Analysis of clinical outcomes of cervical carcinoma surgery in fertile age patients

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Navruzova Visola Sarimbekovna, National cancer research center of Uzbekistan E-mail: drsharof@mail. ru
Analysis of clinical outcomes of cervical carcinoma surgery in fertile age patients
Abstract: In the NORC MH Uz we analyzed the outcomes of surgical treatment of 204 young patients with cervical cancer. We observed mainly the patients with exophytic -82 (40.2%) and 68 endophytic growth (33.3%) of cervical tumors. Besides standard examination the patients were determined sex hormone level (estradiol, progesterone), CA-125 level, calcium and phosphate level in blood. The treatment effect was evaluated by dynamic monitoring of patients as well as it was studied the quality of life of a young body. Patient'-s life quality was followed in dynamic by MENQOL American system.
Keywords: cervical cancer, fertile age, squamous cell, systemic chemotherapy, endoarterial regional chemotherapy, sex hormones, fertility-sparing surgery, ovarian transposition, effectiveness of treatment, quality of life, dynamic monitoring.
Today cervical cancer (CC) remains the most common malignant tumor of female genital organs. Every year it is revealed about 500,000 new cases of CC in the world and each year 300,000 wom-
en die from this disease. Herewith, 75% of cases occur in developing countries in Africa, Latin America and Asia, where CC is firmly takes 1st place in the cancer incidence of the female population, and only 25% - in economically developed countries in Europe and North America. Annually, the European Union diagnoses more than 25,000 cases of CC and about 12,000 deaths from this disease [1- 5- 7- 8]. In the structure of oncological morbidity of female reproductive system of the Republic of Uzbekistan CC takes second place after breast cancer and the fourth place in the incidence of all cancers in the country [3]. In 2014, intensive incidence rate was 4.6 cases per 100,000 population. The highest cervical cancer incidence has been reported in women of 45−55 yrs. The world reports have estimated that women under 50 years of age comprise 3% per year, with a particularly significant incidence increase in women up to 29 years, in Russia it is 2.1% per year. The similar trend to CC increase in women of fertile age has been followed in other countries. Currently, there are following methods of CC treatment: surgery, combined radiotherapy, chemotherapy. However, the principal therapeutic methods for cervical cancer are surgery and radiation which are used both separately and in vari-
ous combinations. In severe cases it is necessary to perform advanced surgery, the volume of which is directly depended on the advance of tumor process. Most CC patients who underwent radical treatment tended to keep the former style of life, social status, and work activities. The quality of life as an integral characteristic of physical, psychological, emotional and social functioning of a woman is based on her subjective perception. When performing radical surgery on young women with CC it is advisable to carry out the transposition of both ovaries in the lateral channels of the abdominal cavity, removing them from subsequent exposure to radiation in order to preserve hormone function considering the serious consequences of post-castration syndrome. A distinctive characteristics of extended hysterectomy with ovarian transposition is the preservation of uterus — ovary and fallopian tube and their neurovascular connections located in the funnel — pelvic ligament [4- 9].
To standard cervical cancer surgery for stage IB1-IIIa is to be an extended hysterectomy with appendages. In fertile age patients ovaries can be preserved and led beyond the pelvis. The advantages of surgical approach to beam are the chance to save ovarian function and vagina elasticity in young patients. Ovarian transposition can be performed at squamous cell carcinoma in high and moderate differentiation and the absence of tumor vascular embolism.
Analysis of clinical outcomes of cervical carcinoma surgery in fertile age patients
Material and methods
We have analyzed the survey data and the phases of treatment 204 patients with CC. All patients examined in the treatment guidelines were divided into 2 groups:
1. The study group — 112 patients who had combined and complex therapy with fertility- saving surgery.
2. The control group — 92 patients who had combined and complex therapy with traditional approach. Sources of information are the following data:
1. Complaints data, anamnesis and objective status at the time of examination and treatment, analysis of patient card, medical history, operation log, archive data, pathology laboratory data.
2. The results of dynamic observation, survey of patients, monitoring the treatment effect and quality of life of patients, requests in the oncology clinics and oncology offices domiciliary.
Analysis ofage characteristics shows that over the past 20−25 years in the Republic of Uzbekistan CC occurs more common in younger women. According to WHO, the young age is considered the age of 18 to 45 yrs. Our studies included the patients aged 23 to 45 years, i. e., in the most hard-working and fertile period. The incidence peak is at the age of 31−45 yrs. Of 204 patients 63 (30.8%) were the city residents and 141 (69.2%) of the patients were from rural areas.
Table 1. — Distribution of the followed
Considering the young age of patients of the study group, in addition to standard methods of diagnosis all 112 patients were determined the level of sex hormones (estradiol, progesterone) in order to study the functional state of the ovaries. To study the organic condition of the ovaries and exclude the presence of tumor in the ovary it was performed ultrasound, Doppler ultrasound, CT and determined CA-125 — tumor marker level, as well as some of the patients (34 patients) were determined the level of calcium and phosphate in blood. Complete blood count showed that in most of observed patients, anemia was more frequently detected both in study and control groups. Group I included 112 (55.1%) patients, who underwent surgery with ovarian transposition as a part of combined and complex therapy. Group II included 92 (44.9%) patients, who underwent surgery without ovarian transposition as a part of combined and complex therapy. Each group was divided into 3 subgroups: Subgroup 1 comprised the patients with stage T1b2aN0M0, who underwent surgery + combined radiotherapy (CRT). Subgroup 2 comprised the patients with stage T N M0 who underwent systemic PCT + surgery + CRT. Subgroup 3 comprised the patients with stage TNM0 who underwent endoarterial regional continued chemotherapy (EARCCT) + surgery + combined radiotherapy CRT. The technique of surgical treatment with ovarian transposition for patients with cervical cancer: The distinctive feature of extended hysterectomy with ovarian transposition is the preservation of the uterus (ovaries and fallopian tubes) and their neurovascular connections located in funnel-pelvic ligament. There are several wing, posterior wall of pelvic, on both sides of spinal column, the upper
The mean age of patients was 36.7 ± 4.4 yrs. Analysis of the obtained data showed that the initial complaints of all 204 patients were general weakness, fatigue, watery or sanious discharges from the genital tract, pain in the abdomen and lower back. The symptom-complexes, specific to cervical cancer lesions, depending on the duration of the first signs in a varying degree were identified. Pain syndrome was in 136 (66.7%) of observed CC patients. Patients noticed the pains of different nature: dull, aching, cramping, or moderate, varying duration — constant, periodic or unannounced, various sites — low abdomen, in the back, in the crotch area, when urinating or during defecation. The condition of initial focus and tumor grading was evaluated as follows: tumor location (anterior lip, posterior lip ectocervix or endocervix, with/without transition on neighboring organs and tissues, tumor size, growth form, parametrical tissue infiltration, invading to regional lymph nodes. During our examination we mainly met the patients with exophytic 82 (40.2%) and endophytic growth — in 68 (33.3%) cervical tumors. Diagnosis was verified morphologically in all 204 (100%) patients. Histologically, 197 (96.6%) patients were diagnosed squamous cell carcinoma of cervix with/without keratinization, 7 (3.4%) — cervical adenocarcinoma. G1 — high degree of differentiation, G2 — moderate degree of differentiation and G3 — low grade were isolated by histo-pathological differentiation of tumor cells. All patients were distributed by TNM system as follows (tabl. 1). patients by groups and stages (n = 204)
abdomen, and others options for ovarian transposition: to iliac. The best optimal version is the transposition of ovary in the upper abdomen. As a result of transposition the ovaries are displaced on supplied & quot-pedicle"- into the upper abdomen and, herewith, they are removed from the zone of postoperative irradiation and become prevented from radiation castration (Fig. 1.).
Fig. 1. The scheme of preservation and lateral transposition of ovaries in upper abdomen, jvary transposition without fallopian tube. After removal of the preparation the main anatomical structures are clearly visualized in the surgical wound: neurovascular bundles (total, external and internal iliac artery and vein), ureters, obturator nerve, the cult of vagina, bladder and rectum. Small bowel loops are fixed in the upper abdomen
Stage Main grou p (n = 112) Control group (n = 92) Total
аbs. % аbs. % аbs. %
TlbNoMo 5 2.5 2 0.9 7 3. 4
T2 aNoMo 18 8.8 19 9.1 37 17. 9
T2 BNoMo 57 27.9 32 15.9 89 43. 8
T2 bNIMo 11 5.5 17 8.3 28 13. 8
T3 aNoMo 21 10.2 22 10.9 43 21. 1
Total 112 54.9 92 45.1 204 100. 0
Fixation of appendages are made with certain silk ligatures to the lateral divisions of the abdominal wall in the hypochon-drium- this makes available to remove the ovaries of the zone of possible exposure in postoperative period- during topometry their location is determined on the plain film of abdominal cavity. This sequence of surgical operations ensures the safety of ovaries and their vascular & quot-pedicles"-.
The main clinical criteria of the effect of antitumor treatment are the immediate objective effect, the development of side effects, recurrence and period of their development, the survival rate of patients within 3 years of observations.
Overall survival analysis of patients showed that the efficacy of treatment in study and in control group were almost the same, in study group is slightly higher than in control.
Table 2. — Survival rate depending on the stage (%)
1 year 2 year 3 year
Stage 100 100 100
T2aNoMo 100 97.1 94. 2
T2bNoMo 98.5 95.5 92. 5
T2bN1Mo 96.7 89.2 81. 3
T3aNoMo 96 76 72
T3aN1Mo 86 71.5 67. 5
To study the quality of life is a relatively new field of clinical research. However, it attracts more and more attention in the study of oncology diseases and can serve as the main criterion for clinical
efficacy. Quality of life is considered one of the key parameters in the study of ultimate results of the treatment. Quality of life of patients in the dynamics of observation was determined by American system MENQOL. Dynamic monitoring of patients was carried out with full examination every 3 months during the first year after treatment completion, in the sequel every 6 months. Observation periods vary more than 3 years.
Technology of functionally — sparing treatment of CC in fertile age women is a new approach without detriment to the outcomes of therapy for cancer patients. To spare the functional activity of the ovaries in young patients with favorable prognostic factors (early stage, high differentiation of the tumor, the absence of ovary affection, the ovaries with preserved function) allows avoiding violations, developing at different times after removal of gonads.
These studies testify the possibility of preserving the uterus and ovaries in women of fertile age with careful pre- and intraoperative examination.
Analysis of conducted data (over 3 years) shows that the fertility — sparing volume of surgery improves the immediate and long-term results of treatment.
Overall, the organ and function-sparing approaches in the treatment of gynecological cancer patients is relevant and promising research direction, allowing not only to cure the patient, but also to maintain the basic functions offemale body, to improve greatly the quality of life, reduce the time of social and psychological rehabilitation.
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Normatova Shakhnoza Anvarovna, Fergana branch of the Tashkent medical academy, Head of the department of hygiene and public health E-mail: shahnozaid@mail. ru
Hygienic assessment of persistent organochlorine pesticides in milk products
Abstract: In this article the hygienic assessment of averages entering the body in the milk and milk products daily doses of persistent organochlorine pesticides in the towns of the Ferghana valley (Ferghana, Andijan, Namangan region). According to a special formula has been determined the actual level of pesticides and on the results of the study made the appropriate conclusions.
Keywords: milk and dairy products, organochlorine pesticides, the sample, the average number, of daily dose, a residue, risk.

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