Y Hoc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien ciiu Y hoc
VAI TRO CUA CAT LpP DIEN TOAN TRONG CHAN DOAN vA PHAN GIAI DOAN UNG THU THl/C Q U A N
Trdn Diic Quang*, Dang Dtnit Hoan*, Le Van Cuong**
TOMTAT
Md ddu: Ung thu thuc qudn la bath ly dc Hnh tuang dm hiem. Xdc dinh chan dodn sdm, plian giai doqn chinh xdc ung thu thuc qudn truoc phau thuat can thiei dedign lua trf lieu thich hgp.
MiJic tieu: Nghien cieu nliam mo td dac dian hinh dnh cdt lap diin todn vd xdc dinh gid tri cua cat lap diin todn trong phdn giai doqn ung thu thuc qudn trudc phdu thuat.
Doi tuang vd phuang phdp nghien aiu Nghiai cmi tiai ahi vd Iwi ciru mo td cat ngang, tie 12/2010 i^i 03/2013 v&i 118 benh nhdn ung thu thuc qudn dieu tri tqi Binh viin Binh Ddn, v&i kei qua gidi phdu binh Id ung thu thuc qudn vd chup cat lap diin todn tru&c phdu thuat. Thu thap kii qud hhih dnh vd so sdnh vdi kii qud phau thuat vd mo binh hoc sau plidu thuat.
Ket qud: Vi tri thuang gap nhdi a 1/3 giiea thuc qudn. Ddy didnh 10-20mm (60,1%) vd chieu ddi u 40- 80mm (66,1%) chiem ty le cao nhdi. Klidt u co bat thuoc edn quang (100%), caii true dong nhai (94.9%), gay hep long thuc qudn (99,2%), gian TQ ti-in u (99,2%), ton thieang u > 2/3 chu vi thuc qudn (88,87o). Do nliqy, do dac hiiu, do chinh xdc ciia phdt hien xam lan ra ngodi didnh thuc qudn lan lugt Id 83,7%, 71,4%, 80,7%. Hqdi canh thuc qudn tiling tlidi Ian lugt 50%, 92,6%, 88,5%. Hgdi co 16,7%, 98,4%, 92,3%. Hach tdng ti-en obung 28,6%, 92,1%, 75%. Di can xa 57,1%, 96,77o, 91,3%. Ty leplidn giai doqn CTphii hgp ehung so vdi ph&u tliuqt la 69,2%, trong do 92,4% (giai doan III) vd 90% (giai doqn N).
Kei luan: Cdt lap dien todn van Id ca sa chinh ciia phdn giai doqn ung thu thuc qudn truac phdu thuat.
Tu khoa: Cdt lap diin todn, ung thu thuc qudn.
ABSTRACT
ROLE OF COMPUTED TOMOGRAPHY IN DIAGNOSING AND STAGING OF THE ESOPHAGEAL CANCER
Tran Due Quang, Dang Dinh Hoan, Le Van Cuong
• YHoeTP. Ho Chi Minh* Vol. 18 - No 1-2014:15-20 Background: Esopliageal cancer is relatively rare malignant disease Early diagnosis and accurate preoperative staging of tlie esophageal cancer are necessary to seled the most appropriate tieatment
Purposes: Tliis study aims to describe the imaging diaraderistics and define the value ofCT in preoperative staging of esophageal cancer.
Subjecs and methods: Retro- and prospective cross section descriptive study of 118 patients in Binh Dan hospital from Dec 2010 to Mar 2013, zoith histologically verified esophageal cancer and using CT preoperatively.
Imaging diaraderistics and staging were made by evaluating imagmg obtained and compared with the operative and postoperative histopathologic results.
Results: The most common location was middle 1/3 esophagus. Tumor wall thickaiing 10-20mm (60.17o) and laigth 40-80mm (66.1%) had the highest percentages. Tumors had constrast aihancanent (lOffVo), homogeneous structure (94.9%), esophageal luminal narroxving (99.2%), esophageal dilatation above tumors
* Khoa Chan doan Hinh anh, BV Binh Dan. "Dgi hpc Y Dupe TPHCM
Tdc gid lien lac. BS.CK.II Tran Due Quang DT: 0937659272Email tranducquang bvbdig'yahoo.com.vn
Hgi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014 15
Nghien cxhi Y hoc Y Hoc TF. Hb Chi M i n h * Tap 18 * So 1 * 2014
(99.2%), tiimor lesion ocaipying larger than 2/3 esoplmgeal draimferaice (88.8%). The sensitivitif, speafidty and acairacy ofCT to evaluating the periesophageal fat invasion were 83.7%, 71.4%. 80.7%. These to ddecting lymph node metastases were 5W/o, 91.6%, 88.5% (for Hie paracsophageal-mediastiml nodes); 16.7%, 98.4%, 92.3% (for the cervical twdes), 28.6%, 92.1%, 75% (for the upper abdomiiml nodes). These to detecting distant metastases were 57.1%, 96.7%, 91.3%, respectively. Parentages of CT staging correlating with operative staging was 69.2%, in zohich stage III was 92.4%, stage P/ was 90%.
CotKlusions: CT is still tlie principle basis f)r preoperative staging of esoplmgeal canca:
Keywords: Computed tomography (CT), esophageal cancer.
M O D A U
Ung thu thuc quan la benh ly ac tinh tuong doi hiem, chiem xap xi khoang 1-2% tong so ung thu va khoang 10% ung thu' dLtong tieu hoai'^i.
Danh gja chinh xae cua do sau xam nhap thanh thue quan, hach baeh huyet va di can xa la quyet dinh eho viee chQn lira dieu tri toi tni.
Phau thuat van eon la su lua chpn dieu tri chinh.
Do do, dieu quan trpng la su phan giai doan ung thu thi^c quan chinh xac truoc mo de xem u eon CO kha nang phau thuat dupe hay khong. Vi vay, xac dinh chan doan som, phan giai doan ehinh xae ung thu thire quan tnroc phau thuat la rat can thietf^-'oi.
O nuoe ta, vai tro eua XQCLDT eo gitip phan loai dupe giai doan ciia ung thu thue quan;
XQCLDT CO giiip duoc gj eho phau thuat vien de chpn Ilia phuang phap phau thuat hay khong?
VI vay, chiing toi thirc hien nghien ciiu "Vai tro oia cat lop dien toan trong chan doan va phan giai do^n ung thu thiic quan".
Myc tieu nghien cmi
Mo ta dae diem hinh aith X quang eat lop dien toan eiia ung thu thuc quan.
Xae dinh gia tri aia X quang dt lop dien toan trong phan giai doan ung thu thirc quan.
DOITU'ONG-PHU'ONGPHAPNGHIENaJtJ Dbi tirgmg
118 BN dupe dieu tri tai Benh vien Binh Dan TP.HCM tu thang 12/2010 den thang 03/2013 vm chan doan UTTQ. BN dupe kham Iam sang, chup X quang cat lop dien toan co can quang
truoe phau thuat; npi soi sinh thiet vtM GPB la UTTQ va / hoae phSu thuat.
Tieu c h u i n loai t r a
Nhung BN khong eo phim XQCLDT, khong CO ket qua giai phau benh, UTTQ tai phat hoac UTTQ da dupe xa tri, hoa tri; u TQ thij phat hoae lanh tinh.
Phuong p h a p nghien cmi
-Thiet ke nghien emi: Mo ta eat ngang, tien euu va hoi euu.
-Phuang phap tien hanh: BN duoc chpn thoa dieu k i ^ , nghien ciiu ho so benh an, phim chiip XQCLDT de thu thap cac bieh sb dupe djnh nghia truoe theo de cuong nghien euu, phan tich cac yeu tb theo mau thu thap so lieu thong nhat da dupe lap trinh de xii ly sb l i ^ . So lieu dirpc nhap vao bang dii kien aia phan mem Excel 2007, Epi Info 6.04 va thue hien cac kiem dinh tuong quan. Cac dau hieu thu thap tren XQCLDT dupe so sanh va dbi chieu voi ket qua PT va GPB. May chup eat lop dien toan 64 lat cat PHILIPP BRILLIAN, may chup cat lop dien toan 4 lat ck TOSHIBA AQUIUON.
KET QUA NGHIEN CUtJ Tubi va gioi
Tubi TB la 55,6 ± 10,6 tubi. Nhom tubi 51-60 chiem da sb (40,7%). Ty le Nam/ Nii= 23/1 Dac diem hinh a n h va phan giai doan XQCLDT cua u n g t h u thuc quan Vi triu
Thuong 6 1/3 giiia voi 55 BN (46,6%) va 1/3 duoi voi 53 BN (44,9%).
Y Hoc TP. Ho Chi Minh * Tap 18 * So 1 * 2014 Nghien cuu Y hgc
Day thdnh u
Trung binh la 20.3 mm ± 8,0, Ion nhat la 42nun va nho nhat la 5nun. DQ day 10-20mm: 71 BN (60,1%); > 20mm: 40 BN (33,9%); <10mm: 7 BN(5,9%).
Chieu ddi u
Tmng binh 51,0 mm ± 21,4, dai nhat la 120mm va ng5n nhat la 4mm. Chieu dai 40-80 mm (66,1%); < 40mm (27,1%); > SOmm (6,8%).
Ton thuang theo chu vi TQ
> 2/3 (88,8%); 1/3-2/3 (12,7%); < 1/3 (2,5%).
Muc do ngam thuoc
118/118 (100%) BN CO ngam thuoc. TB la 24 ± 2,8 HU, manh nhat la 43 HU va nho nhat la 15 HU. Ngam thuoc manh 84 BN (71,2%).
Mot so dac diem khac
Hep long thuc quan va gian TQ tren cho hep vol 117 BN chiem 99,2%. Ngain thuoc dong nhat 112 (94,9%). 6 BN (5,1%) u thuc quan nhieu vi tri Bac diein xam lan cua UTTQ tren XQCLDT
Xam lain mo quanh thuc quan 83,1%. Xam lah khi phe quan 44,9%. Xam \sn dong mach chu 61,7%. Goc Kcus >90 dp (63,0%), goc Picus 45-90 do (37,0%). Mat tam giac mo giua UTTQ-than song-dpng mach chu chieiai 39,7%. Cac truong hop xam lan khac: Xam lan mang tim (19,5%), da day (19,5%) va mang phoi (1,5%). Khong TO truong hop nao xam lah co hoanh.
Hach viing
35 BN chiem 29,7%. Hach tang tren 6 bung (51,4%), hach thuc quan tnmg that (37,1%) va hach vimg co (11,4%).
Dican xa
Co 14 BN (11,9%). Di can gan (50,0%), phoi (21,5%), xuong (7,1%) va mot so vi tri khac (21,4%).
Phan giai doan UTTQ Hen XQCLDT Phan GD theo TNM 2009: GD ffl chiem 64,4%, GD 113,6%, GD n, FV deu 11%.
SO SANH KET QUA TREN XQCLDT VOI GPB VA P H A U THUAT
- Doi chieu vi tri u voi phau thidt pO,001 So sdnh ddy thinh UTTQ tren XQCLDT vai
phdn giai doan PT
Day thanh 10-20mm (77,8%) va >20mm (84,9%) CO GD PT ffl. Giai doan PT IV: 10-20mm (17,5%), >20mm (9,1%).
So sdnh chieu ddi UTTQ tren XQCLDT vai phdn giai doan phdu thuat
Da so chieu dai u<40mm, 40-80mm va
>80mm deu nam trong giai do?n phau thuat in Ian luot la 79,3%, 77,6% va 71,4%. 6 giai doan phau thuat IV, ty le tang theo chieu dai u Ian luot la 6,9%, 14,9% va 28,6%.
Xdm lan ngodi thdnh thuc qudn doi chieii XQCLDT vai phau thuat
Dp nhay (Sn)=90,9%, Dp dac hieu (Sp)
=68,8%, Dp chinh xac (Ace) =87,5%
Xdm lan cdc tang lan can dot chieii XQCLDT vai phdu thu^t
Do nhay (Sn) = 73,8%, Dp dac hieu (Sp)
*66,7%, Dp chinh xac (Ace) = 72,1%
Di can xa doi chieit XQCLDT vai phau thudt Do nhay (Sn) = 57,1%, Dp dac hieu (Sp)
=96,7%, Dp chinh xac (Ace) = 91,3%
Hach viing co doi chieii XQCLDT vai phdu thuat
Dp nh?y (Sn) =16,7%,, Dp dac hieu (Sp) -96,9%, Do chinh xac (Ace)=92,3%
Hach canh TQ trung that doi chieit XQCLDT vai phdu thuat
Dp nhay (Sn) =50%, Dp d?c hieu (Sp) -92,6%, Do chinh xac (Acc)=88,5%
Hach idng tren 6 hung doi chieit XQCLDT vai phan thudt
Do nhay (Sn) =28,6%, Do dac hieu (Sp)
=«2,1%, Dp chinh xac (Ace)» 75%
Doi chieu phdn giai doan giua XQCLDT vd phdu thuat
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014 17
Nghien cixu Y hpc Y Hoc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014
Bdng 1: Ddi chieii phdn giai doqn giiea XQCLDT vd PT(n=104)
GB 1 GO 2 GS3 GO 4 T6ng
Giai do^n tren ph^u thu^t GB1
1 2 0 0 3
GD2 3 1 2 0 6
GD3 11
8 61 1 81
GO 4 0 2 3 9 14
Tong 15 13 66 10 104 Ty!? phii hop trong vi|c phan giai doan giira XQCLDT voi phau thuat la 69,2% (72/104). 92,4%
(61/66) doi vol giai doan 3, 90,0% (9A0) dbi vod giai doan 4.
Xdm lah ngodi thdnh TQ dot chieu XQCLDT vai gidi phdu binh (n=57)
Bdng 2: Xdm lan ngodi thdnlt TQ ddi diiHi XQCLDT vdi GPB (n=57)
~"^^^.,^^^ GPE KQCLDT"""---...^
Ngoai thdnh Tfong thanh T6ng
Ngodi thdnh 36
7 43
Trong thanh 4 10 14
TSng 40 17 57 Dp nhay (Sn)=83,7%, Dp d?c hieu (Sp)
=71,4%, Dp chinh xac (Ace) = 80,7%
BAN LUAN Tubi va gioi
Tubi chu yeu tren 50 tubi chiem ty le 83,9%
va ty le nam / nii la 23/1. Phii hpp voi ket qua Clia cac tac gia khae, khong khae so voi y van*^'''*''*'.
D^c diem hinh anh XQCLDT aia UTTQ Vi triton thuemg
Ket qua phu hpp voi y van va cac nghien euu khac"-^. Yamabe thay tbn thuong u 1/3 giiJa, 1/3 duoi, 1/3 tren la 65,9%, 20,2%, 19,l%n^. Bid van L^nh eho thay lan luoi: la 52%, 39,2%, va 8%i'. Vi tri tbn thuong co y nghia anh huong trong nhirng each tiep e$n khac nhau trong PT cit TQ">. Theo mpt nghien cuu khae, vi tri ton thuung anh huong den tien lupng<^'.
Ddu hieu ddy thdnh thuc qudn
Ket qua phu hpp voi nghien eiiu cua Biii Van
Lenh va Vo Trpng Hao voi t\' le day thanh TQ theo thii hr tren"'". XQCLDT co uu diem la danh gia day thanh UTTQ kha tbt nhung co nhupc diem la khong khao sat duge chi tiet lop niem mac va cau tnic lop thanh TQ'''^>. Khbi u cang 6 giai doan mupn (giai doan lU, IV) thi dp day thanh cang cao, kha nang lan tran ra ngoai thanh TQ ke ca xam lan trung that va cac tang lan can.
Chieu ddi u
Ket qua phii hpp vdi nghien cuu ciia Nguyin Cong Minh va Hamda<'\ Co nghia la BN den tri, chi dinh mb triet de kho khan. Gaur (2011) cho thay chieu dai u co y nghia trong hen doan thoi gian song con va sy nguy hiern cua su tai phat(«>. Griffith va es eho thay BN UTTQ voi chieu dai u > 33cm co tien luong kem hon BN co chieu dai u ngan hon sau phau thuat eat UTrQ'^>. Khbi u CO chieu dai cang Ion tM giai doan nang cang cao va kha nang PT kho khan hoac khong nen PT nija. Ke't qua nay phu hop vai cac nghien euu chieu dai u co y nghia tien lupng trong PT'^). Sillah va Gao cho ring XQCLDT CO khuynh huong qua uoe tinh chieu dai u TQ khi so sanh voi chieu dai mau benh hoc tuong ungf"'. Trong liic Dnidi va es lai thay chi^u dai u tren XQCLDT truoc phau thuat thuong ngan hon chieu dai tuong ling eiia mau bi eat"3).
Cdc ddc diem hinh dnh khac tren XQCLDT Clia UTTQ
UTTQ CO tang quang (100%), tang quang manh (92,4%). Co the giai thieh dau hieu nay do UTTQ dien hinh tang maeh mau va qua trinh phat trien cung cap maeh mau dong mach moi, su tiianh \$p vi maeh mau u trong u dan den tang len ro rang gia tri dam dp tang quang ®.
Hep long TQ va gian TQ tren u la ket qua tat yeii Clia day thanh UTTQ. Nghien cmi cua chiing toi cho thay tbn thuong thuong gap nhat la >2/3 chu vi TQ vai 88%. Phii hgp vba nghien cuu ciia Bid Van Lenh <^K Nhu vay, da sb b?nh nhan deu den benh vien o giai doan mupn.
Hpi Nghi Khoa Hpc Ky thu?t BV. Binh Dan 2014
Y Hoc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014 Nghien cihi Y hpc
Phan giai doan LTTQ tren XQCLDT Xdm lan trong thdnh vd ngodi thdnh
Ket (pia phii hpp voi y van va cac n^iien cuu khac'-"'. XQCLDT rat co gia fri trong diah doan UTTQ xam ]an ra ngoai thanh TQ. Mae dii tham nhiem mo quanh TQ anh huong bat loi den ti&i luong, no khong phai la ehohg chi dinh dbi voi su cit bo u toan bp**-"'. UTTQ gjai doan som CO the khraig duoe phat hi?n voi
xQcmr?'.
Xdm lan dgng mach chu
Phat hien daii hieu xam lah tang lan can la Sn 73,8%, Sp 66,7%, Ace 72,1%. Ket qua phii hop voi n^iien ciiu eua Pongpomsup'''. Theo Bid Van Lenh, khi goc Picus > 90 do kha nang boc tach UTTQ ra khoi dpng mach chu van ihi^ hien duoc tuy kho, khong phai la chong chi dinh cat UTTQ'". Dau hieu mat tam giac md chiing to u xam lan lan rong va kha nang boc tach u kho khan hon'''. Tri lieu phu tro u truoc phau thuat CO Ihe" lam ttng khoang each u voi dpng mach chu va gjam kich thuoc u toi da va goc Picus, noi ehung la giam giai doan tu T4b xubng T4a, T3~.
Xam lan khi phe qudn
Theo Bid Van Lenh, daii hieu de day va va bien dbi long khi quan la dau hieu quan trpng huong toi CO xam lah KPQ. Doan xam lah cang dai du kha nang phau tich cang kh6"\ Tuy nhien, Haaga cho r&ig dau hieu vSng mat phang mo xen vao va khoi tao ra dp 16m phan sau KPQ CO the khong co su xam \St\ \-i vong sun khong hoan toan trong phan sau KPQ'^'"-"'- Theo Yamatje, tieu ehuan day lech va bien dang KPQ tren XQCLDT co khuynh huong phan qua giai doan'^"^.
Phdn giai doan N
So sanh vdi nghien ciiu cua Bid Van Lenh nghi&i ciiu ciia chiing toi co Sn thap hon nhung CO nhieu diem tuong dong la Sp va Ace cao, kha nang phat hien hadi canh TQ \-a trung that tbt hon eae hach cb va &\g tren b bung^>. Y van die thay bien do rpng \ e su chinh xac trong phat hien di can hach'^'. Theo Haaga, Sn la 45''o deh
36"o''. Theo nghien ciiu eua Consigliere, Ace la 63'^o'-'. Theo Kim. Ace la 85,7%'^i. Yoon va es, Sn 31%, Sp 86%, Ace 49%. Ket qua aia chiing toi
^ n vcd voi ket qua aia Yoon nhaf^. Iheo bao cao cua Quint da cho thay nhiing ket qua khac the hien bien dp rong \di Sn ll%-69%, Sp 71- 95% va Ace 66%-83%'"Oi. C^n day nhat (2012), theo Pongpomsup va cs, XQQi5T phat hien khong CO hach di can (NO) voi Sn 50%, Sp 33%, Ace 81,8° o; va phat hien CO hach di can noi ehung (NI) voi Sn 33%, Sp 50%, Ace 38%5). Kich thuoc hach khong dang tin eay trong UTTQ^"'^* \'i ^ so cao nhimg ket qua duong tinh gia va am tinh gia*. Vi$c ap dung nhiing tieu ehuah kich thiroc khac nhau dbi voi vai chuoi hadi co the cai tiiien kha nang XQCLDT trong phat hien di can hach(^«".
Giai doqn M
Tan suat xuat hien di can xa phii hop voi y van'^'. Theo Goliub va cs, ty le di can gan, phoi, xuong, tiiuong tfian Ian lupt la 32%, 31%, 9%, 2%. Theo Bhat, cac ty le nay Ian lupt la 35%, 20%, 9% va 2%<5). Sn, Sp, Ace cua XQCLDT phat hien di can xa, phii hpp voi cac ket qua khae. Vliet va cs, trong nghien cuu 569 UTTQ co ty le di can sea la \T,o. va &i 65% va Sp 95% cho phat hien di can xa thue hien cho tat ca cac eo quan. Nghien cuu tiiay rang thuc hanh CLDT duy nhat khong du Sn trong viec phat hien di can xa^^.
Phdn giai doqn theo TNM
Theo nghien eiiu Reid, dua theo phan C3) mdi TNM 7* 2010, tj' le sbng sot 3 nam aia UTTQ CD 1 la 62,2%, GD H la 50,7%, GD m la 17,6% va CD IV la 0%. Theo Jobe, t>' le nay co thay dbi it Ian luot la giai doan I (60%), giai doan n (31%), giai doan HI (20%), giai doan IV (4%).
Noi ehung bieu hien tien lupng cang xaii khi giai doan tang len'^. Phoi hpp hinh anh eat ngang (XQCIIH" hoae CHT), SANS, PET va phiu thuat xam lah tbi thieu duoc sii dung trong phan giai doan UTTQ phat hien mdi. Phan gjai doan chinh xae tiep tuc la mpt thach tiiiic*^.
Hpi Nghi Khoa Hpc Ky thuat BV. Binh Dan 2014 19
Nghien ciru Y hpc Y Hpc TP. Hb Chi Minh * Tap 18 * Sb 1 * 2014
KET LUAN
XQCLDT CO gia tri cao trong mo ta dac diem hinh anh gop phan chan doan, la co so chinh ciia phan giai doan va van con la thanh phan thiet yeu eho phan giai doan hen khoi va danh gia benh ly di can xa ung thu thuc quan. Vi vay, XQCLDT luon la mpt trong hinh anh tiiuong quy phan giai doan lam sang truoe phau thuat.
TAI LIEU THAM KHAO
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Est^hageal cancer, pp 93-118, Elsevier Inc; Boston 4 Haaga JR et al (2008), GastrtMntestinal tract. In: Haaga JR CT
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Reinig JW et al (1983), " C I evaluation thickened esophageal walls", AJR :40 931-934
SiUah K, WiUiams LR (2010), "Computed tomography overestmialion of esqjhageal tumor length: Implications tat radiotherapy plannmg", Worid J Gastroenterol Oncol 2(4),197-204
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Ngdy nhdn bdi bdo: 04/11/2013 Ngdy phdn bien nhan xet bdi bdo: 1/12/2013 Ngdy bdi bdo diegc ddng: 20/02/2014
Hgi Nghi Khoa Hoc Ky thuat BV. Binh Dan 2014
