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.

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.

An original method of proximal gastrectomy was used to eliminate hemorrhage from gastric and oesophagal varicose veins in 27 patients with portal hypertension. The follow up period varied from 1 to 23 years. The risk of hemorrhage and the degree of vein dilatation were assessed by endoscopy and endoscopic ultrasonography. It is concluded that the method used in the study may be recommended as the first-line surgery for the management of hemorrhage from gastric and oesophagal varicose veins with good functional results in the late postoperative period and rare complications.

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.

Experience of 10-years observation of 164 patients who underwent radiation impact, 38 (23%) afterwards had chronic obstructive pulmonary disease (COPD), is analyzed in the article. It is demonstrated, that timely COPD diagnostics must be based on thorough gathering of anamnestic data, analysis of clinical manifestations and results of annual examination of pulmonary ventilation function. Changes in time of COPD clinical symptoms among COPD patients who underwent radiation influence are considered. It was established, that in patients who underwent radiation influence, COPD began in younger age, coursed more severe, with more frequent aggravations, requiring inpatient treatment. Therapy of this category of persons required all drugs used at COPD treatment.

© КОЛЛЕКТИВ АВТОРОВ, 2008 ... УДК 616.24 - 036:2 - 07 ... СИМОНЕНКО В. Б., заслуженный веятель науки РФ, заслуженный врач РФ, член-корреспондент РАМН, профессор, генерал-майор медицинской службы ... СУВОРОВ В. В., полковник медицинской службы ... ПАНФИЛОВ Д. Н., профессор, полковник медицинской службы ... ДУЛИН П. А., профессор, полковник медицинской службы ... Заболеваемость хронической обструктивной болезнью легких (ХОБЛ) в последние годы в мире имеет тенденцию к росту. Эта патология занимает четвертое место в общей структуре причин смертности [1, 8, 9]. ... ХОБЛ характеризуется частично обратимым прогрессирующим ограничением скорости воздушного потока в дыхательных путях, что связано с воспалительным ответом дыхательных путей на повреждающие частицы или газы [7]. Происходят разной выраженности патологические изменения в центральных и периферических дыхательных путях, паренхиме и сосудах легких. Эти изменения приводят к патофизиологическим расстройствам - гиперсекреции слизи и цилиарной дисфункции, ограничению скорости воздушного потока и гиперинфляции, нарушению газообмена, легочной гипертензии и системным эффектам [2]. ... В результате хронического воспалительного процесса в разных анатомических образованиях легких выявляются повышенные количества макрофагов, Т-лимфоцитов и нейтрофилов. Активированные воспалительные клетки выделяют большое количество медиаторов: лейкотриен В4 (LTB4), интерлейкин 8 (IL-8), фактор некроза опухоли (TNF-б) и др., которые способны повреждать структуру легких и поддерживать нейтрофильное воспаление. Существенное значение в патогенезе ХОБЛ имеют дисбаланс протеолитических ферментов и антипротеиназ, оксидативный стресс [3, 4]. Для ХОБЛ характерны нарушение архитектоники (ремоделирование) терминальных отделов дыхательных путей и избыточная продукция бронхиального секрета [5]. ... В целях предупреждения развития ХОБЛ или снижения скорости потери легочной функции требуется эффективная система динамического наблюдения за больными. Это особенно необходимо в связи с тем, что хронические заболевания легких с сезонными обострениями требуют противорецидивного лечения. ... В Вооруженных Силах РФ действует устоявшаяся система диспансерного наблюдения за состоянием здоровья военнослужащих [6]. В ранее существовавших методиках в отношении больных с легочной патологией основное внимание уделялось рентгенологическому исследованию либо малоинформативной пневмотахометрии. Подобный подход недостаточен у больных с ХОБЛ, при которой показатели функции внешнего дыхания (ФВД) носят определяющий характер в оценке состояния пациента, в связи с чем методика динамического наблюдения за больными с ХОБЛ требует дополнения. ... На амбулаторно-поликлиническом этапе особенно велика роль правильного сбора анамнеза, учета ранних клинических симптомов дыхательной и начальных проявлений легочно-сердечной недостаточности. Своевременная регистрация этих изменений позволяет лечащему врачу вносить своевременные коррективы в схему проводимой терапии, что обеспечивает сокращение сроков лечения, предупреждение осложнений. ... Во 2-м Центральном военном клиническом госпитале (2 ЦВКГ) им. П. В. Мандрыки существует стройная система наблюдения за больными ХОБЛ. На базе консультативно-диагностической поликлиники работает диспансерное отделе- ... Таблица 1 Распределение больных по степени тяжести течения ХОБЛ ... Стадия ХОБЛ ... Всего ... I - легкая ... II - средней тяжести ... III - тяжелая ... IV - крайне тяжелая ... n ... f ... n ... f ... n ... f ... n ... f ... n ... f ... 55 ... 0,46 ... 44 ... 0,37 ... 14 ... 0,12 ... 5 ... 0,05 ... 118 ... 1,0 ... Примечание: n - абсолютное число больных, f - частота встречаемости признака в группе больных. ... ние, использующее в своей деятельности принцип семейного врача. На основании результатов осмотра составляется план лечебно-диагностического наблюдения, который заносится в медицинскую книжку военнослужащего. ... Для оценки эффективности проводимой работы были изучены медицинские документы диспансерного отделения 2 ЦВКГ: медицинские книжки и истории болезни, журналы учета лиц, находящихся под динамическим врачебным наблюдением, планы лечебно-оздоровительных мероприятий, осуществлен ретроспективный межгрупповой анализ существующей системы динамического наблюдения за больными ХОБЛ. ... Изучено 1268 медицинских книжек военнослужащих кадра и запаса, а также членов их семей, 397 историй болезни стационарных больных. Отобраны документы на лиц с диагнозом ХОБЛ. Эту группу составили 118 больных, или 7% от числа обследованных. Проведен анализ состояния здоровья данного контингента за период с 1992 по 2006 г. ... Статистическая обработка результатов исследований выполнялась с использованием программы Statistica. Достоверность различий (р) в частотах (0 изучаемых признаков определялась по критерию χ2, а в случаях, когда в группе было менее 5 наблюдений, использовался двусторонний критерий Фишера. ... Как показано в табл. 1, различной выраженности течение ХОБЛ диагностировалось у более 53% взятых на учет больных.

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 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.

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.

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.

Clinical practice has been recently applied new approaches to classifying patients with arterial hypertension (AH), which are based on the determination of the summary risk suggesting the prognosis of the disease. This approach is quite efficient due to the fact that it takes into account a combination of the comparable clinical symptoms of AH, which characterize its course. The paper presents data on the values of blood pressure (BP) in AH and on daily BP profiles (DBPP) in 494 patients with different categories of a risk and on their endothelial function. It also gives the results of achievement of target BP levels in patients with AH having different categories of a risk during long-term (36-month) treatment with enapril and perindopril, as well as data on its impact on endothelial vasomotor function. The findings suggest that the higher the risk is, the more severe the hypertensive syndrome is; that the redistribution of DBPP occurs towards prognostically poor types and endothelial dysfunction (EDF) progresses. Treatment with angiotensin-converting enzyme (ACE) inhibitors results not only to the achievement of target BP levels and to the normalization of DBPP, but also to the amelioration of EDF. Moreover, the co-administration of ACE inhibitors and isosorbide-5-mononitrates causes additional antiischemic effects.

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.

A comparative ultrasound and radiological investigation of gallbladder and hepatic tree function was made in patients after operation with creation of artificial stomach, Billroth I and Roux operations. The control group consisted of 30 unoperated patients. Scintigraphy discovered gallbladder dyskinesia in 12 (18.7%) patients of the study group and in 6 (20%) controls. Ultrasonography--in 15 (33.3%) patients of the study group, 5 (25%) patients after distal resection of the stomach with pyloriform gastroduodenoanastomosis, 18 (51.47%) patients operated by Roux and 5 (16.6%) controls, respectively. It is shown that normal transduodenal passage of food has a positive effect on gallbladder and liver functions.