Сборник статей d Ставрополь, 2012 удк (082): 159. 9: 616-085:=>616-089: 616-053. 2: 616. 31 Ббк 72. 471. 3я431(2Рос-4Ста) и 66 Научно-практическая конференция с международным участием «Инновации молодых учёных»

Fig. 1. Preoperative CT scan
He underwent exploration and right radical nephrectomy (fig. 2). Histopathology was consistent with a highly cellular necrotic tumor with monotonous population of sheets of round cells with scanty basophilic cytoplasm with perivascular pattern of arrangement (fig. 3). Tumor was infiltrating the capsule and the perinephric fatty tissue. Sections from the urether were free of tumor infiltration. The tumor cells were positive for CD99 and vimentin. The tumor was negative for cytokeratin and CD45 and chromogranin. A diagnosis of Ewing’s sarcoma/PNET of right kidney was made. Bone scan and bone marrow study were negative for disease involvement.



Fig. 2. Right nephrectomy sprcimen
Conclusion. Ewing’s sarcoma initially was believed to be of perivascular endothelial origin. The Ewing’s sarcoma family of tumors (EFT) includes ES of bone (ESB), extra osseous ES (EES), peripheral primitive neuroectodermal tumor of bone (pPNET), and Askin’s tumor, all of which are now known to be neoplasm’s of neuroectodermal origin. Because the behavior, prognosis, and treatment appear to be similar for all subsets of EFT, this histopathologic sub-classification may not be clinically significant. Light microscopy shows a tumor of small, round blue cells that lacks markers for lymphoma, neuroblastoma and rhabdomyosarcoma. Cytogenetically 90% to 95% of the Ewing’s family of tumors have a translocation between the EWS gene on chromosome 22 and the FLI1 gene on chromosome 11 [t(11:22) (q24:q12)] or the ERG gene on chromosome 21 [t21;22) (q22;q12)].

Approximately 20% of patients present with metastatic disease of metastatic patients, 44% present with lung metastases only and 51% have bone or bone marrow involvement (with or without lung metastases) and 5% present with metastases in other organs. Effective local and systemic therapies are necessary for the cure of Ewing’s sarcoma. Most chemotherapy regimens are a combination of cyclophosphamide, doxorubicin (Adriamycin), vincristine dactinomycin, ifosphamide and etoposide. Both surgery and radiation therapy are effective local therapy for the primary lesion.

Fig. 3. Histological examination of tumor
Ewing’s sarcoma/primitive neuroectodermal tumor of kidney is a rare and aggressive tumor, only few cases are reported in the literature. It has a rapid clinical progression with early metastases and death. Jimenez et al. published clinicopathologic and immunohistochemical analysis of 11 cases of Primary Ewing’s sarcoma/PNET of the kidney and mentioned a mean age of 18-49 years and mean follow up of 28 months (range 6-64 months) which showed 4 lung and pleural metastases, 1 bone metastases, liver metastases, 2 local recurrences and 5 deaths from disease (mean time to death 16.8 months) [9].

Bone and soft tissue Ewing’s tumor have been treated similarly. The 5 year overall survival rate of patient is more than 40% with localized disease at diagnosis. The prognosis of patients with metastatic disease at diagnosis is poor. In a report from the EICSS, the 5 year relapse free survival for patients with lung metastases only was 29%. In patients with metastatic disease at diagnosis, less than 50% of all Ewing’s sarcoma patients survive and it has been difficult to show a significant improvement over the last 20 years despite alteration of chemotherapy strategy.

With regards to local therapy the focus should be on improving function and decreasing the incidence of long term sequel. It is unlikely that refinements in local therapy with radiotherapy or surgery will significantly improve the cure rate as metastases and distant failure remains the primary mechanism of failure. Major improvements in the long term survival rate will probably not occur until development of better systemic agents or genetic therapy targeted at the t (11,12) translocation that produces PNET.
Reference

1. 
   Parada, D. Primary Ewing’s Sarcoma/primitive Neuroectodermal tumour of the kidney. An infrequent finding // D. Parada, A. Godoy, F. Liuzzi, K.B. Pelia, A. Romero, A.M. Parada. – Arch EspUrol. – 2007. – № 60. – P. 321-325.
   
2. 
   Saxena, R. Ewing sarcoma/primitive neuroectodermal tumor of the kidney: a case report. Diagnosed by immunohistochemistry and molecular analiysis // R. Saxena, S. Sait, P. Mhawech-Fauceglia. – Ann Diagnpathal. – 2006. – №10. – P. 636-636.
   
3. 
   Cotterill, S.J. Prognostic factors in Ewing’s tumor of bone: analysis of 975 patients from the European intergroup Cooperative Ewing’s sarcoma Study Group // S.J. Cotterill [et al.]. – J. Clinoncol. – 2000. – №18. – P. 3108-3114.
   
4. 
   Carvajal, R. Ewing’s sarcoma and primitive neuroectodermal family of tumors // R. Carvajal, P. Meyers. – Hematoloncolclin nothth Am. – 2005. –№19. – P. 501-525.
   
5. 
   Sandberg, A.A. Updated on cytogenetics and molecular genetics of bone and soft tissue tumors: Ewing’s sarcoma and peripheral primitive neuroectodermal tumors // A.A. Sandberg, J.A. Bridge. – Cancer Gen Cytogenet. – 2000. – №123. – P. 1-26.
   
6. 
   Arai, Y. Kun LE, Brooks MT, Fairclough DL, Fantanesi J, Meyer WH, et al Ewing’s sarcoma: local tumor control and patterns of failure following limited volume radiation therapy // Y. Arai [et al.]. – Int J RadiatOncolBiolPhys. – 1991. – №21. – P. 1501-1508.
   
7. 
   Bacci, G. Predictive factors of histological response to primary chemotherapy in Ewing’s sarcoma // G. Bacci [et al.]. – Acta Oncol. – 1998. – № 37. – P. 671-676.
   
8. 
   Jimenez, R.E. Folpe Al, Lapham Rl, Ro JY, O’Shea PA, weiss sw et al. Primary Ewing’s sarcoma/primitive neuroectodermal tumor of the kidney: a clinicopathologic and immunohistochemical analysis of 11 cases // R.E. Jimenez Jimenez. – Am J Surgpathol. –2002. –№ 26. –P. 320-327.
   

K. Rathnam, T.R. Murali, R. Ravichandran

PRIMITIVE NEUROECTODERMAL TUMOR OF THE KINDNEY

A case of Primitive Neuroectodermal Tumor (PNET) of the kidney in a 32 year old gentleman is presented. PNET is the second most common primary tumor of bone in childhood. Its occurrence in adults by itself is rare. Still more, Ewing’s sarcoma/primitive neuroectodermal tumor (ES/PNET) is an extra ordinarily rare primary tumor in the kidney. 1. Only very few cases of primary renal Ewing’s sarcoma have been reported in the literature to date. 2. We present a case of primary right renal Ewing’s sarcoma in a 32 years old gentleman who was diagnosed as a case of stage I, PNET of kidney. Right nephrectomy was done. Adjuvant chemoradiotherapy has been planned for this patient.

Keywords: primitive neuroectodermal tumor, Ewing’s sarcoma, kidney

УДК 618.32:612.646:616-001.18

K. Thirumangal, N. Vijayakumar

PREGNANCY FOLLOWING FROZEN EMBRYO TRANSFER

Meenakshi Mission Hospital and Research Centre, Tamil Nadu, India

Background. The first of human pregnancy through transfer of frozen and thawed embryos was published in 1983; and a year after, the first birth through such transfer was reported. The advances can easily be attributes to a better understanding of the embryo selection process, embryo transfer (ET) technique, ovarian stimulation and advantage and the clinical outcome of frozen Embryo transfer is given in table 1.

Material and Methods. 33 years old infertile couple, who conceived by previous ICSI in our hospital had come again for the second baby. During the past ICSI procedure we had retrieved 6 oocytes. All these oocytes were fertilized to 6 embryos with the husband sperm. Three were preserved for the future and the remaining was transferred to the uterus. The couple had delivered live male baby and was doing well. They had come for the second issue to our department. The proliferative phase was induced by daily oral administration of oestradiol, from day 1 of the menstrual cycle of the patient by Bourn Hall Protocol. When the endometrial thickness was > 7 mm, vaginal micronized progesterone oral oestradiol was continued.

Table 1

Frozen Embryo Transfer

Indication rate	Advantages	Clinical pregnancy rate	Embryo Survival
Patients risk for Ovarian Hyper Stimulation Syndrome (OHSS)	Increased cumulative pregnancy rate Restriction of risks of multiple pregnancies	20-35%	30-60%
Patients undergoing treatment for chronic illness	No OHSS	-	-
Cancer therapy	Cost effectiveness of the Thaw cycles Reduces wastage of Embryo	-	-

After two days of vaginal progesterone administration, the thawing of embryos was accomplished rapidly by removing the embryos from the freezing tank. Once thawed, the embryos were washed with decreasing concentrations of cryoprotectants, then washed with decreasing concentrations of cryoprotectants, then washed with embryo freezing medium and finally placed in fresh, equilibrated culture medium at 37 degree Celsius Embryos were considered as alive f at least 50% of the blastomeres were transferred regardless of the degree of evolutivity. Serum HcG became positive for pregnancy in our patient 12 days post transfer. The USG showed a single live intrauterine pregnancy. The patient is then regularly followed up in our department: 1) technique of Frozen Embryo Transfer; 2) cryopreservation of Embryos by vitrification (during the previous ICSI); 3) thawing of embryos (de freezing); 4) Embryo culture (checking for embryo survival and further cleavage in 4-12 hours); 5) Embryo transfer; 6) Urine Pregnancy Test (12 days post transfer) (USG guided); 7) Pregnancy (UPT Positive).

Results and Discussion.

Vitrification is an ultra-rapid method of cryopreservation whereby the embryo is transitioned from 37 degree Celsius to 196 degree Celsius in < 1 s, resulting in extremely fast rates of cooling (>10 000 degree Celsius/min). high concentrations of cryoprotectants together with rapid cooling rates are essential to cryopreserve embryos in a vitrified, glass-like state. To facilitate rapid heat transfer, minimal volumes are used in vitrification, facilitated through the use of minute tools as carriers. The carrier systems that have been developed for the vitrification procedure include the electron microscope grid, pulled and hemi-straws, flexipipet, cryotop and cryotip and the cryoloop. It has the following advantages:

1. 
   Lack of ice crystal formation, made possible through increased speed of temperature conduction, reducing associated chilling injuries.
   
2. 
   Speed minimizes the period of the embryo out of the incubator.
   
3. 
   Minimal set up time.
   
4. 
   Can be performed as needed during the course of the day.
   
5. 
   Not expensive.
   

The disadvantage is that it is technically more challenging.

Thawing is de freezing the stored embryos. It is done by placing the embryo into thawing sequential media, rinsed thoroughly and placed in embryo culture media under oil and cultured in 5% CO2 and air at 37 degree Celsius approximately four to twelve hours prior to transfer.

Conclusion. Embryo freezing now forms an integral part of routine IVF programs which yield surplus embryos for cryopreservation. Cryopreservation not only reduces wastage of valuable embryos, but also maximizes the number of conception attempts per stimulation cycle/oocytes collection, and significantly increases the cumulative pregnancy rate and reduces the health risks, inconvenience and costs. The concept can also be expanded and applied to the patient at risk of OHSS, as well as to the ovum recipient whose cycle is asynchronous with her donor.
Reference

1. 
   Trounson, A. L. Human pregnancy following crypreservation, thawing and transfer of an eight-cell embryo // A. Trounson, L. Mohr. – Nature. – 1983. – № 307. – P. 707-709.
   
2. 
   Ghobara, T. Cycle regimens for frozen-thawed embryo transfer // T. Ghobara, P. Vandekerckhove. – Cochrane Database, Syst Rev. – 2008. – №1. – CD003414.
   
3. 
   A randomized controlled study of human day 3 embryo cryopreservation by slow freezing or vitrification: vitrification is associated with higher survival, metabolism and blastocyst formation // B. Balaban [et al.]. – Hum reprod. – 2008. – P.1976-1982.
   

K. Thirumangal, N. Vijayakumar

PREGNANCY FOLLOWING FROZEN EMBRYO TRANSFER

Excess embryos provided by patients undergoing IVF/ICSI are cryopreserved and such two / four / eight cell embryos are frozen using dimethy sulphoxide. Subsequently the embryos are thawed at the appropriate time and transferred back to the original patient. This is Frozen Embryo transfer. This is an important tool in the armamentarium of assisted reproductive techniques. We describe successful singleton pregnancy following this novel technique in 33 year old women.

Keywords: ICSI, pregnancy, frozen embryo, transfer, ovarian hyperstimulation syndrome.

cVd

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Актуальные вопросы педиатрии

УДК 616.988.55:612.017.1:616-053.2/.5

А.В. Волкова

СИСТЕМА ФАГОЦИТИРУЮЩИХ КЛЕТОК У ДЕТЕЙ

С ИНФЕКЦИОННЫМ МОНОНУКЛЕОЗОМ ЭПШТЕЙН-БАРР ВИРУСНОЙ ЭТИОЛОГИИ

ГБОУ ВПО «Ставропольская государственная медицинская

академия» Министерства здравоохранения РФ,

Ставрополь, Россия

Проблема Эпштейн-Барр-вирусной инфекции является одной из самых актуальных в детской инфектологии в связи с высокой распространенностью, тропизмом вируса к иммунокомпетентным клеткам, отсутствием средств специфической профилактики и этиотропной терапии [2, 3, 7, 9]. Формирующиеся иммунные нарушения часто носят устойчивый характер и даже при легком течении заболевания сохраняются около 3 месяцев, а при среднетяжелом и тяжелом – до года и дольше [7]. Большинство научных исследований при ВЭБ-инфекции относится к оценке адаптивного иммунитета, тогда как данные о функциональном состоянии нейтрофильных гранулоцитов (НГ) крайне ограничены. Между тем фагоцитарные реакции занимают одно из центральных мест в регуляции структурного гомеостаза, обеспечивая базальный уровень защиты организма от повреждения [4, 5].

Цель - изучить функциональное состояние нейтрофилов периферической крови у детей с ВЭБ-инфекцией.

Материал и методы: проведено иммунологическое обследование 78 детей с инфекционным мононуклеозом (ИМ) Эпштейн-Барр вирусной этиологии: в возрасте 0-3 лет (23), 4-6 (32) и 7-15 лет (23) в острый период заболевания, а также через 6, 12 месяцев и через 2 года после перенесенной инфекции. Обследование детей и наблюдение за ними осуществлялось на базе 2 детского отделения краевой клинической инфекционной больницы (ККИБ), кабинета инфекционных заболеваний ККИБ, городской поликлиники № 3. Диагноз ВЭБ-инфекции подтверждали методом ИФА (IgM ВЭБ) и ПЦР (ДНК ВЭБ). Для оценки апоптоза НГ использовали метод проточной цитофлюориметрии, выявляя количество нейтрофильных гранулоцитов, экспрессирующих Fas (СD95) и Bсl 2 (Invitrogen, США). Содержание лизосомально-катионных белков определяли методом Шубича М.Г., уровень миелопероксидазы – методом Грэхема-Кнолля.

Для статистического анализа данных использовали пакет программ «Primer of Biostat 4,0», Attestat 10.5.1.». Для оценки межгрупповых различий применяли дисперсионный анализ повторных измерений с вычислением критериев Ньюмена-Кейлса, Данна. Количественные значения с нормальным распределением были представлены, как среднее ± стандартная ошибка средней (X±s_x); признаки, характеризующиеся ненормальным распределением – в виде медианы и интерквантильного (25 и 75 процентили) размаха (Me (Q1-Q)). Достоверными считали различия при р<0,05.

Результаты и обсуждение

Клинико-гематологическая манифестация инфекционного мононуклеоза сопровождалась нейтропенией у детей всех возрастных групп (табл.1). Достоверные отличия от здоровых детей отмечались преимущественно в острую фазу заболевания. Однако у детей с тяжелой формой ИМ в возрастной группе до 3-х лет признаки нейтропении сохранялись более длительно – в течение полугода.

При определении маркеров апоптоза у детей раннего возраста выявлено увеличение числа нейтрофилов, экспрессирующих Fas (CD95⁺) (p<0,05). Достоверные отличия от здоровых детей у больных с легкой и среднетяжелой формами заболевания отмечались лишь в острую фазу инфекции, у больных с тяжелой формой – сохранялись в течение 6 месяцев.

Таблица 1

Показатели апоптоза нейтрофилов крови у детей с ВЭБ-инфекцией

Группа обследованных детей			НГ, abs•10^9 kl/l	CD95, %	Bcl 2, %
0-3 года	легкая и среднетяжелая формы (n=8)	острый период	3,23 (2,73-3,72)*	79,35 (76,75-2,05)*/**	3,1 (2,5-3,6)
		через 6 мес.	3,27 (2,80-3,73)	65,8 (59,65-70,45)/**	3,4 (3,0-3,65)
		через 12 мес.	3,81 (3,52-4,11)	64,15 (58,25-69,05)	3,15 (2,95-4,15)
		через 24 мес.	3,81 (3,55-4,07)	61,6 (59,85-63,95)	3,5 (2,7-4,45)
	тяжелая форма (n=6)	острый период	2,97 (2,62-3,32)*	93,15 (89,0-95,30)*	2,65 (1,7-3,2)*
		через 6 мес.	3,22 (2,71-3,73)*	80,55 (78,6-82,2)*	2,75 (2,1-3,1)*
		через 12 мес.	3,82 (3,64-3,99)	68,7 (65,4-72,6)	3,30 (3,0-3,90)
		через 24 мес.	3,88 (3,49-4,18)	67,35 (63,7-77,0)	3,85 (3,40-4,20)
	здоровые дети (n=10)		3,79 (3,51-4,07)	60,55 (54,2-65,2)	3,45 (3,53-4,5)
4-6 лет	легкая и среднетяжелая формы (n=8)	острый период	3,38 (2,91-3,84)*	70,85 (62,65-4,75)*/**	3,4 (2,6-4,25)
		через 6 мес.	3,76 (3,34-4,18)	67,5 (57,35-70,3)	3,75 (3,0-4,05)
		через 12 мес.	4,22 (3,75-4,70)	63,75 (54,9-71,7)	3,85 (3,3-4,15)
		через 24 мес.	4,25 (3,75-4,69)	62,65 (55,65-70,7)	3,67 (3,35-3,95)
	тяжелая форма (n=6)	острый период	3,20 (2,47-3,93)*	85,2 (78,1-89,1)*	2,55 (2,25-3,9)*
		через 6 мес.	3,77 (3,45-4,08)	67,3 (66,2-77,3)	3,6 (2,6-3,8)
		через 12 мес.	4,10 (3,61-4,59)	65,15 (61,2-73,1)	3,7 (3,3-4,10)
		через 24 мес.	3,98 (3,78-4,18)	63,25 (55,1-69,22)	3,75 (3,0-4,20)
	здоровые дети (n=10)		4,29 (4,03-4,55)	62,1 (56,4-68,0)	3,75 (3,1-4,2)
7-15 лет 7-15 лет	легкая и среднетяжелая формы (n=6)	острый период	3,52 (3,24-3,79) *	67,85 (62,1-77,0) */**	3,75 (3,6-4,0)/**
		через 6 мес.	4,08 (3,82-4,34)	65,0 (59,3-72,1)	3,65 (2,6-3,8)
		через 12 мес.	4,48 (4,02-4,94)	63,3 (59,2-64,3)	4,0 (3,6-4,5)
		через 24 мес.	4,52 (4,07-4,96)	60,45 (54,1-65,3)	3,85 (3,5-4,3)
	тяжелая форма (n=6)	острый период	3,38 (2,71-4,06)*	73,1 (72,0-81,2)*	2,6 (1,9-3,3)*
		через 6 мес.	4,01 (3,49-4,53)	67,3 (64,3-77,1)	3,15 (2,5-3,3)
		через 12 мес.	4,28 (3,91-4,66)	66,8 (57,0-71,2)	3,9 (3,6-4,2)
		через 24 мес.	4,43 (4,08-4,79)	65,35 (58,6-71,2)	3,9 (3,7-4,2)
	здоровые дети (n=10)		4,24 (4,0-4,52)	58,7 (53,2-64,3)	4,0 (3,53-4,5)

*-p<0,05 по сравнению со здоровыми, **-p<0,05 по сравнению с тяжелой формой (критерий Ньюмена – Кейлса, критерий Данна)
Уровень экспрессии белков Bcl 2, блокирующих апоптоз, уменьшался только при тяжелой форме ИМ. Изменения показателей регистрировались как в острый период заболевания, так и через 6 месяцев динамического наблюдения (p<0,05).

При обследовании детей в возрасте 4-6 и 7-15 лет (табл. 1) были выявлены те же закономерности. При этом статистически значимые изменения уровней CD95⁺ определялись у детей всех клинических форм преимущественно в острую фазу ИМ. В период выздоровления содержание предуготовленных к апоптозу нейтрофилов (CD95⁺) нормализовалось. Показатели экспрессии Bcl 2⁺ уменьшались только у детей с тяжелой формой заболевания в острый период ВЭБ-инфекции.

При сравнительной характеристике в острый период заболевания наиболее высокие показатели экспрессии CD95, отмечались у детей с тяжелой формой ИМ с достоверными отличиями от легкой и среднетяжелой форм ИМ.

При оценке метаболической активности нейтрофилов выявлены их функциональные нарушения, глубина которых зависела от тяжести заболевания и возраста ребенка (табл. 2).