Y HQC VIET NAM THANG 5 - SO 1/2014
i.
ITNG DUNG KY THUAT MO PHONG XA TRI BANG PET/Ct TRONG UNG THU" THITC Q U A N TAI TRUNG TAM Y HOC HAT NHAFJ
VA UNG BU'aU BENH VIEN BACH MAI
T6M TAT
Ttf nSm 2009, ^ n i ^ u tien 6 Viet Nam, Trung tam Y hoc hat nhan va Ung bu'du Benh vien Bach mai da ti?n hanh trien khai chup mo phong tren may PET-CT 6i lap ke hocich xa tri gia t6c cho benh nhan ung thu".
MMC tieu: Bu'dc dSu danh gia mot so ket qua dieu tri b@nh ung thu' thut qudn bdng xa tri gia tdc co ket hop k9 ttiuat chup PET/CT mo phong. Dot tu'dng vd phudng phdp nghien c u t i : 50 benh nhin ung thu' thtfe quan c6 chi dinh xa tri tif 9/2010 den 12/2012.
K€tqua: Trong mo phong xa tri thi/c quan: PET/CT giS tri cao hdn C^: Lam thay doi the b'ch xa tri d 46%
va phat hi$n them hach vung d 30% cac tru'dng hpp.
Dap utig tocin bp (hoan toan va mpt phan) vdi trieu chifng lam Seing la: 80%, kich thu'dc u thifc quan giam ia: 83%. Bien chiitig hay gSp la suy kiet vdi ty le;
34%. Hau het cac bien chimg deu nh? va co the khSc phuc du^c. Ket lu$n: PET/CT mo phong trong xa tri budc dau dat dUdc ket qua tot.
SUIVIMARY
Background: PFT/CT simulation in Radioth erapy is one of the moderm technics in cancer treatment.
Since 2009, the first time in Vietnam, Center for Nuclear Medicine and Cancer Bach Mai Hospital has conducted successful deployment of simulation taken on PET-CT for radiation treatment planning for patients with accelerated cancer. Objective: Initially an assessment of the results of treatment of esophageal cancer with radiotherapy accelerators Incorporate techniques PET I CT simulation. Subjects an methods: /Assessed response before and after treatment on 50 patients of esophageal cancer to 9/2010 - 12/2012. Results: In the simulation of radiotherapy of esophageal, P E T / C T have a values higher than CT: Detection of damage more precisely and more cleariy. Patients were applied of radiotherapy treatment techniques in the simulation by PET / CT is a good response rate to treatment and minimize complications: overall response (complete and partial) with symptoms dinical: 80%, response to treatment the tumor of esophagus is: 83%, COTipllcations are common depletion rate is: 34%.
Most complications are mild and can be overcome.
'TTyhgch^t nhan va ung budu, Benh vien Badi Mai Phan bl4n khoa hgc: PGS. TS Tran Dinh Hi
Le Chinh Dai*, Tran Ngoc Hai*
Conclusion: PET / CY simulabon in radiotfierapy initially achieved good results.
I. DAT V A N OE
Ung thu' thu'c quan dihig thLf 9 trong cac benh ac tinh pho bi§n nhat tren the gidi va dulig thCr ba trong cac ung thu' du'cfng tieu hoa sau dai trang va da day.
C^c bieu hien lam sang hay gap la nuot nghen, dau ngifc va gay sut. Khi co cac dau hieu nay benh thu'dng d giai doan muon va cho ket qua dieu t n thap. Cac phu'dng phap dieu tn chfnh la: Phau thuat, xa trj, hoa chat.
Xa tri la mpt trdng nhii?ig phu'dng phap dieu ung thu' noi chung va ung thu' thu'c quan noi rieng. Mpt trong nhijtig viec quan trpng^nhat cua xa t n la phai xac djnh chinh xac cac the tfch can dieu trj. Vdi ky thuat PET/CV, ton thuWng du'dc phat hidn d mifc dp chuyen hoa cua te bao, mi!fc dp phan tCf vi vay se chfnh xac hdn nhieu so vdi cac phu'dng tien chan doan hinh anh khac. Viec phat hien chinh xac,^day du thu'dng ton giup cho viec xac djnh cac the ti'ch can dieu trj tot hdn. Si^
dung hinh anh PET/CT de mo phong trong x? trj dii du'dc trien khai rpng rai tai cac trung tam dieu tri ung thu" Idn d cac nu'dc tien tien nhU chau Au, M9, Nhat Ban, Han Qu6c...(2)
Tir nSm 2009, lan dau tien d Viet Nam, Trung tam Y hpc h?t nhan va Ung bu'du B?nh vien Bach mai da tien hanh trien khai thanh cong chup mo phong tren may PET-CT de lap ke hoach xa tri gia toe cho benh nhan ung thu'. Cac ngliien cifu tren the gidi ve van de nay chua nhieu, lan dau d trong nu'dc trien khai ky thuSt mdi nay vl the chiing toi tien hanh nghiSn cifu nay vdi muc tieu: Budc dSu danh gia mgt sdket qua dieu in ung thd thu'c quan bang xa tri gia to: CO uh'g dung ky thuat chup PET/CT mo phong.
II. OOI T U p N G VA PHirOWG P H A P N G H I E N CUU 2 . 1 . O o i t u ' d n g n g h i e n c i h i : 50 benh nhan ung thu'quan dap utig cac dieu kien sau:
- Duac chan doan xac dinh benh bang mo benh hpc - Cd chi dinh xa tri (T3, N,.2. MQ-O
- Ngu'di b4nh d5ng y tien hanh ky thuat b-en.
Y HOC VIET NAM THANG 5 - SO 1/2014
2.2 . Phu'dng phap nghien cihi: nghien
ciru thif nghiem lam sang l<hong <Joi chifng 2.2.1, Binh gii dac diem lim sing va Itei qui dieu tn
- Benh nhan du'dc l<ham iam sang va tham do can lam sang de danh gia chfnh xac giai doan bfnh tri/dc dieu trj.
- Khao sat va so sanh the tfch xa trj tren ciing mpt benh nhan giiJa hai l<y thuat; PET/CT mo phong va CT mo phong thu'dng quy.
- Ghi nhan cac bien chihig gap phai trang dieu tr|
- Banh gia dap-img dieu tri sau 3 thang: Trieu chihig ca nang va tSn thuBng thu'c the (Ki'ch thu'dc u - Ada vao phim X quang)
2.2.2. Qui trinh Icy thu ft
a. ChuSn bj benh nhan: Benh nhan nhjn an sang, l<iem tra du'dng huyet tru'dc l<hi tiem "F- FDG (2-fluoro 2-deoxy glucose)
b. Tien hanh chup PET/CT vdi phu'dng Ben a i djnh va he thong laser djnh vj lihong gian 3 chieu.
c. Lap ke hoach xa trj gia toe vdi phan mem Prowess Panther 4.6, vdi ky thuat ky thuat xa tri
III. KfTQUA NGHliN CCrU Bing l:Qac diem benh nhan
dieu bien lieu (IMRT) hoac xa trj theo hinh dang khoi u (3D. CRT)
• Xac dinh cac the tich can tia xa: the ti'cii khoi u tho- GTV (gross tumor volume), the tfch dfch lam sang CTV (clinical target volume), the tfch dfch dieu tri - PTV (planning target volume). Xac djnh the tich dfch sinh hoc - BTV (biologic target volume) hay GTV-PET.
. Xac djnh cac cd quan lanh lan can can bao ve vdi lieu gidi han chju di/ng da biet
• l i p cac tru'dng chieu, goc chieu, mu'c nang lu'dng.
• Tinh lieu, kiem tra phan lieu tren the tich (^n ha va cd quan lanh xung quanh: tren ban do du'dng dong lieu, hinh anh 3 D, va bieu do liu • the tfch (DVH)
d. Tien hanh kiem tra lieu lu'dng tru'dc khi dieu trj (QA)
e. Tien hanh xa trj tren may gia toe.
2.3. Thdi gian v i dia diSm nghiin cfhi:
Tif thang 9/2010 den 12/2012, tai trung tam YHHN va Ung Bu'du benh vien Bach Mai
N
%
50 100%
Gidi Nam
48 96%
Wi 2 4%
Nhom tuoi
<40 3 6%
40-70 40 80%
>70 7 14%
Nhin xit: Nhdm tuoi hay gap 40 - 70 tuoi. Nam gap nhieu hdn Nif (48/2). Tuoi trung binji 63 i 1,1. ThSp nhat 37 tuoi, cao nliat 86 tuoi.
Bang 2; Glai doan benh
GDI GDIIGem
GSIVn
0 4 388
»/o 8 7 6 16
Nhin xit:T\ le benh d glai doan III chiem cao nhat (76%).
Bing 3: Mufc do thay doi the tfch xa trj (GTV) gliJa PET/CT mo phdng va CT mo phong (NguSng thay doi > 25% the rich)
n
%
Tong 50 100%
Thay doi 23 46%
Khong thay doi 27 54%
Nhan xet: PET/CT mo phdng da lam thay doi the tfch GTV trong md phdng u thifc quan khoang 46%
cac trudng hdp.
Bing 4: Kha nang phat hien them ton thudng hach ciia PET/CT so vdi CT Tong
50
Thay doi 15
Khona thay doi 35
NhSn xit: Kha n§ng phat hien them ton thudng hach ciia PET/CT mo phdng la 30% cac tru'dng hdp
Y HQC VlgT NAM THANG S - SO 1/2014
BangS: Diln bien benh sau dieu tri,
Trieu chimq tam sano Ki'ch thu'dc u qlam
Hach
MCfc do dap u'ng(»/o) Hoan toan
60%
20%
14%
Mot phan 20%
63%
37%
Khong thay doi 20%
17%
49%
Tfing (o/o) 100%
100%
100%
Nhin xet:lrKU chifng lam sang dap img chung (hoan toan H giam va tan het 83%; Kfch thudc hach giam va tan het 51%.
Bing 6: Bien chimg tronq qua trinh dieu tri
mpt phan) khoang 80%; Ki'ch thudc u
Bien chii'ng Pau nqUc Viem da Suy ho hap nhe
Non ra mau Bdi nhiem~
Suy klet 17
6%
Nhanxit:X\ l i suy kiet gap cao nhat, sau dd la bdi nhiem, viem da.
Hinh inh minh hga: Benh nhan Nguyin Van C 53 tuoi. K thuc quan 1/3 gliJS, T3N0M0. GFB:
Carclnom dang vay
Hinh J ; Hinh anh trUdc va sau dieu tri
IV. BAN L U $ N
PET/CT dUdc biet din la mpt ky thuat y hoc hl|n d;l trang chan doan binh ung thU: PET/CT giup chan doan glai doan benh chi'nh xac; phat hlln sdm ung thu'; tien lifdng binh, danh gia dap ilhg vdi diiu tri, theo doi phat hiin tai phat, dl cJn (3).
Gan day, PET/CT dUdc iJng dung nhieu trong xa trj ung thu (4). Trong qua trinh lap ke hoach X(i tij van d i quan tri?ng nhat la xac djnh dude tM tfch khoi u thd - GTV (gross tumor volume), the tfch dich lam sang - CTV (clinical target volume) va thS tfch dfch dieu trj - PTV (planning target volume). Xac djnh GTV, CTV
trin hinh anh CT hole MRI la dUa vao thong tin
v i hinh anh glai phau, trong nhiiu tru'dng hi?p
rat khd xac djnh chinh xac. Tif khi PET/CT ra ddi,
xuat hiin them khai niim mdi la the tich dich
sinh hpc - BTV (biologic target volume) hay
GTV-PET. BTV hay GTVpn- la hinh anh khoi u d
miJc do chuyen hda, mifc dp te bao, thong tin ve
chuyen hda cd kha nang xuat hien sdm hdn
thong tin v i sif thay doi cau true (5). NhU vay
PET/CT la sU ket hdp glOS hai thdng tin: Sif thay
doi v i chuyen hda va stf thay doi ve cau true. Sif
dung hinh anh PET/CT trong md phdng lap ke
hoach xa trj s i cd dp chinh xac hdn CT Scan, do
vay ky thuat nay mang lai hiiu qua cao hdn
Y HOC WgT NAM THANG 5 - SO 1tt014 trong dieu t r i va giam thieu du'dc cac bien
chu'ng(6).
Oa so cac benh nhan du'dc ap dyng hoa xa tri dong thdi, chi co 3 cas xa tri ddn thuan, d o la nhu'ng benh nhan tuoi qua cao hoac co benh fy phoi hdp. Phac do dieu t r i nay da d u ^ lai mpt ty le dap utig toan bo kha cao (khoang 8 0 % trieu chu'ng lam sang giam va mat), khoang 8 3 % cac khoi u thuc quan nho mot phan hoac tan het (danh gia bang each chup iai PET/CT hoac chup CT Scan ket hdp vdi npi soi). Ty le nay cung tu'dng t y vdi tac gia W. Schlegel (7).
Bien chutig xay ra d mpt so it cac tru'dng hdp, da so la suy klet va boi nhiem, viem da, nliutig cac bien bien chiiTig nay deu d mu'c dp nhe va khac phuc du'dc. Theo cac tac gia tren the gidi, suy kiet la trieu chifng thu'dng gap va co the de doa ti'nh mang ngu'di benh, cac benh nhan cua chting toi d^u du'dc ho t r d dinh dudng bang du'dng tTnh mach nang cao the trang. Vi vay t a t ca cac benh nhan deu thyc hien dii lieu trinh dieu tri va den thdi diem hien tai c h y a co ca nao t y v o n g trong qua trinh dieu t r i .
V. Kir LUAN
- PET/CT mo phong lam thay d a the tich xa bi d 46% va phat hien them hach d 30 % cac budng hdp.
- Benh nhan sau dieu b i co dap uTig tot: Trieu chuhg lam sang giam va het: 80%, u t h u t quan giam va tan het: 8 3 % ; Hach giam va tan h ^ : 51%
- Bien chu'ng hay gap la suy kiet vdi ty le la 3 4 % . Hau het cac bien chiiTig ^ u nhe va co tiie khac phuc du'dc.
T A I U E U T H A M KHAO
1 . N g u y i n Ba Bite, Bai giang Ung thu'hoc (2004), Nha xuat ban y hpc.
2. Mai Trpng Khoa, Phan S f An (2007), Bai giing Yhgc Hat nhan, Nha xuat ban Y hoc 3. Mai Trpng Khoa ( 2 0 0 9 ) : ij'ng dung ky thu|t
PETva PET/CT trong lam sang. TapdiiYhoc^
sang, 5/2009, dang 19-25.
1 . Arnord C. Paulino, Bin S. THE (2008) PET-CTin Radiotiierapy Treatment Planning, 1st ed, Saunders, An Imprint of Elsevier
5. DeVita, Vincent T.; Heilman, Samud;
Rosenberg, Steven A (2008) Cancer: fWndples
& Practice of Oncology, 8th Edition. Lippincott Williams aWilklns
6. Halperin, Edward C ; Perez, Carlos A.; Brady, Luther W (2008) Perez and Brady's Prindf^
and Practice of Radiation Oncology, 5th Edition, Lippincott Williams & Wilkins
7. The role of PET/CT In radiation planning for cancer patient treatment (2008), IAEA, Vienna.
XAC DINH GlAl PHAU H | THONG S N G TUY COA RANG HAM LQN THtr N H A T H A M Du-ai
T6MTAT
^ Myc tieu nghien cuU: Xac dinh giai phau he thong ong tuy cua rang ham Idn thu" nhat ham du'di.
Phtftfng phdp nghien c i h i : 1^6 ta c3t ngang tren 19 rSng h&m ldn thCf nhat ham du'di due khoi nhu^ va cat thSnh 5 lat cSt: ( l i t c3t 1: each chop 1mm. l i t c5t 2:
each chop 2mm. l i t eat 3: each chop 3 mm. l i t eSt 4:
qua 1/3 giii^ chan rang, l i t eat 5: qua 1/3 tren chan rSng). Kei qua nghign c i h i : kich thu'dc gan xa cua 2 Chan tuUng t y nhau. Kich thu'dc trong ngoai cua chan g3n ldn hdn chan xa. Cac kich thu'dc t3ng dan qua eac lat cat Chan gan: Loai IV ehi§m da so, khong eo loai I,
* Vien DTRSng H^m m$t TW
Phin bi$n khoa hgc: PGS. TS Mai Dinh Huhg
Trinh Thj Thdi Ha*, Tong Minh SOT*, Nguyen Thj ChSu* Jrinh Minh Biu*
III va V. Chan xa: Loai I chiem da so, khdng cd to^lV.
Chan gBn rang ham Idn thCr nhat ham dUdl ti l | 2 &^
tuy la 100%, chan xa rang 6 HD tl Ie 2 ong biy tt 37
%. Phan nhanh h'Su t\Bt d mieng dng tiiy, trir m^TSB It Chan xa (Loai 111=10.5%). ChSn gan va chan xa ila so la cd lo chdp d vj tri b-ung tam. ChSn xa ed ti l§ t8 chdp lech ve phia xa la 10.5 %.
Ket lu$n: Cac ong tiiy co dp thuon nho tfin tif fren xuong dudi. Dp thuon cua dng tOy glfingv*<S thuon cua chan rgng. Tai Mt cat thir nhat, Sng tiy c6 ki'ch thu'dc nho nhat vi?c. Chan gSn rSng h^m Wftttiii' nhat ham du'di ti le 2 dng tuy 13 100%, chan xa rSngfi HD ti le 2 ong tuy la 37 %. HSu hSt ong tiiy di eS) true hinh tron, hinh ovan. Chan gan vS diSn xB'ife sfi la cd l5 chdp d vj trf trung tSm. Chan xa cd tl tS l5 chfip lech ve phia xa la 10,5 %.
