NGOAI KHOA S6 BAC BIET 1.2, 3/2012
KET QUA DIEU TR! UNG THJ GAN BANG NUT MACH HOA CHAT TAI BENH VIEN VIET OLTC
Trinh Quoc Dat, Nguyin Tiln Quyet, D6 M£inh Hiing, Nguyin Quang Nghia (*)
TOM TAT
Muc tieu: danh gia ket qua dieu trj ung thu"
te bao gan khong co chi djnh can thiep phau thuat tai benh vien HUu nghi Viet DiTc tii" thang 1/2009 den 1/2011.
Doi t&dng va ph&dng phap nghiin c&u:
nghien cu'u mo ta hoi cu'u va tien ciru tren 132 benh nhan du'dc niit mach hoa chat do ung thu' te bao gan khong co chi dinh can thiep phau thuat.
Kit qua: tuoi trung binh: 54.21 ± 11.85 (thap nhat: 19 tuoi, cao nhat: 78 tuoi), nam/nii'=3,77, 59% benh nhan co trieu chu'ng dau HSP, 38% benh nhan gay sut can, 67% co tang AFP, 61% co 1 khoi u, kich thu'dc khoi u trung binh 6,8 i^5,0; 25% benh nhan co u d 2 gan.
Kit luan: can thiep phau thuat la phu'dng phap dieu trj tot nhat trong ung thu* te bao gan, nhu'ng vcfi nhiJhg trUdng hdp u gan khong con chi dinh can thiep phau thuat thi niit mach hoa chat vdi u'u diem la an toan, de thu'c hien, khong CO bien chuhg nang sau thii thuat cung mang lai ket qua nhat dinh vdi thdi gian song them trung binh la 15,96 ± 4,3 thang, ty le tir vong sau thii thuat la 3%
SUMMARY
Objective: to evaluate the results of treahnent Hepato Carcino cellulair (HCC) are not indicated surgical Intervention in VietDuc Hospital from January 2009 to January 2011.
(*)Benh vien Viet D&c
Material and method: a retrospective- perspective research on the 132 patients at the Trans Artery Chymo Embolyzation (TACE) by HCC without surgical intervention indicated.
Results: average age: 54.21 + 11.85 (min:
19 years, max; 78 years), male / female = 3.77, 69% of patients had pain in the righ upper quadrant, 38% of patients with loss weight, 67%
increased AFP, 51% have a tumor, average size of tumor 6.8 ± 5.0 cm, 25% of patients have tumors in two livers. Conclusion: Surgical intervention is the best treatment in HCC, but cases of HCC without surgical intervention indicated, TACE with the advantage that safety , easy to do, no serious complications after the procedure also brings certain results with average survival time was 15.95 ± 4.3 months, death after the procedure was 3%
I. OAT VAN O i
Ung thu gan, trong do ung thu bieu mo te bao gan chiem tdi 90%, la mot benh hiem ngheo, som dem lai tir vong va dang co xu hudng phat trien d nude ta cung nhu nhieu nude khac. Mac dii da dugc tap trung nghien cixu tren nhieu phuong dien, cho den nay ung thu gan vin la ung thu kho chiia. Hien nay tren the gidi c6 nhieu phucmg phap dieu tri ung thu gan, co the chia thanh bon nhom [6]:
a) phau thuat; b) pha hiiy u bang cac tac nhan ly - hoa: tiem con, tiem axit axetic, dot nhiet tan so radio, xa tri trong hoac ngoai; c) niit hoa chat dpng mach gan; d) ghep gan ciing vi
DAI HQI HOI NGOAI KHOA VN LAN THCTXII VA HQI NGHI KHOA HOC NGOAI KHOA TOAN QUdC I J ^ N T H O X I V - tri. Trong do dieu tri phSu thuat (cat gan)
dugc biet nhu phuang phap chiia benh toi uu nhat nhung it khi c6 the lam dugc vi: thudng hinh anh y hpc cho thay co nhieu u hay u qua Idn, the tich gan con lai khong dii, u xam lan cac to chirc khac trong da so trudng hop (80%).
Phuong phap niit hoa chdt dpng mach gan (TACE) dugc cac tac gia ngudi Nhat dua ra va d Phap do Alain Roche pho bi8n ky thuat nay tir nhiing nam 80 ciia tb^ ky 20.
Muc dich cu6i cimg ciia TACE cung nhu cac phuang phap dieu tri tam thdi khac la cai thien chat luong cupc song va keo dai thdi gian song tich liiy cd y nghia. TACE duoc ap dung rpng rai tren the gidi cho phan Idn cac trudng hgp ung thu te bao gan khong the phlu thuat dugc (80%)
Nghien ciiu nay nham daiih gia ket qua dihu tri ung thu te bao gan khong co chi dinh can thiep phau thuat tai benh vien HCru nghi Viet Diic tir thang 1/2009 dSn 1/2011
II. 0 6 ) TUONG VA PHUONG PHAP NGHIEN COU 1. Doi ttfffng nghien cuu. Gom cac benh nhan dugc niit mach hoa chat do ung thu t l bao gan khong co chi dinh can thiep phlu thuat tir thang 1/2009 din 1/2011 tai benh vien Hun nghi Viet Diic
2. Phu'OTig p h a p nghien ciiu. Mo ta cat ngang, hoi ciiu va tien ciiu.
Cac benh nhan dugc nghien ciru ve: Dac diSm lam sang, dac diem can lam sang, th- uong t6n tren phim chiip cat lop vi tinh. ket
qua gan, ket qua xa sau thii thuat. Cac dii li?u thu thap dugc phan tich va xii ly tren phan m l m SPSS 15.0 va kit qua xa dugc danh gia theo phuang phap Kaplan Mayer.
III. KET Q U A
132 benh nhan (BN) thugc dfii tugng nghien cim, tuoi trung binh la 54.21 + 11.85 (thSp nhdt: 19 tudi, cao nhat: 78 tu6i), nam/nij=3,767
1. B a c diem nhom benh nhan; 69%
benh nhan co trieu chimg dau HSP, 38%
benh nhan gay siit can, gan to 22%, 67% co tang AFP vdi miic trung binh rat cao 50097,2
± 185275,17 ng/ml, 7 3 % HbsAG(+), fren kit qua chup c4t Idp vi tinh 6 1 % c6 1 khIi u, 16% CO 2 kh6i u, 2 3 % > 3 kh6i, kich thuac khdi u hung binh 6,8 ji_6,0, 66% khdi u ben phai, 9% khdi u ben trai, 2 5 % benh nhan co u d 2 gan, 80% khdi u co tang sinh mach. Ve chi dinh dieu tri nut mach 39% benh nhan khdng ddng y mo, 37% khdng dii the tich gan, 14% u d 2 thiiy, 10%) do x a gan hoac benh ngi khoa nang kem theo
2. Ket q u a g^n: Tdt ra vien: 97%>, 3%
bien chiing suy gan (tir vong), 36% dau sau niit mach, 18% sot, chay mau tai cho choc 2%
3. Ket qua x a ' thdi gian song them trung binh la 15,96 + 4,3 thang; 6 thang:
70%., 12 thang: 46%,18 thang: 24%, 2 nam 14%.
NGOAI KHOA sO BAC BlgT 1.2,3/2012
Khao sdt da bien anh hudng tdi thdi gian song sau md: cac yeu td nhu miic AFP, sd l4n nut mach, hieu qua tac mach, chi dinh niit mach giiia cac nhom thi thay rang su khac bi$t vl thdi gian song ciia cac nhom khdng CO nghTa thdng ke (p<0,5).
Danh gia ch4t lugng song: 32%) ket qua tdt, 59% trung binh, 9%o xAu
IV. BAN LUAN
1. Dac diem lam s^ng va hmh anh kh6i u gan ciia nhom nghien cuu:
Ung thu gan thudng bilu hien lam sang d giai doan mudn, giai doan sdm khdng cd trieu chiing dac hieu. Mot nghien ciiu trong nude [2] cho thdy hSu het benh nhan da cd hieu chiing lam sang rat ro rang: tren 70%) cd dau vung gan, toan than met moi, rdi loan tieu hoa, 54.6% bi gay siit can nhanh, 67.6%
dugc xac dinh gan to khi tham kham, chi cd 9.3% dugc phat hien tinh cd, chua cd trieu chiing, ket qua nay g&i tuong tu kit qua cua chiing tdi. Do la mot kho khan Idn ma chiing ta phai ddi mat: khdng con chi dinh phau thudt triet de va cac lieu phap tac dpng tai cho hoac nlu phau thuat thi ty le tir vong, biin chiing con cao va thdi gian song them han che
Trong nghien cim ciia chiing tdi co 77%) benh nhan cd tang AFP, trong do 49%) cac trudng hgp AFP tang cao tren 500 ng/ml, miic tang trung binh ciia AFP la 50097,2 ng/ml. AFP tang la mot tieu chuan chan doan xac dinh ung thu te bao gan. Nghien cihx ciia Le Tuylt Anh [3] c6 ty le tang AFP la 82,46.
AFP la chat chi diem khdi u cd gia trj chan doan va tien lugng trong ung thu te bao gan, tuy nhien 1/3 sd benh nhan trong nghien ciiu CO ham lugng AFP d miic binh thudng. Cac tac gia trong va ngoai nude cung phat hien AFP binh thudng d cac benh nhan ung thu te bao gan vdi ty le tir 17-40%) [2]. AFP binh thudng chii yeu d cac trudng hgp ung thu te bao gan biet hda cao giai doan sdm, do do dp nhay ciia AFP trong chan doan ung thu te bao gan ddi vdi nhiing trudng hgp nay khdng cao. Vi vay nhieu tac gia ciing cho rang vai trd cua AFP khdng ro rang trong tham kham sang Igc ung thu te bao gan tir cac benh nhan nguy cocao [7].
Chup cat lap vi tinh ddng vai tro quan trpng trong chan doan xac dinh ung thy te bao gan nguyen phat, vdi ky thuat chup 4 thi, hinh anh diln hinh la khdi u bat thudc rat manh thi ddng mach ddng thdi thai nhanh thi tinh mach (dau hieu Wash - out). Trong nghien ciiu ciia chiing tdi cd 12% benh nhan cd nhilu khdi u gan, ty le u to > 5 cm la 58%)
DAI HOI HOI NGOAI KHOA VN LAN THCT XII VA H O I NGHI KHOA HOC NGOAI KHOA T O A N QUOCLANTHCfXIV
vdi kich thudc u trung binh la 68,1 mm. Vi tri u chu ylu d gan phai (66%.), 25%o u rai rac d ca 2 gan, 76% u cd tang sinh mach. Nghien cim [2] cung thay da sd benh nhan cd 1 ••
(79.6%), 19 trudng hgp cd 2 u (chiem 17.6%i) va chi cd 3 trudng hgp co 3 u (2.8%)).
Hau hit cac benh nhan cd u d gan phai (78.7%)), mot phan nhd co u d gan trai (8.3%)) va d ca 2 thiiy gan (13%)). Sd lugng u tir 2 trd Ien, nhit la cac trudng hgp khu tni d khac phan thiiy, la mot trd ngai doi vdi ngoai khoa, nhung lai khdng phai la kho khan Idn ddi vdi niit ddng mach gan, vi kha nang tac mach chgn Ipc ciia niit dpng mach gan cd the can thiep 2-3 khdi u trong 1 lan dieu tri ma van bao dam duy tri chii'c nang gan. Dac dilm quan trpng nhat trong chan doan hinh anh cac khdi u gan, dac biet la ung thu te bao gan la tinh chit giau mach va ddng hpc thuoc can quang trong u. Muc dp tang sinh mach mau phu thudc chii yeu vao giai doan ciia ung thu gan va miic dp xa gan. Ddi chieu vdi kit qua nghien cihi 201 benh nhan ciia Huynh Dire Long [1], tang sinh mach nhieu chilm 88%, it hoac khdng tang sinh chiem 12%o. Ciing tac gia tren da dua ra nhan djnh vl khdi u it hoac khdng tang sinh mach thudng CO tien lugng xau.
2. Ket qua sdm sau niit dpng mach gan:
Cung nhu cac tac gia trong va ngoai [5]
chiing tdi thudng gap trieu chimg sau niit mach: sot (18%)), dau bung (36%), suy gan sau thu thuat 3%o. Trong qua trinh lam thii thuat khdng co trudng hgp nao bi sdc hay truy mach.Tat ca benh nhan deu dugc chup mach kiem tra sau thu thuat de danh gia hieu qua tac mach.
Sau lan niit mach dau tien chiing tdi thay cd 63%) benh nhan dat hieu qua tac mach hoan toan (chup kiem tra thay u khdng con
ngam thudc can quang). Nhung benh nhan khdng dat hieu qua nut mach hoan toan chii ylu la do khdi u c6 kich thudc Idn tren 7 cm, sau khi bom 10 ml Lipiodol chup kilm tra thdy tac klidng hoan toan, bom tiep 4 ml Lipiodol van khdng tac mach hoan toan, nhung trudng hgp nay chiing tdi dimg thu thuat va hen benh nhan den niit mach lan 2.
3. Ket qua xa:
Do thdi gian theo doi chua dii dai nen nghien cim mdi chi budc dau dua ra nhan xet ve thdi gian song them sau dieu tri Chiing tdi kiem tra dugc thdng tin d 103 benh nhan (78%) vdi thdi gian theo doi it nhit la 10 thang. Thdi gian sdng trung binh ciia nhom nghien ciiu la 15,96 thang, benh nhan sdng dai nhat la 31 thang, ngan nhat la 1 thang. Ty le song sau 1 nam la 46%., sau 2 nam la 14%.
Ddi chieu vdi phuong phap tiem cdn ciia Mai Hdng Bang [4] la 14,2 thang (30 thang theo doi), phuong phap tiem hda chat day chang trdn ciia Le Tuyet Anh [3] la 11,3 thang thi ti le ciia chiing tdi ciing tuong tu. Vdi 25 benh nhan van con sdng tai thdi diem kiem tra thi deu khoe manh, sieu am kiem tra thay u nho di, khdng cd bieu hien di can. Nghien ciiu niit hda chat ddng mach gan cho nhirng trudng hgp ung thu gan tren 5 cm ciing co thdi gian sdng them trung binh 13 thang [2] .
Chiing tdi phan loai ket qua xa dua vao tinh trang song, chet va su phat trien ciia u.
Nhung benh nhan cdn sdng, khde manh, khdng cd bieu hien u lien trien tiep (tang kich thudc, phat trien ngoai gan...) dugc coi la ket qua tot (chiem 32%.); nhirng benh nhan cdn sdng nhung cd bieu hien u tien trien dugc coi la ket qua trung binh (59%o); nhiing benh nhan da chet do u tien trien tiep tuc sau niit mach dugc coi la ket qua xau (9%).
V. KE'T LUAN
Vdi cac trudng hgp ung thu tl bao gan khdng cdn chi dinh phau thuat thi niit dpng
66
NGOAI KHOA SO OAC BI^T 1, 2, 3/2012
mach gan mang lai ket qua nhat dinh vdi thdi gian sdng trung binh tinh tdi thdi diem thdng ke la gan 16 thang, ty le sdng sau 1 nam dat 46%o. Ty le benh nhan dat ket qua tdt chiem 32%.
Day la phuong phap dieu trj an toan, de thuc hien, khdng cd bien chiing nang sau thii thuat, hau het benh nhan ra vien ket qua tot.
Cd 3 trudng hgp nang xin ve coi nhu tu vong sau thii thuat (3%).
TAI LIEU THAM KHAO.
1 Huynh Diic Long, Thi Van Gung, Thai Ngoc Dang, Tran Ngoc Danh, Pham Ngoc Hoa, Dang Van Phu-dc (2000).
LTng dung phuang phap gay nghen mach ket hgp vdi tiem thudc hda tri (TOCE) hong dieu tri ung thu gan nguyen phat, Bao cao 201 trudng hgp tai Benh vien Chg Ray, Thdi su Y Dugc, Hdi Y Dugc TP. Ho Chi Minh, tr. 233-237.
i. Le Van Tru'dng (2006). Nghien ciru dieu tri ung thu bilu mo te bao gan kich thudc tren 5 cm bang phuong phap tac mach hda dau chpn Igc. Luan van tien sT Y hgc.
3. Le Tuyet Anh (1998). Budc dau danh gia kit qua dieu tri ung thu gan bang hda
chat 5- Fluorouracil va Doxorubicil tai khoa tieu hda benh vien Bach Mai, Luan van tot nghiep cdng nhan bac sy chuyen khoa cap 11. Trudng dai hgc Y khoa Ha Ngi, 1998.
Mai Hong Bang (1999). Nghien ciiu dieu tri ung thu bieu md te bao gan bang phuang phap tiem ethanol qua da vao khdi u gan dudi su hudng dan cua sieu am, Luan an Phd tien sT khoa hpc Y Dugc, Hpc vien Quan y, Bd quoc phong.
Ernst O., Sergent G., IMizrahi D., Delemazure O. Treatment of hepatocellular carcinoma by transcatheter arterial cheraoembolization: comparison of planned periodic chemoembolization and chemoembolization based on tumor response, Am J Roentgenol 1999 Jan;
172(1): 59-64
J.P Benhamou, S. Erlinger (2000).
Cirrhoses, p.89-93, Tumeurs malingnes du foie, p.94-99, Maladies du foie et des voies biliaires, Flammarion.
Llovet J. M, Burroughs A, Bruix J (2003), Hepatocellular carcinoma. Lancet 362: 1907-17.
