DANH GIA KET QUA DIEU TRj BJClC DAU UNG THlJ CO TLf CUNG TAI BENH VIEN K TL/1/2007 DEN 8/2008
Ngo Thj T'inW, Ngo Thu Thoa^ Nguyin Van Hie'u^
'Benh vien da khoa Trung uang Thii Nguyen; -Benh vien K
Muc tieu: nghien cdu kit qui dieu trj bUde diu ung thu ed td cung tai benh viSn K td 1/2007 de'n 8/2008. Boi tugng va phuang phap nghien cdu: gom 81 benh nhin cd md benh hge xic chan li ung thU cd td cung xim nhip. Giai doan lam sing theo Heu chuan ciia FIGO trong dd: glal doan IB: 18 chie'm 24%, giai doan lla: 23 chiem 28,4 %, giai doan lib; 36 chiim 44,4%o giai doan IIIA: 4 chiem 4,9%o. Phuang phap dieu trj: xa trj tien phau - phiu thuat cho 20 benh nhin chiim 24,7 %; xa trj - hoi trj ddng thdi 29 benh nhan chiem 35,8%o; phiu thuit dan thuan 7 chiem 8,6%o, xa trj dan thuin 25 chiim 30,9%o. Kit qua: Dip ifng hoin toan 23 benh nhan chie'm 79,3%o trong xa trj hoi trj dong thdi; xa trj tien phiu 18 benh nhin 90%;
trong xa trj dan thuin 10 benh nhin 40%; Dap dng mdt phin 5 henh nhan chiem 17,2%o trong xa trj hoi trj dong thdi; xa trj Hen phiu 2 benh nhin 10%o; trong xa trj dan thuan 12 benh nhin 48%o. Benh Hin tnen gap 2 benh nhan 8% trong nhdtn xa trj ddn thuin. Mdt sd tic dung khdng mong mudn vi bien ehdng trong qui trinh dieu trj khdng cd su khic biet cd y nghTa ve Hnh trang tieu chay va tiet nieu giifa cic nhdm dieu trj, nhifng sU thay ddi ve huye't hgc, Hnh trang ndn, chin an tang ISn cd y nghTa trong nhdm xa trj hoi trj ddng thdi. Kit luan: Kei qui dieu trj thu cd td cung glal doan tiin triin tai chd tai viing dugc eai thien rd ret nhd phuang phip dieu trj da md thdc thdng qua viec dinh gii ty IS dip dng ciia khd'i u, su kiem soil tai vung va dl can eiia te bio ung thtf.
TCr khoa: ung thu co tuf cung
I. DAT VAN DE
Ung thfl cd tfl cung xam nhap cd dac diem quan trpng la xam l i n tai vung va di can hach tieu khung, la yeu td co ban de x l c dinh giai doan benh, xay dflng phac dd dieu tri. Viec danh gia giai doan benh dtfa tren tham kham lam sang va ap dung mpt sd phifong p h i p chan d o l n hinh I n h la het sflc can thiet, cd anh htfdng Idn den ket q u i dieu tri va tien lifpng benh. Quyet dinh phflong phap d i i u tri ung thfl CTC php thupc ldn vao giai doan benh tuy nhien de d i n h gia giai doan benh mpt c l e h chfnh x l e can dtfa vao n h i i u each tham k h l m , trtfdc day viec d i n h g i l chi dfla vao tham kham lam sang don thuan, hien nay tren the gidi ap dung n h i i u ky thuat hien dai ngoai tham kham khac nhfl chup MRI, CT, ddng vi phdng xa ... Cung vdi tie'n bp cua c l e phflpng p h i p c h i n doan benh, phifpng p h i p d i i u trj
khdng ngflng c l i tien vdi muc dich dieu tri triet de nham keo dai thdi gian sdng, nang cao c h i t Itfdng cupc sd'ng cho ngtfdi benh. Vdi mong mud'n cap nhat kien thflc mdi, I p dpng khoa hpc ky thuat tien tien tren the gidi, khdng ngflng c l i thien ket q u i dieu tri chung tdi nghien ct'fu d i tai nham muc tieu:
Banb gia kit qua diiu tri budc diu ung tbU cd td cung tai benh vien K td 01/2007 din 8/2008.
II. DOI TU'ONG VA PHUONG PHAP NGHIEN CL/U
1. Ddi tUdng nghien cu'u
81 benh nhan UTCTC cd chan doan md benh hpc va giai doan benh >IB dieu tri phau thuat, xa tri - h o i tri va xa tri ddn t h u i n tai Benh vien K tfl 01/2007 - 8/2008 Trong dd sd benh nhan dflpc
p h i u thuat la 7; xa tri - phau thuat 20; xa tri - h o i tri 29, xa tri don thuan 25.
Tieu chuan chpn benh nhan vao nghien cflu - Benh nhan dtfpc c h i n d o l n la UTCTC giai doan >IB dtfpc chup cpng htfdng tfl (MRI) tieu khung trtfoc khi dieu trj.
2. Phuong phap nghien cu'u
Nghien ct'fu md t l tien ct'fu.
Nghien ct'fu dac diem lam sang.
* Thu thap thdng t i n :
- Thu thap thdng tin theo m l u benh an nghien ci'iU.
- D i n h g i l giai doan UTCTC theo he thd'ng phan loai UICC (Hiep hpi Chd'ng ung thfl qud'c te) va FIGO (Hiep hpi S i n phu khoa the gidi - 1 997).
Nghien ct'fu phifong phap d i i u trj: benh nhan UTCTC giai doan >IB dtfpc d i i u tri:
Xa tri don thuan: vdi mtic dich dieu tri triet can:
Xa trj tfl ngoai.
Nang Itfpng chum tia: Cobalt hoac Gia td'c 4 - 1 5MV, Co'"".
- The tich d i i u tri: the tfch bia lam s i n g (CTV):
the tfch khd'i u, tfl cung, ntfa tren cua am dao (td'i thieu), d l y chang rpng va td cht'fc canh CTC, hach chau.
- Lap ke hoach d i i u tri: the tfch bia l l m sang + ranh gidi 1 - 1,5cm.
- Hai trtfdng chieu trfldc - sau: hoac 4 trfldng chieu hinh hop (Box - Technique).
- C I c gidi han cua trifdng chieu tieu khung:
Tren: L4/L5 hoae L5/S1; Ben: 1,5 - 2 cm cac thanh ben khung chau chinh thtfc.
Ky thuat 4 tnfdng chieu, c l e trifdng chieu ben:
Trtfdc: XtfOng mu.
Sau: S2/S3, hoac 1 - 1 , 5 cm cac khd'i u nhin thay.
Md phdng: m i y md phdng hoac CT md phdng.
L i i u xa va phan l i i u :
Phan l i i u : 1 , 8 - 2 Gy/ngay, 5 ngay/tuln.
L i i u xa: tdng lieu 50 Cy, 30 - 36 Gy loan bp tieu khung, tiep theo 14 - 20 Gy cd che chi vung giiTa (3 - 4 cm). ,' '' i
Nang lieu 10 Gy cho c i c benh nhan cd tdn thtfong Idn d d l y chang rpng va td cht'fc canh CTC hoac hach chau.
- Xa trj ap s i t . - : . , , , ,• : , Ket hpp dng than tfl cung va bp I p lui bit theo kieu Fletcher, tfnh l i i u xa theo he thdng Manchester.
L i i u xa: LDR: 30 - 40 Gy/1 - 2 lan.
Thdi gian xa tri tfl 6 - 7 tuan, khdng vtfdt qua 60 ngay.
Xa tri ap sat l i i u cao: gan day phtfdng phap xa trj I p sat lieu cao (HDR) da dtfpc ap dpng dieu trj.
Xa trj t i i n phau - Phau thuat.
Xa trj ngoai, xa trj ap s i t : trtfdng chieu va l i i u xa dflpc I p dung nhfl xa trj don thuan
Du l i i u xa trj benh nhan dtfpc d i n h gia lai Bilan ddi vdi benh nhan du d i i u kien p h i u thuat se tien hanh phau thuat Wertheim.
Xa trj - hda trj ddng thdi
Xa trj n g o l i , xa trj ap sat: trifdng chie'u va lieu xa dtfpc I p dpng nhfl xa trj don thuan,
Hda c h i t Cisplatin dtfpc truyen hang tuan tfl tuan 1 - 5 ctia xa n g o l i , lieu 40 mglm' da/hang tuan.
Cisplatin truyen tlnh mach trong thdi gian 1,5 gid.
Benh nhan dtfdc t r u y i n tnfdc hdn 1.500ml dung djch ntfdc mudi dang trflong. Sfl dung thud'c chd'ng ndn (Osetron) va Dexamethasone, thtidc kfch thfch tang bach cau hat trong q u i trinh dieu trj khi bach cau ha.Xa ngoai dtfpc tien hanh sau t r u y i n Cisplatin tfl 2 - 2,5 gid, Cisplatin khdng t r u y i n trong ngay xa trj ap s i t .
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Cich d i n h gia va tieu chuan d i n h g i l ket qua nghien cflu.
- Phan tich va xfl ly sd lieu theo chtfong trinh SPSS.
III. KET QUA dieu trj.
Danh gia ket qua dieu tri sdm theo phifpng p h i p d i i u trj:
Danh gia d i p flng sdm theo tieu chuan d i n h K ^ ?• Cn^i doan 1^ sang^
gia cua W H O , theo 4 mtfc dp: dap flng h o l n loan; Dap flng mpt phan; Benh gifl nguyen;
Benh lien Iridn.
Danh g i l cac mt'fc dp dpc linh c i p va bien chflng sdm lrong va ngay sau ket thuc dieu tri theo 4 mflc dd cua W H O .
Giai doan benh Ib lla IIB
n 18 23 36
(%) (22,2)
(28,4) (44,4) IIIA
Thu thap va xfl ly so'lieu: , Giai doan lam s i n g II chie'm Xy le chu yeu - Thu thap sd lieu dfla vao m l u benh I n trong dd giai doan IIB cao hdn vdi ty le 44,4%.
Bang 2. Phuang phap diiu tri
Phuong phap
Phiu tri DT Xa tri don thuan Xa trj - Phau trj Xa tri - h o i tri Tdng
Tdng l i i u tai diem A(Gy) Lieu trung binh
Thdi gian dieu trj
Trung binh H o i tri
n
7 25 20 29 81 Diem A
72,11
70 Sd dpt
5
Ty le 8,6 30,9
24,7 " ' • "
35,8 100 Diem B
51,5
70 Lieu 5mg/tuan
Tdng
7 25 20 29 81(100)
Tdng 29
Nhan xet bang 2: phtfang phap dieu trj da md thifc dugc ip dung cho nhdng benh nhan chii yeu giai doan II. Ddi vdi benh nhin giai doan sdm I phiu thuat thifdng dtfgc lUa chgn han. Xa trj dan thuin thifdng dtfgc chl djnh cho nhdng benh nhan giai doan lam sang cd the mugn ban
Nhan xet bang 3: Dip dng hoan toan ngay khi kit thtic dieu trj dUOc danh gii eao trong nhdm benh nhan dtfgc hoa - xa dong thdi, ddi vdi glal doan benh ty le dip dng hoan toan cao ddi vdi giai doan sdm. Dap dng mgt phan chie'm ly le cao ddi vdi khdi u cd kich thifdc Idn ban.
Nhan xet bang 4: Trieu cht'fng tieu chay, viem trtfc tring thifdng xiy ra hiu bet ddi vdi benh nhin
Ke't qua DT D U t h e o PPDT
Xa trj DT Xa trj - phau tri Xa trj - hoa trj DUtheo GDB
Ib lla lib IIIA DU theo KTU
< 2cin 2 - < 4 cm
> 4cin
Bang 3. Kit
D U H T
10(40) 18(90) 23 (79,3)
18(100) 18(78,3%)
15(41,7) 2(40)
9(100) 14(51) 15(33,3)
qu'ix diiu tri DL/MP
12(48,0) 2(10) 5(17,2)
0 4 (17,4)
16(44,4) 1(25)
0 9(33,3)
23(51)
KDL/
1(4) 0(0) 0 ( 0 )
0 1 (4,3) 4(17,4)
0
0 4(14,8)
4(8,9)
B T T
2(8) 0(0) 1 (3,4)
0 0(0) 0(0) 1(25)
0 0(0) 3(6,7)
Bang 4. Bgc tinb tren mgt sd ca quan
Co quan Tieu hoa
Xa trj DT Xa trj - phau trj Xa tri - h o i trj
Do 1
17(21) 18(22) 23 (28)
Do II
12(1,5) 2(0,2)
5(0,6)
Do III
1(0,1) 0 0 ( 0 )
Do IV
2(0,2) 0 1 (0,2) Huyet hpc
Xa trj DT Xa trj - phau trj Xa trj - h o i trj Khac
Xa trj DT Xa trj - phau trj Xa trj - hoa trj
12(1,4) 7(0,8) 20 (25)
15(1,9) 18(22) 23(28)
10(1,2) 2(0,2)
5(0,6)
2(0,3) 5(0,6) 5(0,6)
1(0,1) 0 3 (0,4)
0(0) 0(0) 2 (0,2)
0(0) 0 1 (0,1)
0(0) 0(0) 0(0) I V B A N L U A N mudn d ntfdc ta van cdn cao. Trong nghien ct'fu
eua chung tdi giai doan lam sang II chiem ty le 1. Giai doan lam sang
cao hdn c l trong dd giai doan IIA la 23( 28,4%), Mac du hien.nay da cd n h i i u bien phap sang gigi doan IIB la 36 (44,4%). Kdt q u i nay cung Ipc phat hien sdm ung thfl cd tfl cung dtfoc ap ttfong tfl vdi mdt sd t i c gia lrong ntfdc (1, 2]. Tuy dung tuy nhien ty le ung thfl cd tfl cung giai doan nhien n h i i u nghien ct'fu tren the gidi cho t h i y sd
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benh n h i n ung thfl cd tfl cung giai doan sdm dtfdc chan d o l n vdi \y le eao hdn 15, 6, 7). C l e t i c g i l cung khang djnh rang can d i n h g i l giai doan benh chfnh xac trtfdc khi d i i u trj. Gitfa mdi giai doan, dp Idn cua khdi u dd la yeu td quan trpng cho tien Itfpng benh. Kich thfldc ctia khdi u nhd cd tien Itfong tdt hdn ddi vdi khdi ti Idn. D i n h g i l dp sau cua sfl xam nhap khdi u cung khdng kem p h l n quan trpng
2. PhUdng phap dieu trj
N g l y nay vdi sfl p h l t trien khdng ngflng cua khoa hpc ky thuat tren the gidi nhieu phflpng thifc d i i u trj da md thflc da dfldc I p dpng dieu trj cho ung thtf cd tfl cung da mang lai ket q u i k h i quan cho ngtfdi benh nhan. Trong nghien ct'fu cua chung toi cd 25 (30,9%) dtfdc xa tri don t h u i n , 29 "
(35,8%) xa tri - hoa trj ddng thdi va 20 (24,7%) xa trj tien phau. Viec Ifla chpn phtfdng p h i p d i i u trj phu thupc giai doan lam sang. Dd'i vdi n h i i u nghien ctiu tren the gidi cho t h i y phtfong p h i p dieu tri phdi hpp vdi xu the la bao tdn cung cho ket q u i diet! trj k h i quan.
3. Ke't qua dieu trj
Dd'i vdi ung thfl cd tfl cung ket q u i d i i u trj dtfoc danh g i l bang stf kiem solt khdi u tai chd, tai vung va d i n h g i l thdi gian sdng them cua benh n h i n . Tuy nhien trong nghien ct'fu cua chung tdi vdi ket q u i btfdc dau cua dieu trj chl danh g i l ket qua sdm sau khi ket thuc d i i u trj.
D i p flng h o l n toan theo phflpng p h i p d i i u tri: xa trj don thuan 10 (40%); xa tri - p h i u trj 18 (90);
Xa tri - h o i trj 23 (79,3%) D i p flng h o l n toan theo giai doan benh Ib 10(100); lla (78,3%); lib 15(41,7% ); III 2(40%). D i p t'fng theo kich thtfdc cua khd'i u cd sfl k h l c biet rd ret gifla kfch thtfdc cua khdi u < 2cm va > 6cm. ket q u i nay cung phu hpp vdi ke't qua cua mpt sd tac g i l tren the gidi.15, 6, 7, 8].
T i c dung phu va bien chflng trong dieu trj:
tieu c h l y la trieu chflng hay gap n h i t trong nhdm
benh nhan difpc xa tri, dpc tfnh tren eo quan huyet hpc va t h i n kinh gap n h i i u hdn trong nhdm benh nhan dfldc h o i - xa ddng thdi. Trong n h i i u nghien cflu v i xa tri ket hdp vdi h o i trj c i c t i e g i l d i u ghi nhan rang mflc dp dpc tfnh tren huyet hpc cao hon n h i i u so vdi xa trj ddn thuan, va xa Iri t i i n phau 15, 6, 7, 8].
Doe tfnh tren c l e co quan than, gan, va cac cd quan k h l c ft va cd the kiem solt dflpc
V. KET LUAN
Qua nghien cflu 81 benh n h i n ung thfl cd tfl cung giai doan >lb dflpc dieu trj tai benh vien K chflng tdi rut ra ket luan sau:
Giai doan l l m s i n g : chu yeu giai doan II trong dd IIB 36 (44,4%).
D i p flng hoan t o l n trong dieu trj chiem 7 1 % , d i p flng mpt p h l n 23,5%, khdng d i p flng 1,2%, benh tie'n trien 3,6%. Trong dd phtfong phap dieu trj xa trj phau thuat cho ket q u i cao n h i t .
Bien chflng viem trtfc trang thifdng x l y ra tren hau het benh nhan dtfdc xa trj. Dpc tinh tren huyet hpc, gan than... d i u kiem solt difpc.
TAI LIEUTHAM KHAO
1. Nguyin Ba DiJc, Bui Dieu, To Anh Dung, Tran Van Thuan va cong sU (2005), "Ket q u i btfdc dau I p dung dieu trj hda c h i t - tia xa ddng thdi ung thfl ed tfl cung giai doan IIB - IllB", Dae san Ung thfl hpc quy 11/ 2005, tr 1 38 - 1 43
2. Nguydn Thuy HUOng (2004), "Nghien cflu hinh thai hpc cua ung thfl bieu md CTC va sfl lien quan vdi mpt sd dac diem lam s i n g , tien lifpng b e n h " , Tdm t i t luan an tie'n si, Trifdng Dai hpc Y Ha Npi.
3. Hawighorst H, Schoenberg SO, Knapstein PG, et al: (1998) " Staging of invasive cervical carcinoma and of pelvic lymph nodes by high resolution MRI with a phased - array coil in comparison with pathological findings;' . J Comptit
Assist Tomogr 1 998 Jan - Feb; 22(1 ):pp 75 - 81 4. Hricak. H, Gatsonis. C, at, el (2005) 'Role of Imaging in Pretreatment Evaluation of Early Invasive Cervical Cancer: Results of the Intergroup Study American College of Radiology Imaging Network 6651 -Gynecologic Oncology Group 183"
Journal of Clinical Oncology, Vol 23, No 36 (December 20), 2005: pp. 9329 - 9337
5. Hricak. H, Mendelson. E, at, el (2000),
"Rose of imaging in cancer of the cervix.
American College of Radiology", Radiology vol 215. No 1, pp 9 2 5 - 9 3 0 .
6. Kim SH, Choi Bl, Han JK, et al: (1993)
"Preoperative staging of uterine cervical carcinoma: comparison of CT and MRI in 99
patients". J Comput Assist Tomogr 1993 Jul - Aug;
17(4): 633 - 6 4 0
7. Kim SH, Choi Bl, Lee HP, et al (1990)
"Uterine cervical carcinoma: comparison of CT and MR findings". Radiology 1 990 Apr; 1 75(1): 45 - 51
8. Peter. G. P,at, el (1999), "Position Emission Tomography for Evaluating Para - aortic Nodal Metastasis in locally Advanced cervical Before Surgical Staging: A Surgicopathologic Study", Journal of Clinical Oncology, vol 1 7, Issuel.
9. Sironi. S, Belloni. C, at, el (1991)
"Carcinoma of the cervix: value of MR imaging in detecting parametrial involvement"American Journal of Roentgenology, Vol 1 56, pp 753 - 756.
Summary -
EVALUATING RESULT OF THE FIRST STAGE TREATMENT IN WOMEN WITH LOCALLY ADVANCED CERVICAL CANCER IN K HOSPITAL FROM 1/2007 TO 8/2008
Patients with primary untreated invasive squamous - cell carcinoma, adenosquamous carcinoma, or adenocarcinoma of the cervix of stage >lb with adequate hematological, renal and hepatic functions, Karnofsky performance status of > 8 0 % , and no prio chemotherapy, radiotherapy or pelvic surgery, were eligible. 81 patients with stage IB cervical carcinoma were into: 18 patients with IB; 23 patients with lla;
36 patients with lib Stage; 4 patients with 111 stage. Results: tumour responses, pelvic control were different at the end of the treament: Complee resppnse 79.3 percent of concurrent chemotherapy and radiotherapy;
90 percent of radiation - operation; 40 percent of radiation alone. Partial response: 17.2 percent of concurrent chemotherapy and radiotherapy; 10 percent of of radiation - operation and 48 percent of radiation alone. Stable disease 4 percent of radiation alone. Progression 3.4 percent of concurrent chemotherapy and radiotherapy and 8 percent of radiation alone. While there was no significant difference in diarrhoea and urinary complication scores, hematological, emesis and appetite changes were significantly greater in concurrent chemotherapy and radiotherapy group. Conclusions: Result treatment in women with locally advanced cervical cancer with combination of multi therapy improve the rate of tumor responses and pelvic control among women with locally advanced cervical cancer.
Keywords: cervical cancer
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