[OPTIMIZATION OF SURGICAL STRATEGY FOR THE TREATMENT OF THYROID NODULES].

This retrospective analysis of the results of surgical treatment involved 1006 patients with thyroid nodules operated at P V Mandryka Medical Educational and Scientific Centre in 1990-2007. Organ-preserving surgery was necessary to minimize the frequency ofpostoperative complications and maintain the hormone-producing thyroid function. The results of analysis of morphological structure of both nodular and surrounding healthy tissues were used to plan optimal extirpation of the thyroid nodule from the surrounding tissue. Circulatory disturbances with the appearance of fibrotic changes occurred in 69.7% of the cases; thyroiditis developed in 38.8% of the patients. Analysis of repeated operations showed that the risk of relapse depends on etiology and morphological structure ofthe nodule rather than the extent of surgical intervention. Organ-preserving surgery and consideration of endocrinologicalfactors ensured successful treatment of 89.3% of the patients.

[Possibilities for targeted therapy of neuroendocrine tumours].

The treatment of patients with neuroendocrine tumours and hormonally active distant metastases traditionally included surgical removal of the primary neoplasm, embolization of metastases in the liver, therapy with somatostatin analogs and interferon-alpha to prevent excessive production of regulatory peptides (carcinoid and other endocrine syndromes). Patients with neuroendocrine pancreatic tumours were also treated with alkylating chemotherapeutic drugs including streptosocin and temozolomide. The results of such treatment are far from being satisfactory. Recent progress in the treatment of such patients is due to radiotherapy using somatostatin analogs. Moreover, large-scale randomized studies demonstrated the effectiveness of targeted preparations acting on receptors of vascular growth factors and ripamycin target inhibitors ofmammals. Results of the studies on comparative effectiveness of targeted drugs for combined therapy of neuroendocrine tumours are presented.

[Splenic cyst].

True non-parasitic splenic cysts are a rare pathology represented by some 800 cases recorded worldwide. The method of choice for the treatment of this condition is surgical intervention. To-day, open surgery is substituted by low-invasive methods, such as laparoscopic splenectomy. A clinical case is described illustrating approaches to diagnostics and stages of surgical management of this pathology.

[Prostate biopsy in the outpatient setting].

The article describes the methodology of transrectal diagnostic prostate biopsy under ultrasound guidance with regard to settings of municipal polyclinic; existing complications are listed. The analysis of the results of 876 biopsies performed within 3 years is presented. The distribution of the results of histological examination depending on the level of total PSA, ratio of free and total PSA, and PSA density was followed-up. Relationship between PC detection rate using standard biopsy and prostate volume is shown. The analysis of the degree of PC differentiation (Gleason score) depending on the level of total PSA, the ratio of free and total PSA, and PSA density was performed. Practical recommendations to improvement of PC detection rate are presented. Based on the analysis, it was concluded that the screening for prostate cancer for the purpose of its earlier diagnosis is reasonable.

[About the signs of malignant pheochromocytoma].

Morphological criteria for malignant pheochromocytoma remain to be developed According to the WHO recommendations, the sole absolute criteria is the presence of metastases in the organs normally containing no chromaffin tissue. Such signs as cellular and nuclear polymorphism, mytotic activity, vascular invasion, capsular ingrowth are not sufficient to describe a pheochromocytoma as malignant. It is equally dfficult to differentiate between malignant and benign tumours based on histological data since histologically mature neoplasms can produce metastases. Based on the results of original studies, the authors believe that such histological features as vascular and capsular invasion do not necessarily suggest unfavourable prognosis. Therefore, the conclusion of malignancy based on such features can not be regarded as absolute. Probably such neoplasms should be called "pheochromocytomas with morphological signs of malignant growths". They should be referred to the tumours with uncertain malignancy potential based on the known discrepancy between morphological structure and biological activity of neoplasms. Comparative studies of clinical and morphological features of pheochromocytomas showed that their histological type (alveolar; solid, dyscomplexed, trabecular) and morphological signs of malignant growth influence both the clinical picture and arterial hypertension. There are no significant relationship between the above morphological signs, timour mass and clinical manifestations of pheochromocytomas.

[Poorly differentiated stomach adenocarcinoma combined with jejunal stromal tumour. Clinical study].

Gastrointestinal stromal tumours (GIST) first described in 1983 are the commonest mesenchymal neoplsams of the digestive tract. The main pathogenetic mechanism is hypersecretion of tyrosin kinase receptor c-kit (CD-117) by GIST cells and its hyperactivation. A rare clinical case of GIST measuring 1.2 CM with concomitant stomach cancer (poorly differentiated carcinoma) is reported. The tumours were discovered intraoperatively. To our knowledge, data on such cases are practically lacking in the literature.

[Recurring secondary hyperparathyroidism: case report].

The authors report a rare case of persistently recurring secondary hyperparathyroidism concomitant with chronic renal insufficiency. The patient underwent multiple surgical interventions (parathyroidectomy, implantation of parathyroid autograft into a forearm muscle, removal of hyperplastic autograft tissue). Results of clinical, laboratory, instrumental, and morphological studies are presented. Possible causes of relapses and problems of morphological diagnosis are discussed.

[The morphological and immunohistochemical features and malignancy potential of a hyalinizing trabecular tumor of the thyroid].

The paper considers the morphological features of a rare hyalinizing trabecular tumor of the thyroid, which is of follicular cell origin. The signs of invasive tumor growth into to the intrinsic capsule and its blood vessels were observed in 2 of 7 cases. There was a positive immunohistochemical reaction of tumor cells with antibodies to thyroglobulin and neuron-specific enolase and a negative one to calcitonin, galectin 3, cytokeratin 19, and HBME-1. The differential diagnosis of a tumor and papillary and medullary carcinomas of the thyroid, as well as its malignancy potential are discussed in the paper.

[A case of pancreatic glucagonoma].

Neuroendocrine tumor consisting of pancreatic alpha-cells -- glucagonoma -- is a very rare finding (one case per two million people a year). This functionally active, usually malignant tumor has typical clinical manifestations. Glucagonoma syndrome is a disease that has an original clinical picture that includes necrolytic migrating erythema with secondary bullous dermatitis, glucose tolerance disorder or diabetes mellitus, weight loss, anemia, hypoaminoacidemia, venous thrombosis, and alimentary and mental disturbances. By the time diagnosis is made, 60 to 70% of glucagonomas already give metastases, and even small glucagonomas should be considered tumors with unknown malignant potential or malignant tumors. Glucagonomas grow slowly, and patients live long (the survival median is approximately 15 years). The authors describe their own observation.

[Connective tissue dysplasias (hereditary collagenopathies)].

Connective tissue dysplasia (hereditary collagenopathy) presents a group of genetically heterogenous and clinically polymorphic pathological conditions, associated with disturbances in the forming of connective tissue during the embryonal and postnatal periods. Differentiated dysplasias include monofactor diseases with an established genetic defect and clear clinical symptoms, such as Marfan's syndrome, Ehlers-Danlo's syndrome, and osteogenesis imperfecta. The variants of non-differentiated hereditary dysplasias include primary mitral valve prolapse and other minor heart anomalies, tracheobronchial dyskinesia, visceroptosis, join hypermobility, congenital chest deformations, "weakness" of the ligamentous apparatus of the foot and the spine, and a range of other prevalent pathological changes. The author adduces his own observation of a patient with Marfan's syndrome.

[Somatostatin analogues in treatment of gastrointestinal and pancreatic neuroendocrine tumors].

Clinical application of natural somatostatin is limited due to its short effect (the half-life of the preparation is less than 3 min), and a rebound effect after its administration. For these reasons, synthetic analogues of somatostatin, among which sandostatin (octreotide acetate) was the first one, were developed. Other cyclic analogues with similar sensitivity and activity profile, such as lanreotide (somatulin), somatostatin-14, and SOM 230, have been developed as well. These preparations seem to possess certain antiproliferative activity. Somatostatin analogues may be administered in repeated hypodermic injections, or repeated or prolonged intravenous infusions. Long-acting intramuscular preparations (sandostatin LAR) are usually administered once in four weeks, while long-acting lanreotide (somatulin) is administered once in two weeks. Sandostatin therapy is indicated to patients with functionally active neuroendocrine tumors of the stomach, duodenum, small bowel, or appendix. Glucagonomas, vipomas, and, to a lesser degree, gastrinomas and metastatic insulinomas are examples of functionally active endocrine pancreatic tumors that should be treated with sandostatin. Patients are selected according to a positive result of OcreoScan test. Other syndromes, which should be treated with octreotide, include ectopic secretion of adrenocorticotropic hormone in Cushing syndrome, oncogenic osteomalacia, and hypercalciemia resulting from ectopic secretion of parathyroid-like peptide. In patients with an advanced carcinoid syndrome, the starting dose of sandostatin (ocreotide) is 150 mcgr administered three times a day in hypordermic injections during 10 to 14 days, after which sandostatin LAR is administered in a dose of 20 mg once a month. Sandostatin is usually administered for the life-term of the patient, exept cases of intractable adverse effects or the development of total insensitivity.

[A rare case of large-cell gastric lymphoma in a patient with chronic lympholeucosis].

Chronic lympholeucosis (CLL) is a B-cell lymphoproliferative disease, the morphological substrate of which is a clone of lymphocytes similar in size and morphology to normal mature lymphocyte and similar in immunophenotype to B lymphocytes at late stages of differentiation. The occurrence of large-cell lymphoma against the background of B-CLL is called Richter syndrome. A new tumor may occur in lymph nodes, the spleen, the liver, and the gastrointestinal tract (GIT). GIT involvement in Richter syndrome is a very rare case; the authors found only six descriptions of such cases in available literature, and no such description in Russian literature. The authors adduce their own observation.

[Myocarditis in severe typhoid fever].

The article explains the development of toxic infective myocarditis and, in many cases, pancarditis, in patients with severe typhoid fever (TF) with lethal outcome. The authors present the most frequently found symptoms and ECG signs, the main histological features and possibilities of clinical diagnostics of myocarditis. The latter is of special importance, because a significant number of patients do not have typical clinical presentation. The work is based on the data from 109 autopsy records and 42 case histories as well as the results of morphological study of the heart in archive samples received from 47 military men who died of TF.

[Manifestations of local fibrosis in the clinical picture of carcinoids of digestive organs]. / Proiavleniia mestnogo fibroza v klinicheskoi kartine kartsinoidov organov pishchevareniia.

A complex of clinical, functional, and morphological studies was made in 20 patients aged 39 to 78 years who had histologically verified gastrointestinal carcinoids in the pre- and postoperative periods, by employing laboratory tests and instrumental techniques. Removed tumors were morphologically studied. Sixteen patients were operated on. Among them, 10 and 6 patients underwent planned and emergency operations, respectively. On referral for emergency laparotomy, the preoperative diagnoses were acute ileus in 2 cases, acute pancreatitis in 1, and acute appendicitis in 3. The local paracrine effect of serotonin on the intestinal wall leads to spasm and fibrosis, which manifests itself as the clinical picture of obstruction of a hollow organ or acute appendicitis. Cordlike or concentrated deformity as a kink is a characteristic sign of small intestinal carcinoid. Formation of fibrosis occurs not only in the pathways of evacuation of excess serotonin from hepatic metastases into the right ventricle of the heart (Hedinger's syndrome), but by the paracrine pathway in the immediate vicinity of a carcinoid tumor, in whatever organ the tumor is located.

[Significance of argyrophilic proteins of the nucleolar organizer region in differentiation of benign and malignant growth of thyroid epithelial tumors]. / Znachenie argirofil'nykh belkov oblasti iadryshkovykh organizatorov v razgranichenii dobrokachestvennogo i zlokachestvennogo rosta épitelial'nykh opukholei shchitovidnoi zhelezy.

Argyrophilic proteins of nucleolar organizers (NO) were measured in 47 benign (24 follicular and 8 atypical adenomas) and malignant (8 papillary and 7 follicular carcinomas) tumors. The content of argyrophilic NO proteins was significantly higher in malignant cells. The proportion of cells with at least 5 silver grains per cell was 16.8 and 22.8% in follicular and papillary carcinoma, respectively, and 3.2 and 12% in follicular and atypical adenoma, respectively. These data can be used as accessory signs in differential diagnosis.