексному лкуваны хворих на злоякюы новоутворення малого таза : автореф. дис. на здобуття наук. ступеня док. мед. наук : спец. 14.01.07 «Онколопя» / А. В. Чорнобай. - КиТв, 2006. - 36 с.
4. Торопов В. Ю. Результаты эндоректальной ультразвуковой томографии в определении степени местного распространения опухолевого процесса у больных раком прямой кишки. / Торопов В. Ю., Шолохов В.Н., Ца-рюк В.Ф. // Актуальные вопросы онкогастроэнтероло-гии : Межрегиональная научно-практическая конференция : Мат. конф. Т. 2. - Барнаул, 2003, С. 100-101.
5. Абрамчик Р.Р. Мониторинг состояния больных раком прямой кишки методом сонографии. / Р.Р. Абрамчик, А.И. Кушнеров, Г.Е. Тур [и др.] // Военная медицина. -2013. - № 1. - С. 37-39.
6. Ефремова И. Ю. Ультразвуковая диагностика в оценке местной распространенности опухолевого процесса при раке прямой кишки / И. Ю. Ефремова // Онкология. Журнал имени П. А. Герцена. - 2012. - № 1. - С. 39-43.
7. Сандриков В. А. Трансректальное ультразвуковое исследование как метод диагностики местнораспростра-ненного рака прямой кишки / В. А. Сандриков, П. В. Царьков, Л. Е. Беляева // Ультразвуковая и функцион. диагностика. - 2011. - № 4. - С. 131
8. Торопов В. Ю. Возможности эндоректальной ультразвуковой томографии в диагностике и оценке степени местного распространения рака прямой кишки: авто-реф. дис. на соискание наук. степени канд. мед. наук: спец. 14.00.19 «Лучевая диагностика, лучевая терапия». - Москва, 2004 - 83с.
9. Орлова, Л. П. Предоперационная эндоректальная ультразвуковая оценка распространения рака прямой кишки / Л. П. Орлова [и др.] // Ультразвуковая и функциональная диагностика.- 2004. - №4. - С. 40-45.
10. Казакевич В.И. Ультразвуковое иссследование внут-риполостным датчиком при местно-распространенном раке прямой кишки / В.И. Казакевич, JI.A. Митина, JI.A. Вашакмадзе [и др.] // Колопроктология. -2004. - Т.1, №7. - С.11-14.
11. Практическое руководство по ультразвуковой диагностике. Общая ультразвуковая диагностика / под ред. В.В. Митькова. М.: Издательский дом Видар-М, 2006. -720 с.
12. Абдуллаев Р.Я. Ультразвуковая диагностика опухолей абдоминальных органов. / [Р.Я. Абдуллаев, Т.С. Головко, Г.В. Лаврик и др.]. Х.: Нове слово, 2012. - 173 с.
13. Проклов А.А., Затачаев А.В. Ультразвуковая диагностика заболеваний прямой и ободочной кишки. / А.А. Проклов, А.В.Затачаев // Проблемы колопроктологии. -2000. - Т.17, №1.- С. 172—174.
14. Стаценко Е. А. Сонография в диагностике колорек-тального рака / Е. А. Стаценко // Променева дiагностика, променева тератя. - 2011. - № 1/2. - С. 123.
15. Beer-Gabel М. A new rectal ultrasonographic method for the staging of rectal cancer / M. Beer-Gabel, Y. Assouline, O. Zmora [et al.] // Diseases of the Colon and Rectum. -2009. - Vol. 52. - P. 1475-1480. .
16. Halefoglu A.M. Endorectal ultrasonography versus phased-array magnetic resonance imaging for preoperative staging of rectal cancer / А.М. Halefoglu, S. Yildirim, O. Avlanmis [et al] // World Journal of Gastroenterology. -2008. - №14. - P. 3504-3510
ENGLISH VERSION: THE ROLE OF THE TRANSRECTAL ULTRASONOGRAPHY IN NEOADJUVANT CHEMORADIATION TREATMENT OF PATIENTS WITH THE LOCAL RECTAL CANCER
Vasko L.M.
Higher State Educational Establishment of Ukraine "Ukrainian Medical Stomatological Academy", Poltava, Ukraine
Transrectal ultrasound (TRUS) is the one of the most informative methods for determining the depth of tumor invasion of the rectal wall. The work investigates the possibility of using TRUS in evaluating the effectiveness of therapy in patients wtth neoadjuvant therapy of the RC. The changes in ultrasound imaging of the tumor before and after chemo radiotherapy were assed. As a result, dynamic monitoring established tumor shrinkage, component perffocal inflammation and adrectal component. These data confirm the feasibility of TRUS to assess the effectiveness of the neoadjuvant treatment of patients with RC.
Keywords: rectal cancer, neoadyuvant chemo radiotherapy, transrectal ultrasound diagnosis.
Currently, colorectal cancer is one of the most common cancers. Thus, in the structure of cancer incidence in Ukraine, it consistently ranked 5th, while taking 3rd place among tumors of the digestive system. According to the Ukrainian National Cancer Registry, in 29% of patients in the primary treatment, there are neglected diagnosed cases. As a result, during the year 31% of patients died of RC. Regarding the Poltava region, in 29.7% of patients neoplastic process is diagnosed on stages III-IV and 37.9% of patients - do not live one year of diagnosis. [1,2,3]
High mortality among these patients during the first year after diagnosis is one of the most objective parame-
ters that indicate the status of diagnosis and treatment of these patients. Every third patient was first registered on the CSC tumor has spread to adjacent organs, surrounding tissue, regional and distant metastasis, significantly worsens prognosis and prevents the use of surgery in the first stage of treatment. [2,3,5]
In recent years the number of research aimed at improving methods of neoadjuvant, including local chemo -radio therapy for rectal cancer significantly in-creased.This makes it possible to increase the resections of tumors by reducing their size and separation from surrounding organs, which further allows you to perform organ surgery. In this case, the possibility arises particu-
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larly relevant definition of objective tumor response to the treatment and evaluation of residual tumor. [2, 3, 13,16]
The analysis of the literature showed that not all methods used for primary diagnosis may be suitable for this purpose. The Irrigoscopy provides information about the tumor, tumor length set on the inner wall of the intestine, to assess its mobility, determine the shape of tumor growth. However, this method can not accurately judge the incidence of pathological process beyond the intestine and the presence of regional or distant metastases. Endoscopy can diagnose colorectal cancer, even at early stages. But using this method to assess the effectiveness of the treatment complexity does not allow visualization of tumors with infiltrative type of growth and the inability to assess the overall size of the tumor. Application is pretty expensive and not widely available, magnetic resonance imaging in monitoring patients after treatment is almost never used. [4, 7, 8, 14].
As for ultrasound diagnosis, the traditional trans abdominal research of rectum was considered unpromising because of artifacts caused by great depth location of the body imposing an acoustic shadow from pubic bone, the presence of gas in the lumen of the rectum. Recently, due to the accumulation of experience professionals face the possibility of using ultrasound examination of the rectum. Transrectal ultrasound (TRUS) is one of the most informative methods for determining the depth of tumor invasion in rectal wall and regional lymph node lesions. Given that 50% of tumors localized in middle part of the ampulla of the rectum and availability, lack of radiation exposure is advisable to apply this technique to study patients and dynamics. [4, 6-16].
The aim of our study was to explore the possibilities for TRUS LSCRC diagnosis and determine the effectiveness of the neoadjuvant chemoradiotherapy.
Material and methods
The material of our study was the results of examination of 40 patients with RC (29 men and 11 women) who were treated at the Poltava Regional Clinical Oncology Center. In 24 patients the tumors were located in the middle part of ampulla of the rectum, In 16 - in lower part of the ampullar of the rectum. Histologically, in 97.9% it was adenocarcinoma of varying degrees of differentiation.
After the traditional histological examination and verification patients we performed TRUS imaging for prevalence the tumors in the intestinal wall. Ultrasound examination was carried out on the machine Simens Acuson with transrectal access using appropriate sensor with frequency 5.0 MHz.
In accordance with recommendations TRUS was performed only after finger examination of the rec-tum.The study was carried out with the patient on the right side of the abdomen brought to their feet. First, we examined the anal canal, the sphincter apparatus, rectal wall layers, then adjacent organs.
Normally during transrectal scanning rectal wall thickness of 3-4 mm is visualized and is differentiated to five layers: the first layer (hyperechoic) is the limit section: shell gauge - surface mucosa; the second layer -hypoechoic, muscle plate mucosa; third - hyperechoic, submucosa; fourth - hypoechoic actually muscle layer, the fifth - hyperechoic, serous membrane. [6-9].
The main criterion of invasive tumor growth is a violation of the double-wall structure of the bowel wall. Direct ultrasound evidence of tumor is a thickening of the walls
of the body. Internal circuit wall is clear and smooth due to compression of the sensor surface [10-12].
During TRUS patients with RC were evaluated for the tumor relative cross-section of the lumen of the intestine, the condition of the intestinal wall, differentiating layers of the intestinal wall, the outer contour sharpness of intestine, type of tumor growth, changes in adrectal tissue lesions and regional lymph nodes. During such TRUS lymph nodes in adrectal tissue visualized as rounded hypoechoic formation of 0,3 cm size. Note that the presence of metastases in the adrectal lymph nodes are depends on the choice of the method of combined treatment.
Staging of tumors of the rectum, was by TNM classification. To determine the characteristics of ultrasound pictures incidence of each feature depending on the stage of the disease category T were analyzed, which by ultrasound classification are referred to as "uT".
All patients were managed by chemotherapy (cis-platin, 5-fluorouracil, leykovorin) followed by preoperative irradiation mode multi fractionation (SOD 40-44 Gy, Rhode 1,2Hr 1,2Hr+) and continuation by cytostatics throughout the course of radiation therapy. After the treatment TRUS control was performed. All findings were compared with the results of postoperative histological examination material.
Results and discussion
According to TRUS, with tumors of the intestinal wall to the depth at uT3 stage tumors are located circularly in 23 patients (65.7%), thickening of the intestinal wall was observed in 28 patients (80%). The outer contour of intestine was uneven in 16 patients (45.7%) are not determined by its definition in 42.9% of in 15 patients. Partial differentiation layers of the intestinal wall was determined only in 3 patients (8.6%), the tumor tissue infiltrated adrectal in 15 (42.9%) patients, the increase is adrectal lymph nodes was observed in 25 (80%) patients. 5 (14.3%) patients had tumor invasion in the internal and external sphincters, no germination in adjacent organs -100%.
At uT4 stage 3 (60%) patients had tumor internal and external sphincter. In all these patients, 100% of the tumors are observed as circular, with thick walls, with infiltration and adrectal fiber spreading to adjacent organs. As a result, the outer contours of the intestinal wall is not visualized, differentiating layers of the intestinal wall were not determined, visualized enlarged lymph nodes in adrectal tissue. According to our data, the sensitivity in the diagnosis LSCRC was 94.8%, specificity - 85.8%.
TRUS was conducted on patients over 15-21 days after chemoradiotherapy (average 18 days) during fading of clinical manifestations of local radiation reactions.
Most (80%) cases, according to TRUS only decreased tumor size and infiltration of the bowel wall layers remained the same.
As a result of dynamic supervision it was found that the decrease in tumor invasion and depth of the wall of the rectum aredue to several reasons. Reduction of component perifocal inflammation, which is always present in advanced cancer. Reduction of adrectal component of the tumor by cytostatic effect of treatment. Reducing the size of the tumor by sealing the connective tissue structures of the tumor.
Conclusion. Thus, TRUS allows to assess the extent of lesions of rectal wall tumor, to determine the depth of infiltration, adrectal tissue metastatic lesions of adrectal
Tom 18. N 5-6 2014 p.
lymph nodes. This method clearly visualizes tumor spread to adjacent organs and tissues. It is essential to establish the prevalence of tumor stage and choosing the optimal treatment. According to our data, the sensitivity in the diagnosis MPRPK was 94.8%, specificity - 85.8%.
The data confirm the applicability of TRUS to assess the effectiveness of the neoadjuvant treatment of RC.
References
1. Fedorenko Z.P. Byuleten' nazional'nogo kanzer-reestru Ukraini № 14. „Rak v Ukraini, 2011-2012". / [Z.P. Fedorenko, Yu.Y. Michaylovich, L.O. Gulak ta in.].- Kiiv,
2013.- 120s.
2. Analiz vyzhivaemosti bol'nych rakom pryamoy kishki posle spezializirovannogo lecheniya / D. V. Myasnikov, A. V. Ne-sterov, D. V. Nikishin [i dr.] // Izvestiya vysshich ucheb-nych zavedeniy. Povolzhskiy region. Medizinskie nauki. -
2014. - № 2 (30). - S. 84-95.
3. Chornobay A. V. Endolimfatichna terapiya v kom-pleksnomu likuvanni chvorich na zloyakisni novoutvoren-nya malogo taza : avtoref. dis. na zdobuttya nauk. stu-penya dok. med. nauk : spez. 14.01.07 «Onkologiya» / A. V. Chornobay. - Kiiv, 2006. - 36 s.
4. Toropov V. Yu. Rezul'taty endorektal'noy ul'trazvukovoy tomografii v opredelenii stepeni mestnogo rasprostra-neniya opucholevogo prozessa u bol'nych rakom pryamoy kishki. / Toropov V. Yu., Sholochov V.N., Zaryuk V.F. // Aktual'-nye voprosy onkogastroenterologii : Mezhregion-al'naya nauchno-prakticheskaya konferenziya : Mat. konf. T. 2. - Bar-naul, 2003, S. 100-101.
5. Abramchik R.R. Monitoring sostoyaniya bol'nych rakom pryamoy kishki metodom sonografii. / R.R. Abramchik, A.I. Kush-nerov, G.E. Tur [i dr.] // Voennaya medizina. - 2013. - № 1. - S. 37-39.
6. Efremova I. Yu. Ul'trazvukovaya diagnostika v ozenke mestnoy rasprostranennosti opucholevogo prozessa pri rake pryamoy kishki / I. Yu. Efremova // Onkologiya. Zhur-nal imeni P. A. Gerzena. - 2012. - № 1. - S. 39-43.
7. Sandrikov V. A. Transrektal'noe ul'trazvukovoe issledo-vanie kak metod diagnostiki mestnorasprostranennogo ra-
ka pryamoy kishki / V. A. Sandrikov, P. V. Zar'kov, L. E. Belyaeva // Ul'trazvukovaya i funkzion. diagnostika. -2011. - № 4. - S. 131
8. Toropov V. Yu. Vozmozhnosti endorektal'noy ul'trazvukovoy tomografii v diagnostike i ozenke stepeni mestnogo rasprostraneniya raka pryamoy kishki: avtoref. dis. na soiskanie nauk. stepeni kand. med. nauk: spez. 14.00.19 «Lu-chevaya diagnostika, luchevaya terapiya». - Moskva, 2004 - 83s.
9. Orlova, L. P. Predoperazionnaya endorektal'naya ul'traz-vukovaya ozenka rasprostraneniya raka pryamoy kishki / L. P. Orlova [i dr.] // Ul'trazvukovaya i funkzional'naya di-agnostika.- 2004. - №4. - S. 40-45.
10. Kazakevich V.I. Ul'trazvukovoe isssledovanie vnutripolost-nym datchikom pri mestno-rasprostranennom rake pryamoy kishki / V.I. Kazakevich, JI.A. Mitina, JI.A. Vashakma-dze [i dr.] // Koloproktologiya. -2004. - T.1, №7. - S.11-14.
11. Prakticheskoe rukovodstvo po ul'trazvukovoy diagnostike. Obschaya ul'trazvukovaya diagnostika / pod red. V.V. Mit'-kova. M.: Izdatel'skiy dom Vidar-M, 2006. - 720 s.
12. Abdullaev R.Ya. Ul'trazvukovaya diagnostika opucholey abdominal'nych organov. / [R.Ya. Abdullaev, T.S. Golovko, G.V. Lavrik i dr.]. Ch.: Nove slovo, 2012. - 173 s.
13. Proklov A.A., Zatachaev A.V. Ul'trazvukovaya diagnostika zabolevaniy pryamoy i obodochnoy kishki. / A.A. Proklov, A.V.Zatachaev // Problemy koloproktologii. - 2000. - T.17, №1.- S. 172—174.
14. Stazenko E. A. Sonografiya v diagnostike kolorektal'nogo raka / E. A. Stazenko // Promeneva diagnostika, promene-va terapiya. - 2011. - № 1/2. - S. 123.
15. Beer-Gabel M. A new rectal ultrasonographic method for the staging of rectal cancer / M. Beer-Gabel, Y. Assouline, O. Zmora [et al.] // Diseases of the Colon and Rectum. -2009. - Vol. 52. - P. 1475-1480. .
16. Halefoglu A.M. Endorectal ultrasonography versus phased-array magnetic resonance imaging for preopera-tive staging of rectal cancer / A.M. Halefoglu, S. Yildirim, O. Avlanmis [et al] // World Journal of Gastroenterology. -2008. - №14. - P. 3504-3510
MaTepian HagitiujOB go pegamii18.02.2015
