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2TO THE QUESTION OF COMPLEX TREATMENT OF NEUROEPITHELIAL
TUMORS OF THE BRAIN Juraev A.M.
Juraev Anvar Mamatmuradovich - Assistant of the Neurosurgery, DEPARTMENT OF NEUROSURGERY, SAMARKAND STATE MEDICAL UNIVERSITY, SAMARKAND, REPUBLIC OF UZBEKISTAN
Primary brain tumors occur in about 10% of all neurological diseases of non-traumatic origin. In the same percentage of cases, they are the cause of death from all diseases of non-tumor origin and the second most common cause of death in neurosurgical patients after vascular diseases [1,4,13]. Detection of a primary brain tumor, its metastases, as well as the degree of response to subsequent chemoradiotherapy is impossible without the use of modern neuroimaging methods such as CT and MRI. No less important is the diagnosis of complications of the early (in the first two days) postoperative period (hematoma, ischemia, edema, dislocation) and the assessment of the degree of radicalness of the surgical intervention performed [6,11,12]. To date, there is no doubt that the best results therapies for this type of tumors are provided by a comprehensive therapeutic approach, including surgery, cytotoxic chemotherapy, and radiation therapy [2,3,14]. It has been shown that even at a distance of more than 4 cm from the removed tumor node, many tumor cells with increased proliferative activity remain [8,9]. This is due to the variability of tumor cells in the process of growth, development, and therapeutic measures [10]. According to the opinion of most experts, complete cure of a tumor by surgical, radiation, chemotherapeutic or other methods, as a rule, fails, which puts the treatment of these tumors among the most difficult problems of modern neurosurgery [5,6,7,15]. Until now, the problem of complex treatment of intracerebral tumors of the cerebral hemispheres remains one of the most pressing issues of neurooncology, which requires the search for new research in this area.
Purpose of the study. Study of the results of complex treatment of patients with glial tumors of the brain, operated in the department of neurosurgery of the clinic of the Samarkand Medical Institute.
Materials and research methods. In 2003-2014, 569 patients with brain tumors were operated on in our clinic. Of these, neuroepithelial tumors accounted for 47%, and tumors growing from the meninges and other structures accounted for 53%. In this work, we decided to analyze the data of 69 patients with intracerebral brain tumors who were operated on in 2013-2014. The age of patients ranged from 10 to 68 years, on average 39 years. Among the operated patients, 38 (55.1%) were women, 31 (44.9%) were men. 21 (30.4%) patients underwent CT and 48 (69.6%) - MRI. Statistical processing was performed by the Microsoft Office Excel 2017 application package.
Results and its discussion. Of the 69 patients, 64 had primary tumors, and 5 had recurrent tumors. Based on the morphological classification of WHO (2007), histological studies were performed, which revealed piloid astrocytomas in 10 patients (14.5%), fibrillar and protoplasmic astrocytomas in 24 (34.8%), oligodendrogliomas in 8 (11.6%), and oligodendrogliomas in 18 (26.1%) - anaplastic astrocytomas, 4 (5.8%) - anaplastic oligodendroglioma, 2 (2.9%) - anaplastic ependymoma, 2 (2.9%) - glioblastoma and 1 patient with choroid carcinoma. These statistics show that, according to the degree of malignancy (WHO grade), highly differentiated intracerebral tumors (WHO grade I, II) occurred in 60.9%, and poorly differentiated and undifferentiated glial tumors (WHO grade III, IV) in 39, 1% of patients. By localization: in 36 (52.2%) patients, the tumor was located in the left hemisphere, in 33 (47.8%) - in the right hemisphere. In most patients, the tumor was localized in the temporal lobes - 15 (21.7%), in the frontal lobes - 10 (14.5%), in the frontotemporal region - in 10 (14.5%) patients, in the temporal in the parietal region - in 9 (13%) patients, in the parietal region - in 8 (11.6%) patients, in the parieto-occipital region - in 7 (10.1%) patients, in the fronto-parietal and temporal-parietal-occipital - in 3 (4.3%) patients, as well as in the temporo-occipital region in 2 (2.9%) patients, in the temporobasal and frontotemporo-parietal regions in 1 patient each. Depending on the localization and degree of malignancy of the tumors, the clinical picture and the course of the disease were different.
During the operation, not only localization was taken into account, but also the functional significance of the tumor location areas so that the surgical approach was physiologically permissible and did not cause additional damage.
functionally significant pathways (FZPP). Operations were performed by osteoplastic trepanation (58 patients) and resection trepanation (11 patients) with tumor localization in the middle cranial fossa. 64 patients underwent total and subtotal removal of tumors, in 5 patients, given the gigantic size with infiltration of two or three lobes of the brain, they limited themselves to tumor biopsy. In case of cerebral edema and the presence of a dura mater defect (DM) at the end of the operation, autoplasty of the DM was performed with a graft from the fascia lata. With the development of severe cerebral edema in 3 patients, the bone flap was removed at the end of the operation.
We have developed and installed in 48 patients a subdural and epidural adjustable closed drainage system using a sterile disposable system. The peripheral end of the system is connected to a sterile, 1/5 filled with furatsilina solution vial. The vial level setting depends on the frequency of drops of bloody tissue discharge (fluid) from the wound, individually. This system is inserted through a mini-incision of the skin into the wound and provides good drainage of the accumulated tissue fluid from the subdural and epidural space, and in this way it is possible to regulate the volume of tissue fluid separated with the prevention of possible compression of the brain
by a fluid or bloody volumetric formation. Among the operated 48 patients with the installation of such a system, no postoperative complications were observed in any case. Also, postoperative complications (cerebral edema, liquorrhea) were not observed in those patients who underwent autoplasty of the dural defect.
All patients received postoperative radiation therapy. Follow-up from 6 months to 1 year was studied in 22 patients who received radiation therapy in a total dose of 56-60 Gy. Of these, in 4 patients with glial hypergrade tumor, control MRI revealed tumor recurrence. 1 of them had glioblastoma and was given radiation therapy, which he did not take. He underwent a second operation, 4 days after the operation, a lethal outcome was observed. The remaining 3 patients, despite complex treatment, including radiation therapy, developed a relapse. These patients received chemotherapy. Conclusions.
1. Among our patients, neuroepithelial tumors were more common in women - 55.1%, and according to the histological picture, highly differentiated intracerebral tumors (WHOgrade I, II) - 60.9% have an advantage.
2. By localization, in 52.2% of cases the tumors were located in the left hemisphere of the brain and most often in the temporal and frontal lobes.
3. When studying the follow-up in 22 patients up to one year in the postoperative period, only 3 patients with a hypergrade tumor had a tumor recurrence. One patient did not receive radiation therapy and died 4 days after the second operation.
4. Postoperative complications (eg, cerebral edema, liquorrhea) did not occur due to the use of free autoplasty of the dura and an adjustable closed drainage system into the epidural and subdural spaces.
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