<<
>>

INTRODUCTION

Research urgency.

One of the most difficult for treatment of forms of malignant neoplasms are primary malignant tumours of a brain. On epidemiological data frequency of primary tumours of a brain makes 2 % from all cases of malignant neoplasms at adults, the case rate makes from 7-8 to 13,9-14,8 cases on 100000 population in a year [Ulitin A.J., 1997; Wrensh M.K.

et al., 2000; Grant R., 2004; McKinney P.A., 2004].

Last years the tendency to case rate augmentation primary tumours of a brain in industrially developed countries that is bound not only to improvement of the organisation of medical aid and diagnostic possibilities, but also actual growth of a case rate [Gajdar B.V., 2000, Enam S.A becomes perceptible. et al., 2000]. In the Russian Federation it is annually registered not less than 10 thousand patients with the primary

nejroepitelialnymi brain tumours [Oljushin V. E and co-workers., 2008].

Unsatisfactory results of treatment gliom high degree zlokachestvennosti force to search for new variants of treatment. Despite achievements radial and chemotherapies in modern nejroonkologii the leader in treatment malignant gliom still has a surgical cytoreduction [Hulshof MC. et al., 2001; Carapella CM. et al., 2011; Eyupoglu IY. et al., 2013]. And, though the question on influence of degree of a resection on the further forecast at patients with malignant gliomami remains unresolved, many authors consider, that more radical oncotomy is pledge of the successful combined treatment, duration augmentation bezretsidivnogo the period and the general survival rate [Konovalov A.N., 2006; Lacroix M. et al., 2001; McGirt et al., 2009; Kuhnt D. et al., 2011; Sanai N. et al., 2011].

However, sensations of the surgeon at definition of degree of radicalism of an oncotomy, are always subjective and insufficiently informative, to what results postoperative control MRT [D testify. Orringer and co-workers., 2012]. So, according to Aguilera D.G. And co-workers. (2009) frequency of total resections makes only 32 %. Even in cases makroskopicheski a total oncotomy, according to control MRT a brain it proves to be true less than at 40-50 % of patients [Qnigley M.R. et.al., 1991]. Thus, objectively degree of a resection malignant gliom can be estimated only according to postoperative nejrovizualizatsii [Ternovoj S.K. from co-workers. 2006; Shaw E.G. et al., 2008].

Though, the postoperative lethality and risk of development of postoperative complications as a whole do not depend on degree of radicalism of an oncotomy [Svistov D.V. and co-workers., 2011; Chang S.M. et al., 2003; Daigle K. et al., 2013] its total excision without development or aggravation of neurologic deficiency is a difficult and actual problem in the absence of accurate borders between a tumoral tissue and cerebral substance at infiltrativnom tumour growth. Despite modern technical possibilities, the risk of occurrence of rasping neurologic deficiency remains at a resection of a tumour within not changed substance of a brain, especially at tumour localisation in functionally significant areas of a brain [Otani N. et al., 2005; Smith J.S. et al., 2008].

Thus, the important problem is search and studying of methods intraoperatsionnoj diagnostics, allowing objectively to estimate borders of volume formation and to carry out a safe resection of a tumour. Application of modern methods intraoperatsionnoj diagnostics, such as electrophysiological kartirovanie, an electrical stimulation [Duffau H.

et al., 2002; Kombos T. et al., 2009], ultrasonic diagnostics [Savello A.V., 2008; Solheim et al. 2010; Unsgaard G. et al., 2006; Tronnier VM. et al., 2001; Unsgaard G. et al., 2002; Nikas D. C. et al., 2003], computerised 3D navigation [Lapshin R. A, 2006; Maesawa S. et al., 2009; Levy R. et al., 2009; Rahmathulla G. et al., 2012], complex navigation [Duffau H., 2008; Gonzlez-Darder J.M. et al. 2010] promote reduction travmatizatsii at access to an intracerebral neoplasm and allows to lower effectively risk of development of postoperative complications, even in localisation cases in functionally significant zones. However possibilities of the majority of methods nejronavigatsii for intraoperatsionnoj indications of tissues of a tumour because of infiltrativnogo growth and an edema are rather limited.

It, undoubtedly, confirms a high urgency of search and development of new effective methods intraoperatsionnoj the navigation, allowing to visualise border between a tumour and substance of a brain, to identify sites of activly proliferating tumoral tissue. In the given direction the method intraoperatsionnoj fluorescent diagnostics which gives the chance effective intraoperatsionnoj to differentiation of zones of tumoral growth from a cerebral tissue and the control of borders of a resection is perspective. At the heart of a method of fluorescent diagnostics ability of some medicinal preparations (photosensitinogens) selectively lays to collect in a tumoral tissue and at influence of radiation of light defined waves are long to initiate fluorescence that gives the chance intraoperatsionnoj to differentiation of a tumour from a cerebral tissue and the control of borders of a resection.

Hence, active studying and method introduction intraoperatsionnoj fluorescent diagnostics in routine practice of surgical treatment malignant gliom, and also working out of standards of its application is a perspective direction modern nejroonkologii.

Degree of a readiness of a theme of research

Now there is an active studying of possibilities intraoperatsionnoj fluorescent navigation at surgical treatment of patients malignant gliomami [Potapov, A.A, etc., 2012; Pinsker, M.O. et al., 2007; Pogue, B.W. et al., 2010; Stummer, W. et al., 2011]. Nevertheless, risks of development of postoperative neurologic complications and the remote outcomes of treatment of patients with malignant gliomami, bound to more aggressive resection are insufficiently studied at use fluorescent intraoperatsionnoj diagnostics. Communication of intensity of observable fluorescence and histological structure of a deleted tissue is badly studied. All it, undoubtedly, testifies to importance of the further, profound studying of efficiency and safety of the given method at surgical treatment malignant gliom, and also working out of the differentiated approach to excision of sites of a tumour with various intensity of fluorescence.

Research objective

To improve results of surgical treatment of patients with malignant gliomami a brain at use intraoperatsionnoj fluorescent diagnostics at the expense of safe augmentation of volume of a remote tumour.

Research problems

1. To estimate influence of volume of a resection malignant gliom a brain on the nearest and remote outcomes of treatment at patients with complete cases.

2. To study influence intraoperatsionnoj fluorescent diagnostics on radicalism of a resection of a tumour according to objective methods of research, frequency of postoperative complications and quality of a life of patients with malignant gliomami a brain.

3. To investigate interrelation between intensity of fluorescence and histological structure of a deleted tissue.

4. To study the prognostic factors defining a current and outcomes of disease at patients with malignant gliomami of a brain, and on their basis to develop diagnostic algorithm of the forecast of survival rate of the given group of patients.

Scientific novelty

Positive influence of augmentation of degree of radicalism of an oncotomy on a current of the postoperative period, duration augmentation bezretsidivnogo the period and the general life expectancy of patients is proved, being based on complete cases.

Application influence intraoperatsionnoj fluorescent diagnostics with use of 5-aminolevulinic acid on frequency of postoperative complications and quality of a life of patients with malignant gliomami is established.

The expediency of an aggressive resection malignant gliom within a zone intraoperatsionnoj is proved fluorescence.

Features of use of a method intraoperatsionnoj fluorestsentsentnoj diagnostics with use of 5-aminolevulinic acid at various stages of excision malignant gliom on the basis of an interrelation estimation between intensity of fluorescence and histological structure of a deleted tissue are taped.

The prognostic factors influencing a current and outcomes of disease at patients with malignant gliomami of a brain are defined

Diagnostic tables allowing are developed to estimate the forecast of a current and outcomes of disease at patients with malignant gliomami a brain for a choice and optimisation of tactics of treatment.

The practical importance of work

By results of the performed work:

- The expediency of the greatest possible surgical cytoreduction for duration augmentation bezretsidivnogo the period and the general life expectancy of patients with malignant gliomami a brain is confirmed;

- Efficiency and safety of a method intraoperatsionnoj fluorestsentsentnoj diagnostics which are carried out by a portable apparatus digital complex, for authentic augmentation of number of total resections at patients with malignant gliomami a brain is confirmed;

- Application influence intraoperatsionnoj fluorescent diagnostics on frequency of development of postoperative complications and the remote outcomes at patients with malignant gliomami a brain is defined;

- The importance of intensity observed intraoperatsionnoj is shown fluorescence for degree definition zlokachestvennosti to a deleted tissue that has allowed to develop references on method use intraoperatsionnoj fluorescence during a resection malignant gliom;

- On the basis of the allocated prognostic criteria of survival rate the diagnostic algorithm of the forecast of a current and outcomes of disease at patients with malignant gliomami a brain is developed. The offered algorithm allows to carry out a choice of volume and treatment tactics, and also to estimate necessity and validity of use of the methods bound to risk of development of complications.

Methodology and research methods

404 patients are included in research with malignant gliomami supratentorialnoj localisations which with 1998 till May, 2012 have been operated in clinic of neurosurgery and on clinical bases of chair of neurosurgery of Army medical college of a name of S.M.Kirova (351 patient retrospective group, 53-basic).

Patients have been included in research with an open microsurgical oncotomy. From retrospective group, according to criteria of including, patients for each spent analysis were separately selected. The basic group included 53 patients with suspicion on malignant gliomy supratentorialnoj the localisations operated since September 2011 g till May, 2012 in VMedA.

The duration analysis bezretsidivnogo the period and survival rate is carried out. Duration bezretsidivnogo the period and life expectancy counted from time of statement of the histological diagnosis before development of objectively confirmed relapse and a lethal outcome because of a tumour progression, accordingly. Actual life expectancy was known at 135 patients with glioblastomami and 111 - with anaplastic astrocytomas.

The basic group included 53 patients with suspicion on malignant gliomy a brain (16 - with anaplastic astrocytomas, 35 - with glioblastomami, at two patients the histological material corresponded to a picture of a medical pathomorphism). The microsurgical oncotomy with application of an expanded complex intraoperatsionnoj diagnostics has been executed. Last included simultaneous use of ultrasonic research and fluorescent diagnostics with preparation reception "Alasens" (GNTS "NIOPIK") inside 3 hours prior to a stage of an oncotomy from calculation of mass of a body of 20 mg/kg. For carrying out of fluorescent diagnostics used the portable apparatus complex combined with an ordinary operative microscope, allowing to carry out surgery field illumination by "dark blue" light from a long wave of 417 and 435 nanometers. The research report has been approved by ethical committee of Army medical college. The basic and control groups did not differ on age, gravity of a condition, the histological diagnosis, volume and tumour localisation, operation volume.

All patients have been surveyed under the standard scheme which included obshcheklinichesky and neurologic surveys, ophthalmologic and radiological inspection. To all patients it was carried out preoperative MRT with introduction of a paramagnetic contrast agent. Neoplasm volume counted on Macdonald D.R. et al., (1990). Thus volume of a resection of a tumour estimated as an expanded biopsy at excision

<< | >>
A source: Anokhina Julia Evgenevna. CLINICO-MORPHOLOGICAL OUTCOMES of the RESECTION MALIGNANT GLIOM the BRAIN With USE INTRAOPERATSIONNOJ of FLUORESCENT DIAGNOSTICS. The dissertation on competition of a scientific degree of the candidate of medical sciences. St.-Petersburg - 2014. 2014

More on topic INTRODUCTION:

  1. in introduction
  2. INTRODUCTION
  3. INTRODUCTION
  4. 10.1. Introduction
  5. INTRODUCTION
  6. approbation and introduction of results.
  7. Introduction
  8. Introduction
  9. INTRODUCTION
  10. INTRODUCTION
  11. Introduction
  12. Introduction
  13. INTRODUCTION
  14. Instead of Introduction …
  15. PRACTICAL INTRODUCTION OF RESULTS OF WORK
  16. 5. Attention strengthening to questions of legal introduction.
  17. Introduction
  18. Introduction