DIENDAN Y HOC
Nghien cu'u khoa hpc
Ap dung phan loai nguyen nhan
u trung that theo bang phan loai cua To chCrc Y te The gidi nam 2004
Nguyin Thanh H6i*, Ng6 Quy Chau*
TdM TAT
Cd nhiiu each phin loai u trung thdt: theo vi trfgiai phiu, dinh khu trung that theo lim sing, theo Td chiic Y ti The gidi (WHO) nam 2004 va theo Shields T.W. Muc ti§u nghien cdu; ^p dung phin loai nguyen nhin u trung thit theo WHO (2004). S6i tifong va phtfong phap nqhifen ct?u: nghiin ciiu tiin ciiu tai khoa H6 hip, binh viin Bach Mai trong thdi gian tCr thang 05/2007 ddn thing 02/2009 trin cac binh nhin dugc chin doan xae dmh u trung that trin phim chup cat Idp vi tfnh (CLVT). Tdt ca cac binh nhin diu dugc tiin hinh sinh thii't khdi u trung thdt xuyin thanh nguc dudi CLVT. Chi djnh npi soi ling nguc khi binh nhin khdng cd chin doan md binh hgc qua STXTN, hach thugng ddn, mang phdi. K6t qua nghifen cilu; cd 109 binh nhin (nam: 80; nd: 29), tudi trung binh: 47,7 ± 15,6. Cac nhdm nguyin nhin theo WHO 2004 gap trong nghiin ctiu bao gdm: u tuyin lie (23 binh nhin), ung thu biiu md tuydn iic (23 binh nhin), u td bio mim (2 binh nhin), u lympho trung thi't (11 binh nhin), cac khdi u trung md tuyin lie vi trung thi't (6 binh nhin), kin trung thi't (7 binh nhin), ung thu di can trung thdt (23 binh nhin). Nguyin nhin khae: 14 binh nhin (lao:9 binh nhin, sarcoidosis: 4 binh nhin, budu giip lac chd: 1 binh nhin). K6t luan; u tuyin lie (u tuydn lie vi ung thu biiu md tuydn lie) li nguyin nhin thudng gap nhit (42,2%) cda eac trudng hgp u trung thi't. Cac u linh tfnh trung thi't (u tuydn lie typ A, qua sin tuyin lie, u md trung thi't, u nang bi trung thi't, ken trung thdt, bii'u giap lac chd) cung chiim ty le dang ki (25,7%).
* Khoa Ho Hap - Benh vien Bach Mai
Nghien cu'u khoa hpc
I. DAT VAN DE
Trung that II viing nam giGa Idng ngyc, dugc gidi ban bdi cic tdi ming phdi d xung quanh.
Trung that dugc chia thanh 3 khu vyc: trung thit trudc, tmng that giira v l trung thit sau[6][8].
C6 rat nhiSu nguySn nhan gay u trung thit nhu:
u tuySn gilp, u tuyen uc, ken khi quan, u lympho, bach di can, u pbS quan, u quii... Tiiy theo vi tri, u trung that cd thS cd cac biSu hien lam sing nhu:
hdi chirng chen ep tmh mach chii tren, chen ep day than kinh quat ngugc, day giao elm cd, chen ep thuc quIn [6] [8].
DS chan doln xlc dinh hdi cbung trung that, bSn canh viec tham khIm lam sing, can dya vao cle tham dd chan doln hinb anh nhu: chyp X quang phdi thang, nghiSng, chup cat ldp vi tinb (CLVT) ngyc... De xlc dinb chac chin ban chit ciia cle khdi u trung that thudng can sinh tbilt khoi u trung that nhu sinh tbilt qua phiu thuat md trung that, ndi soi trung that, ndi soi Idng ngyc, chgc hut kim nhd xuySn tblnb ngyc, khi quan hoac thyc quan hoac sinh thiSt xuySn tblnb nguc dudi hudng dan cua chup CLVT [6] [8].
Co nhiSu cleh phan loai u trung that: theo dinh khu giai phau [4][2], dinh khu lam sang [6], theo Td chuc Y t l Thi gidi nam 2004[6] v l theo Shields T.W [8]. Tuy nhiSn, hien chua cd nghiSn cuu nIo d Viet Nam dS cap tdi ty IS cac khdi u trung that trudc phan thuat, do vay nghiSn eun tiSn hinh nham myc tieu: nghiSn eun ty IS cac khdi u trung that theo phan loai ciia Td chirc Y t l ThS gidi nam 2004.
II. DOI TUffNG VA PHVaNG PHAP NGHIEN CUU
1. Doi tmmg nghien cuu
CIc benh nhan dugc cbin doan xlc dinh u trung thit trSn phim chup CLVT tai khoa Hd hip, Benb vien Bach Mai trong thdi gian tir thing 05/2007 din thing 02/2009.
2, Phuxmg phap nghien ciiu
NghiSn ciru md ta trSn 109 benb nhan co khdi u trung that diSu tri tai khoa Hd hip, Benh vien Bach Mai trong thdi gian tir thing 05/2008 - 02/2009.
Tat c l c i c benh nhan dSu dugc tham kham lam sang, lam c l e xet nghiSm co ban, chup X quang phdi, CLVT phdi. STXTN dugc chi dinh cho nhirng trudng hgp khdng cd chan doln md benh hgc u trung that vdi c i c ky thuat ndi soi phS quan, sinh thiet bach thugng ddn hoac ming phdi (cho nhirng benh nhan cd bach thugng ddn, trin dich m i n g phdi). Nhirng trudng hgp van chua cd chan doln qua tat ca cle bien pblp tham dd nSu trSn dugc chi djnh ndi soi Idng ngyc.
CIc thong tin ghi nhan bao gdm:
- Thdng tin vS nhan khau hgc: tudi, gidi, nghe nghiep, dia cbi.
- Dac diSm tdn thuong trSn phim chup X quang va cat ldp vi tinb phdi: vi tri, kich tbudc khdi u, dac diSm khdi u, ty trgng kbdi u, cle tdn thuang nhu md phdi, bach trung that.
- KSt qua tS bio hgc, md benh hgc tdn thuong qua sinh thiet xuySn thInh ngyc.
- Ap dung phan loai u trung thit theo WHO 2004 [6].
- Xir ly sd lieu trSn phin mem SpSS 15.0.
III. KET QUA NGHIEN CITU
1. Tudi va gidi cua cac benh nhan
Trong sd 109 benh nhan tham gia nghiSn cuu, cd 80 benh nhSn nam v l 29 benh nhan nir.
Tudi trung binb cua c l e benh nhan: 47,7 ± 15,6.
Trong dd, tudi trung binh cua c l e benh nhan u tuyen uc: 49,5 ± 14,4, tudi trung binb cua ung thu biiu md tuySn uc: 50,6 ± 14,1. Tudi trung binh cua c i c benh nhan ung thu phdi di can trung thit: 54,3 ± 9,9.
So 44 (Thang 09/2009) Y HOC LAM SANG I 4 5
DIEN DAN Y HOC
Nghien cii'u khoa hpc
2. Trieu chiing lam sang va X - quang u trung that
Bdng 1. Trieu chieng Idm sdng cua cdc benh nhdn u trung thdt
Trieu chiing n Ty le %
Trieu chimg cff ndng Dau ngijc Ho Khac dom Ho ra mau Kho thd Noi khan Nuot nghen Nhuge ca
64 54 3 8 24 20 17 6
58,7 49,5 2,8 7,3 22,0 18,3 15,6 5,5 Trieu chihtg todn than
s6t Gay sut can Hach ngoai bien Dau xircmg khop Ngon tay, chan diii trong Mong tay khum Vu to mot ben
17 21 19 12 5 4 1
15,6 19,3 17,4 11,0 4,6 3,7 0,9 Trieu chimg thuc the
Hpi ehung chen ep tinh mach chu tren Hoi ehung ba giam
Xep long nguc mot ben Hoi ehung Pancoast Tobias Hoi ehung Claude Bernard Horner
21 9 3 2 1
19,3 8,3 2,8 1,8 0,9 Cdc trieu chiing vd hoi chiing can ung thu
Hoi chiing Piere Marie Viem da ca
2 2
1,8 1,8
Nhan xet: cle trieu cbung co nang gap phd biSn bao gdm ho (49,5%) vl dau ngyc (59,7%). CIc trieu chirng do chen ep cle tblnb phan tmng that gap vdi ty IS khdng cao: ndi khan: 18,3%, nudt ngen: 15,6%, hdi ehung chen ep tinh mach chii trSn: 19,3%. Nhuge co gap d 5,5% sd benb nhan.
Bdng 2. Vi tn khoi u trung thdt tren phim chup CLVT
Vi tri khoi u Trung that trudc Trung that giCra Trung that sau
Trung that trudc + giira Trung thit giira + sau Tren ca 3 khoang trung that
n 45 30 4 21
2 7
Ty le % 41,3 27,5 3,7 19,3
1,8 6,4
Nhdn xet: cic khdi u tmng thit trudc va tmng thit giiia chiSm da sd, u tmng that trudc: 41,3%, u trung thit giiia: 27,5%. NhiSu benb nhan cd khdi u tmng thit nlm trSn nhiSu khoang tmng thit khlc nhau: 27,5%.
Nghien ciiii khoa hoc
Bdng 3. Phdn nhdm u trung thdt theo WHO 2004
Typ mo benh hoc n Ty le %
U tuyen iic lanh tinh U tuyen ire typ A
U tuyen uc typ AB U tuyen ire typ B1 U tuyen irc typ B2 Qua san tuyen uc
3 4 4 10
2
2,8 3,7 3,7 9,2 1,8 Ung thu bieu mo tuyen lie
Ung thu bieu mo tuyen Ung thu bieu mo te bao nho Ung thu bieu mo te bao vay Ung thu bieu mo
Ung thu bieu mo than kinh noi del
8 6 4 4 1
7,3 5,5 3,7 3,7 0,9 Cdc khoi u te bdo mam
U quai U te bao mam
1 1
0,9 0,9 Cdc khoi u lympho trung thdt
U lympho khong Hodgkin U lympho Hodgkin U lympho
U tuong bao
7 2 1 1
6,4 1,8 0,9 0,9 Cdc khoi u trung mo tuyen lie vd trung thdt
U than kinh ngoai vi U te bao Schwann U Ganglioma U ma trung that U nang bi trung that
2 1 1 1 1
1.8 0,9 0,9 0,9 0,9 Ken trung that
Ken phe quan Ken tuyen giap Ken trung that
1 1 5
0,9 0,9 4,6 Cdc khoi u trung that khac
Viem lao Sarcoidosis Bieu giap lac cho
9 4 1
8,3 3,7 0.9 Ung thu phoi di cdn trung thdt
Ung thu bieu mo tuyen Ung thu bieu mo te bao nho Ung thu bieu mo vay Ung thu bieu mo te bao Idn Ung thu bieu mo khong djnh typ Tong
9 9 2 1 2 109
8,3 8,3 1,8 0,9 1,8 100,0
Trong tdng sd 109 benh nhan u trung thit, u tuySn uc: 23 benh nhan, ung thu biS'u md tuySn ire: 23 benh nhan, u lympho trung thit: 11 benh nhan, ken trung thit: 7 benb nhan, ung thu phdi di cin trung thit: 23 benh nhan, u tS bio mim: 2 benh nhan, cic khdi u trung thit khac: 14 benh nhan.
So 44 (Thang 09/2009) Y HOC LAM SANG I 4 7
DIEN DAN Y HOC
Nghien cdu khoa hpc
IV. BAN LUAN
Trung thit la khu vyc khd thuc hien cle tbim do chin doln. CIc tham dd chan doln xlc dinh nguySn nhan u trung thit hien dugc ap dung bao gdm: sinh thiSt u trung thit xuySn thanh phS quan hoac thyc quIn qua ndi soi, ndi soi long nguc, ndi soi trung thit hoac phau thuat md trung that. Tuy nhiSn, sinh thiSt khdi u trung thit xuyen tblnb phe quan hoac thyc quIn thudng dugc tien hanh dudi sy hudng dan ciia he thdng siSu am qua ndi soi, he thong nly rat dat tiSn v l hien chua dugc trang bi phd biSn d Viet Nam, bSn canh dd kim diing cho sinh thiSt co gil thInh k h i cao. Ndi soi long ngyc vl phau thuat md trung that cd hieu qua cao trong chin doln nguySn nban u trung that. Tuy nhiSn, vdi ca hai ky thuat nly, benh nhan dSu phii chiu thSm cude phau thuat.
Ky thuat sinh thiet xuySn thanh ngyc da dugc Ip dung d Viet Nam tir lau. Trong thdi ky dau, chu ySu II chgc hiit cic khdi u phdi dudi hudng dan ciia X quang[l]. Nam 2002, Doln Phuang Lan va cdng sy tiSn hanh chgc hiit khdi u phdi dudi CLVT, cho hieu qui chan doln dat 69%, sau do da c6 nhiSu de tai nghiSn cuu ciing thay ket qui tuong ty [3][1]. Tuy nhiSn, hau nhu chua cd tie gia nao d Viet Nam dinh gil vS hieu qua chan doln cua ky thuat STXTN trong chan doln u trung that. Trong nghien ciiu, chiing tdi tiSn hinh trSn 109 benh nhan da dugc chan doln u trung that trSn phim chup CLVT ngyc, qua sinh thiSt cbung tdi da lay dugc dii benh pham cho chan doln md benh hgc d 102 benh nhan, 7 benh nhan cdn lai ehung tdi chi hiit dugc dich, djch nay chiing tdi da gui lam cic xet nghiem dm bang cbung ciia nhiSm lao (PCR- BK, cay MGIT), te bao hgc, nhugm soi tim san, tuy nhien deu am tinb. KSt bgp vdi hinh anb X -
quang, phim chup CLVT va hinh anh xep holn toan cua nang sau chgc hut, chiing tdi chin doan day II ken trung that. Trong sd 102 benb nhan cd du benh phim eho chan doln md benh hgc, chiing tdi thu dugc chan doln chac chan trong 96 benh nhan, 6 benh nhan cdn lai, chiing tdi cd chan doln md benh bgc u trung that nhd vio sinh thiSt bach:
02 benh nhan, sinh tbiSt ming phdi: 01 benh nhan, v l ndi soi long nguc: 3 benb nban.
XSp loai u tuySn ire theo Td chuc Y tS ThS gidi 2004 [6], chiing tdi nban thiy cac khdi u tmng thit thudng gap bao gdm u tuyen uc 23/109 ca (21,1%), ung thu bieu md tuySn uc 23/109 (21,1%), ung thu phdi di can trung thit 23/109 (21,1%), u lympho trung thit 11/109 (10,1%). CIc khdi u trung thit khlc cung gap vdi ty IS khdng nhd: 14/109 (12,8%). Trong sd cic nguyen nhan u trung that, ty le u lanh tinh trung that chiSm ty IS dang kS, cic u lanh tinb trung that bao gdm: u tuySn uc typ A, q u i san tuyen ire, ken trung that, u lao hoac sarcoidosis bach trung that. Cac khdi u nly chiSm ty IS: 25,7%.
V. KET LUAN
Qua nghien ciru tren 109 benb nhan u trung that vdi muc tiSu xlc dinb nguyen nban u trung that vdi ky thuat sinh tbiSt eat xuySn thanh ngyc, cbung tdi nhan thay:
- Trong sd 109 benb nban tham gia nghiSn cuu, nam: 80 benh nhan, nir: 29 benb nban. Tudi trung binh: 47,7 ± 15,6.
- CIc trieu cbung lam sang thudng gap bao gdm: ho (49,5%) v l dau nguc (59,7%). Cac trieu chiing do chen ep cle thanh phin tmng thit gap vdi ty IS khdng cao: ndi khIn: 18,3%, nudt ngen:
15,6%, hdi chirng chen ep tmh mach chu tren:
19,3%. Nhuge co gap d 5,5% sd benh nhan.
Nghien cu'u khoa hpc
- Ty IS cle khdi u trung that theo phan loai cua WHO 2004: u tuySn uc: 23/109 (21,1%), ung thu biSu mdtuySn uc: 23/109 (21,1%), ung thu phdi di can trung thit: 23/109 (21,1%), u lympho trung that: 11/109 (10,1%), u trung md tuyen ire va trung thit: 6/109 (5,5%), u tS bio mim: 2/109 (1,8%).
CIc khdi u trung thit khlc: 14/109 (12,8%).
TAI Lieu THAM KHAO
/. Ngo Quy Chau, Dodn Thi Phuong Lan, Nguyen Thanh Hoi, Le Hoan (2005). "Nhan xet gid tri cua sinh thiet cat xuyen thdnh nguc dual huong ddn cua chup cdt lap vi tinh trong chan dodn dam maaphoi". Tap chi Yhoc thuc hdnh - Bo Y ti. 513. 230 - 235.
2. Ellis H, Nguyin Vdn Huy (2001). "Trung thdt". Gidi phdu hoc lam sdng. Nhd xuat bdn Y hoc Hd Not 46-70.
3. Dodn Thi Phuong Lan (2002). "Budc ddu tim hieu gid tri cua sinh thiet phoi cdt xuyen thdnh nguc dudi hudng ddn cua chup cdt ldp vi tfnh trong chdn dodn
cdc ddm md a phoi". Ludn vdn tot nghiep Bdc sy noi trii Benh vien. Trudng Dai hoc Y Hd Noi.
4. Trinh Vdn Minh (2007). "Trung thdt". Gidi phdu ngudi. Nhd xudt bdn Hd Noi. Tdp 2. 208 - 223.
5. BUI Xuan Tdm (1995). "Benh ly trung thdt". Benh ho hdp. Nhd xudt bdn Y hoc. 854-880.
6. Muller-Hermelink H.K, Engel P, Kuo TT, Str#bel PH, Marx A, Harris N.L, Muller P, Menestrina F, Shimosato Y, Asamura H, Masaoka A, Sobin L.H.
(2004). "Tumours of the thymus". Pathology &
Genetics Tumours of the Lung, Pleura, Thymus and Heart. World Health Organization Classification of Tumours. Chapter 3, 147-252.
7. Park D.R.Vallieres E. (2005). "Tumors and Cysts of the Mediastinum". Murray & Nadel's Textbook of Respiratory Medicine, 4th ed.
8. Shields T.W. (2005). "The Thymus". Lippincott Williams & Wilkins. General Thoracic Surgery, 6th Edition. 2347-2356.
[ „ , :
SUMMARY
APPLICATION OF W H O CLASSIFICATION (2004) IN DIAGNOSING MEDIASTINAL MASSES Objectives: there are many mediastinal masses's classifications such as: anatomy, clinical, WHO, and
Shields T.W 's classification. Purpose: this study was performed to apply WHO's classification (2004) in diagnosing mediastinal masses (MMs).
Materials and methods: a prospective study was conducted in patients (pts)with MMs based on radio- logical definition. We performed PTNB using coaxial technique, with either a 20 or 18-gauge core biopsy instrument for all of them. Thoracoscopy performed only after PTNB, peripheral lymph node biopsy and pleural biopsy (if indicated) failed to yield a diagnosis. Results: total 109 pts participat- ed in the study (male 80 pts, female 29 pts). Mean age was 47.7 ± 15.6. The causative groups of MMs were: thymoma 23 pts (21.1%); thymic carcinoma 23 pts (23.1%); germ cell tumor 2 pts (1.8%);
mediastinal lymphoma 11 pts (10.8%); Mesenchymal tumors of the thymus and mediastinum 6 pts (5.5%); mediastinal cyst 7 pts (6.4%); metastasis to mediastinum 23 pts (21.1%); and other diagno- sis 14 pts (12.8%) (tuberculosis 9 pts, sarcoidosis 4 pts, ectopic thyroid tumor 1 patient).
Conclusions: thymoma and thymic carcinoma were the most causes of MMs (42.2%). Benign masses (thymoma type A, hyperplasia thymoma, mediastinal cyst, tuberculosis, sarcoidosis) were consider- able causes of MMs (25.7%).
So 44 (Thang 09/2009) Y HOC LAM SANG I 4 9
