Treponema microbiology. Laboratory diagnosis of syphilis

Main effective method ovarian cancer treatment remains surgical. The operation affects the final result to a greater extent than subsequent therapy. It is from the thoroughness of the primary operation that the effectiveness of further treatment largely depends.

Before operation the entire abdominal cavity must be carefully examined. Special attention pay attention to the state of the surface of the diaphragm and the space between colon and peritoneum, because they may have metastases, sometimes unnoticed. Even if there are no visible nodules in the subphrenic region, peritoneal washes may contain tumor cells.

However, in a significant proportion of patients with diagnosis of a localized tumor sometimes a more extensive process is found, for the treatment of which local methods are not suitable.

For patients in I stage of the disease is effective in most cases surgical method treatment. An abdominal hysterectomy with bilateral salpingectomy and oophorectomy is usually performed. The second ovary is usually removed even with unilateral initial localization of the tumor, since in 20% of cases, due to latent metastases, a tumor usually also develops in it in the future.

Young people female patients Those wishing to preserve the ovary may want to try a more conservative operation. With greater certainty, conservative surgery can be recommended for cases of tumors with an unexpressed malignancy, although most gynecologists, for obvious reasons, prefer a radical approach, unless, of course, the patient plans to have children in the future.

For cases with more late stages of the disease(stages II-IV) most oncologists are of the opinion about the maximum possible removal tumors at primary surgery. A good palliative effect is achieved even if the size of the tumor can be reduced surgically.

However, only a few results indicate that the life expectancy of patients increases if all or almost all of the tumor is not removed. Many resectable tumors are characterized by a low degree of malignancy, which in itself is the basis for a favorable prognosis. Nevertheless, the maximum size of the tumor area remaining after resection is a good guideline for the subsequent appointment of a course of chemotherapy and further prognosis.

At calculation of patient survival according to the linear regression equation, it turns out that the greatest contribution is made by such parameters as the histological characteristics of the tumor and the maximum size of its area remaining after the operation. If, as a result of the operation, the size of the tumor has not decreased to 1.6 cm (or less) in diameter, then such an operation is ineffective.

If after operations the patient palpates residual seals, then the appointment of a course of chemotherapy or radiation therapy is unlikely to be effective. Therefore, at least some of them may require a second operation, which should be performed by an experienced surgeon. Now more often such complex operations such as removal of the pelvic organs, removal of the omentum, resection of the colon, and complete removal of the parietal pelvic peritoneum.

Research carried out within the framework of Inter-European cooperation on a randomized group of 319 initially operated patients who underwent a course of chemotherapy, the effectiveness of reoperation was confirmed. Patients who underwent second-look laparotomy had improved overall survival as well as progression-free survival.

In spite of application of ultrasonic methods, CT and MRI, there is no way to monitor the effectiveness of the treatment of advanced cancer. Again it all comes down to various methods examinations. Therefore, sometimes it is advisable to perform a surgical operation, even beyond the scope of the “second look”. If no tumor foci are detected during laparoscopic examination and the results of the analysis of intraperitoneal washings are negative, then in some cases, a laparotomy can be done to make sure of a favorable outcome.

It is difficult, of course, to argue that laparotomy " second glance» is able to prolong the life of a patient with an ovarian tumor, however, as a result of its implementation, it will be possible to use a more reasonable tactic for further treatment. Now everyone understands that the “second look” laparotomy only determines the choice of the method of subsequent treatment.

Changed significantly in recent times the role of the gynecological surgeon in the treatment of ovarian cancer. The initial examination of patients with localized and generalized tumors and the choice of surgical technique have become of paramount importance. Also no less important was the opinion of the surgeon when choosing a method of treatment. Although "second-look laparotomy" is the most reliable method for monitoring the effectiveness of treatment, its true therapeutic benefit remains questionable.

Classification according to the stages of the disease.

First stage. Tumor within one ovary and without metastases.

Second stage. The tumor has spread beyond the ovary, affecting the second ovary, uterus, one or both tubes.

Third stage. The tumor has spread to the parietal pelvic peritoneum. Metastases in regional lymph nodes, in the omentum. Ascites.

Fourth stage. An ovarian tumor invades neighboring organs: bladder, the rectum into the loops of the intestines with dissemination along the peritoneum outside the small pelvis or with metastases to distant lymph nodes and internal organs. Ascites. Cachexia.

Among cancers occurring in women, ovarian cancer ranks seventh (3-3.5%). According to the statistics of F. A. Sokolov, compiled on the basis of a large sectional material of the Nechaev hospital, for 38 years, cancer occurred in 24% of the entire number of ovarian tumors. Ovarian cancer is divided into: 1) primary, occurring according to M. S. Malinovsky, less often than others, 2) secondary, occurring more often and developing on the basis of malignant degeneration of ovarian cystoma. more often serous, rente - false mucous and dermoid, and 3) metastatic (Krukenberg's tumors), which was previously considered a rarity, but according to the latest data, it is not so rare. According to T. A. Maykapar-Holdina, 60 cases of metastatic ovarian cancer were observed at the Institute of Oncology of the Academy of Medical Sciences for 20 years. However, it should be noted that on the issue of the frequency of one or another form of cancer, statistics differ significantly.

Symptoms. The most characteristic clinical picture of ovarian cancer is that it often affects both ovaries and is mostly accompanied by early onset ascites. Often, especially with papillary forms, ascitic fluid is stained with blood. Metastasis of cancerous elements from the ovary to the uterus, passing through the lymphatic pathways, is rare. Such metastases always cause uterine bleeding, metastasis to distant organs, which occur by the hematogenous route and cause a wide variety of clinical pictures depending on the localization. The most common, but by no means early symptom ovarian cancer are pains that do not have a specific character and a specific localization and are often interpreted by patients, and sometimes by doctors, as a result of a disease of internal organs, food intoxication, etc.

On the predominance in clinical picture N. N. Petrov, A. N. Serebrov and S. S. Rogovenko, A. P. Lebedeva and others also spoke of pain in the abdomen and lower back. According to the observations of A. N. Lebedeva, in the first place in symptomatology malignant tumors ovary is the symptom of abdominal pain, which was observed in 32%, and an increase in the abdomen, observed in 22.6%. The authors must fully subscribe to these conclusions.

As you know, ovarian tumors, both benign and malignant, occur at all ages: from the youngest to the senile. But most often, ovarian cancer occurs between the ages of 40 and 50 years: cases of ovarian cancer in 20 years and younger have been described. Therefore, among the symptoms of ovarian cancer, one would expect menstrual dysfunction, mainly in the form of amenorrhea. However, this symptom is neither permanent nor early, although there have been cases where menstrual function upset even with a unilateral lesion of the ovary. Uterine bleeding may appear due to metastasis of ovarian cancer to the uterus.

Bilateral ovarian lesions are more common, especially in metastatic cancer.

Bleeding, taking on the character of menstruation or menorrhagia. are observed with a kind of ovarian tumor - ovarian folliculoma, or, as it is now called, granulosa cell tumor of the ovary. Hormonal influences are attributed to the cellular elements of these tumors (excessive production of the follicular hormone on the body in the form of its hyperfiminization). The manifestation is menorrhagia in mature women, and in girls or women after menopause, the appearance spotting or bleeding. In one case of folliculoma, described by V. S. Kandaratsky, on the contrary, amenorrhea and enlargement of the mammary glands were observed, as during pregnancy, which the author, on the basis of a histological examination of the uterine mucosa, explains by the action of the luteal hormone secreted by the tumor. It is possible that in this case there was not only a follicle, but also a luteoma.

Despite numerous studies by both domestic and foreign authors of a large number of cases of granulosa cell tumors - ovarian folliculoma, the degree of its malignancy has not yet been finally established. While some authors consider it a malignant tumor, others refer it to benign tumors that do not recur after removal. Hence the disagreement in the choice of the method of operation: while some consider it necessary to apply a radical operation for ovarian follicle, as for ovarian cancer, others are limited only to the removal of the tumor.

In addressing this issue, data must be taken into account. clinical trial before surgery and examination of the tumor and its adjacent abdominal organs by autopsy abdominal cavity if the operation is performed on a girl or a young woman. In an elderly patient, we believe it is correct to use radical surgery for ovarian follicles.

A very peculiar hormonal influence in the opposite direction - towards masculinity (feminization, masculinization) - is exerted by a rare ovarian tumor observed in young women who are menstruating and even giving birth. After the appearance of this tumor, which developed from the inclusion of the remnants of the male germinal glands, women acquired the male type and stopped menstruating.

With regard to metastatic ovarian cancer, of which the so-called Krukenberg tumor is a typical example, it is especially characteristic that the tumor grows very quickly and is much larger in size than the primary cancerous tumor, usually located in the gastrointestinal tract. But not only the lag in the growth of primary gastric cancer from secondary cancer in the ovary characterizes this cancer; others are lagging behind clinical symptoms. So, for example, with metastatic ovarian cancer, the patient already has pain and ascites, but there are no symptoms of stomach disease - nausea and vomiting - yet.

When metastatic cancer is combined with pregnancy, which is very rare, the symptoms of the primary cancerous focus in the gastrointestinal tract, if they manifest themselves in the form of loss of appetite, nausea and vomiting, often do not attract due attention, as they are interpreted as phenomena associated with pregnancy.

The case of pregnancy observed in our clinic at the 8th month with primary gastric cancer in the lesser curvature with multiple cancer metastases to the lymph glands, along the visceral and parietal peritoneum, along the lower surface of the diaphragm and retroperitoneal glands, with huge metastatic tumors of both ovaries, observed in our clinic and cancer metastasis to the cervix.

Diagnosis of ovarian cancer. With the poverty of symptoms that is observed in the initial stage of the development of ovarian cancer, it is not surprising that the diagnosis of a malignant ovarian tumor, at least initially, is very difficult, and sometimes it is impossible. Often, the presence of ovarian cancer is established only when histological examination a tumor that was removed under the diagnosis of an ovarian cyst. In a later stage, the presence of ovarian cancer is said first of all by abdominal pain, the appearance of which cannot be attributed to a disease of the internal organs or any complication that has occurred in the tumor itself, such as partial torsion or rupture; further, the rapid growth of ascites, the development of a tumor in the second ovary, and especially the appearance of tuberous or papillary formations in the pelvis, most often in the recto-uterine cavity, which are well palpable through the posterior vaginal fornix, speak for cancer, and, finally, general poor health.

Treatment of ovarian cancer. The main treatment for ovarian cancer is surgery. In operable cases, the ovarian tumor is removed, and without fail the uterus and the second ovary, even if it is not changed by sight. However, experience shows that most often ovarian cancer, recognized clinically, is neglected and not amenable to complete cure.

The question of the operability of ovarian cancer is almost unresolved until the opening of the abdominal cavity. Here one cannot be completely guided by either the amount of ascites, the speed of its growth, or the degree of tumor mobility. In this regard, ovarian cancer cannot be compared with uterine cancer, where the immobility of the organ, the presence of metastases in the pelvis speaks for the inoperability of the case; in ovarian cancer, a tumor that seemed to be slightly mobile before surgery can still sometimes be completely removed, and, conversely, a tumor that seemed mobile before surgery may turn out to be tightly soldered to the intestine and inoperable. Unfortunately, the latter option is more common. The duration of the disease and the general condition of the patient are great importance when evaluating the case. A particularly important role in assessing the operability of a case is played by the general condition of the patient, while the duration of the disease, i.e., the length of time that has passed since the discovery of the tumor, does not yet absolutely indicate the neglect of the case. In this case, ovarian cancer may be secondary on the basis of malignant degeneration of a primary benign ovarian tumor. A. N. Lebedeva pursues a similar idea in his work “Prognosis of malignant tumors of the ovaries”, confirming it with a detailed study of a large amount of material from the oncological clinic of the Sverdlovsk Research Institute of Physical Treatment Methods. But not only this consideration should guide the doctor's tactics in each individual case when deciding on the operation of ovarian cancer. It should also be taken into account that the question of the operability of ovarian cancer in the sense of the possibility of a radical removal of the tumor is often resolved only with a transsection. Therefore, trial abdominal surgery should find the widest application in the diagnosis of ovarian cancer. As clinical experience shows, patients diagnosed with ovarian cancer rarely go to the operating table at an early stage of the disease, that is, when there are no metastases yet. early stages are found mainly as incidental findings during surgery for a diagnosed benign ovarian tumor. If the diagnosis of ovarian cancer is clear, then the case is often neglected. Trial abdominal surgery usually confirms this, and in such a case, a radical operation is not feasible. The abdominal cavity is closed. Radiation therapy for advanced ovarian cancer is not only ineffective, but often brings the sad end of these patients closer. Deterioration general condition patients with large cancerous tumors after the use of intensive radiation therapy has long attracted attention. We had to observe neglected cases of ovarian cancer, in which intensive X-ray therapy was applied, as a result of which, after a few days, a sharp deterioration in the general condition appeared, it was noted heat, and with the phenomena of severe intoxication, death occurred. Pathological anatomical autopsy revealed complete disintegration of the tumor. Obviously, the absorption of decay products of a large tumor from the abdominal cavity caused the phenomena of severe intoxication, which quickly led to the death of these incurable patients. Such observations have long ago pushed us to use a different tactic in cases where a trial abdominal dissection revealed the impossibility of radical removal of a cancerous neoplasm of the ovaries. At first, these were isolated cases when a radical operation was not possible immediately after opening the abdominal cavity, but only after the main tumor could be separated from neighboring organs and tissues and only small metastases remained associated with them. Applying then deep X-ray therapy, we did not observe those severe phenomena that this therapy caused in the presence of large cancerous masses in the abdominal cavity. These were, one might say, forced cases of application not radical operation with ovarian cancer. Having made these observations and continuing to strictly adhere to the unconditionally correct thesis about the need to apply only radical methods surgery, for inoperable ovarian cancer, we began to use non-radical surgery in order to be able to use radiation therapy for advanced ovarian cancer. If patients have cachexia, this method, of course, is not resorted to. We do not claim that patients with advanced ovarian cancer can be cured in this way, but we have repeatedly observed cases when, after a non-radical operation, patients recovered and lived for another 3-4 years, often felt satisfactory, and sometimes were even able to work. Therefore, we cannot agree with the practice of refusing to remove most of the tumor in cases where radical surgery is not possible. In such cases, we remove the maximum of what can be removed from the cancer, that is, the largest mass of the tumor, sew up the abdominal wound either tightly, if possible, or insert a tampon. Deep X-ray therapy in these cases should be started as early as possible.

Some surgeons believe that such a non-radical operation for inoperable ovarian cancer can sometimes even hasten the onset of death in the patient. According to our observations, this occurs mainly when the surgeon stubbornly continues the operation, despite the impossibility of a radical operation discovered by him. In such cases, the patient is subjected to excessive trauma, with which she is not able to cope.

Like any palliative operation, the proposed incomplete removal of a cancerous tumor in advanced ovarian cancer does not satisfy the surgeon. But if we take into account the failure of other therapy in such cases, then such an operation, despite the known risk (danger of bleeding from the parts of the tumor remaining on neighboring organs, the danger of collateral damage), seems to us not only justified, but also strongly indicated, since without surgery the patient will certainly be doomed.

In cases where an ovarian cancer is recognized as a metastasis from the stomach or from another organ, radical removal of the primary cancer and its metastases is often no longer feasible. In these cases, one has to limit oneself to the removal of cancerous tumors of the ovary, as the most rapidly developing focus, and as for the primary focus in the stomach, one can also resort to gastroenterostomy to prevent obstruction.

postoperative mortality. While primary mortality after removal of benign ovarian tumors does not exceed 2%, and according to K.K. during ovarian cancer surgery is still very high: according to M. V. Elkin, there were two cases of death for 24 operations. K. P. Petrov, A. I. Serebrov and S. S. Rogovenko had 4 cases for 36 operations, A. N. Lebedeva had 30 cases for 161 operations.

As for long-term results after ovarian cancer surgery, based on the material of A. N. Lebedeva (161 cases), the percentage of recovery was only 24.

The need for radiotherapy after ovarian cancer surgery is recognized by most experts.

Thus, we see that the results of ovarian cancer surgery are ten times worse than the results of surgery for benign ovarian tumors.

The reason for the unsatisfactory results of ovarian cancer surgery must be sought in the huge percentage of neglect with which patients with ovarian cancer come for surgery, which must be reminded again. And if we take into account, which we also already said, that in a significant number of patients, cancer develops in the primary benign tumors, it becomes clear that one of the most important factors in reducing the percentage of neglect is the steady implementation of the principle to operate on any neoplasm of the ovary, even if it did not cause any clinical symptoms.

Under the conditions of preventive and curative work of doctors that the healthcare system creates in its consistent development (the last stage was the merger of polyclinics with hospitals), the implementation of this principle becomes a reality, since already at the present time, as K. K. Skrobansky points out, the number of Soviet doctors performing ovariotomy are innumerable. It is produced with a brilliant outcome in the most remote corners of the country.

When with cancer mammary gland need to suppress ovarian function?

In breast cancer, ovarian hormones (estrogens) can serve as a factor in the development of a tumor cell, as a result of which competition between hormones and drugs that affect the tumor cell is possible. It is for this reason that it is necessary to lower the level of female hormones. reproductive system. In women with preserved reproductive function, part of the hormones is produced in adipose tissue, adrenal glands, but the vast majority are produced by the ovaries, respectively, to reduce the production of hormones, suppression of the ovaries is necessary.

Under what conditions is it necessary to suppress ovarian function?

With an immunohistochemical study, which determines positive estrogen receptors (ER), Progesterone (PR) and intact ovarian function (in women of childbearing age), it is possible to carry out one of the above methods of treatment.

What are the ways to suppress ovarian function?

To date, there are three methods:

1. Medicinal-releasing hormone (Buserelin, Zoladex), interrupts the connection between the pituitary gland and the ovaries, thereby, the ovaries stop producing hormones (estrogen), that is, it actually leads to an artificial menopause. An injection of the drug is done 1 time in 28 days. The duration of treatment can be different, from 2 years or more. Ovarian shutdown can be combined with medicines that reduce the concentration of estrogen in the blood, such as Tamoxifen or aromatase inhibitors (Arimidex, Anastrozole). Benefits: advantage this method, is the absence of the need to conduct surgical treatment, relatively good tolerability of the drug. The disadvantages of the method are: The high cost of the drug, the need for constant intake. When you stop taking the drug, the resumption of ovarian function.

2. Surgical - Ovariectomy (removal of the ovaries). As a rule, at the present stage of development of medicine, if possible, laparoscopic oophorectomy is performed. When performing laparoscopic surgery, there is less traumatization of tissues and pain syndrome, rapid recovery in postoperative period. Advantages: The main advantage of this technique lies in the irreversible decrease in the level of estrogen in the blood, the relative low cost in comparison with the drug (drug) method. Disadvantages: Any surgical intervention is associated with a certain degree of risk, and this operation is no exception. With previous surgical interventions, due to the presence of a possible adhesive process, technical difficulties in performing the operation by the laparoscopic method.

3. Radiation therapy - Directed irradiation of the ovaries, in order to stop the production of female sex hormones. Advantages: Relatively inexpensive method that does not require surgical intervention and achieve acceptable results. Disadvantages: The complexity of the method lies in the possible damage radiation therapy adjacent tissues or organs. Just as with medical method, due to the rapid regenerative capacity of the ovaries, there is a possibility of resumption of function. It should be noted that at present this technique is practically not used.

Which side effect possible from treatment?

Regardless of the method of "turning off" the ovaries, women experience the same symptoms as in menopause. dizziness, headaches, hot flashes, sweating, depressive states, decreased libido. In normal practice, the gynecologist prescribes hormone replacement therapy (HRT) to correct the condition. But, with breast cancer, hormone replacement therapy is strictly contraindicated!!! As appointed hormonal preparations contain estrogen, and our task is, just the same, to reduce its amount.

How to determine the onset of menopause?

The onset of menopause can be determined by the concentration of hormones in the blood: - Estrogen. - Luteinizing (LH) - Follicle stimulating hormone (FSH).

Any of the treatment options involves a detailed examination for indications and the possibility of conducting a particular therapy. The decision on treatment tactics is made by the attending physician based on the medical history and examination data.

syphilis
infectious venereal disease caused by Treponema pallidum characterized by damage to the skin, internal organs, bones, nervous system. There is acquired and congenital syphilis.

Syphilis. Taxonomy.
Pale treponema belongs to the family Spirochaetaceae, department Gracilicutes.

Syphilis. Morphology.
Low color ability. A thin bacterium of a spiral shape, from 4-14 microns long, with uniform small curls, is extremely mobile. Stained according to Romanovsky-Giemsa in a slightly pink color.

Syphilis. Cultivation.
Obligate anaerobe, grows poorly on special. pit environments.

Syphilis. Antigenic structure.
It is characterized by antigenic bonds with other triponemes, as well as lipoids of animal and human tissues. Several AGs were found in the pathogen, one of the cat. Lipoid AG - identical to the bovine heart lipoid extract.

Syphilis. resistance.
Weakly resistant to environment, at 55 dies within 15 minutes, sensitive to drying, light, mercury salts, bismuth, arsenic, penicillin. It remains on household items until it dries, it is well preserved in the tissue of a corpse.

Syphilis. Epidemiology.
The source of the infection is a sick person. Infection is sexually transmitted, rarely through household items, infection is possible through kisses, milk of a nursing mother, and blood transfusion.

Syphilis. Pathogenesis and clinic.
Penetrates the body through the skin or mucous membranes, spreads through organs and tissues, causing their damage. The incubation period is 3-4 weeks. After incubation period proceeds cyclically in the form of primary, secondary and tertiary periods.

At the site of introduction (on the genitals, lip), a primary lesion appears - a hard chancre - a seal with an ulcer on the surface.

The secondary period lasts 3-4 years, is characterized by a rash, a violation of the general condition of the body.
Tertiary period - damage to the skin, mucous membranes, internal organs, bones, nervous system, formations appear that are prone to decay, manifestation.

Syphilis. Immunity.
Non-sterile develops, after treatment it does not persist, repeated diseases are possible.

Syphilis. Laboratory diagnostics.
Dark field microscopy is used. By the end of the 1st and 2nd periods, the Wasserman serological rivers and the sedimentary Kahn reactions become established. In mass examinations, a microreaction on glass with a drop of blood and special AG are used. Also use immobilization.

Syphilis. Treatment.
Antibiotics penicillin series and preparations of bismuth, iodine.

Syphilis. Prevention.
There is no specific one. Nonspecific: observance of hygiene rules, protection during sexual intercourse, a complex of sanitary and hygienic measures of a general nature.