NGHIEN CUU KHOA HOC \ i ^ - ^ ^
UNG THU BI^U M O SUI TREN N^N L 6 DAO
6 27 TRUdNG H(?P TAI TRAI PHONG B^N SAN VA BgNH VIEN DA Lieu THANH P H 6 H 6 CHI MINH
Ha Van Phyflc*, Pham Van BSc*, Nguyfin Kim Khoa*
TOM TAT
Td'n thuang thdn kinh ngoai biin trong binh phong thudng ddn din tdn phi, ddc biit Id 16 ddo, neu khdng xd II tot si ddn din biin ehUng nguy hiim han, dd Id Carcimome verruqueux (mdt dang Idm sdng eua Carcinome tibdo gai).
Vat lieu va phWcfng phdp nghiin eWu: Nghiin cdu hoi cdu 27 trUdng hpp ed bUdu sdi d bdn chdn dugc sinh thiit d trai Phong Bin Sdn tU 1989-2005.
Ket quA: trong 27 trUdng hpp, da so Id phong thiBT, BB vd BL, 1 trUdng hgp dLL, khdng cd trUdng hpp ndo d thi TT. Cd 3 trUdng hgp di cdn hach: 2 thiBL vd 1 thiLL; 17 trUdng hgpd vi trf 1/3 sau gan bdn chdn;
10 trUdng hgp dvi trf 1/3 trUdegan bdn ehdn; tile nam, ndid 19:8 (nam gdp ddi nd).
Tfl khda: Carcimome verruqueux. Id ddo, bUdu siji, than kinh ngoai bien.
I.DATVAND^
Benh phong la mdt benh nhiim trung man tfnh dupe gay ra bdi Mycobacterium Leprae ma chu yeu dnh hudng len da va than kinh ngoai bien. Van de Idn nhat trong benh phong la lam tdn thuong thSn kinh ngoai bien d i n den tan phe va ede bien chflng khac lau dai ve sau.
Tdn thuong than kinh ngoai bien la ket qud eua su thay ddi ve tinh trang mien djch (phdn flng ddo nghich) eung nhU sU hien dien eua vi trung Hansen trong than kinh hay la ket qud eua sU XO hda than kinh ngoai bien do tinh trang viem nhiim keo dai. Va chfnh tinh trang viem than kinh ngoai bien man tfnh se dan den rdi loan ve edm gide va van ddng, dae biet la ehi dudi dUa den hlnh thanh 16 ddo. Neu khdng xfl If thfeh hpp thi tfl Id ddo se phat trien gay tdn thuong phan mem va xUOng vdi bien chflng thudng gap la viem xuong - tuy xUong.
*Benh vien Da Lieu TP. Ho chi Minh
Mdt bien chflng khde hiem gap nhung nguy hiem hon dd la Carcinome verruqueux hay edn gpi la Epithelioma Cunieulatum, la mdt dang lam sang dae biet cua Carcinome te bao gai vdi dp de tfnh thap.
Carcinome verruqueux da dUpc md td dau tien vao nam 1941 (6) va sau dd mpt vai nam, eung de cap den cdc tdn thuong de tfnh hien dien tren nen 16 ddo eua benh Hansen. Muc dfch eua de tai nayJaehung tdi mudn gidi thieu 27 trudng hpp Carcinome verruqueux tai Trai phong Ben San va Benh vien Da l i l u thanh phd Hd Chf Minh tfl nam 1989-2005.
Muc tieu nghien eflu:
Khdo sdt mot so tinh hlnh, ddc diim Idm sdng vd vi thi cua Carcinome verruqueux trin nin 16 ddo u sui d binh nhdn Phong.
2. DOI TUONG VA PHUONG P H A P N G H I £ N C U U
2.1. Ddi tuong
27 benh an eua benh nhan dieu trj tai Trai
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phong Ben San va Benh vien Da lilu Thanh phd Hd Chf Minh tfl 1989-2005.
Tieu chuan chpn:
Benh nhan phong ed u sui tren nen 16 ddo nghT nhieu den ac tfnh.
Odng y tham gia nghien eflu.
Tieu ehuan loai trfl:
Benh dn khdng du tieu ehuan.
2.2. Phuong phap nghien eflu 2.2.1. Thiet ke nghiin eWu
Nghien eflu hdi eflu, md td eat ngang.
2.2.2. PhWdng phdp chpn mdu
Tat ed cdc trUdng hpp dat tieu ehuan chpn mau,
3. K^T QUA N G H I £ N C U U
BAng 1. Phan bo theo tuoi va gidi (n=27)
2.2.3. PhWcfng phdp tien hanh
Tat cd ede benh nhan phong ed tieu ehuan chpn mau 6\Jgc ehung tdi tien hanh ede bUde sau:
- Lap phieu dang kf.
Thu thap ede chi sd yeu cau vao phieu dang kf: ten, tudi, gidi tfnh; ede dae diem lam sang...
27 trudng hpp cd bUdu sui d ban ehdn dupe sinh thiet va gfli den phdng giai phau benh tfl trai phong Ben San va phdng md eua benh vien. Sau dd dupe ed djnh bang formol 10%, khfl nude va vui nen, eat Idt mdng 5mm va dupe nhupm bang phuong phdp H.E (Hematoxylin va Eosin).
Tudi Nam Nfl Cdng
4 1 - 5 0 2 3 5(18,5%)
5 1 - 6 0 2 5 7 (25,9%)
6 1 - 7 0 10 10(37,1%)
7 1 - 8 0 5 5(18,5%)
Cdng 19(70,4%)
8 (29,6%) 27(100%) Nhan xet: tudi hay gap nhat la 61-70 ehiem 37,1%, nam Id chu yeu ehiem 70,4%.
BAng 2. Phan bo the binh theo tiiu ehuan eua Ridley - Jopling (n=27) The
Sd trUdng hpp Carcinome Sd trUdng hpp di can hach
TT 0 0
BT 8 0
BB 12 0
BL 6 2
LL 1 1 Nhan xet: Carcinome gap nhieu nhat la the BB (12/27 benh nhan), tiep den la the BT (8/27 benh nhan), BL (6/27 benh nhan), LL (1/27 benh nhan) va theTT khdng gap BN nao.
BAng 2. Vi tribwdu siii trin gan ban chan (n=27) Vi tri
1/3 sau 1/3 trudc Tdng
Phai 7 5 12(44,4%)
Trai 10
5 15(55,6%)
Tdng 17(63,0%) 10(37,0%) 27(100%) Nhan xet: vj trf hay gap la 1/3 sau ban ehdn ehiem 63%, trong dd ban ehdn trdi ehiem 55%.
BAng 3. Dp biit hoa mo hpe cda Carcinome tebao gai (n=27) Dp mo hoe
n
%
D o i 25 92,59
Doll 2 7,41
Do III 0 0
DdIV 0 0
Tdng 27 100
(Dd I: trin 75% tibdo gal biit hda; dd II: trin 50% te bdo gai biit hda; dd III: trin 25% tibdo gai biit hda; dd IV: dudi25% tibdo gai biit hda).
Nhan xet: dp biet hda gap chu yeu d dp I chiem 92,59%.
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4. BAN L U A N
Carcinome te bao gai dMc xem nhU la bien chflng xdy ra d eae vet loet kinh nien trong cdc benh nhu u hat ben, lupus lao, lupus dd kinh nien, viem xUong tuy xUong dd ra da, cac seo bdng lau nam va cdc vet loet dinh dUdng vl man tfnh, do do thudng xdy ra d ngUdi Idn tudi.
NgUdi nhd tudi nhat dUpc ghi nhan la 45 tudi va Idn tudi nhat la 73 tudi, khodng tudi ehiem nhieu nhat la 61-70 tudi.
Ndi ehung, dinh cao eua Carcinome te bao gai la 60 (8). Ti le thodi hda tfl bUdu sui lanh tfnh chuyen sang dc tfnh thi thUe te la mdt sd lUpng tuong ddi nhd va ft dupe neu len eae Y van.
CJ day, ehung tdi ghi nhan vdi ti le la 10,8%
(27 trUdng hpp Carcinome verruqueux dupe ghi nhan qua 250 mau sinh thiet).TT le nay eung gan phu hpp vdi sd lieu eua ede tde gid nhU d Brazin la 17% (9), dThdi Lan la l%-8% (6) tuy theo ede trai phong va theo mdt sd tdc gid khde thi ti le nay thay ddi tfl 1% -15% (9),
Nam thudng bi nhieu hOn gidi nfl vdi ti le la 19 nam so vdi 8 nfl (nam gap 2 lan nfl).
Sau day la mdt vai sd lieu lien quan ve gidi tfnh d ede nghien eflu khde:
BAng 4. Kit quA nghiin eWu eiia ede tde giA
Nepal Thai Lan
Brazin Nigeria
Nam 15 30 12 5
Nfl 2 8 4 0 Ti le nfl gap ft hon nam. Cd le la khi bi Id ddo, phu nfl cham sdc vet loet can than hon nam eung nhU khi lao ddng d ngoai, hp mang dep hay mang giay thudng xuyen hon nam; do dd ft bj tdn thuong viem siji man tinh d 16 ddo va han che dupe bien chflng ung thU hda.
Xet ve phan bd the loai theo tieu ehuan eua Ridley va Jopling thi ta thay, nhdm the BT (8 trudng hpp) va the BB (12 trUdng hpp) la bj Carcinome nhieu nhat trong khi dd nhdm the LL (1 trudng hpp) ehiem ft va ehung tdi ghi nhan khdng ed trUdng hpp nao d theTT.
Nhu vay, d nhdm the phong gidp bien (Bordeline) nhUthe BT- BB - BL ed ti le Carcinome eao hon nhdm TT va LL; ed le la do tdn thUOng than kinh nhieu va nang hon vl d the nay ed cdc phdn flng lam tdn thuong than kinh nang. Chang han nhu phdn flng ddo nghjch va tfl dd d i n den loet dinh dUdng nang hon so vdi ede the khac.
Carcinome verruqueux la loai Carcinome te bao gai cd tien lUpng tdt nhat so vdi ede loai khde vl da sd nd xam lan tai eho ede md lan can chang han nhU eo va xUOng, ft eho di can xa.
6 day, chung tdi ghi nhan 3 trUdng hpp di can hach: 1 d the LL va 2 d the BL va ed 2 trUdng hpp nay deu tfl vong.
So sanh vdi ede sd lieu d eae tde gid khde (6), (9), (7) ghi nhan, cd tat cd 5 trUdng hpp di can hach, trong dd: 3 trUdng hpp la the LL, 1 trUdng hpp la the BB va 1 la the BT. NhU vay, ehung tdi nhan thay da sd ede trUdng hpp di can nam trong the LL. Dieu nay eung ed the hieu 6ugc do dnh hudng eua m i l n djch trung gian te bao vl Hansen the BB, BL va LL thi m i l n djch trung gian te bao [CMI) khdng cdn nfla (phdn flng Mitsuda (-)] cho nen eo the khdng edn du sflc de khdng ehdng lai sU phdt trien te bao de tfnh.
Ve vj trf eua ede bUdu siJi, chung tdi ghi nhan ban chan phdi la 12 trUdng hpp va ban chan trdi la 15 trudng hpp. Vj trf 1 /3 sau (vung xUOng gdt) eua Idng ban chan thudng gap hon (17 trUdng hpp) so vdi 1/3 trude Idng ban ehdn (10 trUdng hpp) dieu nay trdi vdi su phan bd cdc Id ddo ban chan cua benh nhan phong.
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Dieu nay cung phu hpp vdi nghien eflu Pleury va Opromolla (9) cung nhU cua Reddy (7), ti le bj Carcinome verruqueux thudng gap d 1/3 sau lUng ban chan, 1/3 trUdc lUng ban chan thi ft bj hon.
Oieu nay dupe gidi thfeh do vung xUOng gdt (1/3 sau) tdn thuong viem khd hdi phuc vl sU phd hCiy xuong manh an lan den chd khdp gifla xUOng ehdy va xuong cd chan (the tibial - tarsal jont) lam eho khdp nay bj tdn thuong, tao thanh cdc Id dd trd ra da chung quanh khien eho Id ddo d vung xUOng gdt khdng the lanh dupe ma tien trien thanh viem man tfnh va tfl dd thoai hda dc tfnh.
NgUpe lai, mac du 1/3 trUde (forefoot) ed ti le bj 16 ddo eao hon nhUng ede xUOng ddt ban ehdn (metatarsal) va xUOng dot ngdn ehdn (phalanx) vdi kfch thude ngan hon nhung ed be mat rdng va dieu quan trpng la ede xUOng nay khi bj viem huy xuong ed the hdi phuc trd lai eung nhU khdng gay ra ede Id dd nhu d vj trf xUOng gdt eho nen 16 dao vung nay d l lanh hon, ft tien trien man tinh va do do ft bj thodi hda de tfnh hon.
Ve dac diem md hpc Carcinome verruqueux la mdt dang cua Carcinome te bao gai bat ngudn tfl Idp te bao keratinoeyte eua Idp thuang bl, thudng ed hlnh dnh biet hda rd va ed
tien lupng tdt nhat trong tat ed cdc Carcinome te bao gai bdi vl nd ehi an sau xudng be mat d md CO va xUOng tai chd va rat ft ed trUdng hpp di eanxa.
d day, ehung tdi ed 25 trUdng hpp biet hda tdt (dp I) va 02 trUdng hpp biet hda vfla (dp II). Mdt sd trUdng hpp te bao de tfnh xuat phdt tfl te bao gid ung thU (hyperlasie pseudo- epitheliomateux) trUdc dd. NhUng vl ngUdi ta v i n xep loai tan sinh gid ung thU la lanh tfnh do dd van de dieu trj v i n gidng nhUcac tdn thuong lanh tfnh (5,7). Theo Fleury va Apromolla (9) va Lever (5) thi sU phan biet gifla hlnh dnh eua mdt tan sinh gid ung thU vdi hlnh dnh Carcinome te bao gai dp I biet hda tdt thi rat khd tren ede mau sinh thiet tien phiu (biopsie preoperatoire). Chung tdi ghi nhdn trUdng hpp sinh thiet lan dau eho thay hlnh dnh ehi Id mdt tdn thuong viem da man tfnh vdi sUtang sinh Idp thuang bi gid ung thU va mdt thdng sau do benh nhan nay dupe sinh thiet lan 2 va dupe chan dodn la Carcinome te bao gai dp I (biet hda tdt). TrUdng hop nay ed the hode la do sinh thiet dau tien khdng dung vj trf eung nhU khdng du sau hode la ed the ede te bao ehi vfla mdi ehuyen dang thanh de tfnh. Do dd, khdng du tfnh chat cua te bao nen khdng phdt hien dupe vd ngUdi ta khuyen trong trUdng hpp ed tan sinh gid ung thU thi nen theo ddi kT ludng ve lam sang vd neu nghi ngd thi nen sinh thiet lai sau dd vl thdi gian ehuyen tfl giai doan gid ung thu khdng ai xdc djnh chfnh xae dupe.
Hlnh dnh md hpe sau day la dae trUng eua mdt Carcinome verruqueux:
1. Cd hlnh dnh tang nhu (papillomatose), tang sflng (hyperkeratose) vdi sU hlnh thanh ede cau sflng nam sau trong md bl. Trong Idp thupng bl, thi ede eau ndi lien bao khdng edn
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nfla va te bao gai ed hlnh nhieu canh vdi te bao chat ddng dang Ua toan.
2. Su sflng hda va sU phan tan cua cdc te bao gai tao thanh ede eau sflng tfl sU thoat ra thupng bl va tuy theo ti le phan tram te bao gai biet hda ma ta cd cac dp biet hda khde nhau (dp I, II, III, IV).
5. K^T L U A N
Qua nghien eflu carcinome xuat hien tren TAILI£UTHAMKHAO
1. Arnold, ODOM, James. "Andrews Diseases ofthe skin elinieal Dermatology eighth edition" pp:
777-781.
2. Benh vien Phong va Da Lieu Quy Hoa.
"Sdn sdc vd diiu trj 16 ddo". R8.
3. Civatte (7). "Histopathologie cutanie 2 - edition" P.330.
4. D.Soares, Y.Kimula. "Squamous cell Carcinoma ofthe foot arising in the chronic ulcers leprosy patients".
5. Lever (W). "Histolopathology ofthe skin 7 th edition" P.558.
6. JH Riehardus and Smith. "Squamous cell carcinona in the chronic unleers in the leprosy a
loet Id ddo eua 27 trUdng hpp bi benh phong, ehung tdi ed mdt sd ket luan sau:
Nam (70,4%) gap nhieu hon nfl (29,6%).
Tudi 61-70 chiem 37,1%; 51-60:25%; 41-50 va 71-80 deu chiem 18,5%.
-The phong hay gap la BB (12/27 benh nhan), BT (8/27 benh nhan), BL (6/27 benh nhan) va LL (1/27 benh nhan).
- Biet hda chu yeu la dp I chiem 92,59%, dp 117,41%
review of 38 consecutive cases Lepr rew (1991)"
62,381-383.
7. J.H.Saurat. "Dermatologie et maladies sexuellement transmissibles 3-edition"P.583.
8. NBB Reddy, TS Rinivasan, Sat krishnan, SR Bhusnurmath. "Malignancy in chronic ulcers in Leprosy: a report of cases from Northern Nigerie Lepr rev (1985)" 56.249-253.
9. Nguyen Sao Trung, Nguyen Chan Hung.
"Benh hgc ung bUdu ca bdn,Trung tdm ddo tao vd boi dudng edn bp y ti 1992", P-129-135.
10. RN Fleury and DVA opromolla.
"Carcinoma In plantar ulcers in leprosy". Lepr Rev (1984)55,369-378.
SUMMARY
VERRUCOUS CARCINOMA ON 27 LEPROSY CASES ATTHE BEN SAN LEPROSY CENTER AND HOSPITAL OF DERMATO-VENEREOLOGY IN HO CHI MINH CITY
Introduction: peripheral nerve damage in leprosy often leads to disability, especially plantar ulcer. Without appropriate care, this disability can result in dangerous complication such as verrucous carcinorma.
Material and method: This is a retrospective study on 27 eases with papilloma on foot at Ben San leprosy Treatmant Center from 1989 to 2005.
Results: Most of 27 eases are BT, BB and BL leprosy, one ease LL leprosy, no TT leprosy ease.There are 3 metastasis cases: 2 BL and 1 LL. 17 eases on the heel; 10 eases on the forefoot; Male/female ratio is 19:8.
Key word: Verrucous carcinorma, plantar ulcer, papilloma, peripheral nerve.
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