Analysis of study rezults of biopsies of the vagina mucous membrane in women with recurrent genital prolapse

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ɄɅȱɇȱɑɇȺ ɆȿȾɂɐɂɇȺ

618.131/.138-007.43/.44-036.87-092-07-089-036.83 Ɋ.Ɇ.Ȼɚɧɚɯɟɜɢɱ,

Ʉ.Ȼ.Ⱥɤɢɦɨɜɚ, ɉ.Ɉ.Ƚɪɢɰɟɧɤɨ, ȯ.ɘ.Ɋɨɠɧɶɨɜ

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ȾɁ «Ⱦɧɿɩɪɨɩɟɬɪɨɜɫɶɤɚ ɦɟɞɢɱɧɚ ɚɤɚɞɟɦɿɹ ɆɈɁ ɍɤɪɚʀɧɢ»

ɤɚɮɟɞɪɚ ɚɤɭɲɟɪɫɬɜɚ ɬɚ ɝɿɧɟɤɨɥɨɝɿʀ

(ɡɚɜ. – ɞ.ɦɟɞ.ɧ.,ɩɪɨɮ.ȼ.Ɉ.ɉɨɬɚɩɨɜ)

ɜɭɥ.Ⱦɡɟɪɠɢɧɫɶɤɨɝɨ, 9, Ⱦɧɿɩɪɨɩɟɬɪɨɜɫɶɤ, 49044, ɍɤɪɚʀɧɚ

SE "Dnipropetrovsk medical academy of Health Ministry of Ukraine" Department of obstetrics and gynecology

Dzerzhinsky str., 9, Dnipropetrovsk, 49044, Ukraine e-mail: banahevich@yandex.ru

Ʉɥɸɱɨɜɿ ɫɥɨɜɚ:ɝɟɧɿɬɚɥɶɧɢɣ ɩɪɨɥɚɩɫ,ɪɟɰɢɞɢɜ,ɿɦɭɧɨɝɿɫɬɨɯɿɦɿɹ,ɫɥɢɡɨɜɚ ɩɿɯɜɢ

Key words: genital prolapse, relapse, immunohistochemistry, vaginal mucosa

Ɋɟɮɟɪɚɬ.Ⱥɧɚɥɢɡ ɪɟɡɭɥɶɬɚɬɨɜ ɢɫɫɥɟɞɨɜɚɧɢɹ ɛɢɨɩɬɚɬɨɜ ɫɥɢɡɢɫɬɨɣ ɜɥɚɝɚɥɢɳɚ ɭ ɠɟɧɳɢɧ ɫ ɪɟɰɢɞɢɜɨɦ ɝɟɧɢ

-ɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɚ.Ȼɚɧɚɯɟɜɢɱ Ɋ.Ɇ., Ⱥɤɢɦɨɜɚ Ʉ.Ȼ., Ƚɪɢɰɟɧɤɨ ɉ.Ⱥ.,Ɋɨɠɧɟɜ ȿ.ɘ.ɉɪɨɜɟɞɟɧɨ ɨɛɫɥɟɞɨɜɚɧɢɟ

53 ɠɟɧɳɢɧ ɫ ɪɟɰɢɞɢɜɨɦ ɝɟɧɢɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɚ. ɋɪɟɞɧɢɣ ɜɨɡɪɚɫɬ ɨɛɫɥɟɞɨɜɚɧɧɵɯ ɠɟɧɳɢɧ 62,8±9,8 ɝɨɞɚ,

ɜɨɡɪɚɫɬ ɠɟɧɳɢɧ ɝɪɭɩɩɵ ɤɨɧɬɪɨɥɹ 57,2±6,3 ɝɨɞɚ (ɪ>0,05). Ɉɰɟɧɟɧɵ ɨɫɨɛɟɧɧɨɫɬɢ ɭɪɨɜɧɟɣ ɷɤɫɩɪɟɫɫɢɢ

ɷɫɬɪɨɝɟɧɨɜɵɯ ɢ ɩɪɨɝɟɫɬɟɪɨɧɨɜɵɯ ɪɟɰɟɩɬɨɪɨɜ, ɦɚɪɤɟɪɨɜ ɩɪɨɥɢɮɟɪɚɰɢɢ ɢ ɤɨɥɚɝɟɧɚ ɜ ɛɢɨɩɬɚɬɚɯ ɫɥɢɡɢɫɬɨɣ

ɜɥɚɝɚɥɢɳɚ. ȼ ɫɥɢɡɢɫɬɨɣ ɜɥɚɝɚɥɢɳɚ ɩɚɰɢɟɧɬɨɜ ɫ ɪɟɰɢɞɢɜɨɦ ɢɫɫɥɟɞɨɜɚɧɢɹ ɷɤɫɩɪɟɫɫɢɢ ɦɚɪɤɟɪɨɜ Ki-67 ɧɟ

ɨɛɧɚɪɭɠɢɥɢ ɚɤɬɢɜɧɨɫɬɢ ɩɪɨɥɢɮɟɪɚɰɢɢ. ɍɪɨɜɟɧɶ ɷɤɫɩɪɟɫɫɢɢ ɷɫɬɪɨɝɟɧɨɜɵɯ ɢ ɩɪɨɝɟɫɬɟɪɨɧɨɜɵɯ ɪɟɰɟɩɬɨɪɨɜ ɜ

ɷɩɢɬɟɥɢɢ ɛɵɥ ɧɢɠɟ, ɱɟɦ ɭ ɩɚɰɢɟɧɬɨɤ ɛɟɡ ɩɪɢɡɧɚɤɨɜ ɝɟɧɢɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɚ. ɉɨ ɪɟɡɭɥɶɬɚɬɚɦ ɢɫɫɥɟɞɨɜɚɧɢɹ

ɭɫɬɚɧɨɜɥɟɧɨ ɨɛɳɟɟ ɫɧɢɠɟɧɢɟ ɭɪɨɜɧɹ ɷɫɬɪɨɝɟɧɨɜɵɯ ɪɟɰɟɩɬɨɪɨɜ ɧɚ 76,2% ɭ ɩɚɰɢɟɧɬɨɤ ɫ ɪɟɰɢɞɢɜɨɦ ɝɟɧɢ

-ɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɚ, ɜ ɬɨ ɜɪɟɦɹ ɤɚɤ ɭ ɩɚɰɢɟɧɬɨɤ ɝɪɭɩɩɵ ɤɨɧɬɪɨɥɹ ɷɤɫɩɪɟɫɫɢɹ ɷɫɬɪɨɝɟɧɨɜɵɯ ɪɟɰɟɩɬɨɪɨɜ ɜ

ɧɟɢɡɦɟɧɧɨɦ ɷɩɢɬɟɥɢɢ ɢ ɫɬɪɨɦɟ ɛɵɥɚ ɩɨɥɨɠɢɬɟɥɶɧɨɣ ɜ 100% ɫɥɭɱɚɟɜ.ɍ ɩɚɰɢɟɧɬɨɤ ɫ ɪɟɰɢɞɢɜɨɦ ɝɟɧɢɬɚɥɶɧɨɝɨ

ɩɪɨɥɚɩɫɚ ɭɫɬɚɧɨɜɥɟɧɨ ɫɧɢɠɟɧɢɟ ɷɤɫɩɪɟɫɫɢɢ ɩɪɨɝɟɫɬɟɪɨɧɨɜɵɯ ɪɟɰɟɩɬɨɪɨɜ ɧɚ 83,4 %.

Abstract. Analysis of study rezults of biopsies of the vagina mucous membrane in women with recurrent genital prolapse. Banakhevich R.M., Akimova Ʉ.ȼ., Gritsenko P.O., Roghnev E.Yu. The study involved 53 women with recurrent genital prolapse. The average age of the women studied was 62,8±9,8 years, age of women of the control group was 57,2±6,3 years (p>0,05). Features of expression of estrogen and progesterone receptors levels, markers of cell proliferation and collagen in the biopsy of the vagina mucous membrane were estimated. In the vaginal mucosa of patients with recurrent prolapse expression of Ki-67 markers of proliferative activity was not established. According to the study general lowering of estrogen receptors by 76,2% in patients with recurrent genital prolapse was established, whereas in patients of the control group level of estrogen receptors in the unchanged epithelium and stroma was positive in 100% of cases. In patients with recurrent genital prolapse the decrease of expression of progesterone receptors by 83,4% was identified.

Ƚɟɧɿɬɚɥɶɧɢɣ ɩɪɨɥɚɩɫ (Ƚɉ) – ɨɫɨɛɥɢɜɢɣ ɜɢɞ ɝɪɢɠɿ ɡ ɨɡɧɚɤɚɦɢ ɜɬɪɚɬɢ ɧɨɪɦɚɥɶɧɨʀ ɚɧɚɬɨɦɿʀ ɦ’ɹɡɿɜ ɿ ɮɚɫɰɿɚɥɶɧɨ-ɥɿɝɚɦɟɧɬɚɪɧɨɝɨ ɚɩɚɪɚɬɭ ɫɬɚ -ɬɟɜɢɯ ɨɪɝɚɧɿɜ (ɎɅȺɋɈ) ɬɚ ɨɡɧɚɤɚɦɢ ɨɩɭɫɤɚɧɧɹ ɨɪɝɚɧɿɜ ɦɚɥɨɝɨ ɬɚɡɭ ɡ ɦɨɠɥɢɜɢɦ ɩɨɪɭɲɟɧɧɹɦ ʀɯ ɮɭɧɤɰɿʀ. ɉɪɨɛɥɟɦɚ ɨɩɭɳɟɧɧɹ ɿ ɜɢɩɚɞɿɧɧɹ ɜɧɭ -ɬɪɿɲɧɿɯ ɫɬɚɬɟɜɢɯ ɨɪɝɚɧɿɜ, ɹɤ ɿ ɪɚɧɿɲɟ, ɡɚɥɢ -ɲɚɽɬɶɫɹ ɜ ɰɟɧɬɪɿ ɭɜɚɝɢ ɥɿɤɚɪɿɜ-ɝɿɧɟɤɨɥɨɝɿɜ ɬɚ ɥɿɤɚɪɿɜ ɫɭɦɿɠɧɢɯ ɫɩɟɰɿɚɥɶɧɨɫɬɟɣ, ɳɨ ɡɭɦɨɜɥɟɧɨ ɧɟ ɬɿɥɶɤɢ ɬɟɧɞɟɧɰɿɽɸ ɞɨ ɡɛɿɥɶɲɟɧɧɹ ɱɚɫɬɨɬɢ ɿ ɬɹɠɤɨɫɬɿ ɰɿɽʀ ɩɚɬɨɥɨɝɿʀ, ɚɥɟ ɣ ɫɬɚɛɿɥɶɧɨ ɜɟɥɢɤɢɦ ɱɢɫɥɨɦ ɪɟɰɢɞɢɜɿɜ ɩɿɫɥɹ ɩɪɚɤɬɢɱɧɨ ɜɫɿɯ ɜɢɞɿɜ ɯɿɪɭɪɝɿɱɧɨɝɨ ɥɿɤɭɜɚɧɧɹ. ȱɫɧɭɽ ɛɚɝɚɬɨ ɬɟɨɪɿɣ ɪɨɡ -ɜɢɬɤɭ Ƚɉ, ɚɥɟ ɠɨɞɧɚ ɡ ɧɢɯ ɧɟ ɡɦɨɝɥɚ ɩɨɜɧɿɫɬɸ ɩɨɹɫɧɢɬɢ ɣɨɝɨ ɩɚɬɨɝɟɧɟɡ ɬɚ ɩɚɬɨɝɟɧɟɡ ɪɟɰɢɞɢɜɭ ɝɟɧɿɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɭ (ɊȽɉ) [16, 18]. Ɂɚ ɞɚɧɢɦɢ

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ɲɨɝɨ ɛɨɤɭ, ɿɫɧɭɽ ɜɟɥɢɤɚ ɤɿɥɶɤɿɫɬɶ ɩɚɰɿɽɧɬɨɤ, ɹɤɿ ɦɚɸɬɶ ɤɿɥɶɤɚ ɮɚɤɬɨɪɿɜ ɿ ɨɡɧɚɤɢ ɊȽɉ ɭ ɧɢɯ ɜɿɞ -ɫɭɬɧɿ [11, 14, 17, 19]. Ɋɨɥɶ ɤɨɠɧɨɝɨ ɡ ɧɢɯ ɱɢ ʀɯ ɤɨɦɛɿɧɚɰɿɣ ɭ ɮɨɪɦɭɜɚɧɧɿ ɊȽɉ ɧɟ ɭɬɨɱɧɟɧɚ. Ɇɿɫ -ɰɟɜɟ ɜɜɟɞɟɧɧɹ ɟɫɬɪɨɝɟɧɿɜ ɬɚɤɨɠ ɧɟ ɩɪɢɜɨɞɢɬɶ ɞɨ ɜɿɞɧɨɜɥɟɧɧɹ ɫɬɚɧɭ ɎɅȺɋɈ [6, 12]. ɇɚ ɫɶɨɝɨɞɧɿ ɧɟ ɿɫɧɭɽ ɽɞɢɧɨʀ ɞɭɦɤɢ ɳɨɞɨ ɩɚɬɨɝɟɧɟɬɢɱɧɨɝɨ ɥɿɤɭɜɚɧɧɹ ɊȽɉ, ɟɮɟɤɬɢɜɧɢɯ ɦɟɬɨɞɿɜ ɩɿɞɝɨɬɨɜɤɢ ɬɚɤɢɯ ɯɜɨɪɢɯ ɞɨ ɨɩɟɪɚɬɢɜɧɨɝɨ ɜɬɪɭɱɚɧɧɹ ɬɚ ɨɫɨɛɥɢɜɨɫɬɟɣ ɩɿɫɥɹɨɩɟɪɚɰɿɣɧɨɝɨ ɜɟɞɟɧɧɹ, ɬɟɪ -ɦɿɧɿɜ ɩɪɨɜɟɞɟɧɧɹ ɪɟɚɛɿɥɿɬɚɰɿɣɧɢɯ ɡɚɯɨɞɿɜ,ɨɰɿɧɤɢ ɟɮɟɤɬɢɜɧɨɫɬɿ ɬɚ ɦɨɠɥɢɜɢɯ ɧɚɫɥɿɞɤɿɜ.

Ⱦɨɫɥɿɞɠɟɧɧɹ ɫɬɪɭɤɬɭɪɢ ɡɜ’ɹɡɨɤ ɬɚ ɚɩɨɧɟɜɪɨɡɭ ɭ ɯɜɨɪɢɯ ɡ ɥɟɝɤɢɦ ɫɬɭɩɟɧɟɦ ɞɢɫɩɥɚɡɿʀ ɫɩɨɥɭɱɧɨʀ ɬɤɚɧɢɧɢ (ȾɋɌ) ɩɨɤɚɡɚɥɢ, ɳɨ ɜɨɧɚ ɡɛɟɪɟɠɟɧɚ ɡɚ ɪɚɯɭɧɨɤ ɩɨɦɿɪɧɨɝɨ ɡɧɢɠɟɧɧɹ ɟɤɫɩɪɟɫɿʀ ɤɨɥɚɝɟɧɭ I ɬɢɩɭ ɬɚ ɡɚɦɿɳɟɧɧɹ ɤɨɥɚɝɟɧɭ III ɬɢɩɭ ɤɨɥɚɝɟɧɨɦ IVɬɢɩɭ, ɩɪɢ ɰɶɨɦɭ ɤɥɿɧɿɱɧɨ ɫɩɨɫɬɟɪɿɝɚɸɬɶɫɹ ɨɡ -ɧɚɤɢ ɩɿɞɜɢɳɟɧɨʀ ɡɞɚɬɧɨɫɬɿ ɞɨ ɪɨɡɬɹɝɧɟɧɧɹ ɡɜ’ɹɡɤɨɜɨɝɨ ɚɩɚɪɚɬɭ [2, 3, 13]. ɉɪɢ ȾɋɌ ɫɟɪɟɞ -ɧɶɨɝɨ ɿ ɨɫɨɛɥɢɜɨ ɬɹɠɤɨɝɨ ɫɬɭɩɟɧɹ ɫɩɨɫɬɟɪɿɝɚɽɬɶ -ɫɹ ɞɟɡɨɪɝɚɧɿɡɚɰɿɹ ɫɬɪɭɤɬɭɪɢ ɡɜ’ɹɡɨɤ ɿ ɚɩɨɧɟɜɪɨɡɭ ɡɚ ɪɚɯɭɧɨɤ ɡɧɚɱɧɨɝɨ ɡɧɢɠɟɧɧɹ ɜɦɿɫɬɭ ɤɨɥɚɝɟɧɭ I– III ɬɢɩɿɜ ɿ ɬɿɥɶɤɢ ɱɚɫɬɤɨɜɨɝɨ ɡɚɦɿɳɟɧɧɹ ʀɯ ɤɨɥɚ -ɝɟɧɨɦ IV ɬɢɩɭ [2]. Ⱦɟɡɨɪɝɚɧɿɡɚɰɿɹ ɫɩɨɥɭɱɧɨ -ɬɤɚɧɢɧɧɢɯ ɫɬɪɭɤɬɭɪ ɛɿɥɶɲɨɸ ɦɿɪɨɸ ɦɨɠɟ ɫɩɨ -ɫɬɟɪɿɝɚɽɬɶɫɹ ɭ ɡɜ’ɹɡɤɨɜɨɦɭ ɚɩɚɪɚɬɿ ɦɚɬɤɢ, ɳɨ ɡɭɦɨɜɥɸɽ ɜɢɫɨɤɢɣ ɫɬɭɩɿɧɶ ɪɢɡɢɤɭ ɮɨɪɦɭɜɚɧɧɹ ɊȽɉ ɩɿɫɥɹ ɝɿɫɬɟɪɟɤɬɨɦɿʀ ɚɛɨ ɊȽɉ ɩɿɫɥɹ ɩɥɚɫ -ɬɢɱɧɨʀ ɨɩɟɪɚɰɿʀ [3, 7]. ɐɿ ɪɟɡɭɥɶɬɚɬɢ ɜɢɦɚɝɚɸɬɶ ɭɬɨɱɧɟɧɧɹ ɿɡ ɜɢɡɧɚɱɟɧɧɹɦ ɜɡɚɽɦɨɡɜ’ɹɡɤɭ ɪɿɜɧɹ ɞɟɡɨɪɝɚɧɿɡɚɰɿʀ ɫɩɨɥɭɱɧɨɬɤɚɧɢɧɧɢɯ ɫɬɪɭɤɬɭɪ ɡɿ ɡɦɿɧɚɦɢ ɜ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ. ɍ ɞɨɫɬɭɩɧɢɯ ɧɚɭɤɨɜɢɯ ɞɠɟɪɟɥɚɯ ɱɚɫɬɨ ɩɪɢɜɨɞɹɬɶ ɫɬɚɬɢɫɬɢɤɭ ɊȽɉ ɛɟɡ ɞɟɬɚɥɶɧɨɝɨ ɚɧɚɥɿɡɭ ʀɯ ɪɨɡɜɢɬɤɭ ɬɚ ɪɨɥɿ ȾɋɌ ɭ ɩɚɬɨɝɟɧɟɡɿ ɡɚɯɜɨɪɸɜɚɧɧɹ. ȼɢɡɧɚɱɟɧɧɹ ɮɚɤɬɨɪɿɜ ɪɢɡɢɤɭ ɿ ɫɬɜɨɪɟɧɧɹ ɩɪɨɝɧɨɫɬɢɱɧɨʀ ɦɨɞɟɥɿ ɮɨɪɦɭ -ɜɚɧɧɹ ɊȽɉ, ɳɟ ɞɨ ɜɢɤɨɧɚɧɧɹ ɨɩɟɪɚɬɢɜɧɨɝɨ ɜɬɪɭɱɚɧɧɹ, ɽ ɚɤɬɭɚɥɶɧɢɦ ɿ ɡɚɛɟɡɩɟɱɢɬɶ ɿɧɞɢ -ɜɿɞɭɚɥɶɧɿɫɬɶ ɩɿɞɯɨɞɭ ɭ ɜɢɛɨɪɿ ɫɩɨɫɨɛɭ ɜɢɤɨɧɚɧɧɹ ɰɿɽʀ ɨɩɟɪɚɰɿʀ [11, 21]. ɍ ɥɿɬɟɪɚɬɭɪɿ ɧɟɞɨɫɬɚɬɧɶɨ ɜɢɫɜɿɬɥɟɧɢɦɢ ɽ ɩɢɬɚɧɧɹ ɟɬɿɨɥɨɝɿʀ ɬɚ ɩɚɬɨɝɟɧɟɡɭ ɊȽɉ, ɮɚɤɬɨɪɿɜ ɪɢɡɢɤɭ ɣɨɝɨ ɪɨɡɜɢɬɤɭ. ȼɢɦɚɝɚɽ ɭɬɨɱɧɟɧɧɹ ɪɨɥɶ ɝɿɩɨɟɫɬɪɨɝɟɧɧɢɯ ɫɬɚɧɿɜ ɭ ɮɨɪ -ɦɭɜɚɧɧɿ ɊȽɉ. ɇɟɞɨɫɬɚɬɧɹ ɟɮɟɤɬɢɜɧɿɫɬɶ ɯɿɪɭɪ -ɝɿɱɧɨɝɨ ɥɿɤɭɜɚɧɧɹ Ƚɉ ɭ ɛɿɥɶɲɨɫɬɿ ɜɢɩɚɞɤɿɜ, ɦɨɠ-ɥɢɜɨ, ɡɭɦɨɜɥɟɧɚ ɦɨɪɮɨɮɭɧɤɰɿɨɧɚɥɶɧɨɸ ɧɟɫɩɪɨ-ɦɨɠɧɿɫɬɸ ɫɬɪɭɤɬɭɪ, ɹɤɿ ɜɢɤɨɪɢɫɬɨɜɭɸɬɶɫɹ ɞɥɹ ɪɟɤɨɧɫɬɪɭɤɰɿʀ ɬɚɡɨɜɢɯ ɨɪɝɚɧɿɜ ɿ ɜɿɞɩɨɜɿɞɚɥɶɧɢɯ ɡɚ ʀɯ ɤɨɧɬɢɧɟɧɰɿɸ. ȼɢɪɿɲɟɧɧɹ ɩɢɬɚɧɧɹ ɩɪɢɱɢɧ ɪɨɡ -ɜɢɬɤɭ ɊȽɉ ɬɚ ɭɞɨɫɤɨɧɚɥɟɧɧɹ ɫɢɫɬɟɦɢ ɞɿɚɝɧɨɫ -ɬɢɤɢ ɛɭɞɟ ɫɩɪɢɹɬɢ ɜɢɪɿɲɟɧɧɸ ɩɪɨɛɥɟɦɢ ɟɩɿ

-ȼɢɤɥɚɞɟɧɿ ɜɢɳɟ ɮɚɤɬɢ ɩɿɞɬɜɟɪɞɠɭɸɬɶ ɚɤɬɭ -ɚɥɶɧɿɫɬɶ ɩɪɨɜɟɞɟɧɧɹ ɞɨɫɥɿɞɠɟɧɶ,ɫɩɪɹɦɨɜɚɧɢɯ ɧɚ ɜɢɡɧɚɱɟɧɧɹ ɪɨɥɿ ɮɚɤɬɨɪɿɜ ɬɚ ʀɯ ɤɨɦɛɿɧɚɰɿɣ, ɳɨ ɩɪɢɡɜɨɞɹɬɶ ɞɨ ɪɨɡɜɢɬɤɭ ɡɚɯɜɨɪɸɜɚɧɧɹ ɬɚ ɪɟ -ɰɢɞɢɜɿɜ ɩɿɫɥɹ ɣɨɝɨ ɯɿɪɭɪɝɿɱɧɨɝɨ ɥɿɤɭɜɚɧɧɹ, ɪɨɡ-ɪɨɛɤɭ ɤɪɢɬɟɪɿʀɜ ɮɨɪɦɭɜɚɧɧɹ ɝɪɭɩ ɪɢɡɢɤɭ ɬɚ ɲɥɹɯɿɜ ɡɧɢɠɟɧɧɹ ɡɚɯɜɨɪɸɜɚɧɨɫɬɿ.

Ɇɟɬɚ ɪɨɛɨɬɢ - ɜɢɡɧɚɱɢɬɢ ɪɿɜɧɿ ɟɤɫɩɪɟɫɿʀ ɟɫɬɪɨɝɟɧɨɜɢɯ ɬɚ ɩɪɨɝɟɫɬɟɪɨɧɨɜɢɯ ɪɟɰɟɩɬɨɪɿɜ, ɦɚɪɤɟɪɿɜ ɩɪɨɥɿɮɟɪɚɰɿʀ ɬɚ ɤɨɥɚɝɟɧɭ ɜ ɛɿɨɩɬɚɬɚɯ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɠɿɧɨɤ ɡ ɪɟɰɢɞɢɜɨɦ ɝɟɧɿɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɭ.

ɆȺɌȿɊȱȺɅɂ ɌȺ ɆȿɌɈȾɂ ȾɈɋɅȱȾɀȿɇɖ

Ɋɨɛɨɬɚ ɜɢɤɨɧɭɜɚɥɚɫɹ ɡ 2005 ɩɨ 2013 ɪ. ɧɚ ɤɥɿɧɿɱɧɿɣ ɛɚɡɿ ɤɚɮɟɞɪɢ ɚɤɭɲɟɪɫɬɜɚ ɬɚ ɝɿɧɟɤɨɥɨɝɿʀ (ɡɚɜ. - ɞ.ɦɟɞ.ɧ., ɩɪɨɮ. ȼ.Ɉ. ɉɨɬɚɩɨɜ) ȾɁ «ȾɆȺ ɆɈɁ ɍɤɪɚʀɧɢ». Ƚɿɫɬɨɥɨɝɿɱɧɿ ɬɚ ɿɦɭɧɨɝɿɫɬɨɯɿɦɿɱɧɿ (ȱȽɏ) ɞɨɫɥɿɞɠɟɧɧɹ ɜɢɤɨɧɭɜɚɥɢɫɹ ɧɚ ɛɚɡɿ ɤɚɮɟɞɪɢ ɩɚɬɨɥɨɝɿɱɧɨʀ ɚɧɚɬɨɦɿʀ ɬɚ ɫɭɞɨɜɨʀ ɦɟɞɢɰɢɧɢ (ɡɚɜ. - ɞ.ɦɟɞ.ɧ.,ɩɪɨɮ.ȱ.ɋ.ɒɩɨɧɶɤɚ)ȾɁ «ȾɆȺ ɆɈɁ ɍɤ -ɪɚʀɧɢ».

ɍ ɯɨɞɿ ɨɩɟɪɚɰɿʀ ɭ 53 ɩɚɰɿɽɧɬɨɤ ɡ ɊȽɉ (ɝɪɭɩɚ Ɋ) ɫɬɚɞɿʀ II – III ɡɚ ɤɥɚɫɢɮɿɤɚɰɿɽɸ POP-Q ɬɚ ɭ 30 ɩɚɰɿɽɧɬɨɤ ɛɟɡ ɨɡɧɚɤ ɩɪɨɥɚɩɫɭ (ɝɪɭɩɚ Ʉ) ɛɪɚɥɢ ɞɿɥɹɧɤɭ (ɮɪɚɝɦɟɧɬ) ɬɤɚɧɢɧ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɞɥɹ ɦɨɪɮɨɥɨɝɿɱɧɨɝɨ ɬɚ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ. Ɂɚɛɿɪ ɚɧɚ -ɬɨɦɿɱɧɨɝɨ ɦɚɬɟɪɿɚɥɭ – ɱɚɫɬɢɧ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɬɚ ɡɜ’ɹɡɨɤ - ɩɪɨɜɨɞɢɜɫɹ ɜ ɦɟɠɚɯ ɡɨɧɢ ɜɬɪɭɱɚɧɧɹ ɜ ɝɿɧɟɤɨɥɨɝɿɱɧɨɦɭ ɜɿɞɞɿɥɟɧɧɿ ɩɿɞ ɱɚɫ ɨɩɟɪɚɬɢɜɧɢɯ ɜɬɪɭɱɚɧɶ ɡ ɜɢɞɚɥɟɧɧɹɦ ɦɚɬɤɢ ɡ ɩɿɯɜɨɸ. Ⱦɥɹ ɚɧɚɥɿɡɭ ɦɿɤɪɨɫɬɪɭɤɬɭɪɢ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɜɢɤɨ -ɪɢɫɬɨɜɭɜɚɥɢ ɫɬɚɧɞɚɪɬɧɭ ɦɟɬɨɞɢɤɭ ɞɥɹ ɩɪɨɜɟ -ɞɟɧɧɹ ɝɿɫɬɨɥɨɝɿɱɧɢɯ ɞɨɫɥɿɞɠɟɧɶ. Ɏɿɤɫɚɰɿɹ ɩɪɟ -ɩɚɪɚɬɿɜ ɩɪɨɜɨɞɢɥɚɫɶ ɜ 10% ɧɟɣɬɪɚɥɶɧɨɦɭ ɮɨɪ -ɦɚɥɿɧɿ, ɩɿɫɥɹ ɱɨɝɨ ɡɚɥɢɜɚɥɢ ɩɚɪɚɮɿɧɨɦ ɡɚ ɡɚ-ɝɚɥɶɧɨɩɪɢɣɧɹɬɢɦ ɦɟɬɨɞɨɦ.Ⱦɥɹ ɨɬɪɢɦɚɧɧɹ ɡɪɿɡɿɜ ɜɢɤɨɪɢɫɬɨɜɭɜɚɥɢ ɦɿɤɪɨɬɨɦ ɡɿ ɫɬɚɧɰɿɽɸ ɩɪɢɣɨɦɭ ɡɪɿɡɿɜ (Microm HM-340).

ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɩɪɨɜɨɞɢɥɢ ɩɿɫɥɹ ɩɨɩɟɪɟɞ -ɧɶɨɝɨ ɝɿɫɬɨɥɨɝɿɱɧɨɝɨ ɞɨɫɥɿɞɠɟɧɧɹ ɡɪɚɡɤɿɜ ɬɤɚɧɢɧ. ɇɟɨɛɯɿɞɧɢɦ ɟɬɚɩɨɦ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɛɭɥɨ ɩɪɨ -ɜɟɞɟɧɧɹ ɬɟɩɥɨɜɨʀ ɿɧɞɭɤɰɿʀ ɟɩɿɬɨɩɧɨɝɨ (ɚɧɬɢɝɟɧ -ɧɨɝɨ) ɡɜɨɪɨɬɭ (HȱER - heat ɿnductɿon of epɿtope retrɿeval), ɭ ɪɟɡɭɥɶɬɚɬɿ ɹɤɨɝɨ ɜɿɞɧɨɜɥɸɜɚɥɢɫɶ ɚɧɬɢɝɟɧɧɿ ɜɥɚɫɬɢɜɨɫɬɿ ɬɤɚɧɢɧɢ.Ʉɪɿɦ ɬɨɝɨ,ɜɢɬɪɢ -ɦɭɜɚɥɢɫɶ ɩɚɪɚɦɟɬɪɢ ɟɤɫɩɨɡɢɰɿʀ ɬɚ ɬɟɦɩɟɪɚɬɭɪɢ ɞɟɦɚɫɤɭɜɚɧɧɹ, ɩɨɪɭɲɟɧɧɹ ɹɤɢɯ ɦɨɠɟ ɩɪɢɡɜɟɫɬɢ ɞɨ ɧɟɩɨɜɧɨɝɨ ɜɿɞɬɜɨɪɟɧɧɹ ɚɧɬɢɝɟɧɿɜ ɚɛɨ, ɧɚɜ -ɩɚɤɢ, ɧɟɫɩɟɰɢɮɿɱɧɨɝɨ ɡɜ’ɹɡɭɜɚɧɧɹ ɚɧɬɢɬɿɥ, ɚ ɬɚɤɨɠ ɡɦɨɪɳɭɜɚɧɧɹ ɬɚ ɜɿɞɩɚɞɚɧɧɹ ɡɪɿɡɿɜ [4].

(3)

ɄɅȱɇȱɑɇȺ ɆȿȾɂɐɂɇȺ

ɩɟɪɜɢɧɧɢɯ ɚɧɬɢɬɿɥ ɦɢ ɜɢɤɨɪɢɫɬɨɜɭɜɚɥɢ ɫɩɟɤɬɪ ɚɧɬɢɬɿɥ, ɹɤɢɣ ɜɤɥɸɱɚɜ ɦɚɪɤɟɪɢ ɪɟɰɟɩɬɨɪɿɜ ɫɬɟ -ɪɨʀɞɧɢɯ ɝɨɪɦɨɧɿɜ: ɟɫɬɪɨɝɟɧɨɜɿ ɪɟɰɟɩɬɨɪɢ (ER) (ɤɥɨɧ 1D5 (DAKO), ɤɥɨɧ SP1 (LabVision)) ɬɚ ɩɪɨɝɟɫɬɟɪɨɧɨɜɿ ɪɟɰɟɩɬɨɪɢ (PgR) (ɤɥɨɧ PgR 636 (DAKO), ɤɥɨɧ SP2 (LabVision)), VEGF – ɮɚɤɬɨɪ ɪɨɫɬɭ ɟɧɞɨɬɟɥɿɸ ɫɭɞɢɧ (ɤɥɨɧ VG1 (DAKO)). Ɂ ɦɟɬɨɸ ɚɧɚɥɿɡɭ ɜɦɿɫɬɭ ȱȽɏ ɦɚɪɤɟɪɿɜ ɭ ɫɩɨɥɭɱɧɿɣ ɬɤɚɧɢɧɿ ɦɢ ɜɤɥɸɱɢɥɢ ɜ ɩɚɧɟɥɶ ɦɚɪɤɟɪɢ ɤɨɥɚɝɟɧɭ IV ɬɢɩɭ (ɤɥɨɧ CV-22), CEA (ɤɥɨɧ COL-1) ɬɚ ɦɚɪɤɟɪ ɩɪɨɥɿɮɟɪɚɰɿʀ Ki-67 ɮɿɪɦɢ LabVision. Ⱦɥɹ ɤɨɠɧɨɝɨ ɦɚɪɤɟɪɚ ɜɢɤɨɧɭɜɚɥɢɫɹ ɤɨɧɬɪɨɥɶɧɿ ɞɨ -ɫɥɿɞɠɟɧɧɹ ɞɥɹ ɜɢɤɥɸɱɟɧɧɹ ɩɨɦɢɥɤɨɜɨ ɩɨɡɢɬɢɜ -ɧɢɯ ɚɛɨ ɩɨɦɢɥɤɨɜɨ ɧɟɝɚɬɢɜ-ɧɢɯ ɪɟɡɭɥɶɬɚɬɿɜ [22].

ɇɚɫɬɭɩɧɢɣ ɟɬɚɩ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɩɪɨɜɨɞɢɥɢ ɡ ɜɢɤɨɪɢɫɬɚɧɧɹɦ ɫɢɫɬɟɦɢ ɜɿɡɭɚɥɿɡɚɰɿʀ ɨɫɬɚɧɧɶɨɝɨ ɩɨɤɨɥɿɧɧɹ UltraVision LP (Lab Vision). ȼɬɨɪɢɧɧɿ ɚɧɬɢɬɿɥɚ, ɹɤɿ ɦɿɫɬɢɥɢ ɜɟɥɢɤɭ ɤɿɥɶɤɿɫɬɶ ɦɨɥɟɤɭɥ ɩɟɪɨɤɫɢɞɚɡɢ ɯɪɨɧɭ, ɧɚɧɨɫɢɥɢ ɧɚ ɡɪɿɡɢ ɬɚ ɿɧɤɭ -ɛɭɜɚɥɢ ɭ ɜɨɥɨɝɢɯ ɤɚɦɟɪɚɯ 30 ɯɜɢɥɢɧ ɡ ɩɪɨ -ɦɢɜɚɧɧɹɦ ɭ ɌɊɂɋ-ɛɭɮɟɪɧɨɦɭ ɪɨɡɱɢɧɿ ɦɿɠ ɤɨɠɧɢɦ ɟɬɚɩɨɦ - 10 ɯɜ. ȱɞɟɧɬɢɮɿɤɚɰɿɹ ɪɟɚɤɰɿʀ ɩɪɨɜɨɞɢɥɚɫɶ ɡɚɜɞɹɤɢ ɧɚɧɟɫɟɧɧɸ ɯɪɨɦɨɝɟɧɭ (DAB (Lab Vision)) ɩɿɞ ɤɨɧɬɪɨɥɟɦ ɦɿɤɪɨɫɤɨɩɚ ɩɪɨɬɹɝɨɦ ɜɿɞ 20 ɫɟɤɭɧɞ ɞɨ 3 ɯɜɢɥɢɧ,ɡ ɩɪɨɹɜɨɦ ɭ ɜɢɝɥɹɞɿ ɬɟɦɧɨ-ɤɨɪɢɱɧɟɜɨɝɨ ɡɚɛɚɪɜɥɟɧɧɹ ɫɩɟɰɢ -ɮɿɱɧɢɯ ɫɬɪɭɤɬɭɪ ɡɚɥɟɠɧɨ ɜɿɞ ɦɚɪɤɟɪɭ (ɹɞɟɪɧɚ, ɰɢɬɨɩɥɚɡɦɚɬɢɱɧɚ,ɦɟɦɛɪɚɧɚ ɪɟɚɤɰɿɹ).

Ⱦɥɹ ɞɢɮɟɪɟɧɰɿɸɜɚɧɧɹ ɫɬɪɭɤɬɭɪ ɬɤɚɧɢɧ ɡɪɿɡɢ ɞɨɞɚɬɤɨɜɨ ɡɚɛɚɪɜɥɸɜɚɥɢ ɝɟɦɚɬɨɤɫɢɥɿɧɨɦ Ɇɚɽɪɚ ɩɪɨɬɹɝɨɦ 1-3 ɯɜɢɥɢɧ. ɇɚɫɬɭɩɧɚ ɞɟɝɿɞɪɚɬɚɰɿɹ ɿ ɜɤɥɸɱɟɧɧɹ ɭ ɛɚɥɶɡɚɦ ɡɞɿɣɫɧɸɜɚɥɢɫɹ ɡɝɿɞɧɨ ɡ ɪɨɡɩɨɜɫɸɞɠɟɧɢɦɢ ɦɟɬɨɞɢɤɚɦɢ.

Ɉɬɪɢɦɚɧɿ ɪɟɡɭɥɶɬɚɬɢ ɩɿɞɞɚɜɚɥɢ ɫɬɚɬɢɫɬɢɱɧɿɣ ɨɛɪɨɛɰɿ ɡ ɜɢɤɨɪɢɫɬɚɧɧɹɦ ɩɚɤɟɬɚ ɩɪɨɝɪɚɦ STATISTICA ® for Windows, Release 8.0 ɤɨɦ -ɩɚɧɿʀ StatSoft ® Inc., ɋɒȺ (2010). Ⱦɥɹ ɦɚɬɟɦɚ -ɬɢɱɧɨʀ ɨɛɪɨɛɤɢ ɨɬɪɢɦɚɧɢɯ ɞɚɧɢɯ ɜɢɤɨɪɢɫɬɨɜɭ -ɜɚɥɢ ɦɟɬɨɞɢ ɨɩɢɫɨɜɨʀ ɫɬɚɬɢɫɬɢɤɢ, ɤɨɪɟɥɹɰɿɣɧɢɣ ɚɧɚɥɿɡ [1].

ɊȿɁɍɅɖɌȺɌɂ ɌȺ Ȳɏ ɈȻȽɈȼɈɊȿɇɇə

Ⱦɥɹ ɭɬɨɱɧɟɧɧɹ ɥɚɧɨɤ ɩɚɬɨɝɟɧɟɡɭ ɊȽɉ ɬɚ ɪɨɡɪɨɛɤɢ ɟɮɟɤɬɢɜɧɢɯ ɦɟɬɨɞɿɜ ɥɿɤɭɜɚɧɧɹ ɩɚ -ɰɿɽɧɬɨɤ ɡ ɊȽɉ ɧɟɨɛɯɿɞɧɨ ɛɭɥɨ ɩɪɨɜɟɫɬɢ ɪɹɞ ɥɚɛɨɪɚɬɨɪɧɢɯ ɬɚ ɿɧɫɬɪɭɦɟɧɬɚɥɶɧɢɯ ɦɟɬɨɞɿɜ ɞɨɫɥɿɞɠɟɧɧɹ.ɍ ɡɜ’ɹɡɤɭ ɡ ɰɢɦ ɞɥɹ ɭɞɨɫɤɨɧɚɥɟɧɧɹ ɩɪɨɝɪɚɦɢ ɤɨɦɩɥɟɤɫɧɨʀ ɯɿɪɭɪɝɿɱɧɨʀ ɪɟɚɛɿɥɿɬɚɰɿʀ ɩɚɰɿɽɧɬɨɤ ɡ ɊȽɉ, ɹɤɚ ɫɩɪɹɦɨɜɚɧɚ ɧɚ ɥɿɤɜɿɞɚɰɿɸ ɞɟɮɟɤɬɿɜ ɩɿɯɜɨɜɨʀ ɚɧɚɬɨɦɿʀ, ɭɫɭɧɟɧɧɹ ɮɭɧɤɰɿɨ -ɧɚɥɶɧɢɯ ɩɨɪɭɲɟɧɶ ɫɭɦɿɠɧɢɯ ɬɚɡɨɜɢɯ ɨɪɝɚɧɿɜ, ɩɨɩɟɪɟɞɠɟɧɧɹ ɩɨɪɭɲɟɧɶ ɮɭɧɤɰɿʀ ɫɭɦɿɠɧɢɯ ɨɪ -ɝɚɧɿɜ ɬɚ ɡɦɟɧɲɟɧɧɹ ɜɿɞɫɨɬɤɚ ɿɧɬɪɚɨɩɟɪɚɰɿɣɧɢɯ ɬɚ ɩɿɫɥɹɨɩɟɪɚɰɿɣɧɢɯ ɭɫɤɥɚɞɧɟɧɶ, ɹɤɿ ɦɨɠɭɬɶ ɛɭɬɢ ɡɭɦɨɜɥɟɧɿ ɫɚɦɢɦ ɯɿɪɭɪɝɿɱɧɢɦ ɜɬɪɭɱɚɧɧɹɦ, ɛɭɥɨ ɩɪɨɜɟɞɟɧɨ ɩɪɨɫɩɟɤɬɢɜɧɟ ɞɨɫɥɿɞɠɟɧɧɹ ȼɨɧɨ

ɫɤɥɚɞɚɥɨɫɹ ɡ ɝɿɫɬɨɥɨɝɿɱɧɨɝɨ ɬɚ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɛɿɨɩɬɚɬɿɜ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ. ɇɟɨɛɯɿɞɧɨ ɜɿɞɡɧɚɱɢɬɢ ɬɨɣ ɮɚɤɬ, ɳɨ ɜ ɫɭɱɚɫɧɿɣ ɥɿɬɟɪɚɬɭɪɿ ɜɿɞɫɭɬɧɿ ɨɞ -ɧɨɡɧɚɱɧɿ ɜɢɫɧɨɜɤɢ ɳɨɞɨ ɞɨɰɿɥɶɧɨɫɬɿ ɩɪɨɜɟɞɟɧɧɹ ɬɚɤɢɯ ɞɨɫɥɿɞɠɟɧɶ ɭ ɩɨɜɫɹɤɞɟɧɧɿɣ ɩɪɚɤɬɢɰɿ ɥɿɤɚɪɹ ɬɚ ɪɨɥɶ ɤɨɠɧɨɝɨ ɡ ɧɢɯ ɭ ɩɪɨɮɿɥɚɤɬɢɰɿ ɊȽɉ, ɡɛɿɥɶɲɟɧɧɿ ɿɧɮɨɪɦɚɬɢɜɧɨɫɬɿ ɞɿɚɝɧɨɫɬɢɱɧɢɯ ɡɚɯɨ-ɞɿɜ ɬɚ ɟɮɟɤɬɢɜɧɨɫɬɿ ɥɿɤɭɜɚɧɧɹ ɠɿɧɨɤ ɡ ɊȽɉ.

ɋɟɪɟɞɧɿɣ ɜɿɤ ɨɛɫɬɟɠɟɧɢɯ ɠɿɧɨɤ ɝɪɭɩɢ Ɋ ɫɬɚ -ɧɨɜɢɜ 62,8±9,8 ɪɨɤɭ, ɝɪɭɩɢ Ʉ – 57,2±6,3 ɪɨɤɭ (ɪ>0,05). ɋɟɪɟɞ ɧɢɯ ɩɚɰɿɽɧɬɨɤ ɪɟɩɪɨɞɭɤɬɢɜɧɨɝɨ ɜɿɤɭ ɧɟ ɛɭɥɨ.Ɍɪɢɜɚɥɿɫɬɶ ɡɚɯɜɨɪɸɜɚɧɧɹ ɜ ɝɪɭɩɿ Ɋ ɫɬɚɧɨɜɢɥɚ ɜɿɞ 1 ɞɨ 5 ɪɨɤɿɜ. ɍ ɪɟɡɭɥɶɬɚɬɿ ɩɪɨ -ɜɟɞɟɧɨɝɨ ɞɨɫɥɿɞɠɟɧɧɹ ɡ ɿɧɞɢɤɚɰɿɽɸ ER ɬɚ PgR ɭ ɫɬɿɧɰɿ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɦɢ ɜɫɬɚɧɨɜɢɥɢ,ɳɨ ɭ ɠɿɧɨɤ ɝɪɭɩɢ Ʉ ɪɟɚɤɰɿɹ ɞɨ ER ɹɤ ɭ ɧɟɡɦɿɧɧɨɦɭ ɟɩɿɬɟɥɿʀ, ɬɚɤ ɿ ɫɬɪɨɦɿ (ɩɪɢ ɤɪɢɬɟɪɿʀ ɤɿɥɶɤɨɫɬɿ ɫɩɟɰɢɮɿɱɧɨ ɡɚɛɚɪɜɥɟɧɢɯ ɤɥɿɬɢɧ ɛɿɥɶɲɟ ɧɿɠ 10%) ɛɭɥɚ ɩɨ -ɡɢɬɢɜɧɚ ɭ 100% ɜɢɩɚɞɤɿɜ (ɬɚɛɥ. 1), ɳɨ ɩɨɹɫɧɸ -ɽɬɶɫɹ ɜɿɞɨɦɢɦ ɮɚɤɬɨɪɨɦ ɟɫɬɪɨɝɟɧɡɚɥɟɠɧɨɫɬɿ ɟɩɿ -ɬɟɥɿɸ ɫɬɿɧɤɢ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ.ɉɪɢ ɰɶɨɦɭ ɤɿɥɶɤɿɫɬɶ ɤɥɿɬɢɧ ɡ ɿɧɬɪɚɧɭɤɥɟɚɪɧɨɸ ȱȽɏ ɦɿɬɤɨɸ ɜ ɛɚ -ɡɚɥɶɧɨɦɭ ɲɚɪɿ ɩɟɪɟɜɢɳɭɜɚɥɚ ɱɢɫɥɨ ɩɨɡɢɬɢɜɧɨ ɡɚɛɚɪɜɥɟɧɢɯ ɤɥɿɬɢɧ ɭ ɩɚɪɚɛɚɡɚɥɶɧɨɦɭ ɲɚɪɿ. Ɋɟɚɤɰɿɹ ɞɨ PgR ɜ ɫɬɿɧɰɿ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɛɭɥɚ ɩɨɡɢɬɢɜɧɚ ɭ 100% ɜɢɩɚɞɤɿɜ. Ʉɥɿɬɢɧɢ ɡ PgR ɦɿɬɤɚɦɢ ɪɿɜɧɨɦɿɪɧɨ ɪɨɡɬɚɲɨɜɭɜɚɥɢɫɹ ɭ ɫɬɪɨɦɿ ɬɚ ɟɩɿɬɟɥɿɚɥɶɧɨɦɭ ɲɚɪɿ.

ɍ ɜɫɿɯ ɜɢɩɚɞɤɚɯ ɩɨɡɢɬɢɜɧɨʀ ɪɟɚɤɰɿʀ ɡ ER ɜ ɟɩɿɬɟɥɿʀ ɫɬɪɨɦɚɥɶɧɿ ɤɥɿɬɢɧɢ ɬɚɤɨɠ ɛɭɥɢ ER – ɩɨɡɢɬɢɜɧɢɦɢ, ɩɪɢɱɨɦɭ ɿɧɬɟɧɫɢɜɧɿɫɬɶ ɪɟɚɤɰɿʀ ɜ ɫɬɪɨɦɿ ɛɭɥɚ ɧɢɠɱɨɸ, ɧɿɠ ɜ ɟɩɿɬɟɥɿɚɥɶɧɨɦɭ ɲɚɪɿ, ɹɤɚ ɫɜɿɞɱɢɥɚ ɩɪɨ ɛɿɥɶɲɭ ɟɫɬɪɨɝɟɧɡɚɥɟɠɧɿɫɬɶ ɫɚɦɟ ɟɩɿɬɟɥɿɚɥɶɧɨɝɨ ɲɚɪɭ. ɋɬɪɨɦɚɥɶɧɿ ɤɥɿɬɢɧɢ ɛɭɥɢ ER – ɩɨɡɢɬɢɜɧɢɦɢ ɜ 67,3% ɜɢɩɚɞɤɿɜ, ɰɟɣ ɩɨ -ɤɚɡɧɢɤ ɧɟ ɡɚɥɟɠɚɜ ɜɿɞ ɬɪɢɜɚɥɨɫɬɿ ɦɟɧɨɩɚɭɡɢ, ɚ ɤɿɥɶɤɿɫɬɶ ɤɥɿɬɢɧ ɫɬɪɨɦɢ ɡ ɩɨɡɢɬɢɜɧɢɦ ɡɚɛɚɪ -ɜɥɟɧɧɹɦ ɛɭɥɚ ɧɚ ɪɿɜɧɿ 28-37%.ɉɚɪɚɛɚɡɚɥɶɧɿ ɤɥɿ -ɬɢɧɢ ɞɟɦɨɧɫɬɪɭɜɚɥɢ ɧɟɡɧɚɱɧɭ ɩɨɡɢɬɢɜɧɭ ɪɟɚɤ -ɰɿɸ ɡ ER. ɉɪɨɬɟ ɭ ɛɿɥɶɲɨɫɬɿ ɜɢɩɚɞɤɿɜ ɪɟɚɤɰɿɹ ɡ ERɬɚ PgR ɛɭɥɚ ɧɟɝɚɬɢɜɧɚ.

(4)

ɹɤɢɯ ɫɩɨɫɬɟɪɿɝɚɜɫɹ ɦɚɤɫɢɦɚɥɶɧɨ ɧɢɡɶɤɢɣ ɪɿɜɟɧɶ ɩɨɡɢɬɢɜɧɨ ɡɚɛɚɪɜɥɟɧɢɯ ɤɥɿɬɢɧ. ɍ ɝɪɭɩɿ Ɋ ɜ ɚɩɿ -ɤɚɥɶɧɨɦɭ ɫɟɝɦɟɧɬɿ ɪɿɜɟɧɶ ɟɤɫɩɪɟɫɿʀ ɛɭɜ ɩɨɞɿɛɧɢɦ ɞɨ ɩɨɤɚɡɧɢɤɿɜ ɝɪɭɩɢ Ʉ, ɬɨɛɬɨ ɤɿɥɶɤɿɫɬɶ ER

(ɬɚɛɥ.). ȼɫɿ ɩɨɡɢɬɢɜɧɨ ɡɚɛɚɪɜɥɟɧɿ ɤɥɿɬɢɧɢ ɪɨɡɬɚ -ɲɨɜɭɜɚɥɢɫɹ ɭ ɛɚɡɚɥɶɧɨɦɭ ɬɚ ɩɚɪɚɛɚɡɚɥɶɧɨɦɭ ɲɚɪɿ.

ȿɤɫɩɪɟɫɿɹ ER ɜ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɭ ɠɿɧɨɤ ɡ ɪɟɰɢɞɢɜɨɦ ɝɟɧɿɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɭ, n (%)

ȿɤɫɩɪɟɫɿɹ ER ɜ ɟɩɿɬɟɥɿʀ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ȿɤɫɩɪɟɫɿɹ ER ɭ ɫɬɪɨɦɿ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ

Ƚɪɭɩɚ

<10% >10% <10% >10%

ɊȽɉ ɩɟɪɟɞɧɿɣ ɫɟɝɦɟɧɬ, n=10 _(20,0)2 _(80,0)8 _(40,0)4 _(60,0)6

ɊȽɉ ɡɚɞɧɿɣ ɫɟɝɦɟɧɬ, n=10 2

(20,0)

8 (80,0)

3 (30,0)

7 (70,0)

ɉɨɫɬɝɿɫɬɟɪɟɤɬɨɦɿɱɧɢɣ ɩɪɨɥɚɩɫ,

n=10

6 (60,0)

4 (40,0)

6 (60,0)

4 (40,0)

ɊȽɉ ɚɩɿɤɚɥɶɧɢɣ ɫɟɝɦɟɧɬ, n=23 1

(4,4)

22 (95,6)

4 (17,4)

19 (82,6)

ȼ ɝɪɭɩɿ ɡ ɊȽɉ ɪɚɡɨɦ, n=53 _(20,8)11 _(79,2)42 _(32,1)17 _(67,9)36

Ƚɪɭɩɚ ɩɨɪɿɜɧɹɧɧɹ, n=30 2

(6,7)*

28 (93,3)

5 (16,7)*

25 (83,3)*

ɉ ɪ ɢ ɦ ɿ ɬ ɤ ɚ. * - ɫɬɚɬɢɫɬɢɱɧɨ ɞɨɫɬɨɜɿɪɧɚ ɪɿɡɧɢɰɹ ɦɿɠ ɩɨɤɚɡɧɢɤɚɦɢ ɝɪɭɩɢ Ɋ ɿ ɝɪɭɩɢ Ʉ (p<0,05).

ɋɟɪɟɞ ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ɋ ɛɭɥɨ 14 (26,4%) ɜɢ -ɩɚɞɤɿɜ ɡ ɧɟɝɚɬɢɜɧɢɦ ɫɬɚɬɭɫɨɦ ɟɤɫɩɪɟɫɿʀ ER, ɭ ɩɟɪɟɜɚɠɧɿɣ ɛɿɥɶɲɨɫɬɿ ɫɩɨɫɬɟɪɟɠɟɧɶ ɜɫɬɚɧɨɜɥɟɧɨ ɪɟɚɤɰɿɸ ɜ ɨɤɪɟɦɢɯ ɤɥɿɬɢɧɚɯ ɡ ER, ɿɧɬɟɧɫɢɜɧɿɫɬɶ ʀɯ ɛɭɥɚ ɫɥɚɛɤɨɸ, ɤɿɥɶɤɿɫɬɶ ɩɨɡɢɬɢɜɧɢɯ ɤɥɿɬɢɧ ɧɟ ɩɟɪɟɜɢɳɭɜɚɥɚ 10%, ɪɨɡɬɚɲɨɜɭɜɚɥɢɫɹ ɜɨɧɢ ɬɚɤɨɠ ɭ ɛɚɡɚɥɶɧɨɦɭ ɬɚ ɩɚɪɚɛɚɡɚɥɶɧɨɦɭ ɲɚɪɚɯ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ.

ȼɫɿ ɫɩɨɫɬɟɪɟɠɟɧɧɹ ɡ ɩɨɡɢɬɢɜɧɨɸ ɪɟɚɤɰɿɽɸ ɜ ɟɩɿɬɟɥɿʀ ɯɚɪɚɤɬɟɪɢɡɭɜɚɥɢɫɹ ɜɿɞɩɨɜɿɞɧɨɸ ɩɨɡɢ -ɬɢɜɧɨɸ ɪɟɚɤɰɿɽɸ ɜ ɫɬɪɨɦɿ, ɩɪɢɱɨɦɭ ɿɧɬɟɧɫɢɜ -ɧɿɫɬɶ ɪɟɚɤɰɿʀ ɜ ɩɿɞɥɟɝɥɢɯ ɬɤɚɧɢɧɚɯ ɛɭɥɚ ɧɢɠɱɨɸ, ɧɿɠ ɭ ɟɩɿɬɟɥɿɚɥɶɧɨɦɭ ɲɚɪɿ, ɡ ɩɟɪɟɜɚɠɧɨ ɩɨ -ɦɿɪɧɨɸ ɿɧɬɟɧɫɢɜɧɿɫɬɸ ɪɟɚɤɰɿʀ. Ʉɿɥɶɤɿɫɬɶ ɤɥɿɬɢɧ ɫɬɪɨɦɢ ɡ ȱȽɏ ɪɟɚɤɰɿɸ ɞɨ ER ɛɭɥɚ ɜ ɦɟɠɚɯ ɜɿɞ 10 ɞɨ 30%.

ɉɨɪɿɜɧɹɧɨ ɡ ɪɟɡɭɥɶɬɚɬɚɦɢ ɝɪɭɩɢ Ʉ ɭ ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ɋ ɩɨɡɢɬɢɜɧɚ ɪɟɚɤɰɿɹ ɡ PgR ɛɭɥɚ ɜɢɡɧɚɱɟɧɚ ɭ ɦɟɧɲɿɣ ɤɿɥɶɤɨɫɬɿ ɜɢɩɚɞɤɿɜ (14,0±1,2% ɩɪɨɬɢ 40,2±2,9, ɪ<0,05), ɡɚɛɚɪɜɥɟɧɧɹ ɛɭɥɨ ɫɥɚɛɤɨʀ ɿɧɬɟɧɫɢɜɧɨɫɬɿ, ɤɿɥɶɤɿɫɬɶ ɩɨɡɢɬɢɜɧɨ ɡɚɛɚɪɜɥɟɧɢɯ ɤɥɿɬɢɧ ɤɨɥɢɜɚɥɚɫɹ ɜɿɞ 2 ɞɨ 10%. ɉɨɡɢɬɢɜɧɿ ɤɥɿɬɢɧɢ ɪɨɡɬɚɲɨɜɭɜɚɥɢɫɹ ɩɟɪɟɜɚɠɧɨ ɭ ɫɬɪɨɦɿ. ɋɬɪɨɦɚɥɶɧɿ ɤɥɿɬɢɧɢ ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ʉ ɭ ɜɫɿɯ ɜɢɩɚɞɤɚɯ ɞɚɜɚɥɢ ɩɨɡɢɬɢɜɧɟ ɡɚɛɚɪɜɥɟɧɧɹ, ɩɪɢɱɨɦɭ ɿɧɬɟɧɫɢɜɧɿɫɬɶ ɪɟɚɤɰɿʀ ɬɚ ɤɿɥɶɤɿɫɬɶ PgR ɩɨɡɢɬɢɜɧɢɯ ɤɥɿɬɢɧ ɭ ɩɿɞɥɟɝɥɢɯ ɬɤɚɧɢɧɚɯ ɛɭɥɚ

ɡɧɚɱɧɨ ɜɢɳɨɸ, ɧɿɠ ɜ ɟɩɿɬɟɥɿʀ, ɦɢ ɜɢɡɧɚɱɚɥɢ ɜɿɞ 10ɞɨ 20% ɹɞɟɪ ɡ ȱȽɏ ɪɟɚɤɰɿɽɸ ɫɬɨɦɢ ɩɨɦɿɪɧɨʀ ɬɚ ɜɢɫɨɤɨʀ ɿɧɬɟɧɫɢɜɧɨɫɬɿ.

ɍ 43 ɜɢɩɚɞɤɚɯ,ɹɤɿ ɦɢ ɜɿɞɧɟɫɥɢ ɞɨ ɧɟɝɚɬɢɜɧɢɯ ȱȽɏ, ɤɿɥɶɤɿɫɬɶ ɤɥɿɬɢɧ ɟɩɿɬɟɥɿɸ ɡ ȱȽɏ ɪɟɚɤɰɿɽɸ ɛɭɥɚ ɜ ɦɟɠɚɯ ɜɿɞ 2 ɞɨ 9%. Ȼɿɥɶɲɚ ɩɨɥɨɜɢɧɚ ɛɿɨɩɬɚɬɿɜ ɛɭɥɢ ER- ɧɟɝɚɬɢɜɧɢɦɢ ɜ ɟɩɿɬɟɥɿʀ,ɩɪɨɬɟ ɜ ɫɬɪɨɦɿ ɰɢɯ ɭɬɜɨɪɟɧɶ ɡɭɫɬɪɿɱɚɥɢɫɹ ɜ ɞɨɫɬɚɬɧɿɣ ɤɿɥɶɤɨɫɬɿ ɤɥɿɬɢɧɢ ɡɿ ɫɥɚɛɤɨɸ ɬɚ ɩɨɦɿɪɧɨɸ ɪɟɚɤ-ɰɿɽɸ. ɏɚɪɚɤɬɟɪɧɨ, ɳɨ ɫɬɪɨɦɚɥɶɧɿ ɤɥɿɬɢɧɢ ɪɟɲɬɢ ɫɩɨɫɬɟɪɟɠɟɧɶ, ɹɤɿ ɜɿɞɧɟɫɟɧɨ ɞɨ ɝɪɭɩɢ ɡ ɧɟɝɚ -ɬɢɜɧɢɦ ɫɬɚɬɭɫɨɦ, ɛɭɥɢ ɩɨɡɢɬɢɜɧɨ ɡɚɛɚɪɜɥɟɧɿ, ɿɧɬɟɧɫɢɜɧɿɫɬɶ ɪɟɚɤɰɿʀ ɛɭɥɚ ɫɥɚɛɤɨɸ ɬɚ ɩɨɦɿɪɧɨɸ, ɤɿɥɶɤɿɫɬɶ ɤɥɿɬɢɧ ɡ ɪɟɚɤɰɿɽɸ ɤɨɥɢɜɚɥɚɫɹ ɜɿɞ 10 ɞɨ 20%. ɓɨɞɨ ɪɟɡɭɥɶɬɚɬɿɜ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɟɤɫ -ɩɪɟɫɿʀ PgR, ɬɨ ɧɚɦɢ ɜɫɬɚɧɨɜɥɟɧɨ,ɳɨ ɭ ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ɋ ɤɥɿɬɢɧɢ ɟɩɿɬɟɥɿɸ ɬɚ ɫɬɪɨɦɢ ɛɭɥɢ PgR- ɧɟɝɚɬɢɜɧɢɦɢ ɿ PgR- ɩɨɡɢɬɢɜɧɢɦɢ ɡ ɩɨɦɿɪɧɨɸ ɬɚ ɜɢɫɨɤɨɸ ɿɧɬɟɧɫɢɜɧɿɫɬɸ ȱȽɏ ɭ ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ʉ.

(5)

ɄɅȱɇȱɑɇȺ ɆȿȾɂɐɂɇȺ

ɪɚɡɢ – ɧɿɠ ɭ ɠɿɧɨɤ ɡ ɊȽɉ ɩɿɫɥɹ ɝɿɫɬɟɪɟɤɬɨɦɿʀ (ɪ<0,05).

ȼɫɬɚɧɨɜɥɟɧɨ ɡɦɟɧɲɟɧɧɹ ɤɿɥɶɤɨɫɬɿ ɤɥɿɬɢɧ ɡ ɩɨɡɢɬɢɜɧɨɸ ȱȽɏ ɦɿɬɤɨɸ PgR ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ɋ, ɳɨ ɜɿɞɩɨɜɿɞɚɥɨ ɬɿɣ ɡɚɤɨɧɨɦɿɪɧɨɫɬɿ, ɹɤɭ ɦɢ ɜɢ -ɡɧɚɱɢɥɢ ɞɥɹ ɟɤɫɩɪɟɫɿʀ ER ɜ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɩɚɰɿɽɧɬɨɤ ɚɧɚɥɨɝɿɱɧɢɯ ɝɪɭɩ. ɍ ɜɫɿɯ ɠɿɧɨɤ ɝɪɭɩɢ Ʉ ɿ ɝɪɭɩɢ Ɋ ɜ ɛɿɨɩɬɚɬɚɯ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɛɭɥɢ ɩɪɨɜɟɞɟɧɿ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɡ ɜɢɤɨɪɢɫɬɚɧɧɹɦ ɦɨɧɨɤɥɨɧɚɥɶɧɢɯ ɚɧɬɢɬɿɥ ɦɚɪɤɟɪɚ ɩɪɨɥɿɮɟɪɚɰɿʀ Ʉɿ-67, ɦɚɪɤɟɪɚ ɚɧɝɿɨɝɟɧɟɡɭ VEGF ɬɚ ɦɚɪɤɟɪɚ ɤɨɥɚɝɟɧɚ IV ɬɢɩɭ. ȿɤɫɩɪɟɫɿɹ ɪɟɰɟɩɬɨɪɿɜ ɦɚɪɤɟɪɿɜ ɩɪɨɥɿɮɟɪɚɰɿʀ Ki-67 ɬɚ ɦɚɪɤɟɪɚ ɚɧɝɿɨɝɟɧɟɡɭ VEGF ɭ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɛɭɥɚ ɧɢɡɶɤɨɸ ɹɤ ɭ ɩɚɰɿɽɧɬɨɤ ɝɪɭɩɢ Ʉ, ɬɚɤ ɿ ɝɪɭɩɢ Ɋ ɛɟɡ ɞɨɫɬɨɜɿɪɧɨʀ ɪɿɡɧɢɰɿ ɭ ɝɪɭɩɚɯ (ɪ>0,05).

ɍ (80,0%) ɠɿɧɨɤ ɝɪɭɩɢ Ʉ ɜ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɫɩɨɫɬɟɪɿɝɚɥɚɫɹ ɩɨɡɢɬɢɜɧɚ ȱȽɏ ɪɟɚɤɰɿɹ ɫɬɪɨɦɚɥɶ -ɧɨɝɨ ɤɨɦɩɨɧɟɧɬɭ ɞɨ ɦɚɪɤɟɪɚ ɤɨɥɚɝɟɧɚ IV ɬɢɩɭ, ɚɥɟ ɡɧɚɱɧɨ ɦɟɧɲ ɜɢɪɚɠɟɧɚ,ɧɿɠ ɭ ɝɪɭɩɚɯ ɠɿɧɨɤ ɡ ɊȽɉ. ɇɟɝɚɬɢɜɧɢɣ ɫɬɚɬɭɫ ɳɨɞɨ ɟɤɫɩɪɟɫɿʀ ɦɚɪɤɟɪɚ ɤɨɥɚɝɟɧɚ IV ɬɢɩɭ ɫɩɨɫɬɟɪɿɝɚɜɫɹ ɥɢɲɟ ɭ 3 (5,7%) ɡ 53 ɠɿɧɨɤ. ɍ ɰɶɨɦɭ ɜɢɩɚɞɤɭ ɫɩɨɫɬɟɪɿɝɚɥɚɫɹ ɧɟ-ɜɟɥɢɤɚ ɤɿɥɶɤɿɫɬɶ ɤɥɿɬɢɧ ɡ ɪɟɚɤɰɿɽɸ ɜ ɹɞɪɚɯ (2%-3%). ɍ ɪɟɲɬɢ ɠɿɧɨɤ ɡ ɊȽɉ ɜɫɬɚɧɨɜɥɟɧɚ ɩɨɦɿɪɧɚ ɪɟɚɤɰɿɹ ɬɤɚɧɢɧ ɡ ɰɢɦ ɦɚɪɤɟɪɨɦ, ɤɿɥɶɤɿɫɬɶ ɡɚɛɚɪ -ɜɥɟɧɢɯ ɤɥɿɬɢɧ ɤɨɥɢɜɚɥɚɫɹ ɜɿɞ 1% ɞɨ 10% ɡɿ ɫɥɚɛ -ɤɨɸ ɬɚ ɿɧɨɞɿ ɩɨɦɿɪɧɨɸ ɿɧɬɟɧɫɢɜɧɿɫɬɸ ɡɚ -ɛɚɪɜɥɟɧɧɹ.

ɍ ɛɿɨɩɬɚɬɚɯ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɩɚɰɿɽɧɬɨɤ ɡ ɊȽɉ ɫɩɨɫɬɟɪɿɝɚɜɫɹ ɮɨɤɚɥɶɧɢɣ ɬɢɩ ɡɚɛɚɪɜɥɟɧɧɹ ɡ ɰɢɬɨɩɥɚɡɦɚɬɢɱɧɨɸ ɪɟɚɤɰɿɽɸ ɫɥɚɛɤɨʀ ɿɧɬɟɧɫɢɜ -ɧɨɫɬɿ, ɩɟɪɟɜɚɠɧɨ ɜ ɩɟɪɢɜɚɫɤɭɥɹɪɧɿɣ ɞɿɥɹɧɰɿ. Ʉɿɥɶɤɿɫɬɶ ɡɚɛɚɪɜɥɟɧɢɯ ɤɥɿɬɢɧ ɫɬɚɧɨɜɢɥɚ 35-65%. ɉɪɢ ɚɧɚɥɿɡɿ ɿɧɬɟɧɫɢɜɧɨɫɬɿ ȱȽɏ ɪɟɚɤɰɿɣ ɭ ɰɿɣ ɝɪɭɩɿ ɜɿɞɦɿɱɚɜɫɹ ɩɟɪɟɜɚɠɧɨ ɩɨɦɿɪɧɢɣ ʀɯ ɪɿɜɟɧɶ,ɥɢɲɟ ɜ ɨɤɪɟɦɢɯ ɜɢɩɚɞɤɚɯ ɫɩɨɫɬɟɪɿɝɚɥɢɫɹ ɜɚɪɿɚɧɬɢ ɪɟɚɤɰɿɣ ɹɤ ɫɥɚɛɤɨʀ,ɬɚɤ ɿ ɜɢɫɨɤɨʀ ɿɧɬɟɧɫɢɜɧɨɫɬɿ.ɍ ɩɚɰɿɽɧɬɨɤ ɡ ɊȽɉ ɩɿɫɥɹ ɝɿɫɬɟɪɟɤɬɨɦɿʀ ɫɩɨɫɬɟ -ɪɿɝɚɜɫɹ ɮɨɤɚɥɶɧɢɣ ɬɢɩ ɡɚɛɚɪɜɥɟɧɧɹ, ɤɿɥɶɤɿɫɬɶ

ɩɨɡɢɬɢɜɧɢɯ ɤɥɿɬɢɧ ɤɨɥɢɜɚɥɚɫɹ ɜ ɞɿɚɩɚɡɨɧɿ ɜɿɞ 20% ɞɨ 40%, ɿ ɰɿ ɤɥɿɬɢɧɢ ɪɨɡɬɚɲɨɜɭɜɚɥɢɫɹ ɬɚɤɨɠ ɩɟɪɟɜɚɠɧɨ ɭ ɩɟɪɢɜɚɫɤɭɥɹɪɧɿɣ ɡɨɧɿ. ɍ ɞɿɥɹɧɤɚɯ ɫɥɢɡɨɜɨʀ ɿɡ ɤɭɤɫɢ ɫɤɥɟɩɿɧɧɹ ɩɿɯɜɢ ɜɿɞɦɿɱɚɥɚɫɹ ɫɥɚɛɤɚ ɪɟɚɤɰɿɹ ɫɬɪɨɦɢ ɜ ɨɤɪɟɦɢɯ ɤɥɿɬɢɧɚɯ (ɜɿɞ 2% ɞɨ 5%) ɡɿ ɫɥɚɛɤɨɸ ɿɧɬɟɧɫɢɜɧɿɫɬɸ ɡɚɛɚɪ -ɜɥɟɧɧɹ.

Ɂɚ ɪɟɡɭɥɶɬɚɬɚɦɢ ɞɨɫɥɿɞɠɟɧɧɹ ɟɤɫɩɪɟɫɿʀ ɦɚɪ-ɤɟɪɿɜ Ki-67 ɭ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɩɚɰɿɽɧɬɨɤ ɡ ɊȽɉ ɧɟ ɜɫɬɚɧɨɜɥɟɧɨ ɚɤɬɢɜɧɨɫɬɿ ɩɪɨɥɿɮɟɪɚɰɿʀ. ɍ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɫɩɨɫɬɟɪɿɝɚɽɬɶɫɹ ɡɦɟɧɲɟɧɧɹ ɟɤɫɩɪɟɫɿʀ ER ɧɚ 76,2% ɬɚ PgR – ɧɚ 83,4% ɩɨɪɿɜɧɹɧɨ ɡ ɪɟɡɭɥɶ -ɬɚɬɚɦɢ ɞɨɫɥɿɞɠɟɧɧɹ ɜ ɝɪɭɩɿ Ʉ.

Ⱥɧɚɥɿɡ ɪɟɡɭɥɶɬɚɬɿɜ ɩɪɨɜɟɞɟɧɨɝɨ ɧɚɦɢ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɞɚɜ ɦɨɠɥɢɜɿɫɬɶ ɡɪɨɛɢɬɢ ɜɢɫɧɨɜɨɤ, ɳɨ ɜɢɡɧɚɱɟɧɧɹ ɪɟɰɟɩɬɨɪɿɜ ɫɬɟɪɨʀɞɧɢɯ ɝɨɪɦɨɧɿɜ, ɦɚɪɤɟɪɿɜ ɩɪɨɥɿɮɟɪɚɰɿʀ ɭ ɩɚɰɿɽɧɬɨɤ ɡ ɊȽɉ ɦɨɠ -ɥɢɜɟ ɥɢɲɟ ɞɥɹ ɩɪɨɜɟɞɟɧɧɹ ɧɚɭɤɨɜɢɯ ɞɨɫɥɿɞɠɟɧɶ. əɤ ɫɤɪɢɧɿɧɝɨɜɚ ɦɟɬɨɞɢɤɚ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɫɬɚɧɭ ɫɥɢɡɨɜɨʀ ɩɿɯɜɢ ɽ ɦɟɧɲ ɞɨɰɿɥɶɧɨɸ,ɨɫɤɿɥɶɤɢ ɡɚɛɿɪ ɦɚɬɟɪɿɚɥɭ ɞɥɹ ɞɨɫɥɿɞɠɟɧɧɹ ɦɨɠɥɢɜɢɣ ɥɢɲɟ ɩɿɞ ɱɚɫ ɨɩɟɪɚɬɢɜɧɨɝɨ ɜɬɪɭɱɚɧɧɹ. Ɋɟɡɭɥɶɬɚɬ ȱȽɏ ɞɨɫɥɿɞɠɟɧɧɹ ɜ ɰɶɨɦɭ ɜɢɩɚɞɤɭ ɧɟ ɦɨɠɟ ɛɭɬɢ ɜɢɤɨɪɢɫɬɚɧɢɣ ɹɤ ɤɪɢɬɟɪɿɣ ɞɥɹ ɜɢɛɨɪɭ ɦɟɬɨɞɭ ɨɩɟɪɚɬɢɜɧɨɝɨ ɜɬɪɭɱɚɧɧɹ ɬɚ ɩɪɨɝɧɨɡɭɜɚɧɧɹ ɪɟ-ɡɭɥɶɬɚɬɿɜ ɨɩɟɪɚɰɿʀ. Ɉɞɧɚɤ ɨɬɪɢɦɚɧɿ ɪɟɡɭɥɶɬɚɬɢ ɞɚɥɢ ɦɨɠɥɢɜɿɫɬɶ ɨɛʉɪɭɧɬɭɜɚɬɢ ɩɪɢɡɧɚɱɟɧɧɹ ɦɿɫ -ɰɟɜɢɯ ɟɫɬɪɨɝɟɧɜɦɿɫɧɢɯ ɩɪɟɩɚɪɚɬɿɜ ɭ ɩɟɪɿɨɞ ɩɿɞɝɨɬɨɜɤɢ ɞɨ ɨɩɟɪɚɬɢɜɧɨɝɨ ɜɬɪɭɱɚɧɧɹ.

ȼɂɋɇɈȼɄɂ

1. ɍ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɠɿɧɨɤ ɡ ɪɟɰɢɞɢɜɨɦ ɝɟɧɿ -ɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɭ ɫɩɨɫɬɟɪɿɝɚɽɬɶɫɹ ɡɦɟɧɲɟɧɧɹ ɟɤɫɩɪɟɫɿʀ ɟɫɬɪɨɝɟɧɨɜɢɯ ɪɟɰɟɩɬɨɪɿɜ ɧɚ 76,2% ɬɚ ɩɪɨɝɟɫɬɟɪɨɧɨɜɢɯ ɪɟɰɟɩɬɨɪɿɜ – ɧɚ 83,4%.

2. Ɂɚ ɪɟɡɭɥɶɬɚɬɚɦɢ ɞɨɫɥɿɞɠɟɧɧɹ ɟɤɫɩɪɟɫɿʀ ɦɚɪ -ɤɟɪɿɜ Kĩ67 ɧɟ ɜɫɬɚɧɨɜɥɟɧɨ ɚɤɬɢɜɧɨɫɬɿ ɩɪɨɥɿ -ɮɟɪɚɰɿʀ ɜ ɫɥɢɡɨɜɿɣ ɩɿɯɜɢ ɩɚɰɿɽɧɬɨɤ ɡ ɪɟɰɢɞɢɜɨɦ ɝɟɧɿɬɚɥɶɧɨɝɨ ɩɪɨɥɚɩɫɭ.

ɋ

ɋɉ

ɉɂ

ɂɋ

ɋɈ

Ɉ

Ʉ

Ʌȱ

Ʌ

ȱɌ

Ɍȿ

ȿɊ

ɊȺ

ȺɌ

Ɍɍ

ɍɊ

Ɋɂ

ɂ

1. Ⱥɧɬɨɦɨɧɨɜ Ɇ.ɘ.Ɇɚɬɟɦɚɬɢɱɟɫɤɚɹ ɨɛɪɚɛɨɬɤɚ ɢ

ɚɧɚɥɢɡ ɦɟɞɢɤɨ-ɛɢɨɥɨɝɢɱɟɫɤɢɯ ɞɚɧɧɵɯ. – Ʉ.: ɂɡɞ-ɜɨ „Ɇɚɥɢɣ ɞɪɭɤ”, 2006. – 558 ɫ.

2. Ƚɚɫɩɚɪɹɧ ɋ.Ⱥ.Ⱦɢɫɩɥɚɡɢɹ ɫɨɟɞɢɧɢɬɟɥɶɧɨɣ ɬɤɚ

-ɧɢ (ȾɋɌ)ɤɚɤ ɩɪɢɱɢɧɚ ɪɚɡɜɢɬɢɹ ɩɪɨɥɚɩɫɚ ɝɟɧɢɬɚɥɢɣ /

ɋ.Ⱥ. Ƚɚɫɩɚɪɹɧ, ȿ.ɉ. Ⱥɮɚɧɚɫɨɜɚ, Ʌ.ȼ.ɋɬɚɪɢɱɟɧɤɨ //

ɀɭɪɧɚɥ ɚɤɭɲɟɪɫɬɜɚ ɢ ɠɟɧɫɤɢɯ ɛɨɥɟɡɧɟɣ. – 2009. –

Ɍ. 58, ʋ5. – ɋ.Ɇ29–Ɇ30.

3. Ⱦɢɫɩɥɚɡɢɹ ɫɨɟɞɢɧɢɬɟɥɶɧɨɣ ɬɤɚɧɢ / ɩɨɞ ɪɟɞ.

Ɍ.ɂ. Ʉɚɞɭɪɢɧɨɣ, ȼ.ɇ.Ƚɨɪɛɭɧɨɜɨɣ. – ɋɚɧɤɬ–ɉɟɬɟɪ

-ɛɭɪɝ:ɗɥɛɢ, 2009. – 714 ɫ.

4. ɉɟɬɪɨɜ ɋ.ȼ. Ɋɭɤɨɜɨɞɫɬɜɨ ɩɨ ɢɦɦɭɧɨɝɢɫɬɨɯɢ

-ɦɢɱɟɫɤɨɣ ɞɢɚɝɧɨɫɬɢɤɟ ɨɩɭɯɨɥɟɣ ɱɟɥɨɜɟɤɚ / ɋ.ȼ.

ɉɟɬɪɨɜ,ɇ.Ɍ.Ɋɚɣɯɥɢɧ. – Ʉɚɡɚɧɶ, 2004. – 452 ɫ.

5. ɉɪɢɦɟɧɟɧɢɟ ɦɚɥɨɢɧɜɚɡɢɜɧɵɯ ɬɟɯɧɨɥɨɝɢɣ ɜ

ɥɟɱɟɧɢɢ ɨɫɥɨɠɧɟɧɧɵɯ ɮɨɪɦ ɩɪɨɥɚɩɫɚ ɝɟɧɢɬɚɥɢɣ / Ⱥ.Ⱥ.

ɉɨɩɨɜ, Ɍ.ɇ. Ɇɚɧɚɧɧɢɤɨɜɚ, Ƚ.Ƚ. ɒɚɝɢɧɹɧ [ɢ ɞɪ.] //

Ⱥɤɭɲɟɪɫɬɜɨ ɢ ɝɢɧɟɤɨɥɨɝɢɹ. – 2004. – ʋ 3. – ɋ. 32–34. 6. ɉɪɨɮɿɥɚɤɬɢɤɚ ɩɨɫɬɝɿɫɬɟɪɟɤɬɨɦɿɱɧɨɝɨ ɩɪɨɥɚɩɫɭ

ɩɿɞ ɱɚɫ ɬɪɚɧɫɚɛɞɨɦɿɧɚɥɶɧɨʀ ɟɤɫɬɢɪɩɚɰɿʀ ɦɚɬɤɢ – ɧɨɜɢɣ

ɩɿɞɯɿɞ / ȼ.ɇ.Ɂɚɩɨɪɨɠɚɧ,Ⱥ.Ⱥ.ɉɪɨɰɟɩɤɨ,Ɇ.ɇ.Ⱦɪɚɱɟɜ

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ɥɨɝɚ. – 2005. – ʋ5 – ɋ. 19–23.

8. ɋɟɦɟɧɸɤ Ⱥ.Ⱥ. Ʌɟɱɟɧɢɟ ɛɨɥɶɧɵɯ ɫ ɭɪɨɝɟɧɢ

-ɬɚɥɶɧɵɦ ɩɪɨɥɚɩɫɨɦ ɢ ɧɟɞɟɪɠɚɧɢɟɦ ɦɨɱɢ / Ⱥ.Ⱥ.ɋɟɦɟ

-ɧɸɤ, ɇ.ɇ. Ȼɢɬɸɤɨɜ, ɂ.ȼ. ɉɨɫɩɟɥɨɜ // ɍɪɨɥɨɝɢɹ. – 2006. – ʋ1. – ɋ. 61–64.

9. ɋɦɢɪɧɨɜ Ⱥ.Ȼ. ɋɪɚɜɧɢɬɟɥɶɧɚɹ ɨɰɟɧɤɚ ɦɟɬɨɞɨɜ

ɯɢɪɭɪɝɢɱɟɫɤɨɣ ɤɨɪɪɟɤɰɢɢ ɪɟɤɬɨɰɟɥɟ / Ⱥ.Ȼ.ɋɦɢɪɧɨɜ,

ȼ.ȼ.ɏɜɨɪɨɜ // ɏɢɪɭɪɝɢɹ. – 2006. – ʋ 10. – ɋ. 22–26. 10. ɋɨɜɪɟɦɟɧɧɵɣ ɩɨɞɯɨɞ ɤ ɤɨɪɪɟɤɰɢɢ ɪɟɤɬɨɰɟɥɟ ɭ

ɝɢɧɟɤɨɥɨɝɢɱɟɫɤɢɯ ɛɨɥɶɧɵɯ ɫ ɩɪɨɥɚɩɫɨɦ ɝɟɧɢɬɚɥɢɣ /

Ⱥ.Ⱥ.ɉɨɩɨɜ [ɢ ɞɪ.] / Ɋɨɫ.ɜɟɫɬɧɢɤ ɚɤɭɲɟɪɚ–ɝɢɧɟɤɨɥɨɝɚ. – 2006. – Ɍ.6, ʋ 2. – ɋ. 38–40.

11. ɋɭɯɢɯ Ƚ.Ɍ. ɉɨɢɫɤ ɷɬɢɨɥɨɝɢɱɟɫɤɢɯ ɮɚɤɬɨɪɨɜ

ɩɪɨɥɚɩɫɚ ɝɟɧɢɬɚɥɢɣ / Ƚ.Ɍ.ɋɭɯɢɯ, Ⱥ.ɘ. Ⱦɚɧɢɥɨɜ,

Ⱦ.Ⱥ.Ȼɨɬɚɲɟɜɚ // Ɋɨɫ. ɜɟɫɬɧɢɤ ɚɤɭɲɟɪɚ–ɝɢɧɟɤɨɥɨɝɚ. – 2010. – Ɍ. 10, ʋ 5. – ɋ. 28–32.

12. Ɏɭɧɤɰɢɨɧɚɥɶɧɵɟ ɧɚɪɭɲɟɧɢɹ ɩɪɢ ɜɵɪɚɠɟɧɧɵɯ

ɩɪɨɹɜɥɟɧɢɹɯ ɩɪɨɥɚɩɫɚ ɝɟɧɢɬɚɥɢɣ / ȼ.ȼ. Ȼɚɯɚɟɜ,

ȼ.ɗ.Ƚɨɪɢɧ,ȼ.ɗ.Ƚɸɧɬɟɪ [ɢ ɞɪ.] // ɀɭɪɧɚɥ ɚɤɭɲɟɪɫɬɜɚ

ɢ ɠɟɧɫɤɢɯ ɛɨɥɟɡɧɟɣ. – 2009. – Ɍ. 58, ʋ 5. – ɋ.Ɇ17–

Ɇ18.

13. De Lancey J.O. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved pre-vention and treatment / J.O. De Lancey // Am. J. Obstet. Gynecol. – 2005. – Vol. 192. – P. 1488–1495.

14. Diez–Itza I. Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: a review at 5 years after surgery / I. Diez–Itza, I. Aizpitarte, A. Becerro // Int. Urogynecol. J. Pelvic Floor Dysfunct. – 2007. – Vol. 18, N 11. – P. 1317–1324.

15. Fialkow M.F. Incidence of recurrent pelvic organ prolapse 10 years following primary surgical manage-ment: a retrospective cohort study / M.F. Fialkow,

tomy: A population–based cohort study / R.E. Blandon, A.E. Bharucha, L.J. Melton [et al.] // Am. J. Obstet. Gy-necol. – 2007. – Vol. 197, N 6. – P. 664.

17. Jeon M.J. Risk factors for the recurrence of pelvic organ prolapse / M.J. Jeon, S.M. Chung, H.J. Jung // Gy-necol. Obstet. Invest. – 2008. – Vol. 6, N 66 (4). – P. 268–273.

18. Long–term results of the anterior Delorme's ope-ration in the management of symptomatic rectocele / S. M. Abbas [et al.] // Dis. Colon Rectum. – 2005. – Vol. 48. – P 317–322.

19. Medina C.A. Wide genital hiatus is a risk factor for recurrence following anterior vaginal repair / C.A. Medina, K. Candiotti, P. Takacs // Int. J. Gynaecol. Obstet. – 2008. – Vol. 101, N2. – P. 184–187.

20. Primary surgery of genital prolapse: a shift in treatment tradition / K. Crafoord, A. Sydsjo, K. Nilsson, P. Kjolhede // Acta. Obstet. Gynecol. Scand. – 2006. – Vol. 85, N9. – P. 1104–1108.

21. Risk factors for prolapse recurrence after vaginal repair / J.L. Whiteside, A.M. Weber, L.A. Meyn [et al.] // Am. J. Obstet. Gynecol. – 2004. – Vol. 191. – P. 1533– 1538.

22. Shan-Rong Shi. Standardization of Immunohisto-chemistry for Formalin-fixed, Paraffin-embedded Tissue Sections Based on the Antigen-retrieval Technique: From Experiments to Hypothesis / Shan-Rong Shi, Cheng Liu, Clive R. Taylor // J. Histochemistry Cytochemistry. – 2007. – Vol. 55, N2. – Ɋ. 105–109.

23. The relationship of vaginal prolapse severity to symptoms and quality of life /G.A. Digesu [et al.] // BJOG. – 2005. – Vol. 112. – P. 971–976.

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incon-tinence]. Russian announcer of acc.-gyn. 2005;5:19–23. Russian.

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ɄɅȱɇȱɑɇȺ ɆȿȾɂɐɂɇȺ

prevention and treatment. Am J. Obstet Gynecol. 2005;192:1488–95.

14. Diez–Itza I, Aizpitarte I, Becerro A. Risk factors for the recurrence of pelvic organ prolapse after vaginal surgery: a review at 5 years after surgery. Int Urogynecol J Pelvic Floor Dysfunct. 2007;18(11):1317–24.

15. Fialkow MF, Newton KM, Weiss NS. Incidence of recurrent pelvic organ prolapse 10 years following primary surgical management: a retrospective cohort study. Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(11):1483–87.

16. Blandon RE, Bharucha AE, Melton LJ. Incidence of pelvic floor repair after hysterectomy: A population–based cohort study. Am J Obstet Gynecol. 2007;197(6):664.

17. Jeon MJ, Chung SM, Jung HJ. Risk factors for the recurrence of pelvic organ prolapse.Gynecol Obstet Invest. 2008;6(4):268–73.

18. Abbas SM. Long–term results of the anterior Delorme's operation in the management of symptomatic rectocele. Dis Colon Rectum. 2005;48:317–22.

19. Medina CA, Candiotti K, Takacs P. Wide genital hiatus is a risk factor for recurrence following anterior va-ginal repair. Int J Gynaecol Obstet. 2008;101(2):184–187. 20. Crafoord K, Sydsjo A, Nilsson K, Kjolhede P. Primary surgery of genital prolapse: a shift in treatment tradition. Acta Obstet Gynecol Scand. 2006;85(9):1104– 08.

21. Whiteside JL, Weber AM, Meyn LA. Risk factors for prolapse recurrence after vaginal repair. Am J Obstet Gynecol. 2004;191:1533–38.

22. Shan-Rong Shi, Cheng Liu, Clive R. Taylor Standardization of Immunohistochemistry for Formalin-fixed, Paraffin-embedded Tissue Sections Based on the Antigen-retrieval Technique: From Experiments to Hy-pothesis. Journal of Histochemistry & Cytochemistry. 2007;55(2):105–9.

23. Digesu GA. The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG. 2005;112:971–76.

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Ʉɍ «Ⱦɧɟɩɪɨɞɡɟɪɠɢɧɫɤɚɹ ɝɨɪɨɞɫɤɚɹ ɛɨɥɶɧɢɰɚ ʋ 9» ȾɈɋ

ɩɪ.Ⱥɧɨɲɤɢɧɚ, 72, Ⱦɧɟɩɪɨɞɡɟɪɠɢɧɫɤ,Ⱦɧɟɩɪɨɩɟɬɪɨɜɫɤɚɹ ɨɛɥ.,51900, ɍɤɪɚɢɧɚ Municipal Institution “Dniprodzerzhynsk City Hospital ʋ 9”

of Dnipropetrovsk Regional Council

Anoshkina av., 72, Dniprodzerzhynsk, Dnipropetrovsk region, 51900, Ukraine e-mail: aleksei2009@i.ua

Ʉɥɸɱɟɜɵɟ ɫɥɨɜɚ:ɤɟɫɚɪɟɜɨ ɫɟɱɟɧɢɟ,ɤɨɝɧɢɬɢɜɧɵɟ ɮɭɧɤɰɢɢ,ɚɧɟɫɬɟɡɢɹ

Key words: caesarian section, cognitive functions, anesthesia

Ɋɟɮɟɪɚɬ. ȼɩɥɢɜ ɦɟɬɨɞɭ ɚɧɟɫɬɟɡɿʀ ɩɪɢ ɨɩɟɪɚɰɿʀ ɤɟɫɚɪɿɜ ɪɨɡɬɢɧ ɧɚ ɩɚɦ'ɹɬɶ, ɫɩɪɢɣɧɹɬɬɹ ɬɚ ɦɨɜɥɟɧɧɹ.

ȼɨɥɤɨɜ Ɉ.Ɉ.ȼ ɚɤɭɲɟɪɫɬɜɿ ɩɿɫɥɹɨɩɟɪɚɰɿɣɧɚ ɤɨɝɧɿɬɢɜɧɚ ɞɢɫɮɭɧɤɰɿɹ ɦɨɠɟ ɦɚɬɢ ɦɿɫɰɟ ɩɿɫɥɹ ɤɟɫɚɪɟɜɚ ɪɨɡɬɢɧɭ ɿ

ɜɚɝɿɧɚɥɶɧɢɯ ɩɨɥɨɝɿɜ,ɩɪɢɡɜɨɞɹɱɢ ɞɨ ɫɭɦɧɢɯ ɧɚɫɥɿɞɤɿɜ ɞɥɹ ɦɚɬɟɪɿ ɬɚ ɞɢɬɢɧɢ.Ɇɟɬɨɸ ɞɨɫɥɿɞɠɟɧɧɹ ɛɭɥɨ ɜɢɜɱɢɬɢ

ɜɩɥɢɜ ɦɟɬɨɞɭ ɚɧɟɫɬɟɡɿʀ ɩɪɢ ɨɩɟɪɚɰɿʀ ɤɟɫɚɪɿɜ ɪɨɡɬɢɧ ɧɚ ɩɚɦ'ɹɬɶ,ɫɩɪɢɣɧɹɬɬɹ ɣ ɦɨɜɥɟɧɧɹ ɜ ɩɿɫɥɹɨɩɟɪɚɰɿɣɧɨɦɭ

ɩɟɪɿɨɞɿ. Ɂɚɥɟɠɧɨ ɜɿɞ ɦɟɬɨɞɭ ɚɧɟɫɬɟɡɿʀ ɠɿɧɤɢ ɛɭɥɢ ɪɨɡɩɨɞɿɥɟɧɿ ɧɚ 2 ɝɪɭɩɢ: 1 ɝɪɭɩɚ (n=31) – ɫɩɢɧɧɨɦɨɡɤɨɜɚ

ɚɧɟɫɬɟɡɿɹ, 2 ɝɪɭɩɚ (n=34) – ɬɨɬɚɥɶɧɚ ɜɧɭɬɪɿɲɧɶɨɜɟɧɧɚ ɚɧɟɫɬɟɡɿɹ. ɋɩɿɧɚɥɶɧɚ ɚɧɟɫɬɟɡɿɹ 1,8-2,2 ɦɥ ɝɿɩɟɪ

-ɛɚɪɢɱɧɨɝɨ 0,5%% ɛɭɩɿɜɚɤɚʀɧɭ.ɉɪɢ ɌȼȺ ɡ ɂȼɅ ɬɿɨɩɟɧɬɚɥ ɧɚɬɪɿɸ (4 ɦɝ/ɤɝ), ɫɭɤɰɢɧɿɥɯɨɥɿɧ (1-1,5 ɦɝ/ɤɝ). ɉɿɫɥɹ

ɜɢɬɹɝɚɧɧɹ ɩɥɨɞɭ ɮɟɧɬɚɧɿɥ (10-5-3 ɦɤɝ/ɤɝ/ɝɨɞ.) ɿ ɞɿɚɡɟɩɚɦ (10 ɦɝ). Ⱦɥɹ ɨɰɿɧɤɢ ɩɚɦ'ɹɬɿ ɜɢɤɨɪɢɫɬɚɧɢɣ ɬɟɫɬ Ʌɭɪɿɹ,

ɝɧɨɡɢɫ ɨɰɿɧɸɜɚɥɢ ɡɚ ɞɨɩɨɦɨɝɨɸ ɬɟɫɬɭ ɭɩɿɡɧɚɜɚɧɧɹ ɱɚɫɭ. Ɇɨɜɭ ɨɰɿɧɸɜɚɥɢ ɡɚ ɞɨɩɨɦɨɝɨɸ ɬɟɫɬɭ "ɧɚɡɢɜɚɧɧɹ

ɩɚɥɶɰɿɜ". Ɍɨɱɤɢ ɤɨɧɬɪɨɥɸ: 1 - ɞɨ ɨɩɟɪɚɰɿʀ, 2 - ɱɟɪɟɡ 1 ɞɨɛɭ ɩɿɫɥɹ ɨɩɟɪɚɰɿʀ ɤɟɫɚɪɿɜ ɪɨɡɬɢɧ, 3 - ɧɚ 3 ɞɨɛɭ ɩɿɫɥɹ ɨɩɟ

-ɪɚɰɿʀ ɤɟɫɚɪɿɜ ɪɨɡɬɢɧ, 4 - ɩɪɢ ɜɢɩɢɫɰɿ (5-7 ɞɨɛɚ ɩɿɫɥɹ ɨɩɟɪɚɰɿʀ). ȼɫɬɚɧɨɜɥɟɧɨ, ɳɨ ɩɿɫɥɹ ɨɩɟɪɚɬɢɜɧɨɝɨ ɪɨɡ

-ɪɨɞɠɟɧɧɹ ɫɩɨɱɚɬɤɭ ɡɧɢɠɟɧɢɣ ɪɿɜɟɧɶ ɩɚɦ'ɹɬɿ ɭ ɜɚɝɿɬɧɨʀ ɠɿɧɤɢ ɪɟɝɪɟɫɭɽ ɡ ɱɚɫɨɦ ɡɛɿɥɶɲɟɧɧɹ ɬɟɪɦɿɧɭ ɩɿɫɥɹ

-ɨɩɟɪɚɰɿɣɧɨɝɨ ɩɟɪɿɨɞɭ. ɉɚɦ'ɹɬɶ ɜɿɞɧɨɜɥɸɽɬɶɫɹ ɞɨ 3 ɞɨɛɢ ɩɿɫɥɹɨɩɟɪɚɰɿɣɧɨɝɨ ɩɟɪɿɨɞɭ ɧɟɡɚɥɟɠɧɨ ɜɿɞ ɦɟɬɨɞɭ

ɚɧɟɫɬɟɡɿʀ.ɉɪɢ ɫɩɿɧɚɥɶɧɿɣ ɚɧɟɫɬɟɡɿʀ ɧɚ 5-7 ɞɨɛɭ ɩɿɫɥɹɨɩɟɪɚɰɿɣɧɨɝɨ ɩɟɪɿɨɞɭ ɩɨɤɚɡɧɢɤɢ ɩɚɦ'ɹɬɿ ɩɟɪɟɜɢɳɭɸɬɶ ɬɚɤɿ

ɩɪɢ ɬɨɬɚɥɶɧɿɣ ɜɧɭɬɪɿɲɧɶɨɜɟɧɧɿɣ ɚɧɟɫɬɟɡɿʀ. Ɋɿɜɟɧɶ ɫɩɪɢɣɧɹɬɬɹ ɬɚ ɦɨɜɥɟɧɧɹ ɭ ɩɨɪɨɞɿɥɶ ɞɨɫɬɨɜɿɪɧɨ ɧɟ