Tap chi Tai MQi Hpng Vi$t Nam -Volume (59-19). N°1 - March. 2014
NGHIEN c t r u ITNG DUNG VI PHAU THUi^T THANH QUAN LASER C02 TRONG DIEU TRI UNG THlT THANH QUAN
GIAI DOAN SdM
Li Minh ^, Hodng VU Giang, Nguyin Tiin Himg, Nguyin Quang Trung, iSng Xudn Thing, Nguyen Dinh phdc, Vo Thanh Quang. *
TOM TAT
Muc 0ch nghiin cuu: Budc ddu ddnh gid hiiu qud^ vi phdu thuat thanh qudn Laser C02 trong dieu tri ung thu thanh qudn giai dogn sdm. Ddi tteprng vd phmmg phdp nghien cim: nghien cuu md td timg truang hap cd can thiip. Ddi tupng: 25 binh nhdn bi ung thu thanh qudn giai dogn Tl, Ididng phdn biit tudi, giai tinh, duac diiu tri bang phdu thudt tit thdng 4.13 din thdng 9.13 Kit qua: 25 benh gdm 24 nam vd 1 nU. cd 22 truang hap TldNOMO, 3 truang hop TlbNOMO, tdn thuang ddy thanh mdt ben chua lan din mep trudc 15 truofng hap, cd 7 trudng hgp tdn thuang day thanh 1 ben cd lan din mep^ truac, 3 trudng hpp tdn thuang ddy thanh 2 bin cd lan din mep truac, 3 trudng hop cd tdn thuang lan den mep sau day thanh vd mdu thanh sun phiu. Md khi qudn dugc tiin hdnh trin 4 trudng hgp chiim 16% trong do 3 trudng hgp do khdi u lan ra mep sau, 1 trudng hpp do diin cdt rpng. Kit qud ria vet cdt an todn trin 100% trudng hgp. Khdng cd trudng hgp ndo dieu tri phdi hap tia xg sau md. Td chirc hgt phdt trien d di$n cdt tren 6/25 ca, trong do 2 caphdi cat td chuc hgt. Tdi phdt tai chd 1 caphdijrhdu thudt lgi bang Laser. Khdng cd trudng hgp ndo bien chung chdy mdu, khd thd. Kit lugn: Vi phdu thugt thanh qudn Laser Co2 chung td budc ddu cd hiiu qud tran§ dieu tri ung thu thanh qudn giai dogn sdm, b$nh nhdn trdnh dupc phdu thudt md, da so trdnh dugc md khi qudn, hgu phdu nh?
nhdng, it bien chimg. Cd thi thay thi cho mdt sd trudng hpp chi dinh phdu thudt md s\in gidp cdt ddy thanh. Kit qud ldu ddi cdn dupc theo doi thim.
SUMMARY
C02 laser laryngeal microsurgery for early glottic carcinoma
Aim of study: To evaluate the primary results ofC02 laser laryngeal microsurgery for laryngeal cancer at early state. Patients and methods: 25 patients with laryngeal cancer at Tl stage, age from 49 to 76, were treated by C02 laser laryngeal microsurgery, from Apr. 2013 to Sep. 2013, at ENT National Hospital, Ha Not Results: There were 24 males and 1 female, 22 cases were at TlaNOMO stage, 3 cases TlbNOMO, the anterior commissure was involved in 10 cases, the two vocal cords were involved in 3 cases, the posterior commissure was involved in 3 cases. Tracheostomy was done in 4 cases (16%). The marginal security was good in all cases, no severe complications such as haemorrhage, dispnea was noted. Granuloma post-op was noted in 6 cases. One relapse in place was noted after 2 months, and C02 laser laryngeal microsurgery was done again Conclusion: C02 laser endoscopic surgery is initiallly effective and scfe in the treatment ofecn-ly glottic carcinoma not infiltrating the cartilaginous skeleton.
The rate of tracheostomy was low. It could replace for open cordectomy's operation in some indications.
Keywords: glottic cancer; endoscopic surgery;
C02 laser ' BV Tai MQi Hpng trung trcmg
Nh$n bh\ 10/1/2014. Duy§t in 20/1/2014
Tap chi Tai Mui Hpng Viet Nam - Volume (59-19)- N''l - March, 2014
1. D^T VAN DE
Dfii voi- ui^ thu tiianh quan giai doan som vific difiu tri phai dat dupc muc dich loai bfi dupc khfii u nhimg van giu lai dupc chiic nang thanh quan. Chiic nang nay bao gom ca chiic nang phat am va chiic nang nufit. Su dung tia xa va phlu Ihuat mo cat ban phan thanh quan la cac phuong phap tmyfin thfii^
van dupc ap dung trong difiu tri.
Nha nhihig tien bp vfi cfing nghe Laser trong nhihig nam gan day, phucmg phap vi phlu thuat ung thu thanh quan bang Laser, qua duong mifing, bat dau dupc ling dung va ngay cang dupc chap nhan nhu la phuang phap tri lieu co hieu qua.
Nam 1967, Polanyi da thir laser Co2 tren thanh quan nguoi chet, cho thay kha nang gay thuang tfin it. Tir do nguoi ta bat dau nghien cuu phat trifin he thong laser gan vao kinh hifin vi. Nam 1972, Jako lan dau tien da su dung he thfing nay tren tho.
Nam 1975 Strong lan dau tifin da bao cao 11 benh nhan giai doan Tl tang thanh mon da dupc phau thuat bang Laser Co2 duoi soi treo vi phau thuat. Blakeslee va cfing su da sii dung Laser Co2 trfin 68 bfinh nhan ung thu thanh quan giai doan Tl, ty lfi sfing sau 3 nam la 88%.
Nam 1978 Ossoff da su dung Laser Co2 phau thuat cho cac ung thu 1/3 giiia dSy thanh trfin 25 bfinh nhan, 24 bfinh n h ^ van song sau 3 nam (96%).
Tir do dfin nay, nhieu trung tam difiu tri benh ung thu thanh quan trfin thfi gioi da dua Laser Co2 vao phau thuat ung thu
thanh quan. Do lpi ich cua phau thuat b5ng Laser Co2 chmh xac, it lam tfin thuong, it phu nfi tfi chiic xung quanh, co thfi gan vao kinh hifin vi phau thu|it duoi soi treo, ty le cSn phai mo khi quan trong mo th^p, bpnh nhan hfii phuc nhanh, chit lupng gipng t6t hem..., vific su dung Laser Co2 trong phau thu^t ung thu thanh quan ngay cang phfi bifin 6 cac nuac trfin thfi giai.
Tuy nhifin do phlu truong hep, tia Laser di thing, nen kho khan khi phau thu$t a cac ngach cua thanh quan, nhat la fif viing mep truac day dianh, bfin canh do Laser Co2 it CO tac dimg cam mau nfin dfii khi gSy chay mau lam kho khan trong khi m6.
Do do, vific danh gia vimg cat an toan cho khfii u doi khi kho khan han so voi phlu thuat ma, khfii u se bi tai phat tai ch§ nfiu khong lay dupc het.
Vi vay, cho den nay van con mpt so ban luan ve cac chi dinh ciia phau thuat bang Laser trong ung thu thanh quan, nhat la van de co nen sir dung Laser Co2 phSu thuat cho cac khfii u lan dfin mep truac day thanh,x6 nen chLdinh cho cac khfii u thanh quan giai doan mufin hon T3 hay khfing?.
Laser co thfi thay thfi cho cac phau thuyit ma cat thanh quan ban phan truyfin thong khfing?...Day la nhung van dfi dang con tifip tuc nghifin ciiu.
Chung toi tifin hanh dfi tai nghifin ciiu ling dung Laser Co2 phau thu^t ung thu thanh quan giai doan som nhlm budc dSu danh gia hieu qua vi phau thu^t thanh qu^
Laser C02 trong difiu tri ung thu thanh quan.
Tgp chi Tai MOi Hpng Vifit Nam -Volume (59-19). N°1 - March. 2014
2. B 6 I TlTQNG VA PHlTONG PHAP NGHIEN c t r u
2.1. Doi tirgng nghieo cvtu: 25 bfinh nhan bi ung thu thanh quan giai doan Tl, dupc difiu trj bang phSu thuat tir thang 4.13 dfin thang 9.13
-Tifiu chuan lira chpn:
Bfinh nhan dupc xdc dinh chfin doan ung tiiu thanh quan, co kfit qua GPBL ung thu bifiu mfi vay.
Giai doan Tia; Tib NOMO Khfing phdn bifit tufii, gioi
Khfing bi bfinh nfii khoa man tinh nang, co thfi gay mfi phdu thuat dupc.
2.2. PhuffDg phap nghifin ctru: nghifin ciiu tifin ciiu, mfi ta timg truomg hpp co can thi^p.
3. ld:T QUA VA BAN LU^^N 3.1. TuSi va gioi
^ ^
40-49 50-59 60-69 70-79
BN CO dp tufii tir 42 dfin 76, Do tufii g§p nhieu nhit la tir 50-59 hjfii. Nam gioi chifim da so cac trucmg hpp (24/25 truong hpp). Dp tufii thucmg gap cua ung thu tiianh quan phu hpp vfii cac nghien ciiu
khac trong nuac, dfiy la dp tuoi da tich luy dii lau cac yfiu tfi nguy ca nhu thufic la, rupu.
Khac voi cac phlu thuat bao tfin ma, dfii voi phfiu thuat bang Laser, co thfi phlu thuat dupc cho cac bpnh nhan lou tufii, Trong nhom nghifin ciiu nay, bfinh itiian Ion tuoi nhat la 76 tuoi.
3.2. Phan do khoi u (T)
20 15 10 5
-
r i 3
1
Tib Tl T3 T4
• Tia
• Tib T2
• T3 B T 4
Tit ca benh nhan duac phau thuat trong nhom nghien ciru nay deu a giai dopi TI, trong do chvi yju la giai doan Tl a (22/25 trucmg hop).
Ty le ung thu thanh quan dupc phlu thuat tai BV Tai Mui Hong trung uong (2204-2008) d6i vcri Tia va Tib la 7,4 va 13,7% cac trucmg hop duoc phau thuat [4 ) Theo nghien cuu cua Ralph [ 6 ] tren 444 benh nhan phlu thuat bing Laser, giai doan Tia ( c6 292 BN), giai doan Tib ( co 50 BN), giai doan T2a (co 102 BN).
That vay d6i voi chiing toi, budc dau nghien cuu, vcri kinh nghiem chua nhieu, trang thife bi chua day du, chung toi chi gioi han chi dinh trong cac khoi u giai doan Tl. Tuy nhien cin than trong timg budc de
Tap chi Tai MQi Hpng Viet Nam - V o l u m e (59-19). N°1 - March. 2014
dam bao an toan ve mat benh tich va ung thu hpc, trong thoi gian toi, chung toi se dan chi dinh rpng hon cho mpt so khoi u chpn lpc o giai doan T2.
3.3.Hiroiig lan khoi u Huwng
lan Khu trLI fi" binh difin thanh mdn
Vj tri j Sd i lipomg^
1 ben day thanh | 15 lan chua dfin l mep truo-c 1 1 ben day- thanh j 7 lan dfin mep [ tru'O'c
Lan ca hai ben day thanh Va mep truo-c Lan den mSu day thanh vS sun pheu
3
3 le
Trong nhom nghien ciiu cua chung tfii, ton thuang day thanh mpt bfin chua lan dfin mep truac 15 truong hpp, co 10 truong hpp CO ton thuang lan dfin mep truoc day thanh trong do: 7 truong hpp ton thucmg day thanh 1 bfin CO lan den mep truoc, 3 truong hpp tfin thuang day thanh 2 ben-c6 lan den mep truorc. 3 truong hpp co ton thuang lan den mep sau day thanh va mau thanh sun phfiu.
Van dfi CO thfi iing dung Laser trong trucmg hpp ung thu lan den mep truoc day thanh cho dfin nay van con dupc ban luan, cac phuang tifin chan doan hinh anh ve dfi lan s^u cua khfii u vao mep truac nhu chup cat lop vi tinh, chup MRI dfiu khong ro rang.
Chung tfii chi dinh phau thuat Laser cat mep truoc day thanh khi trfin phim CI ciing
nhu MRI khong co hinh anh th3m nhiem khfii u vao mep truac sun giap, nhung quan trpng nhit la dua vao kfit qua soi thanh quan true tifip co phong dai duoi npi soi.
3.4. Mcf khi quan
Ma khi quan dupc tifin haitii trfin 4 truofng hap chifim 16%, trong do 3 truang hpp do khoi u lan ra mep sau, 1 truong hpp do difin cat rpng.
Chung toi tifin hanh ma khi quan trong cac truong hop lan nhifiu ra mep sau vfii muc dich lam rpng rai phau truong, dfing thoi tranh kha nang tia laser co thfi ban vao fing npi khi quan. Con truong hpp thii 2 la khi dien cat qua rpng, kha nang co the chSy mau sau mfi, mof khi quan trong truang hpp nay mang tinh chat du phong.
Cac truong hpp mo khi quan nay dfiu la tam thai, chiing toi deu nit dupc canuyn an toan sau mo.
3.5. Phmmg phap phau thuat
- Phau thuat cat ca 1 day thanh don thuan chifim da so cac trucmg hpp: 15/25 truang hpp.
- Phlu thuat type II cat mpt ben co day thanh va mep truoc chifim 7/25 truang hpp.
- Phlu thuat cat hai bfin ca day thanh va mep truoc chifim 3/25 trucmg hpp
- Doi voi khoi u lan vao mep sau day tiianh, chiing tfii tifin hanh cit ra sau dfin het miu thanh, tham chi co thfi cat hfit 1 sun phia 3.5. Giai phau benh Iy ria dien cit
Trong tit ca cac truang hpp, chiing toi dfiu lam giai phlu bfinh ly lia dien cit ttr 2- 4 mlu, kfit qua cho thiy dfiu am tinh.
Tap chi Tai MOi Hong Vi$t Nam - Volume (59-19). N°1 - March, 2014
So sanh voi ket qua nghifin curu vfi phau thuat ung thu thanh quan gjai doan Tl bang phlu thu$t mo [5] trong 50 trufing hpp, CO 3 truang hpp ria difin cit duong tinh.
Ket qua nay cua chung tfii co thfi noi tuong ducmg voi phau thu^t mo cit day thanh duong ngoai.
3.6. Theo doi gin
Bien chung: Trong 25 trudng hpp phlu thu^t, chung tfii khfing gap bifin chiing nao dupc ghi nh§n, nhat la bien chung chay mau difin cat sau mfi. D3y la bifin chiing nguy hifim do chay mau vao duong tho, nhit la khi bfinh nhan khfing duac mo khi quan. Tuy nhifin bifin chiing nay chua xay ra trong sfi cac bpnh nhan n ^ e n ciiu, buac dau cho thay tinh an toan cua phau thuat bing Laser Co2.
T6 chiic hat phat trien a dien cat trfin 6/25 ca, trong do 2 ca phai cat lai tfi chiic hat, kfit qua giai phau benh ly lanh tinh.
Tai phat tai cho 1 ca phai phau thuat lai bang Laser. Day la mfit trucmg hpp da phau thu^t cit u bang soi treo vi phau, sau dfi kfit quh giai phlu bfinh ly la ung thu. Chung tfii tien hanh cat lgi bang Laser, rtiiung co the da khong kiem soat hfit dien cat do khfing cfin xac dinh ro ranh gioi khfii u.
4. Kk tuan
Vi phlu thuat thanh quan Laser Co2 chung to buoc diu co hieu qua trong difiu trj ung thu thanh quan giai doan sam. Bfinh nhan tranh dupc phau thuat mo, hau phlu nh? nhang, da so t r ^ i dupc mo khi c^uan, cfi thfi thuc hien fif bpnh nhan Ion tuoi, it bien chiing. Kfit qua Ifiu dai can dupc theo dfii thfim
Cfi tiifi noi day la each mai^ trong phlu
thuat cGeu tri ung tiiu thanh quan, chuyen tu phlu tiiuat ma sang phau thuat kin.
TAI LIEU THAM KHAO 1. Adams G.L. (1999) Malignant
neoplasms of the hypopharynx.
Gumming C.W.; Otolaiyngology-Head and Neck Surgery. Mosby Year Book.
Baltmiore,USA.1955-73.
2. Brasnu D. (1996) Cancer du larynx.
Tran Ba Huy P.: Otorhinolaryngologie.
Ellipse. Paris, France.65-76.
3. Nguyen Dinh Phuc, Ph^m Thi Kir va cs (1999) Dgc diim ldm sdng cua ung thu thanh qudn vd ung thu hg hpng qua 132 benh nhdn tgi khoa Bl Benh vien Tai Mui Hpng trung uang tit 1995-1998. Nfii san Tai Mui Hpng 2000.
4. Nguyin Dinh Phiic, Lfi Minh Ky va cs.
Nghifin ciiu lam sang va phau thuat dieu tri ung tiiu tiianh quan tai BV TMH TU"
Tap chi Y Hpc Viet Nam-2, 390,2012 5. Ph^m Van Hiru. N ^ e n ciiu dac difim
lam sang, nfii soi, kfit qua dieu tri ung thu thanh quan giai doan som. Luan van tfit nghifip BSNT-Dai hpc Y Ha Nfii, 2008
6. Ralph M. W. Ro" del, MD, Wolfgang Steiner, MD,Roland M. Mu" Her, MD,Martina Kron, PhD,Christoph Matthias, MD. Endoscopic laser surgery of early glottic cancer:
involvement of the anterior commissure Head & Neck 10.1002/hed. May.
2009-583
7. Sasaki C T . et al. (1999) Malignant neoplasms of the larynx. Cumming CW.:
Otolaryngology-Head and Neck Surgery. Mosby Year Book. Baltimore, USA.1925-55.
