Первый опыт лечения рака поджелудочной железы методом

ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà, 2004, ÚÓÏ 9, ‹ 1, Ò. 150–155
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èÂ‚˚È ÓÔ˚Ú Î˜ÂÌËfl ‡Í‡ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
ÏÂÚÓ‰ÓÏ Ï‡ÒÎflÌÓÈ ‡ÚÂˇθÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË
Ñ. Ä. É‡ÌÓ‚,
Ä. Ç. 臂ÎÓ‚ÒÍËÈ,
è. É. í‡‡ÁÓ‚
ñÂÌÚ‡Î¸Ì˚È
̇ۘÌÓ-ËÒÒΉӂ‡ÚÂθÒÍËÈ
ÂÌÚ„ÂÌÓ‡‰ËÓÎӄ˘ÂÒÍËÈ
ËÌÒÚËÚÛÚ (‰Ë. – ‡Í‡‰. êÄåç
Ä.å.É‡ÌÓ‚) åËÌÁ‰‡‚‡ êî,
ë‡ÌÍÚ-èÂÚÂ·Û„
Ç ÍÎËÌËÍ ñçàêêà åËÌÁ‰‡‚‡ êî ‡Á‡·ÓÚ‡Ì ÒÔÓÒÓ· ‚ÌÛÚˇÚÂˇθÌÓÈ Ï‡ÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÓÔÛıÓÎË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚. ç‡ ‰ÓÍÎËÌ˘ÂÒÍÓÏ ˝Ú‡ÔÂ
χÒÎfl̇fl ‡ÚÂˇθ̇fl ˝Ï·ÓÎËÁ‡ˆËfl ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‚˚ÔÓÎÌÂ̇ Û 12 ·ÂÒÔÓÓ‰Ì˚ı ÒÓ·‡Í. 燷β‰ÂÌË Á‡ ÊË‚ÓÚÌ˚ÏË Ë „ËÒÚÓÎӄ˘ÂÒÍÓ ËÁÛ˜ÂÌË Ú͇ÌÂÈ ÔÓ͇Á‡ÎË ÓÚÒÛÚÒÚ‚Ë ÍÎËÌ˘ÂÒÍËı Ë ÏÓÙÓÎӄ˘ÂÒÍËı ÔËÁ̇ÍÓ‚ ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡ ‚
ÔÓÒÚ˝Ï·ÓÎËÁ‡ˆËÓÌÌÓÏ ÔÂËÓ‰Â.
å‡ÒÎfl̇fl ˝Ï·ÓÎËÁ‡ˆËfl Ó·ÂÒÔ˜˂‡ÂÚ ÔÓÎÓÌ„ËÓ‚‡ÌÌ˚È ÍÓÌÚ‡ÍÚ ÓÔÛıÓÎË Ò ‚˚ÒÓÍÓÈ ÍÓ̈ÂÌÚ‡ˆËÂÈ ıËÏËÓÔÂÔ‡‡Ú‡. ùÚÓ ÔÓÁ‚ÓÎflÂÚ ‰Ó·ËÚ¸Òfl ‚˚‡ÊÂÌÌÓ„Ó ÔÓÚË‚ÓÓÔÛıÓÎÂ‚Ó„Ó ˝ÙÙÂÍÚ‡ ·ÂÁ Û‚Â΢ÂÌËfl ÒÛÏχÌÓÈ ‰ÓÁ˚.
ᇠÔÂËÓ‰ Ò 1999 ÔÓ 2002 „. ‰Ë‡„ÌÓÒÚ˘ÂÒ͇fl ‡Ì„ËÓ„‡ÙËfl ·˚· ‚˚ÔÓÎÌÂ̇ Û 63 ·ÓθÌ˚ı ÏÂÒÚÌÓ-‡ÒÔÓÒÚ‡ÌÂÌÌ˚Ï ÔÓÚÓÍÓ‚˚Ï ‡ÍÓÏ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
(T4NxM0). èË ˝ÚÓÏ Û 32 (51%) ·ÓθÌ˚ı Ôӈ‰Û‡ ·˚· Á‡‚Â¯Â̇ ‚˚ÔÓÎÌÂÌËÂÏ
‚ÌÛÚˇÚÂˇθÌÓÈ Ï‡ÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÒÓÒÛ‰Ó‚ ÓÔÛıÓÎË. ÇÒÂ„Ó ‚˚ÔÓÎÌÂÌÓ 98 Ôӈ‰Û (ÓÚ 1 ‰Ó 11). é‰ÌÓÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ·ÓθÌ˚ı ÔÓÒΠıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË Ò „ÂψËÚ‡·ËÌÓÏ ÒÓÒÚ‡‚Ë· 50%, 2-ÎÂÚÌflfl – 15%. ë‰Ìflfl ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÊËÁÌË ÛÏÂ¯Ëı ÒÓÒÚ‡‚Ë· 12.1 + 5.7 ÏÂÒ.
ë‰ÂÎ‡Ì ‚˚‚Ó‰, ˜ÚÓ Ï‡ÒÎfl̇fl ‡ÚÂˇθ̇fl ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËfl fl‚ÎflÂÚÒfl ·ÂÁÓÔ‡ÒÌ˚Ï
Ë ÔÂÒÔÂÍÚË‚Ì˚Ï ÏÂÚÓ‰ÓÏ ÚÂ‡ÔËË ‡Í‡ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
First Experience of Oily Arterial Chemoembolization
for the Treatment for Pancreatic Cancer Treatment
D. A. Granov,
A. V. Pavlovsky,
P. G. Tarazov
St. Petersburg Research Institute
of Roentgenology and Radiation
Therapy, Ministry of Public
Health of the Russian Federation
Method of intra-arterial oily chemoembolization of the pancreatic tumor was offered. The
essence of this method comprises a slowing-down of regional blood flow in the pancreas and
tumor by injection of gemcitabin-in-oil. Slow passage of chemoembolisant along the microcirculatory bed provides a prolonged contact between tumor and highly concentrated chemotherapeutic drug. It causes enhanced diffusion of gemcitabine into the tissue resulting in a
marked antitumor effect without any increase of the systemic toxicity.
Between 1999 and 2002, diagnostic angiography was performed in 63 patients with locally
advanced cancer of the pancreas (T4NxM0). Intra-arterial oily chemoembolization was made
in 32 patients (51%). In total, 98 oily chemoembolization procedures were performed (1 to 11
per patient). One and two-year survival rates of patients were 50% and 15%, respectively.
It is concluded that oily chemoembolization is a safe and potentially effective method for the
treatment of pancreatic cancer.
ǂ‰ÂÌËÂ
èÓ·ÎÂÏÓÈ Ô‡ÎΡÚË‚ÌÓ„Ó Î˜ÂÌËfl ‡Í‡ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ fl‚ÎflÂÚÒfl Ì‚˚ÒÓ͇fl ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ıËÏËÓÚÂ‡Ô‚Ú˘ÂÒÍÓ„Ó ‚ÓÁ‰ÂÈÒÚ‚Ëfl [3,
15, 16]. èÓ ÒÓ‚ÂÏÂÌÌ˚Ï Ô‰ÒÚ‡‚ÎÂÌËflÏ, ÛÒÚÓȘ˂ÓÒÚ¸ ‡‰ÂÌÓ͇ˆËÌÓÏ˚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Í ıËÏËÓÚÂ‡ÔËË Ó·ÛÒÎÓ‚ÎË‚‡ÂÚÒfl ̇΢ËÂÏ ‚
ÍÎÂÚ͇ı ÓÔÛıÓÎË ‚˚ÒÓÍÓÈ ÍÓ̈ÂÌÚ‡ˆËË „ÂÌÓ‚
ÏÌÓÊÂÒÚ‚ÂÌÌÓÈ ÎÂ͇ÒÚ‚ÂÌÌÓÈ ÂÁËÒÚÂÌÚÌÓÒÚË
[17]. äÓÏ ÚÓ„Ó, ‚˚‰ÂÎÂÌ Â˘Â ˆÂÎ˚È fl‰ ÏÂı‡ÌËÁÏÓ‚, Ò ÔÓÏÓ˘¸˛ ÍÓÚÓ˚ı ÓÔÛıÓθ ÏÓÊÂÚ ÌÂÈÚ‡ÎËÁÓ‚‡Ú¸ ‰ÂÈÒÚ‚Ë ıËÏËÓÔÂÔ‡‡ÚÓ‚. ÇÒ ÓÌË
̇ÒΉÒÚ‚ÂÌÌÓ ‰ÂÚÂÏËÌËÓ‚‡Ì˚, ˝‚ÓβˆËÓÌÌÓ
Á‡ÍÂÔÎÂÌ˚ Ë fl‚Îfl˛ÚÒfl Ú‡ÍÊ ˜‡ÒÚ¸˛ Ò‚ÓÈÒÚ‚
ÍÎÂÚÓÍ ÌÓχθÌÓ„Ó ˝ÔËÚÂÎËfl, ‚˚ÒÚË·˛˘Â„Ó
ÔÓÚÓÍÓ‚Û˛ ÒËÒÚÂÏÛ Ôˢ‚‡ËÚÂθÌ˚ı ÊÂÎÂÁ Ë
Í˯˜ÌËÍ [16].
Ç ˝ÍÒÔÂËÏÂÌÚ‡ı ÛÒÚ‡ÌÓ‚ÎÂÌÓ ÛÒËÎÂÌË ÔÓÚË‚ÓÓÔÛıÓÎÂ‚Ó„Ó ˝ÙÙÂÍÚ‡ ÔË ÔÓ‚˚¯ÂÌËË ÍÓ̈ÂÌÚ‡ˆËË Ë ‚ÂÏÂÌË ‚ÓÁ‰ÂÈÒÚ‚Ëfl ıËÏËÓÔÂÔ‡‡ÚÓ‚
̇ ÍÛθÚÛÛ ÍÎÂÚÓÍ ‡Í‡ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
[10]. ÇÓÒÔÓËÁ‚‰ÂÌË ڇÍËı ÛÒÎÓ‚ËÈ ‰Îfl ÓÔÛıÓÎË
‚ ÍÎËÌ˘ÂÒÍÓÈ Ô‡ÍÚËÍ Ô‰ÒÚ‡‚ÎflÂÚ ‡ÍÚۇθÌÛ˛ Á‡‰‡˜Û [15, 16, 19].
é‰ÌËÏ ËÁ ÔÛÚÂÈ ÔÓ‚˚¯ÂÌËfl ˝ÙÙÂÍÚË‚ÌÓÒÚË
ıËÏËÓÚÂ‡ÔËË fl‚ÎflÂÚÒfl ÒÂÎÂÍÚË‚ÌÓ ‚ÌÛÚˇÚÂˇθÌÓ ‚‚‰ÂÌË ÔÂÔ‡‡ÚÓ‚. Ç˚ÒÓÍÓ ÒÓ‰ÂʇÌË ÎÂ͇ÒÚ‚ÂÌÌÓ„Ó Ò‰ÒÚ‚‡ ‚ ÓÍÛʇ˛˘ÂÏ
ÓÔÛıÓ΂˚ ÍÎÂÚÍË ÔÓÒÚ‡ÌÒÚ‚Â ÔË‚Ó‰ËÚ Í ËÌÚÂÌÒË‚ÌÓÏÛ Á‡ı‚‡ÚÛ ˆËÚÓÒÚ‡ÚËÍÓ‚ ‚ Ú̸͇-Ï˯Â̸,
Ì ‚˚Á˚‚‡fl ÔÓ·Ó˜Ì˚ı ˝ÙÙÂÍÚÓ‚, ‚ÓÁÌË͇˛˘Ëı
ÔË ÒËÒÚÂÏÌÓÈ ÚÂ‡ÔËË. ê„ËÓ̇̇fl ÍÓ̈ÂÌÚ‡ˆËfl ˆËÚÓÒÚ‡ÚËÍÓ‚ ËÏÂÂÚ Ó·‡ÚÌÓ ‚Á‡ËÏÓÓÚÌÓ¯ÂÌËÂ Ò „ËÓ̇Ì˚Ï ÍÓ‚ÓÚÓÍÓÏ: ˜ÂÏ ÌËÊ ÍÓ‚ÓÚÓÍ, ÚÂÏ ‚˚¯Â ÍÓ̈ÂÌÚ‡ˆËfl Ë Ì‡Ó·ÓÓÚ [5].
150
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
É‡ÌÓ‚ Ë ‰.
(·)
(‡)
êËÒ. 1. ÄÌ„ËÓ„‡ÏÏ˚ ·ÓθÌÓ„Ó ‡ÍÓÏ „ÓÎÓ‚ÍË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
‡ – ÒÂÎÂÍÚ˂̇fl ͇ÚÂÚÂËÁ‡ˆËfl „‡ÒÚÓ‰ÛÓ‰Â̇θÌÓÈ ‡ÚÂËË Ò ÛÒÚ‡ÌÓ‚ÍÓÈ ÒÔË‡ÎË (ÒÚÂÎ͇) ‰Îfl ‰Û͈ËË ÍÓηÚÂ‡Î¸ÌÓ„Ó ÍÓ‚ÓÚÓ͇;
· – ÔË ‚‚‰ÂÌËË Ï‡ÒÎflÌÓ„Ó ıËÏËÓ˝Ï·ÓÎËÁ‡Ú‡ ÓÔ‰ÂÎflÂÚÒfl Â„Ó Ì‡ÍÓÔÎÂÌË ‚ ÓÔÛıÓÎË.
çÂÒÏÓÚfl ̇ ÚÂÓÂÚ˘ÂÒÍË ÔÂËÏÛ˘ÂÒÚ‚‡ ÒÂÎÂÍÚË‚ÌÓ„Ó ËÌÚ‡‡ÚÂˇθÌÓ„Ó ‚‚‰ÂÌËfl ıËÏËÓÔÂÔ‡‡ÚÓ‚, Ú‡ÍÓÈ ÒÔÓÒÓ· ÚÂ‡ÔËË ÔËÏÂÌËÚÂθÌÓ
Í ‡ÍÛ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ì ÔË‚ÂÎ Í ÒÛ˘ÂÒÚ‚ÂÌÌÓÏÛ Û‚Â΢ÂÌ˲ ‚˚ÊË‚‡ÂÏÓÒÚË, ÒÓÒÚ‡‚Ë‚¯ÂÈ
5–9.9 ÏÂÒ [6]. LJÊÌ˚ÏË Ô˘Ë̇ÏË ÌÂÛ‰Ó‚ÎÂÚ‚ÓËÚÂθÌ˚ı ÂÁÛθڇÚÓ‚ fl‚Îfl˛ÚÒfl ÓÚÌÓÒËÚÂθÌÓ Ò··‡fl ‚‡ÒÍÛÎflËÁ‡ˆËfl ÒÓÒÛ‰Ó‚ ÓÔÛıÓÎË ÔÓ Ò‡‚ÌÂÌ˲
Ò ÌÓχθÌÓÈ Ú̸͇˛ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ [9],
ÌÂÍÓ̈‚ÓÈ ÚËÔ Â χ„ËÒÚ‡Î¸Ì˚ı ‡ÚÂËÈ, ‚˚‡ÊÂÌÌ˚ ÒÓÒÛ‰ËÒÚ˚ ‡Ì‡ÒÚÓÏÓÁ˚ Ò ÒÓÒ‰ÌËÏË Ó„‡Ì‡ÏË: ÊÂÎÛ‰ÍÓÏ, ‰‚Â̇‰ˆ‡ÚËÔÂÒÚÌÓÈ Ë ÚÓ˘ÂÈ
Í˯ÍÓÈ, ÒÂÎÂÁÂÌÍÓÈ. í‡ÍË ÓÒÓ·ÂÌÌÓÒÚË ÍÓ‚ÓÒ̇·ÊÂÌËfl Ó·ÛÒÎÓ‚ÎË‚‡˛Ú Î˯¸ ˜‡ÒÚ˘ÌÓ ÔÓıÓʉÂÌË ıËÏËÓÔÂÔ‡‡Ú‡ ˜ÂÂÁ Ú̸͇ ÓÔÛıÓÎË, ‡
Ú‡ÍÊÂ Â„Ó ·˚ÒÚÓ ‚˚Ï˚‚‡ÌËÂ. èÓ‚˚¯ÂÌË ˝ÙÙÂÍÚË‚ÌÓÒÚË ‚ÌÛÚˇÚÂˇθÌÓÈ ıËÏËÓÚÂ‡ÔËË
‡Í‡ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ô‰ÒÚ‡‚ÎflÂÚ ÒÓ·ÓÈ
‡ÍÚۇθÌÛ˛ Á‡‰‡˜Û, ¯ÂÌË ÍÓÚÓÓÈ ÏÓÊÂÚ ·˚Ú¸
̇ȉÂÌÓ Ì‡ ÒÚ˚Í ÚÂıÌ˘ÂÒÍËı ‰ÓÒÚËÊÂÌËÈ ËÌÚÂ‚Â̈ËÓÌÌÓÈ ‡‰ËÓÎÓ„ËË Ë ËÒÔÓθÁÓ‚‡ÌËfl ÌÓ‚˚ı
ıËÏËÓÚÂ‡Ô‚Ú˘ÂÒÍËı Ò‰ÒÚ‚.
å‡ÚÂË‡Î Ë ÏÂÚÓ‰˚
Ç ÍÎËÌËÍ ñçàêêà åËÌÁ‰‡‚‡ êî Ô‰ÎÓÊÂÌ ÏÂÚÓ‰ ‚ÌÛÚˇÚÂˇθÌÓÈ Ï‡ÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÓÔÛıÓÎË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
(Ô‡ÚÂÌÚ Ì‡ ËÁÓ·ÂÚÂÌË ‹ 215637 ÓÚ 20.09.2000)
[1]. ç‡ ‰ÓÍÎËÌ˘ÂÒÍÓÏ ˝Ú‡Ô χÒÎfl̇fl ‡ÚÂˇθ̇fl ˝Ï·ÓÎËÁ‡ˆËfl ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‚˚ÔÓÎÌÂ̇ Û 12 ·ÂÒÔÓÓ‰Ì˚ı ÒÓ·‡Í. 燷β‰ÂÌË Á‡ ÊË‚ÓÚÌ˚ÏË Ë „ËÒÚÓÎӄ˘ÂÒÍÓ ËÁÛ˜ÂÌË Ú͇ÌÂÈ ÔÓ͇Á‡ÎË ÓÚÒÛÚÒÚ‚Ë ÍÎËÌ˘ÂÒÍËı Ë ÏÓÙÓÎӄ˘ÂÒÍËı
ÔËÁ̇ÍÓ‚ ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡ ‚ ÔÓÒÚ˝Ï·ÓÎËÁ‡ˆËÓÌÌÓÏ ÔÂËÓ‰Â. ëÛÚ¸ ÏÂÚÓ‰‡ Á‡Íβ˜‡ÂÚÒfl ‚ ÂÁÍÓÏ Á‡Ï‰ÎÂÌËË „ËÓ̇ÌÓ„Ó ÍÓ‚ÓÚÓ͇ ‚ ÔÓ‰ÊÂÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
ÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁÂ Ë ÓÔÛıÓÎË ÔÛÚÂÏ Ó·‡ÚËÏÓÈ Ï‡ÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË. èË ˝ÚÓÏ Ï‰ÎÂÌÌÓÂ
ÔÓıÓʉÂÌË ıËÏËÓ˝Ï·ÓÎËÁ‡Ú‡ ÔÓ ÏËÍÓˆËÍÛÎflÚÓÌÓÏÛ ÛÒÎÛ Ó·ÂÒÔ˜˂‡ÂÚ ÔÓÎÓÌ„ËÓ‚‡ÌÌ˚È
ÍÓÌÚ‡ÍÚ ÓÔÛıÓÎË Ò ‚˚ÒÓÍÓÈ ÍÓ̈ÂÌÚ‡ˆËÂÈ ıËÏËÓÔÂÔ‡‡Ú‡ Ë ÛÒËÎÂÌÌÛ˛ ‰ËÙÙÛÁ˲ Â„Ó ‚ Ú̸͇, ˜ÚÓ
ÔÓÁ‚ÓÎflÂÚ ‰Ó·ËÚ¸Òfl ‚˚‡ÊÂÌÌÓ„Ó ÔÓÚË‚ÓÓÔÛıÓÎÂ‚Ó„Ó ˝ÙÙÂÍÚ‡.
èÓ͇Á‡ÌËÂÏ Í Ï‡ÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË
Ò˜ËÚ‡ÎË ÌÂÓÔÂ‡·ÂθÌ˚È ÏÂÒÚÌÓ-‡ÒÔÓÒÚ‡ÌÂÌÌ˚È „ËÒÚÓÎӄ˘ÂÒÍË ÔÓ‰Ú‚ÂʉÂÌÌ˚È ÔÓÚÓÍÓ‚˚È ‡Í ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ·ÂÁ ÓÚ‰‡ÎÂÌÌ˚ı
ÏÂÚ‡ÒÚ‡ÁÓ‚ (í4NxM0). èÂ‰ ‡Ì„ËÓ„‡ÙËÂÈ, ÍÓÏ ӷ˘ÂÍÎËÌ˘ÂÒÍËı ËÒÒΉӂ‡ÌËÈ, ‚˚ÔÓÎÌflÎË
äí Ë ìáà Ó„‡ÌÓ‚ ·˛¯ÌÓÈ ÔÓÎÓÒÚË, ÂÌÚ„ÂÌÓ„‡Ù˲ „Û‰ÌÓÈ ÍÎÂÚÍË, îÉÑë, ÂÌÚ„ÂÌÓ„‡Ù˲
ÊÂÎۉ͇. èË ÓÚÒÛÚÒÚ‚ËË „ËÒÚÓÎӄ˘ÂÒÍÓ„Ó ÔÓ‰Ú‚ÂʉÂÌËfl ‰Ë‡„ÌÓÁ‡ ‚˚ÔÓÎÌflÎË ˜ÂÒÍÓÊÌÛ˛
ÚÓÌÍÓË„ÓθÌÛ˛ Ú͇ÌÂ‚Û˛ ·ËÓÔÒ˲ ÌÓ‚ÓÓ·‡ÁÓ‚‡ÌËfl ÔÓ‰ ÍÓÌÚÓÎÂÏ ìáà.
ÇÒ ԇˆËÂÌÚ˚ ·˚ÎË ËÌÙÓÏËÓ‚‡Ì˚ Ó ‚ÓÁÏÓÊÌÓÒÚË ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÓÔÛıÓÎË Ë ‰‡ÎË ÔËÒ¸ÏÂÌÌÓ Òӄ·ÒËÂ. èÓÚË‚ÓÔÓ͇Á‡ÌËÂÏ Í ‚˚ÔÓÎÌÂÌ˲
Ôӈ‰Û˚ Ò˜ËÚ‡ÎË ÏÂı‡Ì˘ÂÒÍÛ˛ ÊÂÎÚÛıÛ, ··Ó‡ÚÓÌ˚Â Ë ÍÎËÌ˘ÂÒÍË ÔËÁ̇ÍË ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡, ıÓ·̄ËÚ‡, flÁ‚Û ÊÂÎۉ͇ ËÎË ‰‚Â̇‰ˆ‡ÚËÔÂÒÚÌÓÈ Í˯ÍË. èÓ˝ÚÓÏÛ Û ˜‡ÒÚË ·ÓθÌ˚ı ÔÓ͇Á‡ÌËfl Í
‡Ì„ËÓ„‡ÙËË ÒÚ‡‚ËÎË ÔÓÒΠÒÓÓÚ‚ÂÚÒÚ‚Û˛˘Â„Ó ÛÒÔ¯ÌÓ„Ó Ï‰Ë͇ÏÂÌÚÓÁÌÓ„Ó Î˜ÂÌËfl ËÎË ıËÛ„˘ÂÒÍËı Ô‡ÎΡÚË‚Ì˚ı ‚ϯ‡ÚÂθÒÚ‚.
ÇÌÛÚËÒÓÒÛ‰ËÒÚ˚ χÌËÔÛÎflˆËË ‚˚ÔÓÎÌflÎË ‚
ÛÒÎÓ‚Ëflı ÂÌÚ„ÂÌÓÓÔÂ‡ˆËÓÌÌÓÈ ‚ „ÓËÁÓÌڇθÌÓÏ ÔÓÎÓÊÂÌËË ·ÓθÌÓ„Ó Ì‡ ÒÚÓΠ‡Ì„ËÓ„‡Ù˘ÂÒÍÓ„Ó ÍÓÏÔÎÂÍÒ‡ “Angiostar” ÙËÏ˚ “Siemens”.
ÑÎfl Ôӂ‰ÂÌËfl Θ·Ì˚ı Ôӈ‰Û ÔËÏÂÌflÎË
˜ÂÁ·Â‰ÂÌÌÛ˛ ͇ÚÂÚÂËÁ‡ˆË˛ ÔÓ ëÂθ‰ËÌ„ÂÛ Ë
‹1
2004
151
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èÖêÇõâ éèõí ãÖóÖçàü êÄäÄ
(‡)
(·)
(‚)
(„)
êËÒ. 2. ÄÌ„ËÓ„‡ÏÏ˚ ·ÓθÌÓÈ ‡ÍÓÏ Í˛˜ÍӂˉÌÓ„Ó ÓÚÓÒÚ͇ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚. éÔ‰ÂÎflÂÚÒfl ÍÓ‚ÓÒ̇·ÊÂÌË ÓÔÛıÓÎË ÓÚ ‚ÂÚ‚ÂÈ ÒÂÎÂÁÂÌÓ˜ÌÓÈ (‡) Ë ‚ÂıÌÂÈ ·˚ʘÌÓÈ (·) ‡ÚÂËË. ëÛÔÂÒÂÎÂÍÚ˂̇fl ͇ÚÂÚÂËÁ‡ˆËfl
‰Ó҇θÌÓÈ Ô‡ÌÍ‡Ú˘ÂÒÍÓÈ ‡ÚÂËË (‚) Ë ÔÂ‚ÓÈ Â˛Ì‡Î¸ÌÓÈ ‡ÚÂËË („) Ò ‚‚‰ÂÌËÂÏ Ï‡ÒÎflÌÓ„Ó ıËÏËÓ˝Ï·ÓÎËÁ‡Ú‡
˜ÂÂÁ ÏËÍÓ͇ÚÂÚÂ.
(‡)
(·)
êËÒ. 3. äÓÏÔ¸˛ÚÂÌ˚ ÚÓÏÓ„‡ÏÏ˚ ·ÓθÌÓ„Ó ‡ÍÓÏ „ÓÎÓ‚ÍË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‚ ÔÓÒÚ˝Ï·ÓÎËÁ‡ˆËÓÌÌÓÏ ÔÂËÓ‰Â
‡ – 7- ÒÛÚÍË: ̇ÍÓÔÎÂÌË ıËÏËÓ˝Ï·ÓÎËÁ‡Ú‡ ‚ ÓÔÛıÓÎË „ÓÎÓ‚ÍË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ë ÔÂËÙÂ˘ÂÒÍËı ‚ÂÚ‚flı
‚ÓÓÚÌÓÈ ‚ÂÌ˚.
· – 28- ÒÛÚÍË: ÒÓı‡ÌflÂÚÒfl ÍÓÌÚ‡ÒÚËÓ‚‡ÌË ÎËÔËÓ‰ÓÎÓÏ Ô˜ÂÌË Ë „ÓÎÓ‚ÍË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
152
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
É‡ÌÓ‚ Ë ‰.
͇ÚÂÚÂ˚ “Hook” Ë “Cobra” 4–5 F, ‰Îfl ÒÛÔÂÒÂÎÂÍÚË‚ÌÓÈ Í‡ÚÂÚÂËÁ‡ˆËË – ÍÓ‡ÍÒˇθÌ˚È ÏËÍÓ͇ÚÂÚÂ 3F. ç‡ ‰Ë‡„ÌÓÒÚ˘ÂÒÍÓÏ ˝Ú‡Ô ‚˚ÔÓÎÌflÎË
‚ÂıÌ˛˛ ÏÂÁÂÌÚÂËÍÓ- Ë ˆÂΡÍÓ„‡Ù˲, ÍÓÚÓ˚ ÔÓÁ‚ÓÎflÎË ÓÔ‰ÂÎËÚ¸ ÒÚÂÔÂ̸ ‚ӂΘÂÌËfl
χ„ËÒÚ‡Î¸Ì˚ı ÒÓÒÛ‰Ó‚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‚
ÓÔÛıÓθ, ‚˚fl‚ËÚ¸ ‡ÚÂËË, ÌÂÔÓÒ‰ÒÚ‚ÂÌÌÓ Ò̇·Ê‡˛˘Ë ÍÓ‚¸˛ ÌÓ‚ÓÓ·‡ÁÓ‚‡ÌËÂ, Ë ÓˆÂÌËÚ¸ ‚ÓÁÏÓÊÌÓÒÚ¸ Ëı ͇ÚÂÚÂËÁ‡ˆËË Ò ˆÂθ˛ ‚‚‰ÂÌËfl ıËÏËÓ˝Ï·ÓÎËÁ‡Ú‡. ÖÒÎË ‰Ë‡ÏÂÚ ‡ÚÂËË ÔÓÁ‚ÓÎflÎ,
ËÒÔÓθÁÓ‚‡ÎË Ëı ÒÂÎÂÍÚË‚ÌÛ˛ ͇ÚÂÚÂËÁ‡ˆË˛ Ò
ÔÓÏÓ˘¸˛ ÏËÍÓ͇ÚÂÚÂ‡ (ËÒ. 1). èË Ì‡Î˘ËË
ÏÌÓÊÂÒÚ‚ÂÌÌ˚ı ÒÓÒÛ‰Ó‚ χÎÓ„Ó ‰Ë‡ÏÂÚ‡, ÔËÚ‡˛˘Ëı ÓÔÛıÓθ ÓÚ „‡ÒÚÓ‰ÛÓ‰Â̇θÌÓÈ ËÎË ÒÂÎÂÁÂÌÓ˜ÌÓÈ ‡ÚÂËË, ÔËÏÂÌflÎË ÔÂÂ‡ÒÔ‰ÂÎËÚÂθÌÛ˛ ÚÂıÌËÍÛ (ËÒ. 2). ÑÎfl ˝ÚÓ„Ó ‚ χ„ËÒÚ‡Î¸Ì˚È
ÒÓÒÛ‰ ÛÒڇ̇‚ÎË‚‡ÎË ÒÔË‡Î¸, ‰ۈËÛ˛˘Û˛
ÍÓ‚ÓÚÓÍ ‰ËÒڇθÌ ÏÂÒÚ‡ ÓÚıÓʉÂÌËfl ‡ÚÂËÈ,
Ò̇·Ê‡˛˘Ëı ÍÓ‚¸˛ ÓÔÛıÓθ, ÔÓÒΠ˜Â„Ó ‚‚Ó‰ËÎË ıËÏËÓ˝Ï·ÓÎËÁ‡Ú. èÓ‚ÚÓÌ˚ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÔË Ú‡ÍÓÈ ÏÂÚÓ‰ËÍ ÌÂÒÍÓθÍÓ ÛÔÓ˘‡ÎËÒ¸.
ïËÏËÓ˝Ï·ÓÎËÁ‡ˆË˛ ÓÒÛ˘ÂÒÚ‚ÎflÎË ÔÛÚÂÏ ·ÓβÒÌÓ„Ó ‚‚‰ÂÌËfl ˝ÏÛθÒËË 400 Ï„/Ï2 ‚Ó‰ÌÓ„Ó
‡ÒÚ‚Ó‡ „ÂψËÚ‡·Ë̇ ‚ 2–10 ÏÎ Ò‚ÂıÊˉÍÓ„Ó
ÎËÔËÓ‰Ó·. á‡ÚÂÏ Í‡ÚÂÚÂ Û‰‡ÎflÎË Ë Ì‡Á̇˜‡ÎË
ÔÓÒÚÂθÌ˚È ÂÊËÏ ‚ Ú˜ÂÌË 18 ˜. èÓ‚Ó‰ËÎË ËÌÙÛÁËÓÌÌÛ˛ ÚÂ‡Ô˲ ‚ Ó·˙ÂÏ 1.5 Î Ò ‚Íβ˜ÂÌËÂÏ
ÒÔ‡ÁÏÓÎËÚËÍÓ‚, ̇Á̇˜‡ÎË ÓÍÚÂÓÚˉ 0.1 Ï„ ÔÓ‰ÍÓÊÌÓ ˜ÂÂÁ 8 ˜ ‚ ÔÂ‚˚ ÒÛÚÍË. ìÓ‚Â̸ Ô‡ÌÍ‡Ú˘ÂÒÍÓÈ ‡ÏË·Á˚ Ô·ÁÏ˚ ÍÓ‚Ë Ô‡ˆËÂÌÚ‡ ÓÔ‰ÂÎflÎË ‰Ó Ôӈ‰Û˚ Ë ˜ÂÂÁ 24 ˜ ÔÓÒΠ Ôӂ‰ÂÌËfl. ê‡ÒÔ‰ÂÎÂÌË ıËÏËÓ˝Ï·ÓÎËÁ‡Ú‡ ‚ ÓÔÛıÓÎË Ë
ÓÍÛʇ˛˘Ëı Ú͇Ìflı ÍÓÌÚÓÎËÓ‚‡ÎË Ò ÔÓÏÓ˘¸˛
äí ̇ 7-Â Ë 28- ÒÛÚÍË (ËÒ. 3). èӈ‰ÛÛ ÔÓ‚ÚÓflÎË ÂÊÂÏÂÒfl˜ÌÓ ‰Ó ÔÓfl‚ÎÂÌËfl ÔËÁ̇ÍÓ‚ ÓÔÛıÓ΂ÓÈ ÔÓ„ÂÒÒËË.
êÂÁÛθڇÚ˚
ë 1999 ÔÓ 2002 „. ‰Ë‡„ÌÓÒÚ˘ÂÒ͇fl ‡Ì„ËÓ„‡ÙËfl ·˚· ‚˚ÔÓÎÌÂ̇ Û 63 ·ÓθÌ˚ı Ò ÏÂÒÚÌÓ-‡ÒÔÓÒÚ‡ÌÂÌÌ˚Ï ‡ÍÓÏ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
(T4NxM0). èË ˝ÚÓÏ Û 32 ·ÓθÌ˚ı (51%) Ôӈ‰Û‡ ·˚· Á‡‚Â¯Â̇ ‚˚ÔÓÎÌÂÌËÂÏ ‚ÌÛÚˇÚÂˇθÌÓÈ Ï‡ÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÒÓÒÛ‰Ó‚
ÓÔÛıÓÎË. ì ÓÒڇθÌ˚ı Ô‡ˆËÂÌÚÓ‚ ‡Ì‡ÚÓÏ˘ÂÒÍËÂ
ÛÒÎÓ‚Ëfl ‰Îfl Ôӂ‰ÂÌËfl ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÓÚÒÛÚÒÚ‚Ó‚‡ÎË: ‚ 17 (27%) ̇·Î˛‰ÂÌËflı ËÁ-Á‡ ÓÔÛıÓ΂ÓÈ ÓÍÍβÁËË „‡ÒÚÓ‰ÛÓ‰Â̇θÌÓÈ ËÎË ÒÂÎÂÁÂÌÓ˜ÌÓÈ ‡ÚÂËË, ‚ 14 (22%) ̇·Î˛‰ÂÌËflı ÔË ‰Ë‡„ÌÓÒÚ˘ÂÒÍÓÈ ‡Ì„ËÓ„‡ÙËË ÓÔÛıÓ΂˚ ÒÓÒÛ‰˚ ÌÂ
ÍÓÌÚ‡ÒÚËÓ‚‡ÎËÒ¸ (ÒÏ. Ú‡·ÎˈÛ). Ç ·Óθ¯ËÌÒÚ‚Â
̇·Î˛‰ÂÌËÈ (81%) ÓÔÛıÓθ ·˚· „ËÔÓ‚‡ÒÍÛÎflÌÓÈ
Ë ÚÓθÍÓ Û 6 (19%) ·ÓθÌ˚ı ÌÓÒË· „ËÔÂ‚‡ÒÍÛÎflÌ˚È ı‡‡ÍÚÂ. èË ‡Í „ÓÎÓ‚ÍË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ
ÊÂÎÂÁ˚ Û 26 (87%) ËÁ 30 ·ÓθÌ˚ı ‰Îfl ‚˚ÔÓÎÌÂÌËfl
ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÓÔÛıÓÎË ËÒÔÓθÁÓ‚‡ÎË Òڇ̉‡ÚÌ˚ ͇ÚÂÚÂ˚ Ë ÔÂÂ‡ÒÔ‰ÂÎËÚÂθÌÛ˛ ˝Ï·ÓÎËÁ‡ˆË˛ „‡ÒÚÓ‰ÛÓ‰Â̇θÌÓÈ ‡ÚÂËË. èËÏÂÌÂÌËÂ
ÏËÍÓ͇ÚÂÚÂ‡ ‰Îfl ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÔÓÚ·ӂ‡ÎÓÒ¸ Î˯¸ Û 6 ·ÓθÌ˚ı: Û 4 ÔË ‡ÒÔÓÎÓÊÂÌËË ÓÔÛÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
êÂÁÛθڇÚ˚ ‰Ë‡„ÌÓÒÚ˘ÂÒÍÓÈ ‡Ì„ËÓ„‡ÙËË Û ·ÓθÌ˚ı Ò ÏÂÒÚÌÓ-‡ÒÔÓÒÚ‡ÌÂÌÌ˚Ï ‡ÍÓÏ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ (T4NxM0)
íÓθÍÓ ‰Ë‡„ÌÓÒÚ˘ÂÒ͇fl
‡Ì„ËÓ„‡ÙËfl
ÄÌ„ËÓ„ãÓ͇ÎË- óËÒÎÓ
‡ÙËfl
ÒÓÒÛ‰˚
Á‡ˆËfl
·ÓÎ¸Ë ıËÏËÓ˝Ï- ÓÔÛıÓÎË ÌÂ
ÓÔÛıÓÎË Ì˚ı
·ÓÎËÁ‡ˆËfl ÍÓÌÚ‡ÒÚËÛ˛ÚÒfl
ÓÍÍβÁËfl
χ„ËÒÚ‡Î¸ÌÓÈ
‡ÚÂËË
ÉÓÎӂ͇
52
30
12
10
íÂÎÓ
10
2
2
6
ï‚ÓÒÚ
1
–
–
1
ÇÒ„Ó:
63
32
14
17
100
51
22
27
‡·Ò.
%
ıÓÎË ‚ „ÓÎÓ‚ÍÂ, ‚ ÚÓÏ ˜ËÒÎÂ Û 1 ÔË ÎÓ͇ÎËÁ‡ˆËË ‚
Í˛˜ÍӂˉÌÓÏ ÓÚÓÒÚÍÂ Ë Û 2 ÔË ‡Í Ú· ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
ÇÒÂ„Ó Û 32 ·ÓθÌ˚ı ‚˚ÔÓÎÌÂÌÓ 98 Ôӈ‰Û
χÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË (ÓÚ 1 ‰Ó 11). èË
˝ÚÓÏ Ì ̇·Î˛‰‡ÎË ‰ÂÒÚÛÍÚË‚ÌÓ„Ó Ô‡Í‡ÚËÚ‡
ËÎË ÓÒÚ˚ı ˝ÓÁËÈ ÒÎËÁËÒÚÓÈ ÊÂÎۉ͇ Ë ‰‚Â̇‰ˆ‡ÚËÔÂÒÚÌÓÈ Í˯ÍË. ÅÓθ¯ËÌÒÚ‚Ó ·ÓθÌ˚ı ÔÂÂÌÂÒÎË Ôӈ‰ÛÛ Û‰Ó‚ÎÂÚ‚ÓËÚÂθÌÓ. í‡ÍËÂ
ÒËÏÔÚÓÏ˚, Í‡Í ÚÓ¯ÌÓÚ‡, ‚ÓÚ‡, ‚˚‡ÊÂÌÌ˚ ·ÓÎË, ‚ÓÁÌËÍÎË ÚÓθÍÓ Û 5 (16%) ·ÓθÌ˚ı Ë Ì‡·Î˛‰‡ÎËÒ¸ ‚ Ú˜ÂÌË ÔÂ‚˚ı ÒÛÚÓÍ ÔÓÒΠÔӈ‰Û˚.
ÅÓ΂ÓÈ ÒË̉ÓÏ ÍÛÔËÓ‚‡ÎË ÌÂ̇ÍÓÚ˘ÂÒÍËÏË
‡Ì‡Î¸„ÂÚË͇ÏË. ç‡ 2- ÒÛÚÍË Ò‡ÏÓ˜Û‚ÒÚ‚Ë ·ÓθÌ˚ı ·˚ÎÓ Û‰Ó‚ÎÂÚ‚ÓËÚÂθÌ˚Ï, ·ÓÎË Ì ·ÂÒÔÓÍÓËÎË ËÎË ·˚ÎË ÌÂÁ̇˜ËÚÂθÌ˚ÏË. èÓ‚˚¯ÂÌËÂ
ÛÓ‚Ìfl α-‡ÏË·Á˚ ÍÓ‚Ë, Á‡„ËÒÚËÓ‚‡ÌÌÓ Û
1/3 ·ÓθÌ˚ı, Ì Ô‚˚¯‡ÎÓ 20% ËÒıÓ‰ÌÓ„Ó ÛÓ‚Ìfl.
чθÌÂȯ ̇·Î˛‰ÂÌË ÔÓ͇Á‡ÎÓ ÍÎËÌ˘ÂÒÍÓ ÛÎÛ˜¯ÂÌË ÔÓÒΠıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË Û 88%
Ô‡ˆËÂÌÚÓ‚. ó‡ÒÚ˘Ì˚È ÓÚ‚ÂÚ Ì‡ ΘÂÌË ̇·Î˛‰‡ÎÒfl Û 50%, ÒÚ‡·ËÎËÁ‡ˆËfl – Û 28%, ÔÓ„ÂÒÒËÓ‚‡ÌË – Û 22% ·ÓθÌ˚ı. àÁ 32 Ô‡ˆËÂÌÚÓ‚ ̇ ̇ÒÚÓfl˘ËÈ ÏÓÏÂÌÚ ÊË‚˚ 10. ìÏÂÎË 22 Ô‡ˆËÂÌÚ‡ ‚ ÒÓÍË: ÓÚ 1 ‰Ó 6 ÏÂÒ – 1, ÓÚ 6 ‰Ó 12 ÏÂÒ – 15, ÓÚ 12 ‰Ó
1.0
0.8
0.6
0.4
0.2
0
6
12
18
24
28 ÏÂÒ
êËÒ. 4. Ç˚ÊË‚‡ÂÏÓÒÚ¸ ·ÓθÌ˚ı ‡ÍÓÏ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ÔÓÒΠχÒÎflÌÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÓÔÛıÓÎË (ÔÓ Kaplan–Meyer).
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153
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èÖêÇõâ éèõí ãÖóÖçàü êÄäÄ
18 ÏÂÒ – 6, Ò‰Ìflfl ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÊËÁÌË
ÛÏÂ¯Ëı ÒÓÒÚ‡‚Ë· 12.1 + 5.7 ÏÂÒ (ËÒ. 4).
é·ÒÛʉÂÌËÂ
àÒÒΉӂ‡ÌË ÔÓ͇Á‡ÎÓ, ˜ÚÓ Ï‡ÒÎflÌÛ˛ ˝Ï·ÓÎËÁ‡ˆË˛ ÏÓÊÌÓ ‡ÒÒχÚË‚‡Ú¸ Í‡Í ÔË̈ËÔˇθÌÓ ÌÓ‚˚È ÒÔÓÒÓ· „ËÓ̇ÌÓÈ ıËÏËÓÚÂ‡ÔËË ‡Í‡
ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚. ùÙÙÂÍÚ ÏÂÚÓ‰‡ ÓÒÌÓ‚‡Ì
̇ ‰ÂÔÓÌËÓ‚‡ÌËË ıËÏËÓÔÂÔ‡‡Ú‡ ‚ ÒÓÒÛ‰‡ı Á‡
Ò˜ÂÚ Ó·‡ÚËÏÓ„Ó ÒÚ‡Á‡ ÍÓ‚ÓÚÓ͇ ‚ ÓÔÛıÓÎË, ‚˚Á‚‡ÌÌÓ„Ó Ï‡ÒÎflÌÓÈ ˝Ï·ÓÎËÁ‡ˆËÂÈ ÏËÍÓÒÓÒÛ‰Ó‚.
Ç Ô‰¯ÂÒÚ‚Û˛˘Ëı ËÒÒΉӂ‡ÌËflı ÒÓÁ‰‡ÌË ‚˚ÒÓÍÓÈ ÔÓÎÓÌ„ËÓ‚‡ÌÌÓÈ ÍÓ̈ÂÌÚ‡ˆËË ÔÂÔ‡‡Ú‡ ‚ ÁÓÌ ÓÔÛıÓÎË ‰ÓÒÚË„‡ÎÓÒ¸ Ò ÔÓÏÓ˘¸˛ ÚÂıÌ˘ÂÒÍË ÒÎÓÊÌ˚ı Ë ‚ ÌÂÍÓÚÓ˚ı ̇·Î˛‰ÂÌËflı
ÓÔ‡ÒÌ˚ı Ôӈ‰Û [7, 8, 12–14]. çÂÁ‡‚ËÒËÏÓ ÓÚ
ÒÔÓÒÓ·‡ „ËÓ̇ÌÓÈ ıËÏËÓÚÂ‡ÔËË ÔÓ‚˚¯ÂÌËÂ
˝ÙÙÂÍÚË‚ÌÓÒÚË ·˚ÎÓ Ò‚flÁ‡ÌÓ Ò ÔËÏÂÌÂÌËÂÏ ‚˚ÒÓÍËı ÒÛÏχÌ˚ı ‰ÓÁ ÔÂÔ‡‡Ú‡, ˜ÚÓ ‚ ÍÓ̘ÌÓÏ
ËÚÓ„Â ÛıÛ‰¯‡ÎÓ Í‡˜ÂÒÚ‚Ó ÊËÁÌË ·ÓθÌ˚ı, ÔË‚Ó‰ËÎÓ Í ‡Á΢Ì˚Ï ÓÒÎÓÊÌÂÌËflÏ, ÒËÒÚÂÏÌ˚Ï ÚÓÍÒ˘ÂÒÍËÏ ˝ÙÙÂÍÚ‡Ï, ÔÓ˝ÚÓÏÛ ·Óθ¯ËÌÒÚ‚Ó ÔÓ‰Ó·Ì˚ı ÏÂÚÓ‰ËÍ Ì ÔÓÎÛ˜ËÎÓ ¯ËÓÍÓ„Ó ‡ÒÔÓÒÚ‡ÌÂÌËfl [11]. Ç ÓÚ΢ˠÓÚ Ô‰ÎÓÊÂÌËÈ ‰Û„Ëı
‡‚ÚÓÓ‚ [6, 8, 14, 18] ̇¯‡ ÏÂÚÓ‰Ë͇ ÔÓÁ‚ÓÎflÂÚ
ÛÏÂ̸¯ËÚ¸ ÒÛÏχÌÛ˛ ‰ÓÁÛ ‚‚Ó‰ËÏÓ„Ó ıËÏËÓÔÂÔ‡‡Ú‡ ‚ 2–5 ‡Á ÔÓ Ò‡‚ÌÂÌ˲ Ò ÂÍÓÏẨÛÂÏ˚ÏË
ÒËÒÚÂÏÌ˚ÏË ‰ÓÁ‡ÏË ÔË Ó‰ÌÓ‚ÂÏÂÌÌÓÏ ÛÒËÎÂÌËË ÔÓÚË‚ÓÓÔÛıÓÎÂ‚Ó„Ó ˝ÙÙÂÍÚ‡ [2].
éÒÌÓ‚Ì˚Ï ÛÒÎÓ‚ËÂÏ ‰Îfl ÛÒÔ¯ÌÓ„Ó ‚˚ÔÓÎÌÂÌËfl Ôӈ‰Û˚ fl‚ÎflÂÚÒfl ‰ÓÒÚÛÔ Í ÒÓÒÛ‰‡Ï, Ó·ÂÒÔ˜˂‡˛˘ËÏ ÌÂÔÓÒ‰ÒÚ‚ÂÌÌÓ ÍÓ‚ÓÒ̇·ÊÂÌËÂ
ÓÔÛıÓÎË, ˜ÚÓ ÌÂ‰ÍÓ ÏÓÊÂÚ ·˚Ú¸ Á‡ÚÛ‰ÌÂÌÓ ËÁÁ‡ ËÌ‚‡ÁË‚ÌÓ„Ó ÓÒÚ‡ ÓÔÛıÓÎË ËÎË Â ÍÓ‚ÓÒ̇·ÊÂÌËfl ÓÚ ÌÂÒÍÓθÍËı ‚ÌÛÚËÓ„‡ÌÌ˚ı ‡ÚÂËÈ.
ÇÌÛÚËÒÓÒÛ‰ËÒÚ˚ χÌËÔÛÎflˆËË Ò ÔËÏÂÌÂÌËÂÏ ÏËÍÓ͇ÚÂÚÂ‡ ‰Îfl ‚˚ÔÓÎÌÂÌËfl Ôӈ‰Û˚ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÔÓÚ·ӂ‡ÎËÒ¸ ÚÓθÍÓ ‚ ˜‡ÒÚË
̇·Î˛‰ÂÌËÈ ÔË ÓÔÛıÓÎË Ú· Ë Í˛˜ÍӂˉÌÓ„Ó
ÓÚÓÒÚ͇ ÊÂÎÂÁ˚, ÚÓ„‰‡ Í‡Í ÔË Ì‡Ë·ÓΠ˜‡ÒÚÓÈ
ÎÓ͇ÎËÁ‡ˆËË ‡Í‡ – ‚ „ÓÎÓ‚Í – Ôӈ‰Û‡ Ïӄ·
·˚Ú¸ ‚˚ÔÓÎÌÂ̇ ÔÓÒΠ‰Û͈ËË ¯ÛÌÚËÛ˛˘Â„Ó
ÍÓ‚ÓÚÓ͇ ÔÓ „‡ÒÚÓ‰ÛÓ‰Â̇θÌÓÈ ‡ÚÂËË. èË
ÒÂÎÂÍÚË‚ÌÓÈ ‡Ì„ËÓ„‡ÙËË Û 22% ·ÓθÌ˚ı ÍÓÌÚ‡ÒÚËÓ‚‡ÌËfl ÒÓÒÛ‰Ó‚ ÓÔÛıÓÎË Ì ̇·Î˛‰‡ÎË. ÇÂÓflÚÌÓ, ÔËÚ‡ÌË ÌÓ‚ÓÓ·‡ÁÓ‚‡ÌËÈ Û ÌËı ÔÓËÒıÓ‰ËÎÓ ÓÚ ‚ÌÛÚËÓ„‡ÌÌ˚ı ‡ÚÂËÈ, ÌÂÔÓÒ‰ÒÚ‚ÂÌ̇fl
͇ÚÂÚÂËÁ‡ˆËfl ÍÓÚÓ˚ı ̇ Ò„ӉÌfl¯ÌËÈ ‰Â̸ ÚÂıÌ˘ÂÒÍË ÌÂÓÒÛ˘ÂÒÚ‚Ëχ. ÑÎfl ıËÏËÓ˝Ï·ÓÎËÁ‡ˆË
ÓÔÛıÓÎË ‚ ˝ÚÓÈ ÒËÚÛ‡ˆËË ÏÓÊÂÚ ·˚Ú¸ ËÒÔÓθÁÓ‚‡ÌÓ Ô‰ÎÓÊÂÌË H. Homma Ë ÒÓ‡‚Ú. [8]. Ä‚ÚÓ˚
ÔÓ‚Ó‰ËÎË ËÌÙÛÁËÓÌÌÌÛ˛ ıËÏËÓÚÂ‡Ô˲ ÔÓÒÎÂ
ÔÂÂ‡ÒÔ‰ÂÎfl˛˘ÂÈ ÍÓ‚ÓÚÓÍ ‚Ó ‚ÒÂÈ ÊÂÎÂÁÂ
˝Ï·ÓÎËÁ‡ˆËË ‚ÌÂÓ„‡ÌÌ˚ı ‡ÚÂˇθÌ˚ı ‚ÂÚ‚ÂÈ
χ„ËÒÚ‡Î¸Ì˚ı ÒÓÒÛ‰Ó‚ ÏËÍÓÒÔË‡ÎflÏË Ò ÒÓı‡ÌÂÌËÂÏ ÚÓθÍÓ Í‡Û‰‡Î¸ÌÓÈ ‡ÚÂËË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚. èÂÔ‡‡Ú ‚‚Ó‰ËÎË ‚ ͇ÚÂÚÂ, ÓÒÚ‡‚ÎÂÌÌ˚È ‚ ÒÂÎÂÁÂÌÓ˜ÌÓÈ ‡ÚÂËË.
èÂ‚˚ ÂÁÛθڇÚ˚ ҂ˉÂÚÂθÒÚ‚Û˛Ú Ó ÔÂÒÔÂÍÚË‚ÌÓÒÚË ÏÂÚÓ‰‡. éÌ ‰Ó‚ÓθÌÓ ·ÂÁÓÔ‡ÒÂÌ Ë
154
ıÓÓ¯Ó ÔÂÂÌÓÒËÚÒfl ÓÒ··ÎÂÌÌ˚ÏË ·ÓθÌ˚ÏË.
ó‡ÒÚ˘Ì˚È ÓÚ‚ÂÚ ÓÚϘ‡ÎÒfl Û 50% ·ÓθÌ˚ı, ˜ÚÓ
‚˚¯Â, ˜ÂÏ ÔË ıËÏËÓÎۘ‚ÓÈ ÚÂ‡ÔËË, ÔË ÍÓÚÓÓÈ ÓÌ Ì Ô‚˚¯‡ÂÚ 15%. ë‰Ìflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸
·ÓθÌ˚ı ÔÓÒΠıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÒÓÒÚ‡‚Ë·
12 ÏÂÒ, ÚÓ„‰‡ Í‡Í ÔË ÓÚÒÛÚÒÚ‚ËË Î˜ÂÌËfl – 3–5 ÏÂÒ,
ÔË ıËÏËÓÎۘ‚ÓÈ ÚÂ‡ÔËË 4–6 ÏÂÒ [4].
ç‡Ë·ÓΠËÌÚÂÌÒË‚ÌÓ ‚ÓÁ‰ÂÈÒÚ‚Ë ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËfl Ó͇Á˚‚‡ÂÚ Ì‡ ÔÂ‚˘Ì˚È ÓÔÛıÓ΂˚È
Ó˜‡„, ÔÓ˝ÚÓÏÛ ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÊËÁÌË ·ÓθÌ˚ı, ÔÓÎÛ˜‡˛˘Ëı χÒÎflÌ˚ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË
ÓÔÛıÓÎË, ÓÔ‰ÂÎflÂÚÒfl Ì ÚÓθÍÓ ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚ¸˛ ÓÔÛıÓÎË Í ıËÏËÓÔÂÔ‡‡ÚÛ, ÌÓ Ë Ì‡Î˘ËÂÏ
ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍÓ„Ó ÔÓ‡ÊÂÌËfl ‰Û„Ëı Ó„‡ÌÓ‚.
åÂÚÓ‰ ÒΉÛÂÚ ËÒÔÓθÁÓ‚‡Ú¸ ÔÂËÏÛ˘ÂÒÚ‚ÂÌÌÓ
ÔË Î˜ÂÌËË Ô‡ˆËÂÌÚÓ‚ Ò ÏÂÒÚÌÓ-‡ÒÔÓÒÚ‡ÌÂÌÌ˚ÏË ÙÓχÏË Á‡·Ó΂‡ÌËfl. ë Û˜ÂÚÓÏ ıÓÓ¯ÂÈ
ÔÂÂÌÓÒËÏÓÒÚË Ë ÍÎËÌ˘ÂÒÍÓ„Ó ÛÎÛ˜¯ÂÌËfl ̇ ÙÓÌ ÚÂ‡ÔËË ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËfl ËÏÂÂÚ ·Óθ¯Û˛
ÔÂÒÔÂÍÚË‚Û ÔË ËÒÔÓθÁÓ‚‡ÌËË ‚ ÍÓÏ·Ë̇ˆËflı Ò
Îۘ‚ÓÈ ÚÂ‡ÔËÂÈ Ë ‚ ͇˜ÂÒÚ‚Â ÌÂÓ‡‰˙˛‚‡ÌÚÌÓ„Ó
ΘÂÌËfl Û ÂÁÂÍÚ‡·ÂθÌ˚ı ·ÓθÌ˚ı.
ëÔËÒÓÍ ÎËÚÂ‡ÚÛ˚
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É‡ÌÓ‚ Ë ‰.
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