TAP CHI KHOA HQC - BAI HQC BONG NAI, SO 04 - 2017 ISSN 2354-1482 AP D U N G KY T H U ^ T XA TRI BA CHIEU
T H E O HINH D A N G KHOI U B A N G M A Y GIA T 6 C TUYEN TINH TAI BENH VIEN DA K H O A D O N G NAI
TkS. Dwang Tkank Tdi^'^
TS. BS. Trwang TkiitDung^
BS.CKIL Dinh Tkank Bink^
TS. Nguyin Van Hai^
TOM TAT
Ung thu la mdt trong nhirng nguyen nhdn hdng ddu gdy tie vong cho con ngu&i vd xg tri Id mgt tiong nhirng phuang phdp img dung bice xg ion hda tiong dieu tri ung thu. Cdc ky thudt xg tri hi^n tgi cd nhieng tiin bg vu0 bgc vd giiip cho syphdn bo liiu tdi uu tgi the tich khoi u, ddng th&i gidm din mice tdi thieu su nguy hgi cho cdc td chuc ldnh [1, 2]. Tu ky thugt phdn bd hai chiiu (2-D); ba chieu theo hinh dgng khdi u (3D-CRT) den xg Pi diiu biin cuang do (IMRT); xg tri du&i sy hu&ng ddn ciia hinh dnh (IGRT); xg tii cat l&p (tomotherapy) vd xg Pf bdng hgt ngng (heavy ion) [2]... Tgi VietNam, ky thudt 3D-CRT Id mgt l^ thugt dugc su dung pho bien hien nay tgi cdc trung tdm xg tri trong cd nu&c. Trong bdi bdo ndy, chung tdi tiinh bay quy tiinh cua ky thudt xg tri 3D-CRT cho mot sd logi binh ung thu thu&ng gap tgi Binh viin Da khoa Ddng Nai vd bu&c ddu ghi nhdn ddp iing cua buc xg ion hda trin khia cgnh vdt ly.
Tw kkoa: Ung thu. Xg tri 3D-CRT, Mdy gia tie tuyin tinh
1. Gidi thifu he thfing may gia tdc xa tri cua hang Hifin nay, 3 phuang phdp chinh dfi Siemens. Ddy Id mdy gia tdc tuyfin tinh difiu tri cho bfinh nhdn ung thu Id phdu
thudt, hda tri, xg tri, trong do xg tri dugc dp dung phd bien ddi vdi hau hfit cac loai ung thu. Muc dich cua xa tri la tifiu diet cdc tfi bdo ung thu bang tia buc xg ion hda vdi nang lugng va lifiu Iugng tMch hpp. Xg tri ngodi Id ky thugt chifiu cdc chura bde xg ion hda tu ben ngodi, tap tmng vdo khdi u, nham cung cdp heu difiu tri thich hpp. Cdng cy phat chum bde xa hien dang dupc dp dyng rdng rai Id may gia tdc. Ngdy 11 thdng 11 nara 2009, Khoa Ung budu - Bfinh vien Da khoa Dfing Nai dugc trang bi 'B?nh vi?n Da khoa D6ng Nai
iru&ng Bai hgc Khoa hpc Tv nhien TP. HCM . , -
^T^r^P Cao Dang Ngha Bk L^t
CO thfi tgo ra cac chum buc xa photon va electron vdi nang lugng thich hpp cho vific difiu tri ung thu.
Bai toan chinh cua xg tri Id ldm sao cung cap lieu hdp thy du cao cho khdi u dfi cd thfi tieu diet nd, trong khi do phai duy tri lifiu hap thy du nhd cho cac co quan Idnh lan can de giam tiiieu tdn thuong cho chung. Sy phat trien cua xa tri trong nhiing nara qua ludn di theo hudng tdi uu hda vific phan bd lieu nay.
0 Viet Nara hien nay, ky thuat dang dugc sd dung phd bifin tai nhifiu tmng tam xa tti chu yfiu la xa tt-i 3D-CRT.
TAP CHI KHOA HQC - BAI HOC BONG NAI, SO 04 - 2017 ISSN 2354-1482 3D-CRT la mdt thudt ngft dugc sd dyng
dfi mo ta ky thu^t phdc thdo va thyc hifin mgt kfi hoach xg tri dugc dya trfin cdc dd lieu td pMm CT (computed tomography) theo ba chieu cung cac trudng chifiu dupc tao theo hinh dang rifing biet phu hgp khdi u [2, 3]. Ky thuat xa tri 3D-CRT Id radt ttong cdc ky thugt xa tri ngoai. So vdi ky thudt xg tri thdng thudng 2D trudc ddy, cac chura
tia dugc phat ra chi cd dgng hinh chd nhdt hogc hinh vudng thi ky thuat 3D- CRT uu viet ban rdt nhifiu. Vdi sy cd mat cua cac tdra che chan chi, dng chudn trye da la MLC (multileaf collimator), chum bde xg phat ra cd thfi dupc difiu chinh vdi hinh dang bat ky de cd the bao khit khdi u theo tung hudng chifiu (hinh lb).
(a) Xa tri thong thucmg 2Ct; Cb)Xatri3D-
Hinh 1: Ky thugt xg tri thdng thu&ng Nhu nhiing gi chung tdi da dfi cgp d phdn tren thi muc tifiu cua xa tri la tao dupc mdt vung phan bd lifiu hdp thu cao tgi the tich bia va do do giam lieu cd hgi cho cac td chdc ldnh xung quanh, qua dd se lam gidm thifiu cac hifiu dng phy hogc bifin chdng mudn, tang xac suat kifim sodt khdi u va cai thien ket qud difiu tri. De thyc hien dupc difiu ndy, bgnh nhan can phdi trdi qua rapt qud trinh rad phdng vd lap ke hach difiu tri.
Chdng tdi tifin hanh de tai nghifin cdu: "Ap dung ky thudt xa tri ba chifiu theo hinh dgng khdi u bang raay gia tdc tuyfin tinh tai Benh vien Ddng Nai" vdi rayc dich:
2D (a) vd ky thudt xg tii 3D-CRT (b) 1. Dua ra quy trinh ky thuat xg tri 3D-CRT tai khoa Khoa Ung budu.
2. Budc dau gM nhdn dap ung cua buc xa ion hda trfin khia cgnh vdt Iy cho bfinh nhan tgi Khoa Ung budu.
2. Ddi tugmg vd phinmg phap nghien cihi
2.1. Doi twffng ngkiin cAu Cdc trudng hgp benh nhan ung thu da dugc lap kfi hoach va xg tri vdi ky thudt xg tti 3D-CRT.
2.2. Pkwffng phdp nghiin ciru Cac benh nhdn dugc lap ke hoach xg hi 3D-CRT, sau dd kich thudc khdi u cua b#nh nhdn trudc vd sau khi difiu tri dupc so sdnh dya tren hinh anh CT
134
TAP CHi KHOA HQC - BAI HOC B 6 N G NAI, SO 04 - 2017 ISSN 2354-1482 de ddnh gid dap ung cua buc xg ion hda
vdi tfi bao ung thu.
2.3. Quy trinh tk^c hank Iam sdng ky tkudt xg tri 3D-CRT
2.3.1. Ddnh gid binh nhdn vd quyit dinh xg tii
I Binh gia bgnh nl
Dl^u Iri
Hinh 2: Quy trinh lap ki hogeh xg tii Budc dau trong quy trinh Id danh gid va quyfit dinh xem bfinh nhan cd the dupc difiu tri nhu thfi ndo. Trong qua trinh ddnh gia tat cd cdc khdu chdn doan, xet nghiem khdc nhau duoc tifin hanh dfi xac dinh tinh trgng, ciing nhu giai doan bfinh. Nhihig yeu td dd bao gdra chdn doan hinh anh, cac xet ngMfim CO ban vfi sinh hda hay nhimg thdng tin vfi md bfinh... dfi giup xdc djnh loai bfinh, giai dogn benh ciing nhu rauc dp xdra Ian cua khdi u. Sau dd, bac sT se dua ra nhimg quyet dinh dieu tri cho bfinh nhdn.
2.3.2. Cd dinh tu thi binh nhdn Trudc khi di den quyfit dinh difiu tri, bde sT va ky su vgt ly thdng nhdt tu thfi benh nhan cd thfi dp dyng cho tung ttirdng hgp vd phuong phdp cd dinh ttr thfi bfinh nhan sao cho thich hgp nhat.
Vific sd dyng phuang tifin cd dinh phu hpp, tgo sy thodi mdi cho benh nhan.
Mdi mdt co sd xa tri cdn trang hi ddy du nhirng phuang tifin, dung cy cfi dinh phu hgp cho tdng vi tt-i, tdng loai bfinh.
2.3.3. Md phdng
Hinh 3: H4 thdng mdy CTmd phdng tgi Khoa Ung buau He thdng md phdng bao gdm may md phdng vd he thdng may tinh difiu khifin mdy md phdng cung nhu luu tru vd xu ly du lieu md phdng. Chdc nang cua rady rad phdng Id thu nhgn du lieu dnh phyc vu cho qua trinh lap ke hogeh, ddng thdi nd ciing dupc sd dyng dfi md phdng, kifim tra viec dieu tri va che chan dugc tgo ra tu hfi thdng lap kfi trudc khi dua benh nhan vdo difiu tri chinh thuc tren may dieu tri.
2.3.4. Ghi nhdn vd xic ly hinh dnh binh nhdn
Vdi nhifiu loai vi tri khdi u khac nhau, nhiing hinh anh chup CT se giup cho vific xdc dinh chinh xac cac thdng sd nhu kich thudc cdng nhu vi tri cua nd.
Nhirng hinh anh duac thyc hifin trfin CT dung cho qua trinh lap kfi hogeh difiu tri
TAP CHI KHOA HQC - BAI HQC BONG NAI, SO 04 - 2017 ISSN 2354-1482 phdi sao cho cang sdt thyc te cang tdt,
ngMa Id phdi day du nhiing gi se dung tren rady difiu tri. Chang hgn cdc dung cy cd dinh, gid dd chdn tay, khung trg giup tu the benh nhdn, he thdng laser dinh vi,... phdi gidng hfit nhau.
2.3.5. Khoanh vimg dieu tii vd vimg bdo vi (contour)
Qua trinh lap kfi hogeh xa tri dua vao hinh dnh dupc xdc dinh theo thfi tt'ch khdi u vd cac td chdc nguy cdp lifin ke. Cdc vung thfi tich ndy dupc ve theo tung lat cat dya trfin bd du lieu cua phira CT. Khi ve cdc dudng bien xdc dinh the tich khdi u va cac the tich lien quan khac, bae si xa tri va ky su vat Iy can phdi tinh den nhung xfi dich cd thfi
xdy ra cua bfinh nhan va cua rapt sd td chuc. Sau ddy la mdt so hudng ddn cM tifit giup vigc xdc dinh cac the tich nay:
a. Thi tick khdi u thd GTV (gross tumor volume): La phara vi bifiu Mgn phat trifin tai chd cua cac te bdo dc tinh raa qua do cd thfi nhm thdy, sd ndn hogc tham kham true tiep.
b. The tich bia ldm sdng CTV (clinical target volume): La the tich md ma trong do bao gdm thfi tich GTV va cdc td chdc ac tinh bieu hifin d muc vi thfi, khd phdt hifin bang Idm sdng nhung cdn phdi logi bd. Vi vdy thfi tich ndy ciing phai dieu tri mgt each day du ve lieu Iugng cd trong trudng hgp xa tri trifiu chung hay trifit de.
Tlitiicl] Up kc hoach dihi Vi
Th^ lich bia Um stag
Th£ Ikh kh6i u A6
TIi£ Ikb dicu in Tlii lidi chicu XV
Hinh 4: Cdc vimg thi tich khdc nhau cdn xdc dinh theo ICRU c. Thi tich bia ndi tgi ITV (intemal
target volume): La radt khai nigra radi dupc gidi thieu trong ban bdo cdo sd 62 cua ICRU. Dfi bu trd cho nhirng thay ddi ve kich thudc, Mnh dgng va vi tri cua CTV.
d. Thi tich Igp ke hogck diiu tif PTV (planning target volume): Ld mdt khdi nigra vfi hinh hgc, dupc xac dinh dfi lya chpn sy phan bd cdc chum tia mdt each thich hgp, trong dd cd tinh den dnh hudng thyc tfi cua nhirng thay ddi vfi mat hmh hgc Ifin thfi tich CTV,
TAP CHi KHOA HQC - BAI HQC BONG NAI, SO 04 - 2017 ISSN 2354-1482 dfi ddm bdo phan bd lifiu Iupng theo
ddng yfiu cdu tren do.
e. Thi tich dieu trf TV (treated volume): Thfi tich difiu tri thudng Idn hon the tich bia ldp kfi hoach va phy thudc vao ky thudt difiu tri cy thfi.
f. The tich chiiu xg IV (irradiated volume): Ld vung thfi tich nhdn mgt lugng lifiu dang kfi (thudng la 50% lieu cM dinh). Thfi tich cMfiu xg ldn ban the tich difiu tri va cung phy thudc vao ky thudt xa tri dupc sd dyng. Vdi ky thu^t xa tti 3D-CRT, thfi tich chifiu xa giara khi sd dyng he thfing may gia tdc cd dng chudn trye da la (MLC) va thfi tich chieu xg tang khi sd trudng chieu tang.
2.3.6. Thiit lap tru&ng chieu vd su dung cdc thiit bi ho trg
Vific thifit lap trudng cMfiu Id lya chpn cac hudng chieu va mdc nang lugng cua tdng chum tia. Viec ndy phy thudc vdo vi tri, kich thudc khdi u trong tung trudng hgp cy thfi vd theo kinh nghiem cua tung ngudi. Su lua chgn muc ndng Iupng cua tdng chum tia phu thudc vao bdn chat cua chum tia hdc xg.Vdi tung trudng hgp cy the, sd Iugng chum tia va cdc hudng chifiu chura tia hodn toan phu thuge vao vj tri, kich thudc khdi u ciing nhu kinh nghiera cua ngudi lap kfi hogeh.
2.3.7. Tinh todn lieu lugng vd phdn bd lieu
Sau khi thiet lap cdc trudng chieu va sd dyng cdc thifit bi phy tt-g cin thifit, ngudi ky su vat Iy Idp kfi hogeh sfi tifin
hdnh tinh todn Ueu dya trfin phan rafim Prowess panther.
2.3.8. Ddnh gid ke hoach Sau khi tinh toan lifiu Iupng vd xem phan bd lifiu, ta tien hanh ddnh gia ke hoach. Khi kfi hoach ndy dugc chdp nhdn thi nd se dupc dua vao difiu tri thyc tfi. Cd hai tifiu chi dugc xet dfin khi ddnh gia kfi hogeh, dd la lifiu lupng tdi khdi u va lifiu Iugng tdi cdc td chdc nguy cap cdn bdo ve. Mdt kfi hogeh tdt la kfi hoach dam bao cdc difiu kien sau:
- Du lieu bac si cM dinh tdi khdi u, viing nhgn lieu ldn nhdt ndra ttxing khdi u va khdng vugt qud 107% lieu chi dinh.
- Lieu tdi cac td chuc nguy cap cdn bdo vfi nara trong gidi hgn lifiu cho phep.
2.3.9. Tien hdnh diiu tri Sau khi kfi hoach da dugc chap nhdn, cdc thdng sd lifin quan den ke hogeh dieu tri dupc chuyfin sang phdng may gia tdc thdng qua h^ thdng mgng LAN. Hg thdng may tinh va phdn mfira se dieu khien may gia tdc phdt tia difiu tri radi ngay cho benh nhan.
3. Ket qud va thao lu^n Tu khi thanh lap Khoa Ung budu (ngdy 11/11/2009) dfin nay, chdng tdi da tifin hdnh xa tri cho nhifiu loai ung thu khac nhau mdy gia tdc tuyfin tinh su dyng k)' thuat xg trj 3D-CRT. Dudi day Id rapt sd trudng hpp benh nhan da xa tri tai Khoa Ung budu, Bgnh vien Da khoa Ddng Nai.
B^nh nhan 1: Nguyfin Thi Thanh X., gidi tinh: Nu, sinh nara; 1983, chdn doan ung thu vdra, dugc chi dinh hda
TAP CHi KHQA HQC - BAI HQC DONG NAI, SO 04 - 2017 ISSN 2354-1482 xg ddng thdi, lifiu cM dinh tai khdi u Id
66 Gy, bgch cd, hgch trfin ddn 2 bfin la 50Gy, phan lifiu 2Gy/Ian.
Chiing tfii su dung 2 trudng chieu ddi song (90**, 270*^ cho vdra, hgch cd cao. Trudng chidu O" cho hgch cd thap (Mnh 5).
i ^ t i ^ ^ ^ ^ ^ ^ ^
Hinh 5: Hinh dnh DRR tru&ng chiiu khdi u vd hgch cd thdp Sau khi thiet lap cac trudng
chieu cho khdi u va hach, chiing tdi tien hanh tinh toan lieu vd ddnh gid kfi
hogeh dya tren Mnh dnh CT va bieu dd lifiu lupng the tich (DVH) (Mnh 6).
Hinh 6: Dw&ng ddng lieu tiin dnh CT vd biiu do lieu lirgng thi tich Sau mdt qua trinh difiu tri (33 Ian)
cho benh nhdn nay, chung tdi tifin hdnh chyp CT de so sdnh, danh gid kich thudc khdi u trudc va sau kM xa
tri. Dua tren hinh dnh CT chiing ta thay rang kich thudc khdi u da gidm (hinh 7). Cdc buc xg ion hda da tifiu diet cac tfi bdo ung thu.
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TAPCHI KHOA HQC - DAI HQC DONG NAI, SO 04 - 2017 ISSN 2354-1482
Hinh 7: Hinh anh CT tnnk Benh nhan 2: Chau Thdnh L., gidi tinh: Nam, sinh nam: 1968, chdn doan ung thu vdm, dupc chi dinh xa tri don thuan, lifiu cM djnh tgi khdi u
(trdi) vd .sau kin ilieu tri (phaij Id 70 Gy, bach cd cao la 60 Gy, hach cd thap la 40 Gy, phan lifiu 2 Gy/Idn.
Chung tdi tien hdnh lap ke hoach dieu tri tuang tu nhu bfinh nhan thu 1.
Hinh 8: Cdc hu&ng chieu xg
Chung tdi tien hdnh danh gid kfi nhdn dupc sau mdt thdi gian dieu tri hogeh (hinh 9) vd ket qua chung tdi (hinh 10).
Hinh 9: Du&ng dong lieu trin dnh CT vd biiu do lieu lugng thi tich
TAP CHI KHOA HQC - BAI HQC BONG NAI, SO 04 - 2017 ISSN 2354-1482
m n h 10: Hinh dnh CTtiir&c Benh nhdn 3: Nguyfin Vdn D., gidi tinh: Nam, sinh nam: 1955. Ddy la radt trudng hgp ung thu phdc tap chung tdi gdp phai. Benh nhan dupc chan doan Id ung thu vdra da Ian len hdc miii. Chung tdi tifin hdnh xa tri vdi trudng cMfiu bao ttdm toan bd khdi u tai vdm lan den hoc raui. Vdi lifiu cM
(tidi) vd sau khi dieuti^'(pfe^) dinh tgi vdm va hgch cd cao Id 50 Gy, hdc miii Id 60 Gy, bach co thdp 40 Gy, phdn lifiu 2 Gy/ldn. Sau mdt thdi gian difiu tri kfi hoach I (20 lan) chiing tdi chyp lgi CT thi khdi u tai hdc mui giara di rat nhifiu vd chiing tdi tifin hanh difiu tri ke hogeh tifip theo cho bfinh nhan.
Hinh W: Hmh anh CT trua- Benh nhdn 4: Nguyfin Van N., gidi tinh: Nara, sinh nara: 1967. Bfinh nhdn dupc chdn doan ung thu phdi va chi dinh xg tri don thuan vdi lieu difiu tri cho ke hoach 1 Id 40 Gy; phan lieu 2,25 Gy/Udn. Kfi hogeh 2 xa tifip vdi
(trail va sail khi ttieu tn (phai) lifiu chi dinh Id 10 Gy; phan lifiu 2 Gy/lldn.
Chdng tdi tifin hanh ldp kfi hogeh cho benh nhan, dudi day Id mpt sd hinh anh lap ke hoach.
TAP CHI KHOA HOC - DAl HOC DONG NAI, SO 04 - 2017 ISSN 2354-1482
Hinh 12: Hinh dnh truang chieu biiu diin du&i dgng 3D vd hinh DRR
Hinh 13: Kit qud sau khi dieu tri
Benh nhan 5: Tran Vinh C , gidi lieu 2 Gy/ngay. Trudng hpp ndy chung tinh: Nam, sinh nam: 1966. Benh nhan tdi sd dyng 3 trudng chifiu (23, 210, dugc chdn doan ung thu phdi dugc chi 300).
dinh xg tri vdi tdng lieu 60 Gy, phdn
Hinh 14: Hinh CT cat ngang vd bieu diin tru&ng chieu du&i dgng 3D
TAP CHI KHQA HQC - DAI HQC DQNG NAI, SO 04 - 2017 ISSN 2354-1482
Hinh 15: Khdi u tru&c vd sau dieu tii 4. Ket lu^n
U'ng dyng buc xg ion hda trong y hgc ndi chung vd trong xa tri ung thu ndi nfing vdn cdn Id mdt ITnh vyc khd mdi me cua chuyfin ngdnh vdt Iy hgt nhdn d Viet Nam. Benh vien Da khoa Ddng Nai Id benh vien tuyen tinh dau tifin trong ca nudc trien khai dugc xa tri bang raay gia tdc tuyfin tinh. Vific vdn dung dung quy trinh difiu tri benh nhdn bdng bde xg ion hda su dyng ky thugt xg tri 3D-CRT tgi Bfinh vien Da khoa
(hinh dwgc chup sau 20 ldn dieu tri) Ddng Nai dd gdp phdn khang dinh vai trd, nang lyc cua benh vien trong chdn doan va difiu tri ung thu. Kfi tu kM thanh lap tdi nay, Khoa Ung budu da cd the ty chu trong vific trien khai ky thudt xa tri 3D-CRT ddng thdi khdng ngdng hgc hdi, tiep thu cdc ky thudt xa tri mdi td cdc bfinh vifin tuyfin trfin va nudc ngodi dfi giup bfinh nhdn tifip can dupc ky thugt xa tri mdi nhat cd the, gdp phan cai thien chat lugng ciing nhu hieu qua trong difiu tri ung thu.
TAI LIEU THAM KHAO
1. Mai Trpng Khoa, Tran Dinh Hd (2009), lfng dung ky thudt xg tri diiu biin liiu Pong diiu tii ung thu tgi benh vien Bgch Mai, Hd Npi
2. Nguyen Xuan Cd, Bui Difiu (2011), Ca s& vgt ly vd nhimg tiin bg vi ky thudt xg tii tiong ung thu, Nhd xudt bdn Y hgc, Hd Ndi
3. C. Yu, Christopher J. Amies (2008), Planmg and delivery of intensity modulated radiation therapy. Medical physics, 35 (12)
4. Daniel A. Low, William B. Harms, Sasa Mutic, and James A. Purdy (1998),
"A technique for the quantitative evaluation of dose distributions", Med. Phys. 25 (5) 5. Dai J. R. and Hu Y. M. (1999), "Intensity-modulation radiotherapy using independent colliraators: an algorithm study", Med.Phys, 26
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TAP CHi KHOA HQC - DAI HQC BONG NAI, SO 04 - 2017 ISSN 2354-1482 6. Gupta T, Agarwal J (2012), "TMee-dimensional conformal radiotherapy (3D- CRT) versus intensity raodulated radiation therapy (IMRT) in squamous cell carcinoma of the head and neck: a randomized controlled trial, Radiother Oncol", 104 (3):343-8
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Treattnent planning with IMRT and 3D conformal radiotherapy", Acta Oncologica, 46, 214-220
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APPLICATION OF 3-D CONFORMAL RADIOTHERAPY IN DONG NAI GENERAL HOSPITAL
ABSTRACT
Cancer is the leading cause of deaths. Radiation therapy is one of the most common tieatments for cancer. The goal of radiation therapy is twofold: maximize the possibility ofdesPoying malignant cells while minimizing the damage to healthy tissue. Advances in computer technology have enabled the possibility of transitioning jrom basic 2- dimensional treatment planning and delivery (2-D radiotherapy) to a more sophisticated approach with 3'dimensional conformal radiotherapy (3-D CRT) and intensity modulated radiation therapy (IMRT),...In Vietnam, one of the most common types of radiation therapy is 3-dimensional conformal radiation therapy (3D-CRT) which can be considered as a standard. In this article, we present the procedure ofthe 3D-CRTfor the most common types of cancer in Dong Nai General Hospital and the results achieved.
Keywords: 3D-CRT, radiation therapy, Linac
