Tgp chi Tai MQi Hpng Vi^t Nam - Volume (59-19). N''l - March, 2014
BlTdC ©AU KHAO SAT ©^C DIEM LAM SANG, HINH ANH CT, MRI VA MO BENH HQC CAC KHOI U VUNG 0AU CO
TJ^ BENH VIEN UNG THlT DA NANG
Ngi^en Bang Quoc Ch&n * BSH&Xu&n Tuin* Phgm Ngoc Di**
T O M T A T
Cdc khdi u viing ddu cd^hdt triin tic nhitng vi tri khdc nhau a vung ddu va cd, khong M nao bQ. Logi u nay bao gdm cdc nhom chinh thudng xudt phdt tic lap md dm uat lot ben trong mi$ng (niim mgc mieng), hdu hQng va thanh qudn, lop da vitng ddu cd, cdc tuyin nuac bpt, tuyin gidp. Muc tiia : Buac ddutim hiiu ddc diim ldm sdng, hinh dnh CT, MRIvd md binh hoc cua cdc benh nhdn cd khdi u vung ddu cd gap tgi Benh vien Ung thu Da ndng. Ddi tirgrng va pbmmgpbap ngbiin cuv: 154 benh nhdn co khdi u viing ddu cd duac chup CT hodc^ MRI tgi benh vien Ung thu Bd ndngtrong thai gian tie 1/2013-12/2013, CO kit qud gidi phdu benh. Ghi nhgn cdc dit lieu ldm sdng, hinh dnh va md b$nh hgc. Ket qua vk ban lu^n: Da sd benh nhdn tren 40 tudi ( 75,9%), Nam nhiiu han nU (61,7%/38,3%). U dc tinh nhieu han u lanh tinh (136 ca/18 ca). Cdc khdi u dc tinh gap nhiiu nhdt Id : hgch dc tinh chua rd nguyin phdt (26 ca), K vdm (15 ca), K luai (14 ca), K d^ ludi ( 8 ca), K tuyen gidp (1 ca). Kit lu$n: Khdi u lanh tinh hay ggp Id u tuyen gidp vd u tuyin nu&c bgt.
Tit khda: Khdi u vung ddu cd, CT.
SUMMARY
Definition: Tumor of the head and neck is all oftumorsfrom the organs of the head and neck, not including the brain tumors. Aims: Study the clinical, pathological and imaging signs of the head and neck tumors of the patients in Danang cancer hospital during the year of 2013.
Methods: There are 154 patients who have tumor of head and neck that were diagnosed and treated in Danang cancer hospital fi-om 1/2013-12/2013. They are all passed CT or MRI examination and had their pathological results. Results: Most of patients is above 40 year old (75,9%). Men are more frequently than women
(6I,7%/38,3%). The malign tumors are much more than benign tumors (88,3%/
U,7%).The most frequently tumors are malign lymphnode (26cas). cancer of the cavum (15 cos), tongue cancer (14 cas), base of tongue cancer (8 cas). thyroide cancer (1 cas).
Conclusion: The benign tumors are from the thyroide gland and salivary gland..
Keywords: Tumor of the head and neck, CTScan.
•Khoa Y Duflrc- D^i hpc D4 NSng
•*B§nh vi§n Ung Thu DS Ning Nh|n bii 21/12/2013. Duy§t in 5/1/2014.
Tap chi Tai Mui Hong Viet Nam -Volume (59-19). N''l - March, 2014
1. DAT VAN DE
Theo Globocan 2012 ung thu 6ku co chilm khoang 4,7 % t3t ca cac loai ung thu.
Theo Hiep hoi Ung thu cua My, nam 2012 so trucmg hop mdi mac la 40.193 trong do CO 9.050 truong hgp tu vong do benh. Cac khoi u vimg d4u co thuong gap a nam nhifiu hon nii (70 - 80%) va 85% co lien quan den tinh trang hut thuoc la va uong rugu. Vai tro cua virut EBV va HPV cung dugc nhae den trong ung thu vom va ung thu khoang mieng. Tuoi mac benh thudng la sau 40 tuoi, dinh cao nhat la 60 - 70 tu6i.
Phan Ion cac ung thu dSu co thucmg xuat phat tir be mat bieu mo va chu yeu la loai carcinoma te bao gai va cac bien the cua no (u bifiu mo tuyen, carcinoma khong biet hoa...), carcinoma tuyen cua cac tuy6n nuoc bot, ngoai ra con mot so loai khac nhu sarcoma, lymphoma...Cac u lanh tinh viJng dau co thuang gap la cac u cua tuyen nuoc bot, tuyen giap (u giap don hat, u giap da hat)... Vung dau co la vung co nhieu he hach bach huyet va mo lympho cho nen tai thai diem chan doan tren 50% benh nhan
CO di can hach c6, ngoai ra con co ti 16 kha cao hach c6 di cSn tu cac vi tri tdn thuong khac khong thuoc vung diu c6 nhu ung thu phoi, duong tiSu hoa, phu khoa...
Ve mat giai phau, vung diu c6 la vioi^
tuy nho nhung co nhilu ca quan va ciu trie phuc tap, do do vific tifip can vj tri t6n tiiuang dfi chan dodn chinh xac vi tri u nguyfin phat kha kho khan. Trong do, cac phuang tifin chan doan hinh anh giiip ich kha nhifiu trong vific xdc dinh vi tri thuong ton va chan doan ban chat ci!ia mfit vai lo^ii u difin hinh. Tuy nhien, m§i phuong tien chdn dodn hinh anh dfiu c6 mdt uu va khuyet difim rifing. Vi dii CT ddnh gid t6t cdc giai phau chi tiet vfi xuong va m6 mem nhung bfinh nhdn phai tifip xiic vdi tia X, chiu tac dimg phu cua thu6c c ^ quang.MRI ddnh gia tfit hon CT \h giii phlu chi tifit va bdn chit t6n thuang c ^ xuang va mfi mfim, bfinh nhdn khfing tifip xuc vai tia X nhung gid thdnh cao, may phdi CO tir truong cao dfi trdnh dugc dnh gia do mach mdu & chuyfin d§ng hfi hip vung
CO.
Hinh CT128iatcit. may GE Hinh MRI 3T may Siemens
Tgp chi Tai MQi Hong Viet Nam - Volume (59-19). N°1 - March. 2014
2. MVC TIEU NGHIEN CUtJ - Tim hieu ddc difim lam sang va mfi bfnh hpc cua cac benh nhdn co khfii u vdng ddu cfi
- Ghi nhan dac difim hinh anh CT va MRI cdc khfii u viing dau cfi theo phan loai cdc khoang.
3. D 6 I TlXONG VA PHU'ONG PHAP NGHIEN c t r u
3.1.Doi tirgug nghien ctru 3.1.1.Tifiu chuan chgn mau:
- Bfinh nhan co khfii u vimg ddu - cfi dugc kham va dieu tri tai benh vien Ung thu Da NEng til thang 01/2013 tdi thang 12/2013.
- Chin doan xac dinh bang giai phau b?nh.
- Chup CT vd/hodc MRI vimg dau cfi tgi bfnh vi|n Ung thu Da Nang.
3.1.2.Tifiu chuan loai trir:
- Khfing CO giai phau benh hoac giai phiu b?nh khfing phu hgp.
- Khfing cfi chup CT hay MRI 3.2.Phir(rag phdp nghien cuu; Hfii cuu mfi td
3.2.1. Ky thuat thu thap sfi lieu: thu thap so lieu theo
- Dac diem lam sang : tufii, gioi, dia chi.
- Dac difim giai phau bfinh: ghi nhan kfit qua GPB bang choc hiit bang kim nho (FNA), mfi b&ih hgc hoac hoa mo miln dich.
- Dac difim hinh anh (CT, MRI) cua u:
vi tri, kich thuoc, dam do, tin hieu, duang ba, ngam thufic sau tiem theo Protocol chuan cho ky thuat chup a vimg dau cfi.
+ Protocol chup CT: mdy CT GE 16 lat va 128 lat voi dp day lat cat 2,5nim, pitch 0,984:1 voi 3 thi khong thuoc, dpng mgch (20-25 giay), tinh mach (45-60 giay) dugc dung hinh voi cac mat cat axial, sagittal, coronal.
+ Protocol chup MRI: may Simens Verio 3T, dp day lat cat 3mm, vdi cdc chufii xung Axial TIW, T2W, Coronal TlW, T2W, Sagital TIW. Sau tiem : Axial, coronal, sagital TlW+Gd
3.2.2. Phan loai vi tri ton thuang tren CT, MRI theo khoang cua tdc gidH.Ric Hamsberger & cpng sir (Diagnosis head and neck imaging): gom 11 khoang.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Vung trfin suong mong -Khoang duoi luai -Khoang duoi ham -Khoang tuyen mang tai -Khoang co nhai -Khoang canh hiu -Khoang niem mac hau -Khoang sau hau -Khoang canh -Khoang quanh sfing
Vung diroi xwcmg mong 1. -Khoang tang 2. -Khoang co sau 3. -Khoang sau hau 4. -Khoang canh 5. -Khoang quanh sfing
T9P chi Tai MQi Hong Viet Nam - Volume (59-19). N°1 - March. 2014
Thanh phan benh ly trong cac khoang:
Khoang t^ng -Thanh quan -Ha hau - thuc quan -Khi qudn -Tuyen gidp -Tuyen can gidp -Hach canh khi quan -TK thanh quan quat ngugc
Khoang canh hau -Mfi
Khoang tuyen mang tai -Tuyen mang tai -Hach bach huyet -TK mat (VII) -DM canh ngoai -TM sau ham duoi
Khoang canh -Bo mach canh -DTK 9,10,12 -DR TK canh giao cam
-Hach bach huyet 26
Khoang cv nhai -Nhom ca nhai -Nhdnh V3 -Bo mach huyet rang duoi
-DR TM chan buom
-Nganh + phin sau than xuang ham duoi Khoang duvi ham
-Phan nfing tuyen duoi ham.
-Hach bach huyfit.
Khoang niem m^c hau -Niem mac hau -Hanh nhan &VA -Cac tuyen nuoc bgt phu
-Ca khi hau trfin &
giira
-Co nang khau cdi -Sun va cho dfi voi eustauch
Khoang CO sau -Ma
-DTK phu XI -DRTK cdnh tay -Hach bach huyet
Khoang dvoi Iv&i
-Tuyen nuac bot duoi luai vd ong duoi luai -Phin sau tuyfin va ong tuyen duoi ham -Bo mach lufii -TKV3 -Ma
Khoang sau hau -Ud
-Hach bach huyfit
Khoang quanh song -Cfit sfing -Cdc CO truoc cot sfing
-Cdc ca canh song
-DRTK cdnh tay -B6 mach dot song
Khoang mieng Cac xoang canh
mui
Tap chi Tai Mui Hpng Vi^t Nam - Volume (59-19). N°1 - March, 2014
3.2.3. Phan loai vi tri ung thu theo Hiep hfii Ung thu cua My (American Joint Committee on Cancer -AJCC 2010):
- Vi tri u n^yfin phdt gfim: Lufii va khoang mi^g, hiu (bao gom cd ddy luai, khiu cdi mfim, luoi ga), thanh quan, miii va cdc xoang canh mui, cac tuyen nuac bpt(tuyfin mang tai, tuyfin duoi ham, tuyfin dudi lufii), da va phdn mfim, tuyen giap.
' - Cdc nhom h ^ h gfim: h?tch duoi lufii (nhfim IA) (thufic khoang duoi luoi), hach dual ham (nhom IB) (thugc khoang duoi ham), hach canh cao (nhfim II) (thufic khoang cdnh), hach canh giiia (nhom III) (thuOc khoang canh), hach canh duoi (nhfim IV) (thupc khoang canh), hach tam gidc c6 sau (nhom V) (thuOc khoang cfi sau), h^ch vimg cfi tnific (nhom VI) va h^ch vimg trung that trfin (nhom VII).
3.3. X^ \f s6 lifu: bSng SPSS 4. K £ T Q U A NGHIEN CUtJ
Qua thong kfi, chiing tfii ghi nhan co 371bfinh nhan dugc chup CT vd/hoac MRI viing diu cfi, trong do chi c6154 bfinh nhan cfi dil tifiu chuan chpn miu.
Bdng 1; D$c dilm ldm sang nhfim nghien ci>u
Tu&l
G\M
B|a chi
D^c d i ^ m n h 6 m n g h i g n ci>u Trung binh Nh6m tu6l
</=20 2 1 - 4 0
>40 Nam NO BA N i n q Qudnq Nam
sa
ca
%
58.5 8 17 129 95 59 45 62
5,2 11,1 83,7 61,7 38,3 29,2 40,3
Quanq Ng3l Binh e i n h Gia l-al Phu Yen Dak Lak Cac tinh khac; Quang Binh (2), Quang Tri (1) Thanh Hoa (1), Ha Tinh (2), Kon Tum (2) Ninh Thuan (1), Binh Phudc (1), Thai Binh (1)
19 5 5 4 3 11
12.3 3,2 3,2 2,6 1,9 7,1
Nhgn xet: Tudi benh nhdn phdt hien khdi u nhieu nhdt la >40 tudi(83,7%), nam nhiiu hon nit, tl le nam/nit =1,6. Benh nhdn den khdm (fe dieu tri tgi benh vien nhieu nhdt Id Qudng Nam
Bang 2: Vj t r i t o n t h v a n g theo H i f p h$l Ung thu* cua MyAJCC
Vj t r i t o n thu'cyng
L u ^ i va khoang mieng (lifoi, sdn mieng, niem mac md, nuou, khau cdi cirnq) Hau (vom hdu mOi, hdu mi#ng, ha hdu, 3ay ILFO-I, khau cai m^m, tu-ffi ga, thuc quan Sogn tr§n) Thanh quan
T 6 n g Sd ca
35
41
5
%
Ldnh t i n h S d ca
1
%
Ac t i n h S d ca
34
41
5
%
Tap chi Tai MQI Hong Viet Nam - Volume (59-19). N°1 - March, 2014
Mui va cac xoang canh mQi Cac tuy§n nv9C bot chinh (tuyen mang tai, tuyen duoi hdm, tuyin du-oi \\f&\) Da va phdn m§m Tuyen gidp Hach cfi dc tinh chira ro nguyen phat Lymphoma Tdng
1
10
9 20 26 7 154
6
3 8
18 1
4
6 12 26 7 136 Nhgn xet: Vi tri tdn thuang thudng gap nhdt la vung hdu, luoi va khoang mieng, tuyen gidp. Ty le hgch cd dc tinh chua ro nguyen phdt cao.
Bang 3: Phan bd khdi u theo tinh chdt lanh va ac tinh
Giai phiu bgnh
Ulanh 18 ca (11,7%)
Uac 136 ca (88,3%)
U gi^p lanh tinh U h6n hop tuyen nuoc hot U Warthin
Polyp U mach mau U mo Carcinoma +Te bao gai +Tuy6n +Kh6ng biet hoa +Khac
Sarcoma (Co, sol, than kinh, mach mau) Lymphoma & khac...
Sd ca 8 4 2 C 3 1 71 15 20 13 4 13
%
5,2 2,6 1,3 0 1,9 0,6 46,1 9,7 13 8,4 2,6 8,4
Nhtn xeVPhin I6n li u ic tinll 136 ca r88,3«J, ulinli Unh IHS ca (11,7%).
Bang 4: Bdi chiiu d$c dilm iam sang &tinll chit Ilinh ic
I«lh6m tuoi - Dudi 20 -Tip 20
Sen 40 - Tren 40 Gioi tinh - Nam -Nif
Tdng saca
8 17 129
95 59
%
5,2 11.1 83,7
61,7 38,3
Uianh S6ca
3 3 12
7 10
%
1,9 1,9 7,8
4,5 6,6
Ute s6ca
6 14 117
88 49
*•
3,3 9,2 75,9
57,2 31,8 Nh$n xet: B$nh nhin ciing l&n tudi tl 1$ c^c u dc tinh g$p cing nhi&u vi nam nhlSu han nO
Bang 5: Vj tri tdn thyang theo cdc khoang
Khoang 1. Tuyen mang tai 2. Co nhai 3. Canh hau 4. Niem mac hau 5. Sau hau 6. Canh 7. Tang 8. Dub-I iuol 9. DuW hSm 10. Co sau 11. Quanh song Ccic phan khSc: lu-oi, xoang mui, da ...
T6ng s6
9 0 0 27 0 26 37 0 7 4 1 45
U ianh
S6 ca 6 0 0 0 0 0 8 0 1 1 0 2
U ic
si ca 3 0 0 27
0 26 29 0 6 3 1 43 Nhan xet: cdc khoang tgng, cdnh, niim mgc hdu la thumg phdt hien tdn thucmg nhdt.
5. BAN LUAN
-Theo y van, cac khoi u vung dSu co thuong gap o dp tu6i sau 40 va dinh cao li
Tgp cht Tai MQi Hpng Vifet Nam - Volume (59-19). N^l - March, 2014
60-80 tu6i. Nam mac nhieu ban nu. Nghien cuu cua chung toi la phu hpp : tren 40 tudi chifim 75%, Nam / Nii lal ,6/1.
- Da so cac khoi u vung ddu co la u dc tinh, theo thong ke cua chiing tfii tin u ac tinh 136 ca chifim 88,3%, con u lanh tmh 18 ca chiem 11,7%. Cdc khdi u ac tinh thuong gap nhat la : carcinoma tfi bao gai viing mui-hiu (K vom) (15 ca), carcinoma te bao gai cua luoi (14 ca), carcinoma tfi bao gai day luoi (8 ca), carcinoma tuyfin giap (11 ca). Khoi u lanh tinh thuong gap nhdt la nhdn gidp lanh tinh (8), " tuyfin nudc bpt lanh tinh (6 ca).
- Ve mdt chan doan hinh anh : cdc u ac tinh thucmg g^p nhat la thupc cac khoang t^g, khoang cdnh, khoang nifim mfic hau gdm : Khoang Tang 37 ca,Khoang Niem mac hhi 27 ca, Khoang Canh 26 ca. Vfi dac difim hinh dnh ciia tung loai u thi do so lieu cdn it nfin chiing to: se thong kfi trong Uiong lai khi c6 sfi lieu Ion hon.
- Theo so lieu thong kfi trfin the gioi Globocan 2012, ung thu viing dau co chu yfiu xuat phat tir bifiu mo hau hgng, chifim khodng 4,7% tfing sfi cdc loai ung thu, so lugng tfnh cd hai gioi la:
Loai ung thu Khoang ml$ng Hiu hpng Thanh qudn
Thi giiii 300373
ca 229078
ca 157877
ca 43,8%
33,4%
22,8%
Vi0t nam 2147 6269 1319
22,1%
64,4%
13,5%
Bi ning
34 41 5
42,5%
51,2%
6,3%
Trfin thfi gioi ung thu vung khoang mieng 300373 ca/nam chifim 43,8%,ung thu hdu hgng 229078 ca ca/ndm chifim 33,4%, ung thu thanh quan la 156877 ca/nam, chifim 22,8%. Trong khao sat nay thi da sfi ung thu xudt phat tu bifiu mo, tror^ do khoang mieng Id 34 ca chifim 42,5%, ung thu hau hgng la 41 ca chiem 51,2%, thanh qudn la 5 ca chiem 6,3%.
Nhu vay ty lfi ung thu vung hau hgng gap tai benh vien xmg thu Da ndng la cao hon va ung thu thanh quan thi thap hon so voi thong kfi trfin thfi gioi. Tuy nhien thfing kfi nay do chi lay trfin mdu nho do do chua thfi kfit luan dugc
-Ve cdc khoi u lanh tinh thi chu yfiu tren thfi gidi la tir tuyfin nuoc bgt va tuyen giap. Doi vdi cdc tuyfin nudc bgt chinh thi 64 -68 % xuat phat tir tuyen nudc bgt mang tai (trong do 15-32% la dc tinh), 7-11 % tu tuyen nudc bgt dudi ham (trong do 41-45
% la ac tinh). Rifing dfii vdi tuyen nudc bgt phu thi chiem 9-23 % va da so la ac tinh.
Trong nghifin cuu cua chung toi thi budu lanh tinh chu yfiu la tuyfin nudc bgt chinh va tuyfin gidp (14 ca), khong thay u ciia tuyfin nudc bgt phu. Vfi cac u cua tuyfin giap cd sir ban chfi ve so Heu u lanh vi sfi bfinh nhan nay chi lam sieu am tnrdc mo ma khong chup CT hoac MRI.
-Ty le hach dc tinh chua ro nguyfin phdt (26/154 ca chifim 16,6%) tuong doi cao so vdi cdc nghien cuu khdc (3-5%).
Dieu nay chiing toi nghi Id do bfinh vien mdi giai doan dau boat dong nfin qui trinh
T^p chi Tai Mui Hong Vifet Nam - Volume (59-19). N°1 - March, 2014 vfi chdn doan va phuong tifin chua dugc
hoan thifin, chua cd PET/CT dfi khdo sat toan than, mpt phin bfinh nhan xin chuyfin tuyfin trfin nen ty le nay cao.
6. K£T L U ^
- C^a nghien cuu ban dau vfi cac khoi u viing dau co trong 1 nam tai benh vien ung thu Da ndng thi khoi u ac tinh thudi^
gap nhat la: hach co dc tinh chua ro nguyfin phdt (26 ca), carcinoma tfi bao gai vung miii-hau (K vom) (15 ca), carcinoma tfi bao gai cua luoi (14 ca), carcinoma tfi bao gai day luoi (8 ca), carcinoma tuyfin giap (11 ca). Khoi u lanh tinh thudng gsip nhdt la nhan giap lanh tinh (8), u tuyfin nudc bgt lanh tinh (6 ca).
- CT va MRI CO vai tro trong xdc dinh vi tri khoang ton thuong cua khfii u.
- Kien nghi:
+ Can tifip tuc nghien curu vdi s6 lieu ldn hon dfi s6 lifiu thfing ke cd y nghia.
+ Can nghifin cuu dac difim chdn dodn hinh anh rieng cho tung loai u.
TAI LIEU THAM KHAO 1. Head and Neck Cancer Imaging.Robert
Hermans (Ed.)
2. Diagnosis head and neck imaging.H.RicHamsberger & cgng su;
American Joint Committee on Cancer.Springer 2010, 7th.
Moeller, Pocket atlas CT & MRI Head
& Neck, tap 1.
Lfi Si Sdm, Nguyen Dac nhan Tdm, Nguyfin Thi Bai Dfing, Lam Quoc Trung,[ 2013] "Co cau bfinh ung thu dugc dieu tri tai bfinh vien Thong nhdt tu 01/2008-10/2012", Tap chi ung thu hoc Viet nam, s6 4-2013,40-47.
Nguyfin Ba Due 2007, "Ung thu bifiu mfi miii hgng". Chan doan va dieu trj benh ung thu, 100-111
Nguyen Lan Huong, Nguyin Thdi Son, Nguyfin Hiiu Nghia; " Kfit qua budc dau difiu tri 39 truong hgp ung thu vom miii hgng tai vien y hgc phdng xa vd u budu quan dfii". Tap chi ung thu hgc Viet nam, sfi 4-2012, 50-55.
Tran thi Kim Cue, Nguyfin Chdn Hiing, Lfi Ddc Ldnh, Nguyfin Thi H6ng, " Virut HPV , gen va protein P53 trong ung thu nifim mac mieng", Tap chi ung thu hgc Viet nam, so 4- 2012, 136-147.
Nguyen thi Nguyet Anh, Lfi Diic Ldnh, Trdn thi Kim Ciic, Dang Huy Quoc Thinh, Pham Hung Van, Nguyin Thj Hong :"Tinh trang nhifim virut EBV trong ung thu hfic mieng". Tap chi ung thu hgc Viet nam, s6 4-2012,119-124
