T?p chi Tai MQi Hpng Viet Nam -Volume (59-19). N°1 - March, 2014
NANG ONG GIAP LlTOfl. NHAN M O T TRlTCOVG HOP UNG THIT Bl£U MO GIAP THE NHU TRONG NANG 6 N G GIAP Ll/Ol
Nguyin Van Himg% Phiing Tien Hiiu**. LeMinh Ky**
TOM TAT
Tdn du nang dng gidp ludi thuang tgo hhdi u ndm phia truac ciia viing cd giifa. Tuy nhien, hien tuang biin ddi dc tinh cua tdn thuang ndy rdt hiim gap. Chiing tdi gidi thi$u trudng hpp ung thu biiu md gidp thi nhu trong nang dng gidp lu&i a binh nhdn nir 30 tudi khdng biiu hiin trieu chung ciia khdi u dc tinh, tgi Vien Tai Mui Hpng Trung uang.
Nghiin cuu hdi cuu chup cat ldp vi tinh, md binh hpc vd hda mo miin dich b$nhphdm sau phdu thudt da phdt Men ung thu biiu md gidp the nhu khdng di cdn hgch Benh nhdn dupc theo doi ldm sdng vd siiu dm vimg co cho thdy Idiong cd ddu hieu cua binh.
Tit khda: Nang dng gidp luai, ung thu bieu md gidp the nhu, tuyin gidp.
Summary
Thyroglossal duct remnants are the most common midline neck swellings, but malignancy arising in them is a rare finding. We are report a case of papillary thyroid carcinoma of in a 30-year-old female without asymptomatic signs and are clinically diagnosed as thyroglossal duct cyst at the Center Otorhino-laryngalogy hospital.Retrospective study of CT scanner and histopathology and immuno-histochemistry present primary papillary thyroid carcinoma of thyroglossal duct cyst. Patient was followed up over twelves months free of disease.
Key words: thyroglossal duct cyst, papillary thyroid carcinoma, thyroid.
Nang fing giap luoi la hien terong benh "*" ^ ^ " *5°/») ^ong sfi ung thu biSu mo ly do tfin du fing giap luoi cua thcri ky bao ^Ijy™ S'f? ^ ^' « "™S giap - lum [1], thai, thuong gap a ducmg cfi giOa cua tee P ] . Do khong co hpac ft teieu chung Imi nho. Benh chiim tcji 70% cac nang bim f^^ * " ° ° 8 khong dac hiSu nen ung thu sinh cua vimg cfi giira va khoang 7% dan '''^" '"° 8'^P ''.""S nang ong giap luoi sfi. Ung thu biSu mfi giap cua nang fing *"<"? duoc chan doan teen lim sang la giap - luoi, flieo Y van, chi chifim khoang °™8 ong giap luoi. Nghien ciiu mo benh 1% cac ung thu biSu mfi cimg vi tei. Mot sfi '"'= ™9t each ty mi la phuong phap, chan nghien ciiu som nhit vfi tfin thuong ung thu * ° ^ "^^^ "^^ •**' * o ung thu bi6u mo bifiu mfi giap cua fing giap luoi duoc Pap cua vi hi nay.
Brentano (nam 1911) va Uchermann (nam Bao cio ca b?nh I9I5) de cap (dan theo I). Thucmg gap typ
Benh nhan Vii T. T., nG, 30 tufii.
•B6 mon GPB-DHY Ha Noi Vao vien Tai Miii Hpng Trung uong
••BV TMH tnmg uong ngay 15/08/2012 vol ly do v4o vien cfi kh6i Nhan bai 5/1/2014. DuySt in 15/1/2014.
56
Tgp chi Tai MQi Hpng Vi^t Nam - Volume (59-19). N°1 - March. 2014
u 6 vimg CO trudc, giGa; ra vien ngay 22/08/2012.
B$nh sit: Benh nhan tinh co phdt hifin khoi u 6 vimg co truoc, giiia cdch ngay vdo vi^n khodng 06 ndm. Luc ddu, khfii u nho sau to ddn Ifin, di dpng theo nhip nuot.
Benh nhan khong cd cdc trifiu chumg nhunufit vucmg, nuot dau, kho tho. Benh nhdn chua dupc difiu tri gi truoc khi dfin Vi?n Tai Mui H p i ^ Trung uong.
Khdm ldm sdng:
- Toan than: mgch: 80L/P, nhiet dp:
36,7"C, huyfit dp: 110/70mmHg.
Dau hieu c a nang: Bfinh nhan khfing dau viing khfii u truoc co, khfing nufit vufifng, khfing nuot dau, khfing kho tha.
- Thuc the: vung cfi trufic, giiia co 01 khfii u nang, lunh tron, kich thufifc 2 x 3cm, m^t d§ mfim, nam sau vimg xuong giap mfing. Khfii u di dpng theo binh difin ngang. Khi nufit hodc the lufii, khfii u nang di dpng dfi dang hon.
Sieu dm: Co khoi tdng dm fif vung gifia CO, phia duoi xuong mfing.
Tuyfin giap binh thuong, khfing CO h^ch cfi.
Chdn dodn ldm sdng kit hap sieu dm:
U nang gidp luoi.
Diiu fr/.Bfinh nhdn dupc phdu thuat theo phuong phap Sistrunk. Rach da theo nip ldn cfi trfin, hoc tdch u nang va duong r6. Do duong ro bdm vdo mat sau than xuong mong nfin phau thuat vifin da tien hdnh cdt than xuong mfing, sau do, tifip tuc phlu thuat hoc tach Ifin trfin va ra sau toi g ^ lo tit vd da ldy hfit duong ro cung khfii CO canh duong ro. Khong chi dinh xa tri nhung yeu cdu bpnh nhdn hang thdng den
Ididm lai trong 05 thdng ddu sau ra vifin, tifip theo 05 thang mpt ldn trong nam sau.
Chdn dodn md binh hpc sau phdu thugt: ung thu bifiu mfi gidp the nhu. Kfit hpp ldm sang, chdn dodn hinh anh va hoa mo mien dich voi cac ddu dn nhu CK, thyro-globulin, T T F l , CK7, CK19, CK20, Cyclin D l , Chromogranin, SI00 cho phep khang dinh la ung thu bifiu mfi giap thfi nhii nguyen phat cua nang fing gidp luoi.
Anh 1: Ung t h u tuyen giap the nhii trong nang giap - luoi Trong nang co cac dam cau iriic nhii (mui
ten) Md sfi GPB: B5100. H E x 100
.!^}il^^
Anh 2: Ung t h u tuyin giap thfi nhii trong nang giap - luoi Cac cdu tnic nhu {mui ten mdu vang) vd
cau canxi (2) Ma sfi GPB: B5100. HE x 200
Tap chi Tai MOi Hpng Vi#t Nam - Volume (59-19). N°1 - March, 2014
W^^'
, ' / ' ^ ^ ^ ^ ^ - ^
* ' - • V^'*^v. "
Anh 3: Ung thir tuyen giap the nhii trong nang giap - Itfoi
Nhan te bao u ducmg tinh voi Cyclin Dl Mas6GPB:B5100. x400
.^.y^ ^-
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..iJV-i-'H'jVi,
•y.'2--' '..*:'- t
" , - ' ' / " > • -»^<,.^ •
•T*. * ^ ' ."-S'^a V t» . i t .-• .. ' J » • *-
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Anh 4: Ung thu tuyen giap the nhii trong nang giap - lir&i
Nhan tfi bao u dm tinh voi CK20 Mas6GPB:B5100. x200 BAN LUAN
Nang fing giap luoi la mpt loai di tich bat thudng dang tui ihita, co ngufin gfic lfi tit bdo thai va nam a duong giira. Khoang 60 -70% cdc nang bam sinh vung cfi la nang fing giap luoi [3],[4].
Cdu tnic nang va xoang co thfi tim
thay nam dpc theo duong di cua ong giap Iu6i. Cdc nang nay phat trifin trong thoi I^
tuyin giap di chuyfin tiit vi tri day luoi dfin vi tri binh thuang ciia no. Nang nam 6 vi tri ducmg giira cfi, thuong phia duoi xuong mong. Duong ro co the g|p khi nang bi bpi nhifim.
Nang ong giap luoi cimg thuong gfim 2 nang giong nhu nang khe mai^. Theo rapt n ^ f i n ciin [1] cho thay trong sfi 1.534 ca nang ong gidp luai, tac gia da phat hifin 67% benh nhan co cau tnic nang va 33% la duong ro.
Gan 90% nang fing giap luoi nam o duang CO giiia; tuy nhifin, cfi thfi mpt sfi truong hpp chiing lai xudt hifin 6 duong canh giiia nhung hdu hfit thuong a ben trdi. Nhin chung, khodng 73,8% nang nam duoi xuong mong, 24,1% or trfin xuong mong va 2,1% o trong luoi. Theo Spinelli va cpng su (ddn theo 1), trong sfi 154 khfii o CO ciia tre em co 17 (26%) ca la nang ong giap luoi, trong khi do nang khe mang thuang It gap hon.
Nang ong giap luoi thuong co ducmg kinh tir 0,5 - 4 cm. Chiing co thfi chi m§t nang hoac nhifiu nang va thuang chiia chdt dich nhay a truang hap nang_ khong bi nhifim khudn. Khi bi bpi nhifim, dich nang tro thanh djch nhdy - mu. Bifiu mo lot vach nang co thfi rdt khac nhau tiiy theo timg ca bpnh, tham chi ngay ca trfin cung mpt n^nh cat mo bfinh hpc. Thuang gap nhdt bifiu mfi try hoac chuyfin thanh bifiu mfi dang khoi xfip nhifiu tdng co hoac khfing cfi Ifing chuyfin, chifim toi 50 - 60% cdc truong hpp [5],[6]. Nfit lympho nam trong vach nang gap trong 15 - 20% truang hpp. Tuy nhifin, khac voi nang fing gidp luoi, tfin thuong nang khe mang thuong gap nfit lympho hon (75% ca) [3],[7]. Khi nang fing giap luoi cfi
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Tgp chf Tai MQi Hpng Vifit Nam - Volume (59-19). N°1-March, 2014
hifin tupng dj san vay kfim cdc nfit lympho trong vach se kho phan bifit voi nang khe mang (nhupm hoa mfi mifin dich voi thyroglobulin se giiip phan bifit dfi dang hon). Ty lfi g|.p mfi giap lac cho ndm ke can vai tfin thuong chifim khoang 3 — 20%
trucmg hop [8]. Su khac biet nay co the lien quan toi dp rpng cua viing mfi quanh tfin thuong dupc ldy di hoac lien quan toi so lupng cdc manh cat mo hpc (cat hang loat mdnh mfi). Cdu tnic cua mfi giap lac cho thuong gfim cdc nang nho, dfing nhat, chiia it chdt keo. Cdu tide vi nang thuang xen voi nhiing spi co vdn ciia luoi.
Trong thuc tfi, hifin tuang co khfii a cfi la dau hieu ldm sang Tai miii hpng thuong g£ip. Tuy nhifin, vific chan doan xac dinh, dac biet Id phan bifit giiia tfin thuong lanh tinh vd dc tinh lai thuong khd phuc tap.
Vdn dfi quan trpng la can sur dung mfit cdch thich hop cac tham kham tfing hop da nganh dfi c h ^ doan xac dinh.
Nang ong giap luai lanh tinh thuorng la mfit kh6i khong coi trieu chiing lam sang vfii mat dp mfim, chac hoac ciing fir duong cfi giira - trufic va thuong di dpng. Tfin thuang nang fing giap luai dupc nghi ngo dc tinh khi co mdt dp ciing, khfing di dfing va bfi mdt khfing deu.
U ac tinh phat trifin tir nang fing giap luoi CO thfi CO 2 ngufin gfic [6],[9]:
- Ung thu bieu mfi tao mfi giap xudt phat tu mfi giap bao thai tfin du trong nang/6ng giap luoi (chifim khoang 80% u ac tinh ciia vi tri nay).
- Ung thu bifiu mfi vay xuat phdt tur cac tfi bao tru cua fing gidp luoi bi di sdn vay.
Ung thu bifiu mo xuat hifin trong nang ong giap luoi Id mfit tfin thuong rat hifim g^p, chifim khodng 1 - 2% cac nang fing
gidp luoi dupc cat bo [1], [8]. Tror^ nhung huong hpp nay, cdu hoi thucmg dupc dat ra la lieu do co phai la u nguyen phdt cua nang fing gidp luoi hay la di can tu tuyfin giap toi. Tlieo mpt sfl nghifin cuu cho thay khodng 80 - 94% cac u ac tinh nguyen phdt dupc phat hifin trong nang ong giap luoi la ung thu bifiu mo co bdn chdt mo tuyfin gidp.
Mfit sfi typ mfi hpc thuong gap cua loai ung diu nay gfim typ nhii (75 - 80%), typ hfin hpp nang ~ libu (6,9%), typ tfi bao vay (5,2%), typ nang (1,7%) vd typ ung thu bifiu mo myfin (1,7%) [1], [5], [6], [2].
Vfi mfi hpc, mfi ung thu co cau tnic nhli, nam trong long nang ong gidp luoi voi vach nang ro va duoc lot mfit phdn boi bieu mfi dang vay. Cdu tnic mfi hpc cung cac bang chung vfi hoa mfi mien dich da chiing minh bdn chdt mfi giap cua u ndy, cu thfi:
Thyroglobulin (+), TTFl (+), Cyclin Dl (+), CK19 (-), CK7 (+), CK20 (-), Chromogramn (-), SI00 (+).
Difiu thii vi lien quan can xac dinh typ ung thu bifiu mfi nhii co ban chat mfi giap nay la xmg thu nguyen phat cua nang fing giap luoi hay la u di can (thii phat) tu myfin giap toi? Nho su lien lac thucmg xuyfin voi nguoi bfinh, viec khdm benh mpt each todn difin da dupc thuc hifin nhdm loai bo kha nang ung thu tuyen giap nguyen phat.
Chung tfii da tham kham ky lam sang ciing cac xet nghifim khac, dac biet Id chan doan hinh anh voi sifiu am va cat Ififp vi tinh da cho phep xac dinh myfin giap khfing phai la vi tri ung thu nguyfin phat.
Bifiu hien lam sdng ciia ung thu bifiu mfi cua nang fing giap luoi thuomg khfing trifiu chiing va trong hau het cdc truong hpp khong thfi phdn biet dupc voi nang lanh tinh nfiu chi can cii vao trieu chiing lam sang [4],[6]. Ung thu bifiu mo cua nang ong
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Tap chi Tai MQl Hpng Vifet Nam - Vplume (59-19). N°1 - March, 2014
giap luoi thuang gap o nguoi Ion trong khi rdt hilm gap 6 tre em mac dii nang ong giap luoi CO thS xuit hien ngay tvt khi sinh [7],[8],[9]. Thuang thi u ac tinh loai nay phat triln rit chim co the toi 20 nam hoac hon va truac khi di can xa, chiing thuang Ian tdi hach khu vuc (dia phuong). Khoang 17% ung thu bilu mo nang 6ng giap luoi lan vao mo mem xung quanh va chi khoang 1,3% CO di can (ty le nay thip hon so vcri ung thu cua tuyin giap) [I],[2],[8].
M6t s6 dau hieu Iam sang co the nghi ngo tinh chit ac tinh cua nang la tin thuang cung, chic, to nhanh, be mat khong deu, it hoac khong di dpng hoac neu dong thoi co bach vimg co xuat hien [2],[6]. Truong hpp chiing t6i phat hien ung thu bieu mo trong nang 6n^ giap luoi voi can tnic nhii co cau canxi dien hinh, dupc phu boi cac te bao bieu mo tru hoac khoi vuong co nhan Ion khong dien hinh ro, nhan sang (dang thiiy tinh mo) va hinh anh the gia vui trong nhan te bao u. Gia the vui trong UTBM tuyen giap the nhii thuong bat mau toan.
Theo cac nghien cuu, thanh phan nang giap lac cho trong vach nang ong giap luoi moi la khoi thiiy ciia ung thu bieu mo giap chu khdng phai la bieu mo vach nang png giap luoi tao ra loai ung thu nay. Nhin chung, rat hiem dau hieu lam sang cho phep nghi ngo ton thuong ac tinh ciia nang ong giap luoi truac phau thuat. Do vay, viec xet nghiem mo benh hpc sau phau thuat la bat bupc vdi cac benh pham phau thuat trcng do co u nang ong giap luoi.
Thudng ung thu bieu mo giap trong nang ong giap luai it gap di can hach hon so voi ung thu bieu mo giap nguyen phat cua tuyin giap [3],[4],[8].
Tai lifu tham khao
1. Cardesa A., Slootweg P.J., (2006).
Pathology of the head and neck.
Springer. 264-269.
2. lynen I., Bozkus F., S,an I., Guldu E, (2011). Papillary carcinoma of the thyro-glossaj duct cyst in a 12-year-old girl. International Joumal of Pediatric Otorhino-Iaryngology Extra 6: 92-94 3. Lin Y-H., Tsai S-T., Ho H-C, (2008).
Primary papillary carcinoma of a thyroglossal duct cyst. TZU CHI MED J. 20 (2): 150-153.
4. Cmcik H., Dogru S., Yihnaz I., Qetin B., Gungor A., (2005). Papillary carcinoma in thyroglossal duct cyst; report of two cases. Haydarpasa Egitim Hastanesi, KBB, ISTANBUL, Tiukiye. JCBB- Forum, 4(2): 95 - 97.
5. Al-Sindi K., AI Hilli F., Veena Nagaraj v., Hameed T., (2008). Papillaiy carcinoma of thyroglossal duct cyst.
Bahrain Medical Bulletin. 30(3): I - 8.
6. Zivaljevic V., Bozic V., (2006).
Papillary carcinoma in thyroglossal duct cyst. Acta chir belg. (106): 252-253.
7. Erydmaz M.A., Toy H., (2011). Primary Papillary Thyroid Carcinoma in The Thyroglossal Cyst. Over Eighty Months Follow Up. Eur J Gen Med 8(1):69-7I.
8. Balalaa N., Megahed M., AI Ashari M., Branicki F., (2011). Thyroglossal duct cyst papillary carcinoma. Case Rep Oncol. 4:39^3
9. Chao C-S., Lin S-Y., Sheu W. H-H., Ho W.L., (2002). Thyroglossal duct cyst with papillary carcinoma. Chinese Medical Joumal (Taipei); 65:183-186
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