TAP CHi V - DirCK HOC QUfiN SU s6 6.2014
VAI TRO cCiA HACH Dl CAN TRONG P H A U THUAT NOI SOI DIEU TRj UNG THU DA DAY. SO LUONG HAY Vj TRI C O A
HACH Dl C A N Q U A N TRONG HON?
Ho CM Thanh'; Hoing M^nh An'; B$ng Vi^t Dung' TOM TAT
eat vln a l : ung thy da dSy (UTDD) l i b$nh Sc tinh thirdng gap nhlt trong difdng tiiu h6a, hgch di cin cd vai trd quan trpng trong xic dinh giai doan b$nh v i tien lu'gng sau ml.
Boi tupng va phu'ang phip nghiin cdu: nghiin cuu 105 binh nhin (BN) ung thu 1/3 du'dl da diy dypc phiu thuit cat da day nao vet hach D2 npi soi ty 9 - 2009 din 3 - 2013 tai B$nli viSn QuSn y 103 Hach nao vSt dTOC dSnh s6, nhupm HE v i dpc kit qui xic dinh tinh trang di can tai Khoa Giai phlu benh
Kit qui; trong 105 BN, 46 BN pN2 theo JGCA 2"°. Trong dd, theo JGCA 3"' cd 10 BN d pNI, 18 BN d pN2 v i 18 d pN3. T} l# sing oOa 46 BN l i 58,7%, trong dd, pNI l i 80%; pN2 l i 66,7%
vi pN3 l i 38,9%, khic biSt cd y nghTa vdi p = 0,001.
Ket lu$n: phin chia giai doan hach theo s l lup'ng hach di cin cd y nghTa tiin luong tit hon vi tri hach di cSn.
* Td khda: Ung thy da diy; Nao vdt hach noi soi; Giai dogn hach di cin.
ROLES OF LYMPH NODE METASTASIS IN LAPAROSCOPIC GASTRECTOMY FOR CANCER. WHICH IS MORE IMPORTANT, QUANTITY OF LYMPH NODE METASTASIS OR ITS LOCATION?
SUMMARY
Background: Gastric cancer is the most common malignancy in the gastrointestinal disease, lymph node metastasis has an important role in determining stage and prognosis after surgery
Method: a study was conducted on 105 lower third gastric carcinoma patients, who underwent laparoscopic gastrectomy with D2 lymph node dissection from 9 - 2009 to 3 - 2013 at 103 Hospital. The lymph node was numbered, HE was stained and its result was used to determined the situation of metastasis disease at Department of Pathology.
Result: Out of 105 patients, according to JGCA T', there were 46 patients with pN2. Among which, according to JGCA 3^, there were 10 patients wIthpNI, 18 patients pN2 and 18 patients pN3.
The overall survival rate for 46 patients was 58.7%, where pN1 occupied 80%; pN2 accounted for 66.7% andpN3 was 38.9%, significant difference with p = 0.001.
Conclusion: The number of lymph node metastasis is more imporiant than its location in significant prognosis.
* Key words: Gastric cancer; Laparoscopic lymph node dissection; N-stagIng metastasis.
' Binh vlin Quin y 103
Ngwbi phin hoi (Corresponding): Hd Chl Thanh (hochlthanh76(@yahoo.com) Ngiy nhin bii: 06/05/2014; Ngiy phin biin dinh gii bii bio: 30/07/2014
Ngiy bii bio dw?c ding: 01/08/2014 150
T9P CHi V . Dir^c H9C QUAN sir %6 a-20i4
DAT VA'N tai
Ung thu da d i y l i benh 1^ ac tinh thCf 2 sau ung thu phli d nam v i ung thu vCi d nD'. Trdn the gidi cd 3 t l chue Idn nghien CLHU v l UTDD l i Uy ban Phdng chlng Ung thu the gidi (UICC), Hiep hdi Phdng chlng Ung thu MJ (AJCC) v i Hdi Ung thy Da d i y Nhlt Ban - JGCA).
Phin io^i UTDD theo he thing TNM dyac UICC i p dijng tCr nam 1954, d i n nam 1966 b i t d l u i p dung cho UTDD.
Nam 1977, phien ban d l u tien phin chia giai doan UTDD theo TNM dude UICC/AJCC cdng bo, d i n nay da qua 7 l l n si>a d l i .
Hpi Ung thu Da d i y Nhit Ban phin loai UTDD theo he thing TNM t u n i m 1952.
Bach huyet i i con dudng di can p h i biln trong UTDD. Phlu thuit eat da d i y kit hdP nao vet h?ch D2 khdng nhCfng dieu trj UTDD ma cdn giup bae sy, phlu thuit vien tien lugng dOng giai dpgn b^nh.
Dilm khac biet giO'a UICC/AJCC v i JGCA la each phin chia giai dpgn h$eh di c i n . Trong cae I n b i n tO' nam 1992 trd v l tnj'do, UICC/AJCC phin chia giai dean hgch di can theo khu VM-C, lly moc 3 cm tInh t u k h l i u: pNo khdng di e i n hach, pNi di can hach trong phgm vi 3 cm; pN2 di c i n hach ngoii pham vi 3 em. Tuy nhien, khi i p dung e i c t i c gia d l u nhan thly cich phan Ipai nay khdng hieu qua v i y l u t l tien lup'ng khdng eao. Nam 1997, I n ban 5"" cua UICC/AJCC thay d l i cich phin chia giai dp^n hach di.ra v i e sp luang hach di c i n t r i n ca sd vet dup'C t l i thilu 15 hach/1 BN; pN, di can t u 1 - 6 h?ch, pN2 di can tCf 7 - 15 hach, pNa di can > 15 hach [4,10],
Hpi UTDD Nhat Bin JGCA cd quan dilm ridng, phin chia nhdm hach v i nao v i t theo vi tri giai phiu. Hach di ein d i n vi tri thupc Chang hach nio se duac x i p v i o giai doan dd [5]. Cich phan chia eic nhdm hach theo vi tri giai phlu rat thuin Idi cho viec nao vet hach. Tuy nhidn, dinh g i i giai doan benh theo vi tri hach khdng hap iy do ed nhQ'ng trudng hap di c i n hach nhay tat. Trong thifc t l v i n gap di can 1 - 2 hach d ching 2 hoac chang 3, nhung tien lugng benh t i t han di cin nhilu hach chang 1. Nghien cuu cua Karpeh, Kranenbarg v i Sayegh da dua ra dinh g i i giai dpan benh v i tien lugng phu thupc v i o s l lugng hach di can hap iy han v| tri hach di can [7, 9, 10].
Sau nhilu nghien cCfu v i hdi thao, nam 2010 iln d l u tien 3 t l ehuc UICC, AJCC v i JGCA cd bang phin loai UTDD thing nhlt vdi cich phin chia giai doan hach di e i n mdi; pN, di e i n tif 1 - 2 hach, pN2 di can tir 3 - 6 hach, pN3a di c i n ti> 7 - 1 5 hach v i pN3b di c i n > 15 hach [3, 6].
Nghien cuu nay so sinh tinh hgp i)/
ciia bang phan chia chang hach thep UICC 7'^ vdi each phan chia theo vi tri cua JGCA 2"" dua tren kit qua phlu thuat ndi soi cat da d i y nao vet hach D2 tai Binh vien Quin y 103.
DOI TUONG VA PHLfONG PHAP NGHIEN CCrU 1. D6i tu'O'ng nghien cu'u.
105 BN UTDD 1/3 dudi, dugc phlu thuit e l t da day nao vet hach D2 ndi soi tai Khoa Ngoai Byng, B|nh vi#n Quan y 103 t u 4 - 2009 d i n 3 - 2013. BN dugc chin doin xac dinh i i ung thu bieu md tuyen da d i y dya tren k i t qua md benh hoc.
151
THP CHi V - Diroc HOC QUAN S ^ i6 6-2014 2. Phu'O'ng p h i p nghien ciru.
- Tien eiru eat ngang, khdng so sinh.
* Trang bj dung cp.
Dan may PTNS Stryker, dgng cij PTNS, dao Hemonic Seapie, Ligasure.
* Cich liy benh pham.
- Trong m l nao vet hach D2 theo quy trinh thing nhlt, dugc Kitano v i cac t i c gia tren t h i gidi i p dung, g l m nhCrng budc sau [2, 8];
+ Bat trocar, bgm CO2 kiem tra I bung, danh g i i t i n thuang va kha nang phiu thuat eat da day nao vH hach D2.
+ Giai phdng mac n i l Idn, v i t nhdm hach 4sb, 4d, 6, 14v.
+ Giai phdng ta tring, vet nhdm 5,12a, 12b, cat t i tring bang stapler.
+ Giai phdng mac n i l nhd, vet nhdm hach 1,3,7, Ba, 8p, 9, 11p.
+ Md dudng nhd s i t mui LPC, l l y benh phlm ra ngoii v i thyc hl$n mieng noi.
- Sau m l , phlu tieh lly ri#ng tC^ng hach, dinh s l theo JGCA 2"", nhan xet v l m i u sac, mat dp, s l lugng v i kich thudc, sau dd, ngim trong dung dich formon 10% trong 24 gid. Gifi Khoa Giai phlu b$nh pha due parafin, nhupm HE va doc kit q u i dudi kinh hiln vi dien tu'.
- Kit qua phin chia chang hach v i danh g i i giai doan benh sau mo theo 2 each JGCA 2"'' v i UICC 7* de so sanh [6, 10).
* JGCA quy di.nh nao vit hach D2 trong tirng mire cit da diy nhw sau:
- Cat t o i n bp da day (hinh 1):
Vet nhdm 1, 2, 3, 4sa, 4sb, 4d, 5, 6, 7, 8a, 9, 10, l i p , l i d , 12a. Khli u tam vi phai vet them nhdm 19,20,110 v i 111.
- Cat b i n phin dudi da d i y (hinh 2):
V i t nhdm 1, 3, 4sb, 4d, 5, 6, 7, 8a, 9, l i p , 12a.
- Cat b i n p h i n trdn da d i y (hlnh 3);
V i t nhdm 1, 2, 3a,4sa, 4sb, 7, 8a, 9, 11 p. Khli u t i m vi phai v i t them nhdm 19, 20,110.
- Cat da d i y b i o t i n mdn vj (hinh 4):
Vdt dudi D2 gom nhdm 1, 3, 4sb, 4d, 6, 7, 8a v i nhdm 9.
" Phuang phipxu' iy s6 ii$u:
- Xir iy s l li$u vdi phin mIm SPSS 16.0.
- Tinh thdi gian sing them theo phyong phap Kaplan - Meier, sCr dung test log rank (Mantel - Cox) khi so sinh thdi gian sing thim.
Hinh 2: Cat ban p h i n dudi.
152
T9P CHi V . DV9C H9C OUfiN Sy S6 6-2014 Bang 2; Phin chia chang hach theo JGCA 2™ v i UICC 7*
Hlnh 3: C i t ban phin tren.
Hinh 4: Cat bap ton mdn vi.
Cie mifc cat da d i y va v i t hach D2 theo JGCA 2010 [5].
KS'T QUA NGHIEN ciru Bing 1: K i t qua vet hach D2 ndi soi.
cA NH6M (n = 105)
pN1 (n = 13) JGCA 1998 pN2 (n := 46)
JGCA 1998
Vet dUdc It nhSt V6t du'p'c nhl4u nhat Trung binh Dicdn Trung binh
Di c3n Trung binh
01 cdn
8 hach 40 hgch 22,18±6,18
4,89 ±6,01 21.54 ±3,75 2,69 ±0,95 23,34 ±7,01 6,32 ± 498
UICC 7™ ^ pNo pN, pNi pN3 COng
pNa 33
33 pN,
6 7
13 pNz
10 18 18 46
pNj
3 10 13
CONG 33 16 28 28 105
Bleu dd 1: Theo ddi sing pNI- UICC 7*
Log rank (Mantel-Cox) X^ = 0,162;
p = 0,687.
S/lu dS 2; Theo doi sing pN2- UICC 7*
Log rank (Mantel-Cox) X^ = 0,892;
p = 0,64.
a l u do 3 Theo ddi sdng pNI-JGCA 2°"
153
TftP CHi V - DVQTC HOC OUfiN SljT i6 6-2014 Lpg rank (Mantel-Cox) X^ = 0,326;
p = 0,568.
Bleu dd 4: Theo ddi sing pN2-JGCA 2"".
Log rank (Mantel-Cox) X^ = 13,304, p = 0,001.
Bang 3; Ty le sing pNI-UICC 7".
JGCA 1398 pNI pN2 C«ng
n 6 10 16
cdN S 6 N G 4 8 12
CHST 2 2 4
%
66,7 80 75 Sang 4: Ty le sing pN2-UICC 7'"
JGCA 1998 pNI pN2 pN3 Cpng
n 7 18 3 28
CdN S 6 N G 6 12 2 27
CHiT 1 6 1 19
%
85,7 66,7 66,7 71,4
Bing 5: Ty 1$ sing pNI-JGCA 2"
uiee 7"^
pN1 pN2 Cpng
n 6 7 13
CdN S 6 N G 4 6 12
CH^T 2 1 4
d
%
66,7 86,7 76,9 Sang 6; T} Id s i n g pN2-JGCA 2™.
UICC 7"' pN1 pN2 pN3 Cpng
n 10 18 18 46
CdN SdNG 8 12 7 27
OH^T 2 6 11 19
%
80 66,7 38,9 58,7
BAN LU^N
1. Quy trinh ky thuat nao v i t hach D2 npi soi d i l u tri ung thu> da d i y .
Phiu thuit n|i soi dieu tri UTDD dygc Kitano thyc hi#n l l n d l u tien n i m 1991.
Cho a i n nay, ky thuat n i y dygc thyc hien tai nhilu nydc tren t h i gidi trong dd cd Viet Nam [2). Tai Nhat Ban, T l chifc Nghien eiru Thyc nghiem L i m sang hpc (JCOG) k i t thuc giai doan II (2008) xic nhin tinh an t o i n va kha thi eua PTNS dieu tri UTDD. Nam 2010, T l chifC PTNS Tieu hda Han QuIe (KLASS) k i t thiic nghien eiru so s i n h PTNS va phlu thuat m l md cat doan da day nao vet hach, kit qua khdng khic bi$t giya hai nhdm. Tren eg sd dd, e i c t i c gia Nh|t Ban v i Hin QuIe da x i y dyng quy trinh PTNS oat da day nao vet hach d i l u tri UTDD [8].
Bat trocar, bam CO2, kilm tra 0 bgng, x i c fflnh t i n thuang va k h i ning phlu thuit cat da d i y nao vet hach D2, sau d6 t i l n h i n h cupc m l . Quy tnnh nao vet hach npi soi bat dau tif giO'a mac nil idn di sang trai tdi lieh, cat bd mac nil vi tji, vet nhdm 4sa, 4sb. Diing dao si#u i m giai phdng sang phai tdi mdn vi t i tring vet nhdm 4d, 6 v i 14v. Giai phdng mdn vi ta tring, vet nhdm 5, 12a, 12b, di dpng t i tring va elt t i tring bang stapler. Giai phdng mac n i l nhd di tif bd tren tyy, vet nhdm 8a trydc, l l y nhdm 8a i i m mlc di sang phai v i o r i n gan v i t nhdm 12p, di sang trii v i t nhdm 9, bde Ip dpng mach t h i n tang v i d l u dpng mach lach d l vit nhdm l i p , bOc ip va cat d i n g mach vi trii sat gle. LCic n i y n l n g da d i y I6n, lly bo toan b | nhdm 7 dpc theo ddng mach vi trii, vet l i . phuc mac thanh sau v i mac n l i nhd l i n s i t t i m vi trij hoinh phai.
154
TQP CHi V - Dtr^c HOC OUfiN sy sd' 6-2014 vet nhdm 1 v i 3 [2]. [8]. L l y hach ra ngoii
qua dudng md nhd Qua 105 trydng hgp, chiing tdi thly PTNS thuan Igi hgn so vdi phiu thuit md d nhii'ng viing t i m phinh vi, r l n lieh va cuing gan, camera vdi man hinh dp net cao cho phep quan s i t rd mach m i u v i he bach huylt giup nao vet dygc triit de.
2. Kit qua nao v i t hach D2 ngi soi v i phin chia giai doan hach.
Kit qua nao vet hach npi soi (bing 1):
ch nhdm nghiin ciru (n = 105) vet dygc trung binh 22,18 ± 6,18 hach, di can 4,89
± 6,01 hach/1 BN. Nhdm di can hach Chang pNI theo JGCA 2"" (n = 13) vet dygc trung binh 21,54 ±3,75 hach, di ein 2,69 ± 0,95 haeh/1 BN, Nhdm di can hach Chang pN2 theo JGCA 2"" (n = 46) vet dygc trung binh 23,34 ± 7,01 hach, di can 6,32 ± 4,98 hach/1 BN. K i t qua niy phii hgp vdi Karpeh (23,9 hach), cao han nghien ciru eua Dd V i n Tring (15,3 hach), Trinh Hing San (18,5 hach) [1, 2, 7].
Phin chia giai doan hach khdng di can 33 BN (31,4%), t h l p han Dd V i n Tring (45,7%) [2], Karpeh (38,5%) [7], eao han Trinh Hing San (19,28%) va Kranenbarg (29,2%) [1, 9]. Chia theo JGCA 2"", ty le pN2 eao (43,8%), chia theo UICC 7'"; pNI (15,2%); pN2 v i pN3; 26,7%.
3. Theo doi sdng sau m l v i vai trd tien lu'gng cua chang hach di can.
Bieu d l 1 va bang 3; theo ddi sing theo pN1, ty le sing 75%, phan tich theo JGCA 2"" khdng ed sy khac bidt vdi p = 0,687.
Bilu d l 2 va bang 4: theo ddi sing theo pN2, ty ie sing 71,4%, phin tich theo JGCA 2"" khdng cd sy khic biet vdi p = 0,64.
Bilu d l 3 v i bang 5; theo doi s i n g theo pNI-JGCA 2"", ty ie s i n g 76,9%, phin tich theo UICC 7'" khdng cd sy khic biet vdi p = 0,568.
Bilu d l 4 v i bang 6: theo ddi sing theo PN2-JGCA 2"", ty le song 58,7%, phin tich theo UICC 7*, ty Id sing theo 3 Chang hach pNI, pN2 v i pN3 cd su khac biet rd ret vdi X ' = 13,304, p = 0,001.
Karpeh nghien ciru 1.038 BN thly, dinh gia giai doan hach theo s l Iygng hach di can chinh xac han khi phai lly du 15 hach [7]. Kranenbarg theo ddi sing theo pN1 v i pN2 (UICC 5*) phin tieh theo UICC 4 * thly khdng khac bipt vdi p > 0,05; phin tieh ngygc lai thly khic biet rd ret vdi p = 0,0005. T i c gia kit Iuan phin chia giai doan hach theo so iygng hach di can hgp ly han theo vi tri hach di can. T i c gia d l nghi chf c i n lly 5 hach xet nghiem ia du (thay vi 15 hach) de x i c dinh tinh trang khdng di c i n [9).
KET LUAN
Qua nghien eiru 105 BN, chiing tdi thly phan chia giai doan hach theo s l lugng hach di ein ed y nghTa tien iygng t i t hgn phan chia theo vi tri hach tren eg sd phai lly hit hach chang 2. Bing phin chia giai doan hach thee UICC 7"^ ed y nghTa tien Iygng phij hgp hgn so vdi phin chia giai doan hach cua JGCA 2"^^.
TAI L i f U THAM K H A O 1. Trinh Hdng Son. Nghien ciru nao vet hach trong dieu tri UTDD. Luin an Tiln sy Y hpc.
Trydng Sai hoc Y. H i Ndi. 2001.
2. Do Vin Tring. Nghien cu'u k? thuat ngo vit hach bing PTNS trong dieu tri UTDD viing hang mdn vi. Luan i n Tien sy Y hpc Trudng Dai hpc Y. Ha Npi. 2012
155
TAP CHI V - Dtf^C HOC QUflN SU* SO 6-2014 3. Ahn H.S, Lee H.J. et al. Evaluation of the seventh American Joint Committee on cancer/International Union against cancer classification of gastric adenocarcinoma in comparison with the sixth classification.
Cancer. 2010,15, pp.5592-5598.
4. American Joint Committee on Cancer.
Chapter 10: Stomach, AJCC cancer staging manual, 5"^ edition. Part II: Staging of cancer at specific Anatomic sites. Lippincott. Philadelphia.
1997, pp.71-76.
4. Japanese Gastric Cancer Association.
Japanese gastric cancer treatment guidelines.
Gastric Cancer. 2010, ver.3, pp.1-11.
5. Japanese Gastric Cancer Association.
Japanese classification of gastric carcinoma' 3'''' English edition. Gastric Cancer. 2011, 14, pp.101-112.
7. Karpeh M. Leon L et al. Lymph node staging in gastric cancer Is location more important than number? An analysis of 1.038 patients. Annals of Surgery. 2000, Vol 232. (3), pp.362-371.
a Kitano S. and Yang H.K. Laparoscopic gastrectomy for cancer' Standard techniques and clinical evidences. Springer. London.
2012.
9. Kranenbarg E.K, Hermans J. et al.
Evaluation of the 5'^ edition of the TNM classification for gastric cancer: Improved prognostic value. British Journal of Cancer.
2001,84(1), pp.64-71.
10. Sayegh M. et a/. TNM and Japanese staging systems for gastric cancer' How do they'coexist?, Gastric Cancer, 2004, 7, pp. 140-148.
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