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"slug": "d06_karcinoma_in_situ_sheyki_matki",
"lead": "Нарушение здоровья, относящееся к группе новообразования in situ",
"description": "Карцинома in situ считается самой ранней формой рака. Врачи нередко рассматривают данную опухоль как предраковое состояние. Это связано с тем, что раковые клетки при данной патологии обнаруживаются только в поверхностном слое шейки матки, и не распространяются на глубокие ткани. Рак шейки матки является одной из наиболее распространенных злокачественных опухолей у женщин, занимает второе место по частоте встречаемости после рака молочной железы.",
"etiology": "<p>Чаще всего раку шейки матки подвержены женщины в возрасте 40 – 55 лет. На развитие рака шейки матки могут влиять:</p>\r\n<p>— ранее начало половой жизни,<br /> — половые инфекции,<br /> — курение,<br /> — несоблюдение интимной гигиены,<br /> — слабый иммунитет,<br /> — хронические воспалительные процессы шейки матки и наличие заболеваний таких как: дисплазия шейки матки, эрозия шейки матки, лейкоплакия,<br /> — заражение вирусом папилломы человека (80-100% пациенток с раком шейки матки заражены ВПЧ). Существует более 100 типов вируса папилломы человека, среди которых 16 и 18 типы вызывают рак шейки матки, а также могут быть причинами плоскоклеточного рака глотки и рака ануса у женщин и у мужчин.</p>",
"pathogenesis": "<p>Факторами, способствующими запуску механизмов вирусного канцерогенеза, являются вирусного канцерогенеза, являются снижение иммунитета. Развитие рака шейки матки имеет ортодоксальный закономерный характер: в поверхностном (базальном) слое матки развивается гиперпластический процесс – дисплазия, для которого свойственна атипия эпителия с нарушением слоистости, но без вовлечения поверхностного слоя и стромы. Затем в этих участках формируется преинвазивный рак с поражением всего эпителиального пласта, затем происходит прорыв базальной мембраны и развитие инвазивного процесса. Чрезвычайно важен факт существования латентного периода (длительность которого весьма вариабельна), необходимого для перехода дисплазии в преинвазивный рак и далее в инвазивный. Этот период обеспечивает возможность активной профилактики заболеваемости инвазивным раком шейки матки путем выявления дисплазии и внутриэпителиального рака и своевременного адекватного их лечения.</p>",
"diagnostics": "<p>В современной онкогинекологии существует двухэтапная система обследования пациентки. На первом этапе производится первичное выявление — скрининг, на втором — используются методы углубленной диагностики при подозрении на предрак или рак репродуктивной системы.</p>\r\n<p>Цель скрининга:</p>\r\n<p>1) определение групп риска развития рака шейки матки;</p>\r\n<p>2) выявление контингента женщин с предраковой патологией шейки матки;</p>\r\n<p>3) направление женщин для второго этапа углубленного обследования.</p>\r\n<p>На этапе скрининга собирают анамнез, проводят общий осмотр и обследование молочных желез, осмотр наружных половых органов, влагалища и шейки матки в зеркалах, цитологическое исследование мазков, взятых с поверхности шейки матки из зоны трансформации и цервикального канала, бимануальное ректовагинальное исследование. Цитологическое залючение составляется с учетом классификации, аналогичной классификации Папаниколау, предусматривающей описание пяти типов мазков:</p>\r\n<p>I — цитограмма без особенностей;</p>\r\n<p>II — воспалительный тип мазка;</p>\r\n<p>III — морфологические изменения клеток, соответствующие дисплазии;</p>\r\n<p>IV — подозрение на рак;</p>\r\n<p>V — цитограмма рака.</p>\r\n<p>На основании клинико-цитологической информации отбираются женщины, которым показано более углубленное обследование.</p>\r\n<p>Задачи углубленной диагностики:</p>\r\n<p>1) верификация и установление стадии заболевания;</p>\r\n<p>2) определение местной распространенности опухолевого процесса;</p>\r\n<p>3) выявление отдаленных метастазов;</p>\r\n<p>4) оценка функционального состояния органов и систем.</p>\r\n<p>Для верификации диагноза производится осмотр шейки в зеркалах, выполняется кольпоскопия, из патологических очагов берется прицельно биопсия конхотомом, скальпелем, электропетлей и выполняется выскабливание цервикального канала ложечкой Фолькманна, кюреткой.</p>\r\n<p>Местное распространение опухоли определяется при осмотре в зеркалах, ректовагинальном бимануальном исследовании органов малого таза, параметральной клетчатки, мочевого пузыря и прямой кишки на глубину пальца. Степень местного распространения уточняется при цистоскопии, ректороманоскопии. Ультразвуковое исследование позволяет выявить метастазы в подвздошных, парааортальных лимфоузлах, печени и других паренхиматозных органах брюшной полости. Под контролем УЗИ выполняется тонкоигольная пункция через влагалищные своды с целью верификации метастатического поражения регионарных лимфоузлов. С целью исключения отдаленных метастазов выполняется рентгенография органов грудной полости, при подозрении метастатического поражения костей проводится сканирование скелета. На основании полученных результатов клинического обследования выставляется стадия заболевания.</p>",
"treatment": "<p>При выборе метода лечения ранней онкологической патологии шейки матки необходимо стремиться к соблюдению двух основных принципов:</p>\r\n<p>1) обеспечение надежного излечения, в результате чего предупреждаются рецидивы заболевания и переход в более выраженный патологический процесс;</p>\r\n<p>2) применение органосохраняющих и щадящих методов лечения у женщин молодого возраста.</p>\r\n<p>Конизация шейки матки (процедура, при которой удаляют конусообразный кусок шейки матки) может быть выполнена скальпелем, электроножом, хирургическим лазером. Основные достоинства метода конизации заключаются в радикальном удалении патологически измененных тканей шейки матки в пределах здоровых тканей, небольшом количестве осложнений, сохранении физиологических функций, включая детородную. Предпочтительнее применять методики конизации, позволяющие исследовать удаленный препарат шейки матки. Метод лазерной конизации исключает эту возможность. Метод электроконизации возможен даже в амбулаторных условиях.</p>\r\n<p>Ампутация шейки матки является альтернативным методом лечения преинвазивного рака шейки матки. Этот метод показан при грубых деформациях шейки матки, вызванных ее разрывами в родах, при поражении цервикального канала, когда выполнение электроконизации шейки матки сопряжено с большим риском развития рецидива.</p>\r\n<p>Экстирпация (удаление) матки показана:</p>\r\n<p>пациентам в возрасте старше 50 лет; при преимущественной локализации опухоли в шеечном канале; распространенном анапластическом варианте с врастанием в железы; отсутствии в препарате участков, свободных от преинвазивного рака (особенно по линии отсечения) после произведенной ранее конизации; сочетании преинвазивного рака с миомой матки или опухолями придатков; рецидивах после крио- или лазерной деструкции.</p>\r\n<p>Методы криодеструкции, лазерной коагуляции, лазерной конизации шейки матки, фотодинамической лазерной коагуляции, электрокоагуляции применяются в онкогинекологии. </p>\r\n<p>Они менее целесообразны для лечения преинвазивного рака шейки матки, так как не позволяют исследовать инвазию патологического процесса</p>",
"prevention": "<p>Предупредительные мероприятия в отношении рака включает:</p>\r\n<ul>\r\n<li>проведение широкомасштабной просветительской работы, с целью повышения онконастороженности;</li>\r\n<li>внедрение плановых скрининговых обследований, начиная с 21-25 лет с целью выявления дисплазии стенок половых органов;</li>\r\n<li>проведение планомерной вакцинации от вируса папилломы человека, в отношении рака шейки, создание системы контроля безопасности вакцинопрофилактики;</li>\r\n<li>совершенствование образа жизни, наиболее реальная рекомендация касается внимательного отношения к нормализации белкового, углеводного обмена.</li>\r\n</ul>\r\n<p> </p>",
"clinical_picture": "<p>Начальные стадии предрака в большинстве случаев протекает бессимптомно. Все это время женщина не замечает признаки серьезного недомогания, считает себя здоровой, планирует личную жизнь, рождение ребенка.</p>\r\n<p>В дальнейшем при прогрессировании заболевания могут возникнуть такие симптомы, как:</p>\r\n<p>Различные выделения в т.ч. кровянистые (не менструация), кровотечения; Боли в нижней части живота; Боли при мочеиспускании; Ощущение тяжести в области таза; Болевые ощущение во время полового акта; Отеки конечностей, наружных половых органов; Нарушение работы кишечника и мочевого пузыря; Задержка мочи (при поражении лифмоузлов); Отек нижней конечности с одной стороны (при поражении лимфоузлов).</p>\r\n<p>Также при раке шейки матки возможно наличие общих симптомов: потеря веса, общая слабость, плохой аппетит, повышенная температура, головокружения.</p>",
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"code": "D03",
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"description": "Меланома in situ – это злокачественное новообразование кожи, развивающееся из клеток меланоцитов, развивающееся в пределах верхнего слоя кожи - эпидермиса. Чаще всего развивается на открытых участках тела, которые больше всего подвержены ультрафиолетовому облучению.",
"etiology": "<p>К предрасполагающим факторам, способствующим развитию меланомы, относят:</p>\r\n<ul>\r\n<li>инсоляция солнечными лучами кожи;</li>\r\n<li>особенности кожи – белая, с трудом поддается загару, солнечный ожог развивается за 30 минут воздействия ультрафиолетовых лучей;</li>\r\n<li>невусы (родинки) – доброкачественные новообразования на коже, вырабатывающие меланин – кожный пигмент;</li>\r\n<li>травмирование родинок;</li>\r\n<li>генетическая предрасположенность – наличие у родственников старшего поколения меланомы;</li>\r\n<li>перенесенный рак кожи;</li>\r\n<li>предраковое заболевание кожи – пигментная ксеродерма;</li>\r\n<li>пожилой возраст;</li>\r\n<li>расовая принадлежность человека. Согласно статистике ВОЗ, чернокожие в 4 раза реже страдают от меланомы, чем европеоиды;</li>\r\n<li>наличие сопутствующих хронических заболеваний, которые приводят к снижению общего иммунитета человека.</li>\r\n</ul>",
"pathogenesis": "<p>При изучении процессов возникновения и развития меланом кожи следует учитывать, что эта опухоль является уникальной для изучения вопросов ее канцерогенеза, так как более 50% первичных меланом кожи развивается на фоне предсуществующих пигментных невусов, что позволяет расценивать последний как факультативный предрак, и так как наиболее важными экзогенными этиологическими факторами этой опухоли являются УФ-радиация и травма невусов.</p>\r\n<p>Механизм канцерогенного действия УФ-радиации может заключаться в образовании в нормальных клетках высокоактивных свободных химических радикалов. В основе возникновения опухоли лежат процессы повреждения этими радикалами ДНК клетки, нарушение ее нормальной репарации. Последовательность процессов возникновения меланомы кожи под воздействием УФ-радиации можно схематически представить в следующем виде: УФ-радиация- меланобласты, меланоциты или невусные клетки - повреждение ДНК клетки - нарушение дифференцировки клетки - изменение белковой структуры клетки с возникновением новых мембранных антигенов - гипореактивность - бесконечно долгое размножение (опухолевый рост). Вероятно, такой механизм канцерогенеза меланом кожи является наиболее коротким во времени, так как в данном случае отсутствует длительная пролиферация нормальных клеток и тканей. Клиническим подтверждением возможности «включения» этого механизма канцерогенеза является факт более частого возникновения меланом после однократного и интенсивного воздействия УФ-радиации (солнечного ожога).</p>\r\n<p>Напротив, механизм канцерогенного действия травмы предсуществующих пигментных невусов включает в себя пролиферацию тканей в ответ на их повреждение, но сама травма не приводит к развитию опухоли. Доказано, что клетки в состоянии пролиферации обладают повышенной чувствительностью к канцерогенному воздействию и особенно уязвимы, находясь в фазе митотического цикла. Поэтому интенсивное размножение (пролиферация) клеток может привести к их неопластической трансформации. Последовательность процессов возникновения меланом кожи в результате травмы предсуществующих пигментных невусов можно схематически представить в следующем виде: повреждение - невусные клетки - воспаление и пролиферация поврежденной ткани - длительная пролиферация + воздействие эндогенных канцерогенных факторов (иммунологических, эндокринных, нейрогенных и др.) - нарушение структуры ДНК клетки - нарушение дифференцировки клетки - изменение белковой структуры клетки с возникновением новых мембранных антигенов - гипореактивность - бесконечно долгое размножение (опухолевый рост).</p>\r\n<p>Что касается действия эндогенных канцерогенных факторов меланомы кожи, то, очевидно, что точкой их приложения являются длительно пролиферирующие нормальные клетки и ткани, которые под воздействием этих факторов могут трансформироваться в опухолевые.</p>",
"diagnostics": "<p>Дерматоскопия -макроскопический осмотр образования при помощи дерматоскопа.</p>\r\n<p>Биопсия с последующим гистологическим анализом. Гистологическая диагностика представляет собой осмотр микропрепарата (тончайший срез исследуемого образца), подвергшегося специфической или неспецифической окраске. Помимо окраски с целью определения клеточного или тканевого атипизма, применяются также иммуногистохимический и иммуноферментный анализы</p>",
"treatment": "<p>Основным методом терапии является локальное иссечение первичной опухоли до фасции. Количество иссекаемых тканей зависит от распространенности опухолей и рассматриваются индивидуально, обычно с небольшим захватом здоровых тканей. Лекарственная терапия меланомы in situ проводится редко, только при гистологической верификации метастазирования опухоли. Поскольку к химиотерапии рак кожи в последние годы всё более устойчив, а химиопрепараты крайне токсичны, активно развивается иммунотерапия. Для лечения прогрессирующей меланомы используют препараты на основе альфа-интерферонов, интерлейкина и моноклональных антител.</p>\r\n<p>Третий вид терапии злокачественных опухолей – лучевая. Облучение назначается до операции с целью уменьшения объема хирургического вмешательства либо после операции.</p>\r\n<p>Комбинацию и методы врач подбирает индивидуально исходя из существующих особенностей меланомы in situ в каждом конкретном случае.</p>",
"prevention": "<p>Чтобы предотвратить переход доброкачественного процесса в злокачественное, люди входящие в группу риска должны регулярно наблюдаться у врача. Любыми видоизменения родинок, усиление пигментации, увеличение родимых пятен в размерах, уплотнение невусов должны стать поводом немедленного обращения к врачу. Люди, на теле которых множество родинок и невусов должны внимательно относиться к своему здоровью. Необходимо избегать попадания прямых солнечных лучей на места скопления родимых пятен, не допускать повреждения образований и регулярно посещать косметолога в целях профилактики. </p>\r\n<p> </p>",
"clinical_picture": "<p>Меланома in situ характеризуется появлением следующих клинических симптомов:</p>\r\n<ul>\r\n<li>Усилением пигментации пятна, его ростом и выраженным затвердением. В отличие от доброкачественных родинок, форма in situ не имеет осевой симметрии, ее очертания неровные. Пигментированное пятно состоит из мелких скоплений. Если у доброкачественных родинок цвет всегда равномерный, то у радиальной меланомы он может сочетаться светло-коричневым и песочным оттенками.</li>\r\n<li>Появление красного ободка вокруг меланомы и застойных явлений</li>\r\n<li>Появление пигментных разрастаний в виде лучей, отходящих от меланомы в разные стороны.</li>\r\n</ul>\r\n<p>В некоторых случаях первым клиническим симптомом прогрессирующей меланомы in situ является увеличение крупных лимфатических узлов, тогда как давно существующая родинка или невус на поверхности кожи не изменяется по своей окраске и в размерах. Прогрессирующее увеличение родинки или невуса на поверхности кожи, а также его затвердение и изменение окраски является первым симптомом того, что заболевание перешло в злокачественную форму течения.</p>\r\n<p>Очень часто рядом с растущим пигментным пятном начинают появляться различные плотные узелки усиленной пигментации. </p>\r\n<p> </p>",
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}
]
}
