Y HOC VIET NAM THANG 3 - SO 2/2012 vimg dudi leu: khdi phat dot ngdt, cap linh
(95,1%); dau dau (87,8%), ndn va budn ndn (65,8%), rd'i loan y thdc (69,3%), hpi chUng giao ben (60,9%) hau het cd liet nira ngudi trung UPng (60,9%), trong do liet nifa ngudi nang (dp IV, V) chiem ty le cao, rd'i loan cd vdng (66,6%).
Hinh anh chup CLVT so nao cho thay vj Iri thudng gap d than nao (61%). Kich thudc dudng kinh d tdn thUdng thudng < 2cm. MUc dp phii ne nao xung quanh o ton thUdng thudng (vien phii ne 0,5 - 1cm),
2. Cac y e u to' tien l U d n g n a n g 6 b e n h n h a n :
Qua phan tich cac ye'u t d tien lupng ve lam sang va chup CLVT chiing tdi thay cd 10 yeu t d tien lupng dd'i vdi BN tai bie'n mach mau nao viJng dudi leu:
- Benh nhan cd tien sir dot quy - Khdi phat dpi ngpt kem rdi loan y thirc ngay tU dau
- Huyet ap tam thu khi vao vien > 200 mmHg
- Diem Glasgow < 9 - Kich thich vat va hoac co giat - Dudi cCfng mat nao
- Liet nira ngudi nang (dp III, IV) + giam phan xa gan xUPng
- Rdi loan than kinh thuc vat - Dudng kinh o tdn thUdng > 2 cm - Vien phu ne nao > 1cm
Trong dd cd 6 yeu 16' cd gia trj tien lupng
cao hPn la: Tien sl!r dot quy, huyel ap lam thu khi_vao vien > 200mmHg, diem Glasgow < 9, dudi cirng mat nao, rd'i loan than kinh thuc vat (sdt > 40°, va md hdi lanh, tang tiet ddm dai, gian ddng tii, mat phan xa ddng t i j vdi ang sang); dudng kinh d ton liiupng > 2cm. Cac trieu chimg dudi cUng mat nao, co giat chie'm ty le thap nhUng la nhUng trieu chifng tien lUdng nang va gap 6 nhdm tCr vong.
TAI LIEU THAM KHAO
1 Bo mon Than kinh - Hoc vien quan y (2003):
Benh hpc Than kinh - Nha xuat ban Quan doi nhan dan.
2 Nguyin Van Chudng (2007): Dot quy nao - Trong Benh hpc Npi khoa - W/?a xuat ban Quan doi nhan dan.
3. Thai Kh^c Chau, Nguyen Minh Hien, Nguyin Manh Hung (2004): Nghien cifu dac diem lam sang va hinh anh chup cat Idp vi linh d benh nhan chay mau nao - Tap chi Y hoc Viet Nam, Sd301. 148-152.
f. Nguyin Van Dang (2003): Tai bien mach mau nao - Nha xuat ban Y hoc.
5. Nguyen Minh Hien, Tran Tuan Anh (2003):
Oac diem lam sang, hinh anh CT.Scanner va yeu to tien lu'dng d benh nhan chay mau du'di leu tieu nao - Hgi thao khoa hgc benh vien Bach h/lai: "NhiJng tien bo mdi trong chan doan va dieu tri benh ly mach mau nao", 141-145.
6. Le Due Hinh va mot nhom chuyen gia (2007): Tai bien mach mau nao' HUdng dan chan doan va xir tn' - Nha xuat ban Yhoc, Ha Noi.
KET QUA DIEU TRj UNG THU VOM HONG GIAI DOAN III, IV(MO) XA TR! 30 DANG M A Y GIA Tdc PHOI HOP HOA TR! DONG THOfI
B u i V i n h Q u a n g * , B u i C d n g T o a n * T 6 M TAT
Nghien cifu 56 benh nhan UTVH giai doan I I I , IV (MO) da dupc dieu tri hda xa tri gia tdc dong thdi tai benh vien K tif thang 4 nam 2007 den thang 4 nam 2009 dat ket q u i ;
Ty le dap Ung tai u hoan toan la 91,1%, mdt phan la 8,9%. Dap irhg hoan toan tai hach la 92,8%, mot phan la 7,2%.
Ty le dap Cihg hoan loan chung la 89,3%, dap
uhg mdt phan la 10,7%.
Ty le sdng them 3 nam toan bd la 85,1%, 4 nam toan bg la 72,2%. Thdi gian sdng them trung binh la 46,6 thang,
Ty le sdng them 3 nam ktrang benh la 81,3%, 4 nam khdng benh la 65,2%.
Tai phat tai vdm la 7 , 1 % , tai hach la 3,6%. Ty le dl can la 16,1%, di can xUPng 8,9%, di can gan 3,6%, di can phoi 1,8%
Binh viin K
Phan biSn khoa hpc: PGS.TS. Nguyin Thi Vinh Ha
Y HOC VIET NAM THANG 3 - SO 2/201?
SUMMARY
The result of NPC with stage I I I , w patients that treated by concurrent radiochencotherapy The result of study 56 NPC with stage Hi i v patients that treated by concurrent radiochemotherapy (linac 3D-CRT) at K hospital during from April 2007 to April 2009 as follows:
The rate of tumoral complete response; partial response is 91,1%; 8,9%, respectively. The rate of nodal complete response; partial response is 92,8%;
7,2%, respectively. Overall rate of complete response;
partial response is 89,3%; 10,7% respectively Rate of 3 year overall survival; 4 year overall sun/ival is 85,1%; 72,2% respectively. The average sun/ival time is 46,6 months.
Rate of 3 year disease free survival; 4 year disease free survival is 81,3% and 65,2%. Rate of recurrence found at nasopharynx; local lymph node is 7,1%; 3,6%, respectively. Rate of long distance metastasis is 16,1% (oss metastasis is 8,9%; liver is 3,6%; lung metastasis is 1,8%; Brain metastase is 1,8%) among them.
r.
OAT VAN o fViet Nam la mpt nudc nam trong khu vuc djch t l cua ung thu vdm hong (UTVH), benh ludn difng hang dau trong cac ung thU dau - co va duTig hang thir 5 trong cac loai ung thu d nam gidi vdi ty' le mac benh chuan theo tudi chung la 6,6/100.000. Dieu tri cP ban nhal cho benh nay la xa trj. That bai trong dieu tri do dap Ung kem, u khdng tan hd'i, tai phat tai chd, tai viing va di can xa gay nen. De giai quyet tinh trang nay, mpt mat phai cai thien each thifc xa In bang cac ky thuat cao tap trung lieu vao u, vao hach, giam lieu tai cac td cht/c lanh xung quanh bang ky thuat 30, t§ng cudng nhay cam cCia khdi u bang hoa tn phdi hop. Mat khac, chd ddng du phdng di can xa bang hoa tri. Chinh vi vay, chiing tdi lien hanh de tai nay nham muc dich
"Danh gia ke't qua dieu tri ung thUvdm giai doan III, IV (MO) bang phac do phoi hpp hoa- xa trj gia td'c 3 chieu (3D) theo hinh dang khdi u".
II. DOI TUdNG VA PHUONG PHAP NGHIEN COu 2,1. Dd'i tUPng: Gom 56 benh nhan dupc
chan doan ung thu vom hong giai doan III, IV (MO) dudi 75 tudi, ca 2 gidi, cd chi sd toan trang Karnofsky > 80. Md benh hpc la_ loai khong biet hoa loai vdm hong. Dupc dieu trj phdi hdp'hoa xa tn dong thdi 3D theo hinh
dang khdi u bang may gia td'c tai benh vien K tif thang 4 nam 2007 den thang 4 nSm 2009.
_ Tieu chuan loai trU: Cd benh ndi khoa chdng chi dinh dieu tri hoa chat (tim mach. dai dudng, suy gan. than), bd dd dieu tri khdng phai vi ly do chuyen mdn.
2.2. PhuOng phap: can thiep lam sang cd theo ddi dpc khdng dd'i chimg.
Cd mlu dupc tinh theo cdng thQc:
.. ' .(''/''
n. so benh nhan can de dam bao nghien c(tu CO du do tin cay.
P t9 !e dap img hoan toan v6i phac do dieu tri tUdng ttr (p = 0,8)
E: dp chfnh xac theo p, iay e = 0,15.
a- mLfc y nghTa thong ke = 0,05.
Z- gia tn thu duoc tir bang Z ung vdi gia tri (a = 0,05), Ap dung cong thut tren rS miu linh dUdc la 42.
Trong nghien cuu nay 56 benh nhan difdc dieu trj^da 6 dot dieu tri hoa xa dong thdi va hoa xa bo tra du'dc danh gia l<e't qua dieu tri.
2.3. Xa trj la phirdng phap dieu tri chinh va chu yeu trong UTVH. Cung vdi sij tien bo cua khoa hoc ky thuat cac phi/ong tiSn xa trj ngay cang hien dai va phong phu tif khi may gia toe xuat hien cijng vdi he thong md phong xac dinh truong chieu, he thong lap ke hoach dieu trj 3D da trd thanh mot cong cij vu'dt troi trong ilng dung lam sang. Ky thuat'xa tri 30 theo tiinh dang khoi u la mpt tien bo trong tfnh toan toi tru lieu ii/ong va cai thien cho cac mo lanh lien quan. Ky thuat nay cho biet cac thong tin ro rang ve tong lieu dieu tri, iieu iirdng mdi budi chieu, iieu itfong tai cao to chirc nguy cap nhi/: than kinh thi giac, than nao, tu^ song hay cac thuy thai duang... va sit khac nhau ve lieu luong tren tifng viing tt-ie tich trong dieu trj UTVH gdp phan cai thien va nang cao chat lilong dieu trj. May xa tri: May gia toe Primus Siemens c6 cac chiim Electron vdi 6 mirc nang lu'dng khac nhau (5, 6, 8, 10, 12, UMeV) va chum Photon vdi 2 mifc nang li/dng 6, 15 MV.
He thong tfnh lieu PROWESS-'3D giiip tfnh
toan ehi'nh xac su phan bo lieu ludng theo
khong gian 3 ehieu cho cae the tich dfiu tri mpt
each tot nhat, khao sal va dua ra nhieu thong
so giup thay thude lUa chon dudng ddng lieu
phij hop, tap trung lieu tdi uu vao u va giJm tdi
da tdn thudng tai td chUc lanh qua dd ket qua
dieu tr[ dUde nang cao.
Y HOC VliT NAM THANG 3 - s o 2/2012 2.4. Hoa t r i : Nhieu thCr nghiem lam sang
ve hoa xa tri dor^g thdi cho thay cd s u cai thien k i l m soat tai chd, keo dai thdi gian song them va giam t^ le tai phat va di can xa cho benh nhan UTVH. Hien nay phac do hoa xa ddng thdi bat dau dupc ap dung tai Benh vien K Cling nhu nhieu trung lam ung thu tren the gidi.
Cisplatin: Benh nhan dupc truyen 2 lit Glucose 5 % va 40mEq KCI/L va 12,5gm mannitol trudc truyen Cisplatin. Cisplatin dupe truyen trong 20-30 phiil sau dd truyen 1 lit
Bang 1. S P do dieu tr[
Glucose 5%, 40mEq KCI, 25gm manitol trong 4 gid va tiep sau dd Hit Glucose 5%, 40mEq KCI, MgS04 trong 8 gid.
Benh nhan dupc dung Ondanxetron va Dexamethasone trudc, sau truyen hda chat de d u phong ndn va dj ifng thud'c.
5FU: Lieu 1000mg/m^/24 gid truyen lien tuc trong 96 gid vao vao cac tuan 11,15.19 sau dpi truyen manitol thU 2 dupc hoan thanh.
So do dieu tri tie'n hanii nhu trong bang 1.
Budc 1: hoa xa dong thdi Xa tri 3D theo hinh dang khoi u bang may gia toe.
The tich khdi u tho PTV' 70Gy/35 budi tia.
Vunq CO nquy cd di can cao PTV' 60Gv/ 30 buoi tia Hoa chat: Cisplatin 100mg/m^da ngay 1, 22 va 43.
Budc 2: hoa tri bo trd Cisplatin- 80mg/mVngay 1 5FU lOOOmg/ m^ ngay 1-4 Truyen vao cac tuan 11,15,19,
2.5. D a n h gia d a p umg v d i d i e u t r j : Kham danh gia ke't qua dieu tri tai u va hach sau moi dpi dieu tri, sau khi ket thiic dieu tri bao gom dap irng chu quan va dap irng Khach quan theo lieu chuan cila W H O .
2.6. Theo doi sau dieu trj: Danh gia tai phat tai chd, tai vung va di can xa, phai hien cac bie'n chu'ng cua xa trj, dpc tinh cOa hoa chat va danh gia chat lupng cudc song, tinh trang sire khoe chung ciia benh nhan. Qua theo ddi riit ra dupc thdi gian sd'ng them loan
bp, thdi gian sd'ng them khdng benh, mdt s d yeu t d lien lUdng anh hudng den thdi gian sdng them, thdi gian kiem soat benh tai cho, tai viing, t^ le benh lien then, tai phai, di cSn,
2.7. Xtir ly so' lieu: Sau khi thu thap, dUpc xCr ly bang phan mem tin hpc SPSS 16,0 va Stada 10.0. Phan tich thdi gian sd'ng them theo phuong phap Kaplan-Meier. So sanh thdi gian sd'ng them giua cac nhdm bang test Log Rank va md hinh hoi qui Cox (trong phan tich da bien).
III. KET QUA VA BAN LUAN
Trong nghien ciflj cOa chiing tdi toan bp benh nhan IhUc hien dung qui trinh xa trj gia toe dat ra.
100% sd benh nhan dieu tri dO 6 dpi hda tri, dat lieu xa lai u nguyen phat va hach di can 70Gy, trong dd cd 5 benh nhan phai keo dai thdi gian xa trj 2-3 tuan do ton thUPng da va niem mac do tia.
B a n g 2. Dap iTng thUc the sau dieu trj Dap ijmg
Hoan toan Mot phan
Tai u n 51 5
91,1
%
8,9
Tai hach n 52 4
92,8
%
7,2
Chung n 50 6
89.3
%
10,7 Cac benh nhan sau khi hoan tat dieu trj dUdc danh gia dap ifng tai u va hach bang lam sang, chup CT hoac chup IVIRI va npi soi v o m hong bang dng soi m e m . Oanh gia dap irng sau dieu tri dua theo tieu chuan cOa T d chCfc y te the gidi. Ty le benh nhan ed dap irng hoan toan tai u la 9 1 , 1 % , dap Ling mpt phan la 8,9%. Ty le benh nhan co d i p ilng hoan toan tai hach la 92,8%, dap img mpt phan tai hach la 7,2%. S d benh nhan dap ilng ehung hoan toan la 60 (89,3%), dap irng mpt phan la 6 ( 1 0 , 4 % ) .
3.1. Thdi gian song tliem
Bang 3. Tinh trang benh nhan den thdi diem dilng nghien cilu nghien cilu s d BIM con sdng ia
Thdi gian song them Con song
Da chet
12thang 55
1
24 thang 49
7
36 thang 48
8
48 thang 45 11
Y HOC VIET NAM THANG 3 - SO 2/2012
Den thdi diem dimg nghien cUu, sd benh nhan da tir vong la 11, hien tai cdn song 45 benh nhan. 10 (18%) benh nhan tir vong do benh tie'n trie'n, tai phat, di can. 1 benh nhan tir vong do viem phoi (1,8%). Trong nghien ciru ciia chung tdi vdi thdi gian theo doi tU 6 de'n 53 thang t^ le song them 3 nam, 4 nam toan bp la 85,1% va 72,2%, lan lUPl. Thdi gian sd'ng them trung binh 46,6 thang. Ty le song them 3 nam, 4 nam khdng benh la 81,3% va 65,2% lan lupt.
3.2. Mot so' yeu to' anh hircing den thdi gian song them
3.2.1. Giai doan u, giai doan hach va
giai doan benhDdi vdi UTVH giai doan u nguyen phat, mirc dp hach di can, tinh trang di can xa va giai doan isenh phan anh trong he thd'ng xep loai
TNM la ye'u to tien lupng quan trpng nhat.
Trong dd giai doan u nguyen phat mudn gan lien vdi t^ le kiem soat tai chd va thdi gian sdng them thap. Giai doan hach di can giiip dU ^oan kha nang di can xa va thdi gian sdng them cua benh nhan. Trong nghien ciru cua chiing tdi t^
le sdng them 4 nam loan bd theo giai doan T la T l : 100%, T2. 80,8%, T3: 64,3%, T4: 50,8%
(p=0,018). Ket qua nghien ciru cua chung tdi ve thdi gian sdng them 4 nam theo giai doan hach la NO: 100%. Nl: 100%, N2: 78,1%, N3: 61,5%
(p=0,214). Giai doan benh khdng nhung phan anh sU lan rpng ciia u nguyen phat va hach di can, tinh trang di can xa ma cdn la yeu to tien lupng quan trpng, Trong nghien cifu cda chiing tdi tj le sd'ng them loan bd 4 nam theo giai doan benh la GD3: 96,2%, GD4: 59,3% (p=0,020).
3.2.2. Phan tich hoi quy da bien Cox Banq 4. NhChiq ydu t d anh hudng den thdi gian
Bien so Nhom tuoi Giai doan benh Dap Ling dieu tri LDH Sut can
< 4 0
>=40 III IV Hoan toan
Mot phan LDH>410 LDH<410
<10%
>10%
Hazar. Ratio 1,0 3,0 1.0 3,9 1,0 8,4 1,0 0.6 1,0 10,6
sdng them qua phan ti'ch da bien P
0.249 0,223 0.003
• 0,495 0,016
95% Conf. interval
0,5-19,5 0,4- 34,4 2,0- 34,6 0,1-2,6 1,6-72,4
Ke't qua phan ti'ch da bien cho thay dap
img sau dieu tri va mi^c dp siit can sau dieu trj la hai yeu to tien lupng cd y nghTa thd'ng ke dd'i vdi thdi gian sd'ng them sau dieu trj (p <0,05).
Dap img vdi dieu trj la yeu to tien lupng quan trpng dd'i vdi UTVH. NhChig benh nhan UTVH cd dap irng hoan toan sau dieu trj cd thdi gian sd'ng them tot hPn va nguy cP di can xa thap hPn. Trong nghien ciru nay ty le sd'ng them 4 nam toan bp d nhdm benh nhan dap ung hoan loan sau dieu trj la 77,7%, dap img mpt phan la 25% (p=0,000) va dap irng sau dieu trj la yeu to tien lUdng cd y nghla qua phan tich hoi quy da bie'n Cox vdi p=0,003.
3.3. Tai phat va di can
T^ le tai phat tai vom la 7,1%, tai hach la
3,6%. J^ le di can xa la 16,1%), trong dd di can xUOng la 8,9%, gan la 3,6% va phd'i la 1,8%.
That bai trong dieu trj ung thu vdm chO ye'u do tai phat tai chd, tai vung va di c§n xa gay nen. Mpt so tac gia cho rang tai phat nghTa la ton thupng xuat hien sau khi benh dap img hoan loan it nhat 1 n§m. Theo Lee va CS khi nghien ciru ket qua dieu tri 5,037 benh nhan UTVH tai Hongkong tU nam 1976-1985: t^ le tai phat tai chd la 20%, t^ le tai phat tai hach 13%. Cdn nghien cuM ciia Le Chinh Dai tren 321 benh nhan UTVH vdi thdi gian theo ddi 3 nam t^ le tai phat chung la 14,02%. Ke't qua ve tai phat tai chd tai vimg trong nghien ciru cCia chung toi phii hpp vdi cac lac gia trong va ngoai nudc ty le tai phat tai u la 7,1% (4 BN) va t9 le tai phat lai^hach 3,6% (2 BN).
' Khi lim hieu ve di can xa chiing tdi thay
trong nghien ciru nay cd 9 BN (16,1%) cd di
can xa, trong so dd cd 5 BN (8,9%) pi cSn
Y HOC VIET NAM THANG 3 - SO 2/2012 XUPng , 2 BN ( 3,6%) di can gan, 1 BN di can
phoi, 1 BN di can nao. Ket qua ve di can xa trong nghien cifu cija chung tdi thap hPn mdt s d nghien ciru trong va ngoai nUdc.Theo Leung va CS (2005) khi nghien ciru 1070 BN UTVH dieu tri lai Hongkong tU nam 1990-1998 : di can xa xay ra tren 191 benh nhan (18%). Ngd Thanh Tiing nghien cUu 367 benh nhan UTVH dupc dieu trj tU nSm 1993-1995 cho thay t^ le di can xa chiem 17,4% sau thdi gian theo ddi 36 thang, xuong bj di can nhieu nhat (25%) sau dd la gan (19,4%), phoi (13,9%). Thdi gian di can chil ye'u dien ra trong 2 nam dau sau dieu trj (63,9%). T ^ le tai phat va di can sau dieu trj trong nghien ciru nay thap hon hau he't cac nghien ciru trong va ngoai nUdc trudc day chimg td vai trd quan trpng ciia phac do hda xa tri dong thdi giup giam t^ le tai phat va di can.
IV. KET LU/kN 1. Dap umg dieu trj:
T9 le dap img hoan toan lai u 9 1 , 1 % , mot phan tai u la 8,9%.
T9 le dap Cmg hoan l o a n tai hach la 92,8%, mpt phan tai hach 7,2%.
T^ le dap img hoan toan chung la 89,3%, dap umg mdt phan la 10,7%.
2. Ket qua song t h e m ;
T9 le sd'ng them 3 nSm loan bd la 8 5 , 1 % ,
4 nam toan bd la 72,2%. Thdi gian sd'ng them trung binh la 46,6 thang.
T^ le sd'ng them 3 nam khdng benh la 81,3%, 4 nam khdng t>enh la 65,2%.
Dap irng va tinh trang siit can sau dieu tri la hai ye'u t d tien lupng cd ^ nghTa thd'ng ke dd'i vdi thdi gian sd'ng them qua phan tich hdi qui da bie'n Cox.
3. Tai phat di c a n :
T9 le tai phat la 10,7% trong do lai phat tai vdm la 7 , 1 % , tai phat lai hach 3,6%.
Ty le di can la 16,1%, di can gan 8,9%, di can gan 3,6%, di can phoi 1,8%
TAI UEU THAM KHAO
1. Lee AW, Foo W, Law SC et al (1997),
"Reirradiation for recurrent nasopharyngeal carcinoma' factors affecting the therapeutic ratio and ways for improvement./nf-J-Rad/a(- Oncol-Biol-Phys. Apr 1; 38(1), pp 43- 2. Leung TW, Tung SY, Wong FC et al (2005)."
Treatment results of 1070 patients with nasopharyngeal carcinoma' an analysis of survival and failure patterns". Head and Neck 27:555-565.
3. Ngo Thanh Tiing (2001): Nghien cOu d$c diem lam sang va ket qua xa tn ung thu bi4u md khong biet hoa vom hgng tai BVK giai doan 93-95. Luan van thac sy y hoc, Tmdng Bai hoc Y Ha Npi.
NGHIEN Cl)U KET QUA DIEU TRj BENH U LYMPHO AC TINH KHONG HODGKIN TAI BENH VIEN TRUNG irCTNG QUAN DO1108
N g u y i n Trung Chinh*
TOM T A T
Qua nghien ciiU 80 benh nhan dieu tn phac do Chop va DHAP Chiing tdi nhan thay Dac diem lam sang, xet nghiem 2 nhom nghien cifu khac biet khdng cd y nghTa thong ke. Dap irng dieu tri hoan loan va dap ifng chung phac do DHAP cao hdn phac do Chop. Thdi gian song them toan bd 2 phac dd khdng c6 •) nghTa thdng ke, Thdi gian sd'ng them khong benh khong c6 •H nghTa thdng ke, Ty le rung tdc phac dd Chop cao hon phac do DHAP,
* Benh vien TWQD 108
Phan bien khoa hgc: PGS.TS. Le Van Don
SUMMARY
ASSESSMENT ON RESULT OF MALIGNANT LYMPHO ADENOMA NON - HODGKIN TREATMENT BY CHOP AND DHAP DIAGRAM
Through the study of 80 patients treated under CHOP and DHAP diagram. We found that: the clinical charactenstics in examination of 2 distinctive study groups have no significant result. To meet the complete treatment and commonly meet, the DHAP diagram is higher than that of CHOP one.
