#1
|
|||
|
|||
Äåâóøêà 29 ëåò : Àòèïè÷íûé êàðöèíîèä ë¸ãêîãî
Äîáðûé äåíü! Íóæíû ñîâåòû! (Ýìîöèé áîëüøå ÍÅÒ)
Ó î÷åíü êðàñèâîé è ìîëîäîé äåâóøêè, 29 ëåò ( ðåáåíêó ãîä) íàøëè àòèïè÷íûé êàðöèíîèä ëåãêîãî, ìåòàñòàç â ëèìôîóçåë (îäèí èç òðåõ íà ñòåêëàõ) 14 èþëÿ áûëà ïðîâåäåíà îïåðàöèÿ: Íèæíÿÿ ëîáýêòîìèÿ ïðàâîãî ë¸ãêîãî ñ ôîðìèðîâàíèåì ìåæáðîíõèàëüíîãî àíàñòîìîçà. Ïðè ðåâèçèè óñòàíîâëåíî, ÷òî â êîðíå íèæíåé äîëè ðàñïîëîãàåòñÿ áîëüøîé îïóõîëåâûé óçåë äî 6 ñì â äèàìåòðå, ðåãèîíàëüíûå ëèìôàòè÷åñêèå óçëû óâåëè÷åíû. Âñå äîñòóïíûå ëèìôîóçëû êîðíÿ ëåãêîãî è ñðåäîñòåíüÿ óäàëåíû ïîñëå øèðîêîãî âñêðûòèÿ ñðåäîñòåíüÿ (Íîìåðà óäàëåííûõ ëèìôîóçëîâ N=3,4,5,7,8,9,10,11,12) ( 6 íà îùóïü óâåëè÷åí íå áûë ) __________ Áûëè ñäåëàíû ñòåêëà è îòäàíû íà ãèñòîëîãèþ â Ãåðöåíà, îïèñàíèå: Àòèïè÷íûé (Óìåðåííî äèôåðåíöèðîâàííûé) êàðöèíîèä ë¸ãêîãî ñ ïåðèáðîíõèàëüíîé, ïåðèíåâðàëüíîé è ïåðèâàñêóëÿðíîé èíâàçèåé.  1 èç 3 ëèìôàòè÷åñêèõ óçëîâ - ìåòàñòàç êàðöèíîèäíîé îïóõîëè áåç èíâàçèè çà ïðåäåëû êàïñóëû. __________ Ñäåëàë èìóíîãèñòîõèìè÷åñêîå èññëåäîâàíèå â Áëîõèíà:  ãîòîâûõ ïðåïàðàòàõ:  ñòåíêå êðóïíîãî áðîíõà, ñ ðàñïðîñòðàíåíèåì íà îêðóæàþùóþ ë¸ãî÷íóþ òêàíü - ðàçðàñòàíèå íåéðîýíäîêðèííîé îïóõîëè; â ëèìôàòè÷åñêèõ óçëàõ - ìåòàñòàçû íåéðîýíäîêðèííîé îïóõîëè. Äëÿ ïîäòâåðæäåíèÿ ãèñòîãåíåçà îïóõîëè ë¸ãêîãî è óòî÷íåíèÿ ñòåïåíè åå çëîêà÷åñòâåííîñòè ïðîâåäåíî èììóíîãèñòîõèìè÷åñêîå èññëåäîâàíèå ñ èñïîëüçîâàíèåì àíòèòåë ê ïàíöèòîêåðàòèíó, õðîìîãðàíèíó À, Ki-67. Êëåòêè îïóõîëè ïîçèòèâíû ïî ýêñïðåññèè ïàíöèòîêåðàòèíà è õðîìîãðàíèíà À, ÷òî ñîîòâåòñòâóåò èììóíîôåíîòèïó íåéðîýíäîêðèííîé îïóõîëè. Èíäåêñ ìå÷åíèÿ ÿäåð Ki-67 â çîíàõ íàèáîëåå àêòèâíîé ïðîëèôåðàöèè ñîñòîâëÿåò îêîëî 8% Çàêëþ÷åíèå: Àòèïè÷íûé êàðöèíîèä ëåãêîãî ñ ìåòàñòàçàìè â ëèìôîóçëàõ __________ Åñòü: âûïèñêà, ðåíãåíû, òîìîãðàôèÿ, èñòîðèÿ áîëåçíè, ôîòîñíèìîê âûðåçàííîé ÷àñòè ë¸ãêîãî. __________ Äåâóøêà íà ïðîòÿæåíèè 4 ëåò (!) êàøëÿëà, íèêàêèõ äðóãèõ ñèìïòîìîâ íå áûëî. (íè äèàðåè, íè ïðèëèâîâ).  ìàå ýòîãî ãîäà áûëà ñäåëàíà ôëþðîãðàôèÿ. Çàòåì ÊÒ. 2 ãîäà íàçàä íà ôëþðîãðàôèè áûëî çàòåìíåíèå îïÿòü æå â íèæíåé äîëå ïðàâîãî ë¸ãêîãî. Ñòàâèëè äèàãíîç "Îñòàòî÷íîå ÿâëåíèå îò ïíåâìîíèè" (çíàòü áû òîãäà!)  4 ãîäà (â 1982ã ) ó íåå áûëî âîñïàëåíèå ë¸ãêèõ (åñòü îïèñàíèå ðåíãåíà) êàê ðàç â íèæíåé äîëåå ïðàâîãî ë¸ãêîãî áûëî çàòåìíåíèå. ________  áëèæàéøåå âðåìÿ áóäóò ñäåëàíû àíàëèçû íà Ñåðîòîíèí, Ãèñòàìèí, 5 ÎÈÓÊ ( äåëàòü áóäó âèäèìî òóò [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ) ________ Êàê ÿ ïîíÿë, çëîêà÷åñòâåííûìè êàðöèíîèäàìè ìàëî êòî âîîáùå çàíèìåòñÿ èìè âïëîòíóþ. Âåùü äîñòàòî÷íî ðåäêàÿ. È î÷åíü âàæíî ïðîêîíñóëüòèðîâàòüñÿ ñî ñïåöèàëèñòàìè â ýòîé îáëàñòè, ÷òî äåëàòü äàëüøå è êàêèå àíàëèçû çäàâàòü è êàê è ãäå ïîòîì ëå÷èòüñÿ. Î÷åíü íóæíû êâàëèôèöèðîâàííûå ñîâåòû! Íóæíî ëè äåëàòü ÏÝÒ? Êàêèì îáðàçîì ñòîèò èññëåäîâàòü ïå÷åíü? (Íà ÓÇÈ ïå÷åíü íåìíîãî óâåëè÷åíà 16.3 ïðè íîðìå 14, ÷òî ìîæåò áûòü ñëåäñòâèåì ïðèìåíåíèÿ àíòèáèîòèêîâ) Íàäî äåâóøêó ñïàñàòü! |
#2
|
||||
|
||||
Çäðàâñòâóéòå, ïîêà ìû æäåì ïðîôèëüíûõ ñïåöèàëèñòîâ - âûëîæèòå, ïîæàëóéñòà ñíèìêè (íàïðèìåð, íà mail.ru ìîæíî âûëîæèòü âñå èçîáðàæåíèÿ, à òîìîãðôàèþ â âèäå àðõèâà äëÿ ñêà÷èâàíèÿ òàì æå).
|
#3
|
||||
|
||||
 íàøåé ñòðàíå ëå÷åíèå áðîíõî- ïóëüìîíàëüíûõ íåéðî-ýíäîêðèíûõ îïóõîëåé - ðàáîòà îíêîëîãîâ, õîòÿ ýòè îïóõîëè è ïðîäóöèðóþò âî ìíîãèõ ñëó÷àÿõ òå èëè ãîðìîíû èëè ãîðìîíîïîäîáíûå âåùåñòâà
Çàäà÷à ýíäîêðèíîëîãà äèàãíîñòèðîâàòü ýòè îïóõîëè, íåðåäêî õèðóðãè - ýíäîêðèíîëîãè óäàëÿþò îïóõîëè, ÷òî ÿâëÿåòñÿ îáÿçàòåëüíûì ýòàïîì ðàáîòû ñ ïàöèåíòàìè Ïðè íàëè÷èè ìåòàñòàçîâ, èìåþùèõ ðåöåïòîðû ê ñîìàòîñòàòèíó, èñïîëüçóþò ëå÷åíèå ñîìàòîñòàòèíîì èëè åãî àíàëîãàìè, êîìáèíèðîâàííàÿ õèìèîòåðàïèÿ ( à íàä åå óñîâåðøåíñòâàíèåì ðàáîòûþò â ðàçëè÷íõ êëèíèêàõ ìèðà) äîáàâëÿåòñÿ ïðè íåîáõîäèìîñòè Íóæíî íà÷àòü ñ áåñåä ñ ëå÷àùèìè âðà÷àìè, òåì áîëåå, ÷òî ïàöèåíòêà óæå êîíñóëüòèðîâàíà â êðóïíåéøèõ ó÷ðåæäåíèÿõ îíêîëîãè÷åñêîãî ïðîôèëÿ
__________________
Ã.À. Ìåëüíè÷åíêî |
#4
|
|||
|
|||
Ãàëèíà Àôàíàñüåâíà, äåëî â òîì îïåðèðîâàëè åå â ÍÈÈ Ôèçèîïóëüìîíîëîãèè èì. Ñå÷åíîâà (íà Äîñòîåâñêîãî), à îíè îíêîëîãèåé íå çàíèìàþòñÿ.  îíêîëîãè÷åñêèõ êëèíèêàõ åå åùå íèêòî òîëêîì íå êîíñóëüòèðîâàë (Ñåé÷àñ ó âðà÷åé ñàìàÿ ïîðà îòïóñêîâ) è íà ëå÷åíèå íå âçÿëè ïîêà. Ïîêà ÿ óñïåë ñäåëàòü òîëüêî àíàëèçû èòî íå âñå.
Ðàçíûå âðà÷è ìíå ñîâåòóþò ðàçíûå âåùè: Ñàìûé äëÿ ìåíÿ ñðî÷íûé âîïðîñ, ýòî âûÿñíèòü, íóæíî ëè äåëàòü ëó÷åâóþ òåðàïèþ (à åå ðåêîììåíäóþò äåëàòü êàê ìîæíî áûñòðåå ïîñëå îïåðàöèè). Äðóãàÿ òî÷êà çðåíèÿ - ÷òî ëó÷åâàÿ òåðàïèÿ çäåñü áåñïîëåçíà. À òàê æå âûÿñíèòü, êàêèå åùå ñòîèò ñäåëàòü àíàëèçû (Íà íèõ îáû÷íî óõîäèò ìíîãî âðåìåíè) Ìîãó ÿ ó Âàñ ïðîêîíñóëüòèðîâàòüñÿ, êîãäà ó ìåíÿ áóäóò ãîòîâû àíàëèçû íà Ñåðîòîíèí, Ãèñòàìèí, 5 ÎÈÓÊ? |
#5
|
||||
|
||||
Íà äàííîì åòàïå ïðåäñòàâëÿåòñÿ öåëåñîîáðàçíûì ïðîâåäåíèå äàëüíåéøåãî ñòàäèðîâàíèÿ îïóõîëè. Èñõîäÿ èç ñêàçàííîãî Âàìè, â íàñòîÿøèé ìîìåíò ìîæíî ãîâîðèòü î ñòàäèè Ò3N2 ?Ì, ïîåòîìó âàæíî îïðåäåëèòüñÿ ñî ñòàäèåé Ì.
ÑÒÀÄÈÐÎÂÀÍÈÅ - ÏÅÒ ïðè êàðöèíîèäå äà¸ò ðàçî÷àðîâûâàþøèå è íåíàä¸æíûå ðåçóëüòàòû; îïòèìàëüíûì ìåòîäîì ÿâëÿåòñÿ ñöèíòèãðàôèÿ ñ 111èíäèóìîì îêòðèîòèäîì. Ðàäèîòåðàïèÿ íå ÿâëÿåòñÿ ñòàíäàðòíûì ëå÷åíèåì. |
#6
|
|||
|
|||
Ñåé÷àñ âûÿñíÿþ, êàê ñêàíèðîâàòü ðåíòãåí-ñíèìêè. Ïîñòàðàþñü ñäåëàòü â áëèæàéøåå âðåìÿ
|
#7
|
||||
|
||||
ß ëè÷íî íå äóìàþ, ÷òî ïðåäîïåðàöèîííûå ñíèìêè íàì çäåñü ñåé÷àñ î÷åíü ïîìîãóò. Ãîðàçäî âàæíåå êîíñåíçóñ ïî äàëüíåéøåé òàêòèêå.
Ïðèâåäèòå, ïîæàëóéñòà, ïîëíîñòüþ âñå çàêëþ÷åíèÿ ïàòîãèñòîëîãîâ. |
|
#8
|
|||
|
|||
2 FRSM: "ìîæíî ãîâîðèòü î ñòàäèè Ò3N2 ?Ì, ïîåòîìó âàæíî îïðåäåëèòüñÿ ñî ñòàäèåé Ì"
Äëÿ òîãî ÷òîáû îïðåäåëèòüñÿ ñî ñòàäèåé íóæíî ñäåëàòü àíàëèçû íà Ñåðîòîíèí, Ãèñòàìèí, 5 ÎÈÓÊ? Èëè ÷òîòî åùå? Íå ïîäñêàæèòå, ãäå äåëàþò ñöèíòèãðàôèþ ñ 111èíäèóìîì îêòðèîòèäîì? Äåëàþò ëè â Ðîññèè? Åñëè íåò, òî êóäà ñòîèò îáðàòèòüñÿ? |
#9
|
|||
|
|||
Ïîëó÷èëè ðåçóëüòàòû àíàëèçîâ ( äåëàëè êîìïëåêñíûé àíàëèç êðîâü+ìî÷à â Ãåìàòåñò)
Ñåðîòîíèí: 1.09 ( Íîðìà 0,3-1,2) 5-ÎÈÓÊ: 4,63 (Íîðìà 0-6) Ãèñòàìèí - ïîêà íå ãîòîâ Ïîõîæå, îïóõîëü íåñåêðåòèðóþùàÿ? |
#10
|
||||
|
||||
Î ñöèíòèãðàôèè ñ îêòðåîòèäîì íàäî ãîâîðèòü â îíêîöåíòðå â îòäåëåíèè ïðîô Ëè÷èíèöåðà
__________________
Ã.À. Ìåëüíè÷åíêî |
#11
|
|||
|
|||
Ñåãîäíÿ áûë â îíêîöåíòðå â îòäåëåíèè ðàäèîèçîòîïíîé äèàãíîñòèêè.
 Ìîñêâå îáåùàþò ñöèíòèãðàôèþ ñ îêòðåîòèäîì ýòîé îñåíüþ (Êîãäà èìåííî - íåïîíÿòíî ïîêà, áóäó óçíàâàòü). Ðåêîììåíäîâàëè óçíàâàòü ó Ñåðãåÿ Âëàäèìèðîâè÷à Øèðÿåâà (çàâ. îòäåëåíèåì) Îäíàêî ëó÷åâóþ òåðàïèþ ðåêîììåíäóþò ïðîâîäèòü êàê ìîæíî ðàíüøå ïîñëå îïåðàöèè (Ðåêîììåíäîâàëè âðà÷è èç Ãåðöåíà îñíîâûâàÿñü íà ðàçìåðàõ îïóõîëè, ìåòàñòàçàõ, èíâàçèè). ×åðåç 3 ìåñÿöà, îíà âîîáùå ìîæåò òåðÿòü ñìûñë. (Âîïðîñ î öåëåñîîáðàçíîñòè ïðîâåäåíèÿ ëó÷åâîé òåðàïèè â äàííîì ñëó÷àå âîîáùå, ïîõîæå, ñïîðíûé?) Ïîýòîìó ÿ ñåé÷àñ ðàññìàòðèâàþ âàðèàíòû ñäåëàòü òàêîå îáñëåäîâàíèå ïîáûñòðåå è çàãðàíèöåé. Åñëè åñòü êàêîé-òî îïûò â ýòîé îáëàñòè, ìîæåò áûòü êòî-òî äåëàë, âîçìîæíî, ãäå-òî êîíêðåòíî âìåíÿåìûå öåíû ... áóäó áëàãîäàðåí ëþáîé èíôîðìàöèè  àíãëîÿçíû÷íîì âàðèàíòå òàêîå îáñëåäîâàíèå ïî èäåå áóäåò: Scan with indium111-labeled DTPA-octreotide scintigraphy (or Octreoscan) Whole body + SPECT Ïîïðàâüòå ìåíÿ, ïîæàëóéñòà, åñëè ÿ íå ïðàâèëüíî ÷òîòî íàïèñàë. Ñïàñèáî îãðîìíîå çà ñîâåòû! |
#12
|
||||
|
||||
Scan with indium111-labeled DTPA-octreotide scintigraphy (or Octreoscan)
Whole body + SPECT...ïðàâèëüíî. |
#13
|
||||
|
||||
Åñëà Âû ïîíèìàåòå àíãëèéñêèé, ÿ ñìîãó âûñëàòü Âàì ññûëêó íà íàèáîëåå ñîâðåìåííóþ ñòàòüþ, ïîêàçûâàþøóþ ñêàçàííîå ðàíåå î ïðîòèâîðå÷èâûõ ðåçóëüòàòàõ ðàäèîòåðàïèè:
Radiotherapy In some studies, all node-positive patients received adjuvant radiotherapy35,50; in another study, only those with N2 disease received adjuvant radiotherapy.6 In this last-mentioned study, radiotherapy was not proven to be beneficial. |
#14
|
|||
|
|||
2 FRSM : Äà, åñëè ìîæíî, ïðèøëèòå ññûëêó....
Òàê âñ¸ ïîíÿòíî âðîäå íàïèñàíî... |
#15
|
|||
|
|||
2 FRSM : Ññûëêà íå ñêîïèðîâàëàñü è íå îòêðûëàñü ïðàâèëüíî
Îäíàêî, ñàéò äåéñòâèòåëüíî íåïëîõîé. Íàøåë ñòàòüþ "Experience in treatment of metastatic pulmonary carcinoid tumors" Annals of Oncology Volume 12, Number 10 / Îêòÿáðü 2001 ã. Íàïèìåð òóò ñêàçàíî ïðî çíà÷èìîñòü áèîõèìè÷åñêîãî ìàðêåðà Õðîìîãðàíèí À. .....The only cure for patients with pulmonary carcinoids is surgery.... ....Elevation of plasma chromogranin A was seen in 93%.... ...Plasma chromogranin A is the most frequently elevated tumor marker. (Ïîêà íå ìîãó íàéòè ëàáîðàòîðèþ, ãäå ìîæíî ñäàòü òàêîé àíàëèç. Íà êàøèðêå Ðîìàíâà Ë.Ô. äî 11 àâãóñòà â îòïóñêå. Ìîæåò áûòü óäàñòñÿ ñäåëàòü òàì. ) È ïðî âàðèàíòû ëå÷åíèÿ: "Chemotherapy with cisplatinum + etoposide, or doxorubicin combined with streptozotocin orpaclitaxel may be of value" Ïîõîæå Èíòåðôåðîí À è Îêòðåîòèä âîñíîâíîì íàïðàâëåíû òîëüêî íà ïîäàâëåíèå ñèìïòîìàòèêè êàðöèíîèäíîãî ñèíäðîìà (Êîòîðûé â ìî¸ì ñëó÷àå íèêàê íå âûðàæåí): "Alpha-interferon and octreotide offerefficient symptomatic relief, but stabilizes tumor growth in merely15% of the cases." Ñàìà âûäåðæêà èç ñòàòüè: Abstract Background:The only cure for patients with pulmonarycarcinoids is surgery. In the present paper, we report the results ofmedical treatment of patients with metastatic tumors, their circulatinghormone markers, and immunohistochemical profile of the tumors. Patients and methods/Results:The response to systemicantitumoral treatment was studied in 31 patients with metastaticpulmonary carcinoids. Median survival from treatment start was 25months. Alpha-interferon treatment has resulted in stable disease in 4of 27 patients (median duration 15 months), while 23 patients showedprogressive disease. Somatostatin analogues given as single drugtreatment resulted in progressive disease. Streptozotocin and5-fluorouracil resulted in progressive disease in seven of sevenpatients. Stable disease was obtained for 8 and 10 months respectivelyin two of two patients treated with streptozotocin + doxorubicin. Two ofeight patients treated with cisplatinum + etoposide showed a significantdecrease in tumor size lasting six and eight months respectively, andone displayed stable disease for seven months. Elevation of plasmachromogranin A was seen in 93%. Conclusions:Theresults of systemic antitumoral treatment of pulmonary carcinoids withdistant metastases are generally discouraging. Chemotherapy withcisplatinum + etoposide, or doxorubicin combined with streptozotocin orpaclitaxel may be of value. Alpha-interferon and octreotide offerefficient symptomatic relief, but stabilizes tumor growth in merely15% of the cases. Plasma chromogranin A is the most frequentlyelevated tumor marker. |