Y HOC VIET NAM THANG 3-SO2^2014 HOI sWcbchafc- Benh vien Viet Ditc Khoa luan
tot nghiep aJ nhan dieu du9ng khoa 2001-2005, fr. 8-33.
Trinh Van Minh ( 1 9 9 8 ) , Giai phau ngu&. Nha xuat ban y hoc, fr518-537.
Le Quoc Thjnh va CS (2003), Tinh hinh de khang khang sinh cua vi khuan phan lap dWdc tai binh vien Nhi dong 1 nam 2003. Hoi nghj tong ket jioat dgng theo doi stf khang thuoc cua vi khuan gay benh thtfdng gap tai Viet Nam (ASTS)
Doan Minh Tuan (2008), Nghiin dtu can nguyen vi khuan, cac yeu to liin quan den nhiem khuan catheter d hai vi hi dnh mach canh trong va tinh mach dwdi don. Luan van tot nghiep thac sy Trtfdng Dai Hpc Y Ha Noi.
Ha ^Manh Tuan (2006), Cac yeu to nguy cd nhiem khuan benh viin tai khoa Hoi site cap cuU nhi tai binh vien Nhi dong 1 thanh pho Ho Chi Minh. Ky yeu hoi nghi khoa hoc ky thuat Hoi stfc tich ctfc thanh pho Ho Chi Minh-2006.
DANH GIA K E T QUA D I E U T R I UNG THU* BANG QUANG GIAI DOAN II
BANG PHAU THUAT CAT BANG QUANG BAN PHAN TAI BENH VIIEN K
Nguyen Van Hieu*, Nguyen Xuan Hau*, Le Van Quang*
T 6 M
TAT
M^c tieu: Danh gia ket qua phau thuat cat bang quang ban phan do ung thtf bieu mo bang quang giai doan II tai benh vien K ttf nam 2008 den 2013. Ooi ttfdng vci phtftfng phap nghien cu'u: Nghien ciTu mo ta hoi ciru ket hop vdi tien ctfu tren 45 benh nhan UTBQ glai doan I I dtfdc PT cat bang quang ban phan tai b§nh vi?n K ttf 2008 - 2013. Ket qua: "Hidi gian mo trung binh 100 ± 21,2 phut, thdi gian hau phau 5,4 ngay; bien chirng sau mo 13%; thdi gian chirc nSng bang quang hoi phuc hoan toan la 3 thang; ung thtf te bao chuyen tiep chiem 95,6%, u xam lan cd n6ng 73,3%; 100% dien cat each u 2cm deu am tinh;
thdi gian song them toan bo 46,4 thang, ty le song them toan bo 3 nam 92,3%; thdi gian song them khong benh 29,1 thang; ty le song them khong benh 3 nSm 41,9%. Ket luan: PT c3t bang quang ban phan vdi dien c3t 2cm an toan, ft tai bien, cai thien chat Itfdng song cho benh nhan trong dieu tn ung thtf bang quang giai doan I I .
Tit khda: ung thtf bang quang, cat bang quang bin phan
S U M M A R Y
EVALUATION OF THE RESULTS OF PARTIAL CYSTECTOMY FOR TREATMENT OF BLADDER CANCER STAGE I I
AT K HOSPITAL
BQ mon Ung thw- Tmdng Dai hgc Y Ha N^
Phin bifn khoa hpc: PGS. TS Doan HOU Nghi
Purposes: To evaluate the results of partial cystectomy for treatment of bladder cancer stage I I at K hospital from 2008 - 2013.
Subjects and Methods: A retrospective and prospective study on 45 patients with bladder cancer stage II were treated by partial cystectomy at K hospital from 2008- 2013.
Results: the average operative time was 100 ± 21,2 minutes, the average postoperative hospital stay was 5,4 days, the ratio of postoperative complications was 13%. The time of completely restored bladder functions was 3 months. Urothelial carcinoma 95,6%;
tumor invades superficial muscularis propria 73,3%;
negatve margins 100%. The overall survival was 46,4 months, the ratio of overall 3-year survival was 92,3%;
the disease-free survival was 29,1 months, the3-year recurrence-free rate was 41,9%, respectively.
Conclusions: A partial cystectomy with negative margins which was from tumor 2cm was safe, has low complkiahons, improve quality of life for patients with bladder cancer stage I I .
Keywords: bladder cancer, partial cystectomy I. OAT VAN o l
Ung thtf bang quang la benh ung thtf thudng
gap nhat trong cac benh ung thtf cua he tiet
nieu. Tren the gidi, nam 2008 oa khoang hdn
450.000 ca ung thtf bang quang mdi mSc, diThg
hang thii' 5 trong tong sd cac benh ung thtf
Y HCX: VIET NAM THANG 3 - SO 2/2014
thtfdng gap d ca 2 gidi vdi ty le 8% va sd benh nhan ttf vong vao khoang 130.000 trtfdng hdp [1], Tai Viet Nam, theo ghi nhan ung thtf Ha Npi (2000 - 2001), ty te m k ung thtf bang quang la 2,2/100 000 dan, lira tuoi hay gap la tir 60 tdi 70 va ty te nam/nff la 2,5/1. Hdn 90% den 95%
UTBQ la LIT bieu md chuyen tiep, sd cdn lai la UT bieu md vay, UT bieu md tuyen.
Phau thuat cat bang quang ban phan trong ung thtf bang quang xam lan cd bao ton dtfdc chu'c n§ng bang quang, kiem soat viec di tieu dong thdi dam bao nguyen tac dieu tri ung thtf.
Tai Viet Nam, chu^ cd nghien ciru nao danh gia ket qua dieu tri doi vdi ung thtf bang quang xam lan cd bang phau thuat cat bang quang ban phan. Do dd, chung tdi thu'c hien de tai nay vdi muc tieu sau: "Oi/iA gii kit qua phau thu$t cit bing quang ban phan do ung thu" bieu md bang quang giai do§n II tai binh viin K tif nim 2008 din 2013".
II. odi TU'ONG VA PHUdSJG PHAP NGHllN COU 2.1. Ooi tu'dng nghien cu'u: Gom 45 benh nhan chan doan xac dinh ung thtf bieu md bang quang glai doan II, dp md hpc thap ( Gl, G2), u nSm d vj trf day, thanh ben bang quang, dtfdc phau thuat cat bang quang ban phan tai Benh vien K tir nam 2008 den 2013.
2.2. Phu'dng phap nghien cuTu: nghien ctfu md ta hdi cu'u ket hdp vdi tien ciTu.
2.3. Oanh gia hieu qua dieu tti:
- Cac dac diem lam sang va can lam sang - Ket qua dieu tri gan: thdi gian mo, thdi gian hau phau, tai bien, bien chirng, chirc nang bang quang trd ve binh thtfdng, giai phau benh, dien cat.
- Ket qua dieu tri xa; thdi gian song them toan bd, thdi gian sdng them khdng benh, ty le thdi gian sdng them 3 nam.
2.4. Phan tich va xuf ly so lieu: tren phan mem SPSS 16.0
III. KFT QUA NGHIEN CU'U
3.1. Mot so dac diem lam sang va c$n lam sang
3.1.1. Tuoi va gidi: Tuoi mac benh trung binh la 58,9 tuoi, nhdm tuoi hay gap tir 50-70 chiem 62,1%, ty le nam/niJ = 1,8/1.
3.1.2. Ly do vao viin: dai mau la trieu chu'ng hay gap nhat chiem 95,5%.
3.1.3. Ngi soi bang quang
Vj trf u d thanh ben chiem nhieu nhat 75,5%, u >2cm chiem 77,8%.
Tren hinh anh npi soi chii yeu gap hinh dang u the sui, trong do u dang siii ddn dpc chiem ty le nhieu nhat 64,5%.
Chup c§t Idp vi tinh
Bang 1. Hinh anh u bang quang tren phim chup cat Idp CT
Kich thu'dc
Vjtri
Xam lain v^
di can hach
< 2 cm 2-3 cm
>3 cm Thanh P ThanhT BayBQ ChL/a xam lan cd
Xam ian cd XI ra ngoai thanh mac
va/hoac di can hacli
SoBf^
10 18 17 20 14 11 2 43
0
Ti ie »/o 22,2 40,0 37,8 44,4 31,1 24,5 4,4 95,6
0
Hau het cac trudng hdp u deu xam lan Idp cd, chi co ^,4% u chua xam lan cd tren CT. Khong tru&ng hdp nao xam ian ra thanh mac va di can hach chau.
3.2. Ket qua dieu tr|
Tticfi gian mo trung binh:100 ± 21,2 phut, nhanh nhat 80 phut, lau nhat 150 phijt. Thdi gian hau phau trung binh; 5,4 ngay, nhanh nhat 4 ngay, lau nhat 10 ngay.
3.2.1, Tai blen, bien chu'ng pliau thuat
Blen chtrng 5au mo chiem 13%, trong do tat ca deu bj nhiem l<huan vet mo.
3.2.2. Chii'c ning bing quang sau phau thuat
Y HOC Vl|T NAM THANG 3 • SO 2120U
Bang 2. Thdi gian chtfc nang bang quang trd ve binh thtfdng
Thdi gian
<1thanq 1-3 thang
SoBN 15 30
Ti le »/o 33,3 66,7
Tat ca benh nhan chdc nang bang guang bd ve binh thudng sau 3 thang, trong do khoang thdi gian trd ve sau 1 thang la 33,3%.
3.2.3. Giai phau binh sau mo
Ung thtf te bao chuyen tiep hay gap nhat chiem 95,6%, dp md hpc 1 chiem 86,7%, u xam lan Idp cd ndng 73,3%, sd hach vet trung binh la 6,3 hach, it nhat la 3 hach, nhieu nhat la 11 hach, 100% dien cat each u 2 cm am tinh.
3.2.4. Thdi gian song thim a. Tbdigian song them toan tjp
Bleu dd 1. Thdi giansong them toan bp
Tbdigian song them toan bg trung binh la 46,4±2,2 thang, tyle OS 3 nam: 92,3%.
b. Tbdigian song them khong benh Bli'ud(^2. Thdi gian song them khpng benh
Thvi gian lAnfl thim kh^ng btnh (OiJng)
Tbdigian song thim khong benh irung hinh li 29,1± 1,8 thang, ^i phat sdm nhat la 3 thang, tai pbat
mu$n nbat la 37 thang. Ty le DFS 3 nSm: 41,9%.
Y HOC Vi§T NAM THANG 3 • 8 0 2/2014
c. Moi lien quan giu^ mdc do xam lan vdi tinh trang tai phat
^ _ _ ^ ^ Xam lan Tinh trang BN " ~ — — - _
Khonq tai phat Tai phat
Tonq
T2a SoBN
30 2 32
Ty le °/o 66,7
4,5 71,2
T2b SoBN
3 10 13
TV le % 6,6 22,2 28,8
P
<0,001 Nguy cd tai phat cang cao khi u xam lan cang sau vao Idp cd (p<0,001).
d. t^di lien quan giita mite do xam ian vdi tinh trangtit vong Banq 4. Mol lien quan qlu^ mijc do xam lan vdl tinh tranq tir vonq ' — ^ _ ^ _ ^ Xam lan
Tinh trang BN ^^ ^ — - _ _ _ Sonq
Chet Tfinq
T2a SoBN
32 1 33
Tv ie % 71,1
2,2 73,3
T2b SoBN
B 4 13
Tv ie % 17,8 8,9 26,7
P 0,004 Tyle tit vong aJa nhdm u xam lan Idp cd sau (T2b) la 8,8% cao hdn han nhom u xam ian idp cd nong la 2,2% vdip= 0,004.
IV. BAN LU^N
4.1. Mpt so'dac diem lam sdng, can lam sang Tudi trung binh la 58,9 tudi, thap nhat la 38 tuoi, cao nhat la 80 tuoi, lu'a tudi hay gap la 50- 70 tudi chiem 62,1%. Ket qua nay phii hdp vdi cac nghien ciTu khac trong va ngoai ntfdc. Theo Do Trtfdng Thanh (2004), tudi trung binh la 60,7 tudi [2]. Ty le nam/nu" la 1,8/1. Ket qua nay cung gidng nghien cifu ciia Nguyen Ky, De Braud cho rang ty le nam mac benh ludn cao hdn niJ [3].
Trong nghien ciru cua chung tdi, hau het benh nhan vao vien vi dai mau, chiem ty le 95,5%, ket qua nay cung phii hdp vdi cac nghien cim khac trong va ngoai ntfdc. Theo Nguyen Ky, Marvicar AD, trieu chiTng dai-mau chiem 90% [3],
Chup cat ldp vi tinh cd vai trd quan trpng de danh gia mirc dp xam lan ciia khdi u va klia nang di can hach vimg. Trong nghien ciilj ciia chung tdi, vai trd ciia CT trong danh gia mirc do xam lan u chinh xac 95%, xac djnh di can hach viing chinh xac 100%. Ket qua nay phii hdp vdi nghien ciru khac tren the gidi. Bostrom va cs (2008) da md ta rat ky luSng vai trd cua chup cht ldp vi tfnh trong viec danh gia mirc dp xam lan u vao thanh bang quang va phat hien di can hach. Tren CJ cd the phat hien miit dp xam lan u vdi dp chi'nh xac cao tir 93- 95%, kha nang phat hien di can hach la 73- 98% [4]. Sawrczuk va cs (2003) cho tliay dp chinh xac ciia CT trong viec danh gia mu'c dp xam !an tai cho cua khoi u la 81%, kha nang phat hien hach vung la 83 - 89% [5].
Soi BQ la tieu chuan quan trpng nhat de chan doan xac dinh benh, theo doi va danh gia
ket qua sau dieu trj. Trong nghien cu'u cua chung tdi, tren ndi soi u dang siii chiem ty le cao nhat 97,8%. Ket qua nay cung phii hdp vdi nghien ciru ciia Nguyen Dieu Htfdng (2008) cho ty le u dang siii chiem 96% [6],
4.2. K€t qua dfeu trj
Thdi gian phau thuat trung binh la 100 ± 21,2 phut, thdi gian nam vien trung binh la 5,4 ngay. Ket qua nay phii hdp vdi nghien ciru ciia Jose thdi gian mo trung binh la UO phut, thdi gian nam vien trung binh la 7 ngay. Cung trong nghien ciru ciia Jose, thdi gian phau thuat cat bang quang toan bp, vet hach chau va duS 2 nieu quan ra da trung binh la 150 phut, thdi gian hau phau trung binh la 7,2 ngay [7]. Bien chutig sau mo trong nghien cu'u ciia chiing tdi la 13%, tat ca deu bj nhiem khuan vet mo. Ket qua nay cao hdn nghien ciru ciia Jose ty le bien chdng sau md chi la 3% [7]. Dao Tien Luc (2013) nghien ciru 36 benh nhan phau thuat cat bang quang toan bd clio ket qua ty le tat bien trong md la 5,6%, t^ le bien chtfng sau md la 16,7%, chii yeu la chay mau sau md va nhiem khuan vet md. Tir ket qua tren chiing tdi thay rang, phau thuat cat bang quang ban phan nhanh hdn, it tai bien hdn so vdi phau thuat cat bang quang toan bd.
Tat ca benh nhan chirc nang bang quang tr6
ve binh thtfdng sau 3 thang trong dd chirc nang
trd ve sau 1 thang chiem 33,3%. Thdi gian chiit
nang bang quang trd ve binh thtfdng nhanh hay
cham phu thupc vao md bang quang cdn lai sau
phau thuat nhieu hay it va kha nang tap nhin tieu
cira benh nhan.
Y HOC VlfT NAM THANG 3 - SO 2/2014 Trong nghien cu\j, ung thtf te bao chuyen
tiep chiem chii yeu 9 5 . 6 % , ket qua nay cung gidng nghien CLTU cua Do Trtfdng Thanh ty le ung thtf te bao chuyen tiep chiem 98,82% [ 2 ] . Tat ca cac trtfdng hdp sau phau thuat cat bang quang tian phan deu dtfdc tien hanh lay dien cat each u 2 cm girt lam xet nghiem md benh hoc thu dtfdc 100% dien cat am tinh. Ket qua nay giong vdi nghien ciitJ ciia Jose 100% dien cat each u 2 cm deu am b'nh [ 7 ] . U xam lan ldp cd ndng chiem 73,3%, u xam lan ldp cd sau chiem 26,7%.
Thdi gian song them toan bd trung binh la 46,4±2,2 thang, ty le OS 3 nam la 9 2 , 3 % . Ket qua nay phu hdp vdi nghien culj ciia Henry va cs (2007) nghien ciru 30 benh nhan ung thtf bang quang giai doan I I dtfdc phau thuat cat bang quang toan bp triet c3n cho ket qua thdi gian song them toan bp trung binh 3 nam la 100%
[9]. Oieu dd cho tliay khdng cd stf khac biet ve thdi gian sdng them toan bd giiJa nhdm benh nhan ung thtf bang quang giai doan I I 6Mc phau thuat cat bang quang toan bd ciia Henry va cat bang quang ban phan ciia chung tdi.
Thdi gian sdng them khdng benh trung binh la 29,1±1,8 thang, ty le DFS 3 nam la 4 3 , 1 % . Thdi gian tai phat sdm nhat la 3 thang, tai phat mudn nhat la 37 thang. Ket qua nay phii hdp vdl nghien cu'u ciia Nader Fahmy va cs (2005) nghien ciru 714 benh nhan phau thuat cat bang quang ban phan cho ket qua ty le sdng them khdng benh 3 nam la 4 0 % .
Nguy cd tai phat u cang cao khi u xam lan cang sau vao trong Idp cd bang quang, ty le tii vong ciia nhdm u xam lan ldp cd sau (8,9%) cao hdn hSn nhdm u xam lan Idp cd ndng bang quang (2,7%).
V. Kfr lUfyN
5 . 1 . M o t so d $ c d i e m l a m s a n g v a c a n l d m sdng
Tudi trung binh la 58,9 tudi; ty le nam/nu' la 1,8/1; Dai mau la trieu chiTng hay gap nhat chiem 95,5%; tren npi soi, vi tri u d thanh ben b^ng quang chiem 7 5 % , u cd kich thtfdc > 2cm chiem 78%, u dang sui chiem 97,8%, ung thtf te bao chuyan tiep chiem 9 5 % ; CT danh gia mirc
dp xam lan cua khoi u vdi dp chinh xac la 95,5%
va di can hach viing vdi d d chinh xac 100%.
5.2. K e t q u a d i e u t r i
Thdi gian m d trung binh la 100 phtit; thdi gian nam vien trung binh la 5,4 ngay; 13%
trtfdng hpp cd bien chtfng sau md, tat ca deu bj nhiem khuan vet md; thdi gian chifc nang bang quang trd ve binh thtfdng tdi da sau 3 thang; u xam ian ldp cd ndng chiem 73,3%; sd hach vet trung binh la 6,3 hach, ft: nhat la 3 hach, nhieu nhat la 11 hach, tat ca cac hach deu am tinh; tat ca dien cat each u 2 cm deu am tfnh; Thdi gian sdng them toan bp trung binh la 46,4 thang, ty le thdi gian sdng them toan bd 3 nam la 92,3%;
thdi gian sdng them khdng benh trung binh la 29,1 thang, ty le thdi gian sdng them khdng benh 3 nam la 4 3 , 1 % ; nguy cd tai phat u cang cao khi u xam lan cang sau vao trong ldp cd bang quang; ty le tir vong ciia nhdm u xam lan ldp cd sau cao hdn han nhdm u xam lan Idp cd ndng bang quang.
TAI L l i u T H A M KHAO
1. National Comprehensive Cancer Network (NCCN) (2013), "Bladder Cancer'; Clinical Practice Guideline in Oncology, tr4-25.
2. Do Tru'dng Thanh (2004), "Ket qua dieu tn phau thuat ung thtf bang quang tai Benh vien Viet DiTc trong 3 nam {2000-2002)" r hoc thWc hanh. 491, tr. 465-469.
3. Nguyen Ky va Nguyen BiTu Trfeu (1995), "Gop phan chan doan sdm ung thtf bang quang trong dieu kien hien tai'; Tap chi ngoai khoa. 6, tr.:6-13.
4. Bostrom PJ, Van Rhijn BWG vd Fleshner N (2010), "Staging and staging errors in bladder cancer", Eur Urol SuppI 9, tr. 2-9.
5. Sawczuk IS (1983), "sensitivity, of computed tomography in evaluation of pelvic lymph node metastases from carcinoma of bladder cancer';
Urolow[2l),\j. 18.
6. Nguyen Dieu Hu'dng (2008), Nhin xet d0c diem lam sang, can lam sang va kit qua dieu tn ung thW bang quang nong tai binh vien K, B^nh vien K, Dai hoc Y Ha Ndi, Ha Noi.
7. Jose, Savic (2007), 'The role of partial cystectomy in treatment of muscle invasive bladder cancer" .; Urol, tr 34-39.
