T C N C Y H Phy trUdng 80 ( 3 8 ) - 2 0 1 2
Summary
C O M M O N CERVICAL H U M A N P A P I L L O M A V I R U S INFECTION IN T H A I N G U Y E N 2011 HPV vaccine is one of the preventive methods for cen/lcal cancer However, the current HPV vaccines only prevent several HPV specific types. This study aimed io explore the prevalence of HPV infection as well as the most common types of HPV in Thai Nguyen city In order to provide updated data for cen/ical cancer control program. Using cmss-sectional design with a sample of 1000 marned women aged 18 - 65, the study interviewed and tested for HPV. HPV genotyping. and Pap smear for alt participants. Results showed the prevalence of HPV in Thai Nguyen was 9.2%>. Most infected cases was with high risk types, possible of causing cancer The most common HPV types detected was 3 high risk types. HPV16, HPV18 and HPV58 and two high nsk types, HPV81 and HPV11 The prevalence of HPV infection in Thai Nguyen was high. The future intervention program In Thai Nguyen should use data from this study for planning.
Key w o r d s : HPV, m o s t c o m m o n t y p e s of HPV, c e r v i c a l c a n c e r
T^ BAO HQC C6 TO' CUNG B A T THU'ONG 6" PHU N U DU'P'C SOI C6 TLF CUNG
TAI BENH VIEN PHU SAN TRUNG U'QNG
C u n g T h i T h u T h i i y t ^ l , Tran Thj Thanh Hongl^t (^> Truing D^i h(?c Y H i Ndi, (^>B$nh vi?n Da khoa Ha Tinh
Di tii du&c thirc hiin nhim phit hiin ty 1$ li bio hpc cd td" cung bit thwang vi ddi chieu voi mgt sd die diim lim sing" ciia phu nO- du&c soi cd tir cung tai bdnh vi$n phi^ san Trung uang. Kit qua cho thiy tdng s6 binh nhin cd ti bio ASCUS, AGUSC chiim 56%). Tdn thuxmg t&bio tiin ung thu la 40,2%
(trong dd 27.3%, la LSIL, 10,9%, la HSIL) vi 4.4%, ti bio uig thw (3.8%o ung thw biiu md vay 0,6% ung thw biiu md tuyin) cd liin quan din dd tudi tir 40 - 49 va vai sd lin sinh. Vi lam sang. CTC binh thuvng cd ty 1$ LSIL(2,1) va HSIL(3,1) rit thap. Ty 1$ HSIL cao nhit & nhdm binh nhan cd thiu chimg thi/c the nghi li tdn thwang ic tinh cd tif cung (62,5%,). Tdn thux>ng ASCUS chiim.t^ 1$ cao (92,4%,) a nhdm b^nti nhin cd trieu chimg thi/c thi linh tinh. TO' kit qui nghiin cuv cd thi kit lu$n ring: tdn thwang tiin ung thw vi ung thw chiim f)J 1$ cao. cd lien quan den dd tudi tii- 40 - 49 va voi sd lin de. Tin thwong ASCUS cao han a nhdm b$nh nhan cd tdn thwang lanh tinh. Ton thwang HSIL cao a nhdm binh nhin cd triiu chirng thi.rc the nghi ngali tdn thuang ic tinh CTC (62,5%,).
T u k h o a : Te b a o C T C b a t t h u d n g ,
I. D A T V A N D £ t i l t kiem. D g c bigt can l u u J n h d n g philn 6h P h u a n g phap s i n g Ipe te b i o hpc phat c l t d eung b i t t h u d n g d l p h l i h y p vdi soi hiOn ton t h u a n g c l t u cung (TTCTC) v i ung C T C , m b benh hpc phat hiOn s d m ung thu
TCNCYH Phy trUdng 80 (SB) - 2012 ton thuang, theo dbi hay dieu trj sdm, gbp
phan giam ty 10 tu vong do bgnh nay Chiing toi tiln hinh nghien cuu de tai nay vdi mye lieu: "Phil hign ty 10 t l bao hpc c l tu" cung bit thudng v i doi chilu vdi mpt so dgc dilm lam sing" d phy nu dupe sol c l tir eung tgi tgi Bgnh vign phu san Trung uang hy vpng cb the cung cip nh&ng kit qua ding tin cOy giiip eho eae nha phy khoa tham khao.
I I . D 6 | TU'O'NG VA PHU'ONG P H A P Chpn 293 bgnh nhin eb kit qui phien db CTC bat thudng, duyc soi CTC tgi bOnh vign phy sin trung uang v i dong y tham gia nghien cuu. Phuang phap mb t i tiln cdu.
Thdi gian nghiOn cuu tu thang 1/2011 din thing 8/2011. Cd miu duyc tinh theo cbng
III. K^T QUA
thuc udc tinh mpt ty 10:
n ^ Z ^ ^ ^ (i-f) d^
Trong db:
n : Ca miu nghien ciru = 293.
Z ^ : l i dp Igch rut gpn irng vbi cac 2^ sai lim a khac nhau va bang 1,96 tuang ung vdi a = 0,05.
p : ubc tinh ty Ig bgnh nhan cb ton thuang le bao vay dp eao (HSIL) l i 14,4%
trong ting so bgnh nhan cb bit thuang TBH (theo nghien ciru cua Nguyin Thu Huang cbng bo nam 2009) [6], p = 0,144
d : dp chinh xie mong muon = 0,04
Bang 1. Phan bo ket qua phien do co tu> cung Ket qua TB
ASCUS AGCUS ASC-H LSIL HSIL Ung thu bieu md Ung thu bieu Tong
md vay tuyen
n 132 32 36 48 32 11 2 293
%
45,1 10,9 12,3 16,4 10,9 3,8 0,6 100,0
Tong so benh nhan cd te bao phan irng (ASCUS, AGCUS) chiem 66%. 12,3% ASC-H. Ton thuong te bao tien ung thu la 40,2% (trong dd 27,3% LSIL, 10,9% HSIL) va 4,4% la te bao ung thu.
205
TCNCYH Phy trUOng 80 (38) - 2012
Bang 2. Lien quan mu>c dp TT TBH vdi nhom tuol
TB khbng TB tien ung t h u
Tuoi \ y d i l n hinh va ung t h u T i n g
20-29 30-39 40-49 a 50 T6ng
41 61 38 4 164
12 48 50 19 129
53 129 88 23 293
18,0 37,2 56,8 8,0 100
<0,05
Nhdm t6n thuong khdng diin hlnh g6m: ASC, AGC. Nhdm t6n thudng tiin ung thu: LSIL, HSIL.ngoai ra t i n thuang ASC- H 1^ t i n thuang thuOc nhdm ASC nhung ASC- H chua loai trir HSIL (Bethesda 2001) ndn chiing tdi x i p loai kit qua te bSo ndy vao nhdm ton thuang tien ung thu d i khSo sit. Nhdm tuii 40-49 c6 kit quS t i bio tiin ung thu v4 ung thu cao hdn d cic nhdm tuii kh^c. Su khic bl$t cd y nghTa thing k§ vdi p < 0,05
Bang 3, Lien quan giira so lan de vd'i TT TBH tien ung thu' va ung t h y
0 lan 1 lin 2 lin 3 lin 4 lin
LSIL (48) HSIL (32) Ung thu (13) TONG OR P
ni 6 2 0 8
<
%
12,5 6,3 0
0,9 0,01
"2 7 4 2 13
<
%
14,6 12,6 15,4
1 0,01
n3 9 7 3 19
%
18,8 21,9 23,1
1,25
<
0,05n4 12 9 4 26
%
25,0 28,1 30,8
2,54
<
0.01ns 14 10 4 28
%
29,2 31,3 30,8
2,1
1,2 <0,05 1,44 <0,05 1,33 <0,05
BOnh nhin cb kit qua te bao ton thuang db thip, db eao v i te bio ung thu tang theo s6 lan sinh, sy khie bigt cb y nghTa thing ke vdi p < 0,05.
TCNCYH Phu truong 80 (38) - 2012 Bang 4. Phan bo ket qua TBH theo trieu chirng thi,rc the
Lam sang Binh thu'dng TT Lanh tinh TT nghi ngd Tong TBH
ASCUS ASC-H AGCUS LSIL HSIL Ung thu biiu Ung thu bleu Tong
md md
vay tuyin
n, (%) 9 (6,8) 0 0 1 (2,1) 1 (3,1)
0 1(50)
12
n2(%) 122(92,4)
36(100) 32(100) 46 (95,8) 11 (34,4) 7 (63,6)
0 254
n3(%) 1 (0.8)
0 0 1 (2,1) 20 (62,5) 4 (36,4) 1(50)
27
132 36 32 48 32 11 2 293 NhO'ng tnj'dng hyp khim thye t h l thiy CTC binh thudng eb ly le LSIL va HSIL rit thip.
Ty le LSIL gap cao nhat d nhbm TT CTC lanh tinh. HSIL tim thay trong tat ca cic hinh thai ton thuang tren lim sing, ke ca cic trudng hyp khbng phit hign thay tin thuang d CTC. Tuy nhien, ty Ig HSIL gOp nhilu nhat d nhbm trigu ehung thye the ton thuang nghi ngd (62,5%).
Nhbm trigu chdng thyc t h l lanh tinh cb ty Ig tin thuang ASCUS eao han cae nhbm cbn Igi.
Bang 5. Phan bo kit qua TBH theo trieu chung ca nang
TBH ^ ASCUS ASC-H AGCUS LSIL HSIL Ung thu bilu Ung thu bilu Tong
Ca
mb mb
nang
vay*
tuyen*
Khong cb tr/c n, (%) 6 (4,5)
0 1(3,1)
0 0
7
Ra khi huf nj(%) 125(94,7)
35(97,2) 31(96,9) 46(95,8) 19(59',4)
266
Ra mau bat thirdng r\j (%)
1(0,8) 0 0 0 12
13
Phoi ho>p
0 1(2,8)
0 2(4,2) 1(3,1) 11(100)
2(100) 17
Tong
132 36 32 48 32 11 2 293
• Met benh nhan cd 2 hole 3 trieu chirng. Ty le ra khi hu nhieu, ddn thuan gap d tat ca cac nhom ton thuang t i bao bat thudng. Benh nh§n ra mau bat thuang gap d nhdm TBH la HSIL. Benh nhan cd phoi hc?p ca ra khi hu nhiiu lln ra mau bat thudng chiim ty le cao trong ton thuang ung thu.
207
TCNCYH Phy trUdng 80 (38) - 2012
IV. BAN LUAN
Kit qua nghlOn ciru niy ciia chung tbi cho thiy ty 10 bOnh nhOn eb t l bio viy khbng diln hinh (ASC) khi cao chilm 45,1%, eao han nhilu so vdi mbt s l lac gii trong v i ngoii nude. Theo nghibn ciru eOa Trjnh Quang DiOn, ty 10 ASC l i 4,07 % - 4,65%, t^
10 AGC l i 0,1% [3]. Theo l i e g i i Nguyin Vin Bing, ly 10 ASC l i 3,44%, AGC l i 0,21% [1].
Kel qui nghien cO'U ciia Meisle v i Morin C l i Igp hpp s l liOu tu nhilu phbng t l bio hpc d My thiy ly 10 ASC khoing 2,8% - 9% [10].
Kit qui nghiOn cuu ciia chiing tbi so vdi cic kit qua nghiOn euu eiia nhilu tic gia trong v i ngoai nude eho thay ty 10 ASC v i AGC trong nghiOn euu nay 10 rit cao nhung Igi hpp ly vl cic t i c gia tren nghien euu sing Ipc tgi
•cpng ding (ty 10 ASC v i AGC so vdi loan bb so bgnh nhin sing Ipc, trong db cb rit nhieu bgnh nhin khbng cb t l bio bit thudng ).cbn nghien cuu eua ehung tbi, doi tuang duyc chpn chi l i nhung trudng hpp cb t l bio bit thudng do vgy thye chit ty Ig ASC, AGC trong nghien cuu cua chiing tbi la ty 10 ASC, AGC so vai cae ty Ig t l bao bit thudng khie (so vdi LSIL, HSILvi ung thu). Mpt nghiOn euu khie eung tgi BVPSTW ciia Cung Thj Thu Thiiy nhung dii tuyng nghien cdu l i nhCrng bgnh nhin khim lim sang cb ton thuang CTC v i dupe soi CTC, vdi kit qua t l bio 15,7% I i binh thudng, 60% t l bao phan ung viOm, ehi cb 13% t l bao ASC v i AGC [6]. Te bio hpc la phuang phip sang Ipc cb gia trj d l phit hign tin thuang tiln ung thu va ung thu CTC d giai dogn sdm khi ehua cb triOu chung lim sang. Ket qua te bao cung eb the ggp ty 10 duang tinh gii hay am tinh gia nlu dieu kiOn lay bgnh phim khbng duyc tuin thu, bOnh pham khbng du tiOu chuin de dinh gia hay do ngudi dpe tieu ban chua nhgn djnh dung t i n thuang
0 nhbm tuoi 30-39 ty 10 te bio khong diln hlnh (ASC v i AGC) l i 27,6%, 16,4% IS t l bio tiln ung thu v i ung thu (SIL v i ung thu) d nhbm tuli n i y ehilm 44% cao nhit so vdi cic nhbm tuli cbn Igi. Nlu chi tinh riOng cic trudng hyp t l b i o nghi ngd va ung th\j Ihi ty 10 bOnh cao nhit Igi gOp nhilu d nhom tuli 40 - 49. BOnh nhin d 66 tuli td 40 - 49 chi eb 88/293 phy nd nhung Igi cb tdi 50/88 trudng hyp eb t l bio nghi ngd hoOc ung thir, Nhu vOy, tinh theo ting s l phy nO- nghien cuu, ty 10 nay chf la 17,1% (50/293 tnrdng hyp) nhung nlu chi tinh riOng trong nhom phy nO- d 6^ tuli 40 - 49 thi t j 10 cb t l bio nghi ngd v i ung thu Ibn din 56,8% (50/88 trudng hpp). trong khi db ty 10 niy d nhom tuoi 30-39 chi la 37,2% (48/129 trudng hyp).
Nhu vgy, cb v l Ty 10 t l bao nghi ngd va ung thu d nhbm tuoi 40 - 49 cao han so vdi cac nhbm tuoi cbn Igi vdi sy khic bigt cb y nghTa thong ke vdi p < 0,01. Mpt nghien cdu khac CLia Cung Thj Thu Thuy d§ kit lugn ring: Cac t i n thuang soi CTC ty Ig thugn vdi tuoi [7j.
Theo chung tbi, kit qua nghiOn cuu nay la hpp ly vi Ijeh su tiln triln ty nhien cua ung thu CTC tu cae te bao binh thudng, trai qua eae biln d i i qua san (bao gom c i cic ASC, AGC), logn sin cic muc dp (bao gom LSIL v i HSIL) r l i d i n ung thu tgi chb, ung thu'vi xim nhgp r l i ung thu xim nhgp. Tien trinh niy diln ra trong khoing tu 15 - 30 nam. M^t khie chimg la d i bilt nguyen nhan hang diu gay ung thu CTC l i HPV [3]. Nguyen nhan do HPV ehilm 99,7% cac trudng hpp ung thu CTC trOn toan t h l gidi [ 4]. Nhu vOy, neu tinh tu thdi dilm sdm nhat ma ngudi phy nO cb kha nang nhiem HPV (khi bat diu cb quan hO tinh dye lin dau tien) liic 16 tuli v i neu qui trinh diln tien bgnh 15 nam thi khi cb ton thuang tien ung thu v i ung thu se rai v^o thgp nien thd 4 cua ddi ngudi.
TCNCYH Phy trUdng 80 (38) - 2012
NghiOn edu cOa chiing tbi cung cho thiy CO mil ii^n quan giua tan suit ciia cic t l bao bit thudng vdi so lan sinh. N l u nhin tong t h l thi se thay nhbm phy nu sinh 1-2 lan cb ty 10 te bao bit thudng cao nhit (62,8%) nhung nlu xem xet chi nOng t i n suit ciia cac t l bio nghi ngd va ung thu thi tan suit cao nhit Igi roi vao nhbm cb td 3 l i n sinh trd 16n (69/100 trudng hyp = 69% so vdi 52/184 trudng hyp
= 28,3% eua nhbm sinh 2 lin). Nhu vgy nguy CO xuat hign t l bao nghi ngd va ung thu d nhbm sinh 3 l i n trd lOn cao han cb y nghra so vdi eae nhbm cb s l lin smh it han. Dilu nay cung hoin loan phu hyp vdi thye te bdi cang sinh nhilu lin thl mue dO ton thuang cua CTC cang nhieu han v i cing nOng han do 66 din tai nguy ea xuit hiOn te bao bit thudng nhilu han [6]. D l so sinh vdi kit qua nghiOn euu ciia mpt so tic gia trong va ngoii nude nghien cipu sang ipc tgi cpng dong nhung khbng nham muc dich so sanh ty Ig gida cic nghien cifu khae vdi kit q u i nghiOn cuu ciia chiing toi (vi duang nhien ty 10 SIL trong nghien cuu ciia chiing tbi se cao han r i t nhiOu do viec lua chpn dii tupng nghiOn ciru khie nhau nhu da giai thich) ma nhim'so sinh ty Ig SIL tgi cpng dong (bao gbm ea nhdng ngudi xet nghigm khOng cb t l bio bit thudng) vdi mpt nghien CCFU tgi benh viOn, d eic phy nd xet nghiOm cb te bio bat thudng. Sy khic biOt r i t Idn nay CO thl coi nhu sy cinh bao v l kha nang r i t cao cb nhu'ng tin thuang bat thudng v l te bao hpe d nhbm nhu-ng phy nu" din khim phy khoa tgi benh viOn, dgc bigt nhO-ng ngudi phy nl> cb nhilu lan mang thai hogc sinh con. Dieu nay se giiip cie nha phy khoa, nha te bao hpc luu tim d l khbng bb sbt ton thu'ang.
Trong eic phuang phap phit hign sdm ung thu CTC, phien d l AD - CTC cb the coi 1^ mpt test sang Ipc hing d i u , da duyc gidi y khoa toin eau thua nhgn. Nhilu nghien cuu
cOa cie tie gia duye thyc hign d cpng dong, do db ty Ig eic ton thuang t l bio tien ung thu thap han so vai nghien cuu ciia chiing tbi ehl chpn nhung bOnh nhin cb kit qua phien do AD - CTC bat Ihuang v i khbng bao gim cac d l l tuyng kilm tra djnh ky hay sing Ipe.
MOt khie, sy khic nhau niy cb t h l dupe ly giai l i d cic vung dia ly khac nhau, tin suit xuat hign cac SIL khbng giong nhau, ngay ea trong cung mpt nuac. Han nO'a, tOp quan, loi sing, tinh trgng kinh te xa hpi, y thuc va mire db ty do linh dye eiia mbi viing, moi quoc gia cQng khac nhau. Them vao do, tiOu chuan chin doan d mbi giai dogn khac nhau, trinh dO kmh nghigm eiia tCrng tac gia cung khbng giong nhau va phuang phip lay benh phim cb t h l chua thbng nhit giO'a eae t i c gii. Tat c i nhO'ng ylu to tren da inh hudng den ty Ig phat hiOn bgnh.
V. K^T LUAN
- Te bio tiln ung thu v i ung thu chilm ty le cao d dp tuoi tu 40 - 49 va eb liOn quan din sb lin de
Ty Ig ton thuang ASCUS cao han d nhbm bOnh nhan eb Ton thuang thye t h l CTC la lanh tinh. Ty le HSIL gap nhilu nhit d nhbm bOnh nhan cb trigu chung thyc the la ton thuang nghi ngd CTC (62,5%).
TAI LIEU THAM K H A O 1. Nguyen Van Bang (2006). Chan doan sing Ipc UTCTC d mot sb cpng dbng tinh Thua ThiOn Hul, Bgnh vign Trung uang Hul, Hpi nghj phbng chlng ung thu toin quoc.
2. Nguyen Thj Chi, Dao Trung Dung, Nguyen Vuang va CS (2001). Chin doin TBH ASCUS trong phat hign sdm UTCTC, Tgp chi Y hpe ViOt Nam, CD GPB-YP: 16-17.
3. Trjnh Quang Dien (2007). Phat hign Condilome, t i n san nbi bieu mo v i UT sdm
T C N C Y H P h y trUdng 80 ( 3 8 ) - 2 0 1 2
CTC, Y hpc ViOt N a m , tOp 330: 143 - 1 4 9 . 4. P h g m T h j H i n g Ha (2000). G i i trj ci^a p h i l n do C T C - A D , Sol C T C v i M B H trong p h i t hiOn s d m ung I h u C T C , Lu$n vOn thge s? y hpe - T r u d n g Dgi hpc Y H i NOi
5. N g u y e n T h u H u a n g (2009). NghiOn c u u d i i c h i l u t l bao, l i m sang, MBH t i n t h u a n g t i l n ung t h u v i ung t h u C T C tgi BVPSTW. LuOn i n T i l n sy y hpc - T r u d n g Dgi Hpc Y H i NOI
6. C u n g T h j T h u T h u y (2011). O l i c h i l u k i t q u i soi e l t u cung v d i p h i l n d l i m d g o - e l t u cung d c i c bOnh n h i n d i n soi c l t u eung tgi khoa k h a m , bOnh viOn Phy S i n Trung U'ang. Tgp chi Nghien euu Y Hpc.
Supplement 74 (3): 112 - 117.
7. C u n g T h j T h u T h u y (2011). T i m h i l u
mOt s l y l u t l liOn q u a n d i n t i n t h u a n g c l ti>
cung d c i c bOnh n h i n soi c 6 t u eung tgi khoa k h i m - bOnh viOn Phy s i n Trung Uang. Tgp chi NghiOn e d u Y Hpc Vol 73 (2) 121 - 26.
8. D e M a y . R M (2006). A n overview of the Bethesda S y s t e m , T h e Pap test: 235 - 244.
9. A . , T e m m e r n a n M., Q u i n t W.G., et a l (1992). Cervical cancer screening and detection of genital HPV infection and Chlamydial infection by PCR in defferent groups of K e n y a n w o m e n , A n n . Soe. Belg.
Trop 7 2 ( 1 ) : 53 - 6 2 .
10. M e i s e l S A , M o r I n C (1999). Atypical Squamous Cell of Undetermined sinigficance (ASCUS), T h e h u m a n pappiloma virus - Induced c h a n g e s , Cytopathology of the uterus 2nd Edition. A S C P Press: 127 - 184.
S u m m a r y
A B N O R M A L C E R V I C A L C Y T O L O G Y OF THE PATIENTS W I T H C O L P O S C O P Y NATIONAL H O S P I T A L OF O B S T E T R I C A N D G Y N E C O L O G Y
The objective of the study was to "Detect the abnormal cer/ical cytology and compared it with some clinical characteristics" of the patients who had colposcopy at NHOG from Jan-Aug/2011, include 293 patients. The results showed that patients with reactive cells (ASCUS, AGCUS) accounted for 56%. ThB rate of the patients with the pre-cancer cells and cancer cytology was associated with the age from 40 to 49 and the number of birth. The patients with normal cen/ical examination had very low incidence of LSIL and HSIL. The highest rate of HSIL was in the patients with suspected lesions (62.5%). The group with benign symptoms had higher rate of ASCUS cells (92.4%o) than other groups In conclusion, the pre-cancer cells and cancer cells accounted for a high proportion in the age 40-49 and associated witti the number of births: The rate of ASC cells were higher In the patients with benign cen/ical lesions. The highest rate of HSIL was In the patients with suspected cen/ical lesions (62.5%,).
K e y w o r d s : a b n o r m a l c e r v i c a l c y t o l o g y HSIL : High grade squamous intraepithelial lesion ASCUS : Atypical squamous cells undetermined significance AGCUS : Atypical galndular cells undetermined significance ASC-H : Atypical squamous cells - High
CIN : Cen/ical intraepithelial neoplasia LSIL : Low grade squamous Intraepithelial lesion
