TAP CHI Y HOC VIET HAM TAP 45Q - THANG 1 - SO 1 - 2017
NHAN XET MOT SO DAC DIEM LAM SANG, CAN LAM SANG UNG THir VIJ GIAI DOAN I, II, III (y PHU NU" CAO TUOI
TAI BENH VIEN K HA NOI
T O M TAT
Muc tieu: NhSn xet mpt so dac diem lam sang>
can lam sang ung thu" vii giai doan I, I I , I I I d piiu nu"
cao tuoi tai Benh vien K Ha Noi. 067 tUg/hg va phUtAtg phap: 195 benh nhan nff, tff 60 tuoi trd len, CO chan doan mo benh hpc la LrTBM tuyen vu, glai doan I, I I , I I I , difdc dieu tn tei Benh vi§n K-Ha Ngi, thdi gian tff thang 01 nam 2007 den ttiang 01 nam 2009. Kiiqua:Tj le mac UTV d phu nff cap tuoi ty le nghjch vdi Iffa tuoi. Vi tri khoi u pho bien la 1/4 tren ngoai (34,4%) va d vj tri 1/2 tren (29,8%). Chl c6 mpt khoi u chiem t / le cao nhat (95.4%), co hach nach cijng ben la 79%. Chyp vu tia mem c6 ket qua du'dng tinh la 67%, chpc hut te bao kim nho tru'dc mo cd ty le du'dng ti'nh ia 95.4%. B#nh nhan d giai doan I I chiem diu yeu (70,8%). The mo benh hoc sau mo hay gap nhat la UTBI^ ong xam nhap (79,5%).
Tit khoa: Ung thu" vu, dac diem lam sang, can lim sang, phu nff cao tuoi
S U M M A R Y
STUDY ON CLINICAL, PARACLINICAL CHARACTERISTICS OF THE BREAST CANCER AT THE STAGES I , I I , I I I I N ELDERLY W O M E N AT HA N O I K HOSPITAL
Objectives: Studying clinical, paraclinical characteristics of the breast cancer at the Sages I, I I , I I I in elderiy women at Ha Noi K hospitai. Methods:
195 female patients, over 60 years old with histopathological diagnosis of breast carcinoma at the stages I, I I , I I I , were treated at K Hospital, Ha Noi from January 2007 to January 2009. Result: The rate of breast cancer in elderly w^omen has been inversely proportnonal to their age. The bjmor usually located on the fourth of the outer (34.4%) and on the half of the top (29.8%). Only one lump has been the highest (95.4%), ipsilateral axillary lumph nodes were 79%. The positive rate of mammography was 67%, the positive rate of fine needle aspiration biopsy was 95.4%. The patients have essentially concentrated on the stage I I (70.8%). Postoperative histopathological, the highest rate was invasive carcinoma (79.5%).
Key words: Breast cancer, clinical, paraclinical characteristics, elderiy women
* Benh vien Quin y 103 ~ Hoc viin Quin y.
** Binh viin 198 - Bg Cong an Chju trach nhiem chinh: Nguyen V3n Nam Email: [email protected] Ngay nhan bai: 14/10/2016 Ngay phan bien khoa hoc: 11/11/2016 Ngay duyet bai: 30/11/2016
Nguyin Van Nam*, Le Thi TuySt Nhung**
L D J ^ T V A N D E
Ung thu* vu la mpt trong nhffng loai ung thff thffdng gap nhat va la nguyen nhan gay tff vong hang dciu d phu nff tren the gidi. Trong cac dac diem lam sang, can lam sang thi Iffa tu6i la mpt yeu t o lien quan den chan doan, cac phffdng phap dieu trj du'dc ap dung cung nhu' tien Iffdng benh ung t h u ' v u . Ngay nay, cljng vdi sff tang len ve sd lu'dng ngu'di cao tuoi trong xa hpi thi ung thu' vu cung gia tang d nhdm Iffa tudi nay.
NhuTig cac nghien effu ve cac dac diem cua ung thff vu d nhdm cao tuoi van cdn c h u ^ nhieu. Do vay, chung tdi tien hanh nghien cffu de tai vdi muc tJeu danh gia mpt so dac diem lam sang, can lam sang ung thu' vu giai doan I , I I , I I I d phu nff cao tuoi.
II. D 6 | TirpWG VA PHU'aNG PHAP NGHllN COlf 2 . 1 . S o i tu'dng nghien cihi
* Ti€u chuan lu'a chon - Tudi > 60.
- Chan doan md benh hpc sau md la ung thff bieu mS t u y i n vu.
- Chan doan giai doan tff I , I I , I I I . - Cd xet nghiem nhupm hda md mien djch xac dinh ER,PR, Her-2/neu.
* Tieu chuan loai triT - Ung thu' vu giai doan khac.
- U n g thu'vu thff phat.
- Ung thff vu d the mo benh hpc khac.
2.2. Phu'tfng phap nghien CIJ'U 2.2.1. Thiet ke nghien cuii: hoi cffu mo ta cat ngang.
2.2.2. Cac chi tieu nghien cu'u
* Dac diem iam sang: phSn bo tuoi, thdi gian bj benh, cac benh ly ket hdp, ly do vao v i | n , cae dac diem ciia khoi u: Vj tri khoi u, sd lu'dng u, kich thffde u, ranh gidi khoi u, be mat khoi u, mat do khdi u, dd di ddng, giai doan lam sang (tlieo UICC-2002).
* Dac diem can lam sang: chup X quang tuyen v u , ehan doan te bao hpe trffdc mo bang phffdng phap FNA, chan doan mo benh hoe theo phan loai cua WHO - 1 9 8 2 .
2.2.3. Xu-l^ so lieu
Sff dung phan mem SPSS 16.0 xff ly sd lieu.
VIETNAM MEDICAL JOURHAL H'1 • JANUARY - 2017
III. KET QUA NGHIEN CU'U 3.1. Mdt so die diem lim sang - Tgoi
Bang 3.1. Phin bo unq thWyd iheo tuoi
Tuoi So benh nhan
60-69
Tong
Trie'A 74,9 23,1
Nhin xei: Benh nhan tre nhat la 60 tuoi, benh nhan cao tu6i nhat la 88 tuoi. Lifa tuoi ttr 6 tuoi chiem ty le cao nhat la 74,9%.
- Th6i gian tCT khi phat hi§n dSn khi du'dc dieu trj Bing 3.2. Thdi gian iWkhi Phit Men binh den khi dieu irl
Thdi gian So faenh nhan Ty le %
1-3 thanc] 105 53,8
> 3 - 6 thang 11,8
> 6 - 1 2 t h a n g . 36 18,5
> 12 thang~" 31 15,9
Tong ' I 195 . I .. . .^°9.-° , . j Nhan xet: Hz so benh nhan du'dc chan doan sSm du'di 6 than^ ke tir khi co trieu chu'ng dau tien (65,6%). Trong do so benh nhan dUdc chan doan s6m du'di 3 thang chiem ty le 53,8%, chan doan sau 6 thang chiem 34,4%.
- Ly do vao vien Bang 3.3. LV d'o vao vien
SS benh nhan (n=195) Ty le °/o Lydo vao vien
Phat hien thav khoi u 162 83,07
13,84 D.au tai vu
Chay djch daii vu
"Tut nam vil I 9 . . I .- . °'° ^ yvA*iJiref/tyle vao vien vi phat hign co khdi u viing vu chiem cao nhat chiem 83,07%, sau do la dau vung vii vdi 13,84%, Idiong co tru'dng hdp nao bj tut num vu.
- Cac b^nh 1^ k^t hdp Bang 3.4. Cac benh iy k ^ hdp
Cac benh Iv kem theo Tim mach Benh Iv ho hap Pai thao du'dnq typ
Benh iy tieu hoa Benh ly than tiet nieu
Benh ly phu khoa Benh ly xu'dng khdp
Benh ly bu'du giap Benhly khac
sa lu'dng (n= 195) Ty le °/o 20,5 2,05 16,4 12,3 2,05 9,74 4,1 . Khdng c6 benh ly ket hdp I 39"
Nhan xeb trong so 195 benh nhan co 39 tru'dng hdp khong cd benh ly ket benh nhan co benh iy ket hdp (80%), chiem ty le cao nliat la cac benh'lien quan (20,5%); du'ng thiJ 2 la benh ly dai thao du'dng (16,4%).
-Tinh chat khSi u Bang 3.5. Vi tK khgi u
2,56 hdp (20%), CO 156;
den benh tim mach
Vitriu 1/4 tren nqoai 1/4 tren tronq 1/4 du'di nqoai 1/4 dudi tronq 1/2 nqoai
Vuidn Vu phai (n=9S)
n 30 9 3 3 2
31.9
%
9.6 3.2 3.2 2.1
thWdna
Vu trii (n=100}
n 37 14 5 5 7
37.0
%
14.0 5.0 5.0 7.0
Tdng cdng (n=195) n 67 23 8 8 9
34.4
%
11.8 4.1 4.1 4.6
TAP CHi Y HOC VlgT HAM TjiP 450 - THANG 1 - S6' 1 - 2017 1/2 tronq
1/2 tren 1/2 dudi Trunq tam Toan bd vii
3 33
2 7 3
3.2
• 35.1 2.1 7.5 3.2
4 25
0 2 1
4.0 25.0
0.0 2.0 1.0
7 58
2 9 4
3.6 29.8
1.0 4.6 2.0 1 Nhan xei: Ung thu' vu ben trai la 100/195 tru'dng hdp (51,3%) nhieu hdn so vdi vu ben phai la 95/195 tru'dng hdp (48,7%). Khoi u chiem nhieu nhat it i/4 tren ngoai (34,4%) va 1/2 tren (29,8%).
KhSi u chiem It nhat d l / 2 du'di (1,0%) Bang 3.6. Pac diem khoi u
Dac diem khoi u So lu'dng
Kfch thu'dc i^nh qidi Be mat khoi u
Mat do
Dp di dpng
1 khdi u Nhieu khoi u
<2cm 2 < u < 5cm
U>5cm Khdnq ro Roret
Nhan Go ghe
Mem Chac Cffng De Kem Khdnq
So benh nhan (n=195) 186
9 23 122 50 147 48 48 147
7 151 37 132 52 11
Ty le % 95.4
4.6 11.8 62.6 25.6 75.4 24.6 24.6 75.4 3.6 77.4 19.0 67.7 26.7 5.6 Nhain xet: So Iffdng 1 khoi u ehlem ty le cao nhat (95.4%), kich thffde khoi u trong khoang 2 cm
< u < 5em la eao nhat vdi 62,6%, 147/195 benh nhan (75.4%) cd ranh gidi khdi u khong rd, mat dp kh^ u ehu yeu la chac hoac effng^vdi 188/195 benh nhan chiem 96,4%, be mat khoi u go ghe chieni da so vdi 147/195 benh nlian chiem 75.4%, khdi u di dpng de vdi 132/195 berih nhan chiem 67,7%.
- Kham phat hi|n hach nach Bang 3.7. Tlnh trang hach nach
TV le % Cung ben Khdng sdthay
Boi ben Co sd thay
21.0
_Tong cong^ 195
Nhanxet:So benh nhan du'dc phat hen hach nach cunq ben tren lam sang la 154/195 benh nhan diiem tl le la 79.0%. Khdng cd tru'dng hdp nao cd hach nach ddi ben.
- Chan doin giai doan tru'dc md (theo phan loai TNM cua UICC 2002) Bang 3.8. Giai doan'lam sang
Giai doan GOI GOII Gem Tong
So lu'dng 12 138 45 195
Ty le »/o 1 6.2 1 70.8
23.0
100,0 1 Nhan xet: So benh nhan du'dc chan doan lam sang d giai doan I I chiem ty ie cao nhat vdi 138/19*5 tru'dng hdp chiem 70.8%.
3.2. Mgt so dac diem can ISm sSng
- Chan'doan te bao Ithdi u bang choc hut kim nho Bang 3.9. Chan doan choc hut tg bao khSi u
Te bao hoc Du'dng tmh
So benh nhan Tyle%
Nghi ngd 186 95.4
Lanh tmh
Tongcgng j , , ^•^p Nhan xet! chan doan bang FNA trffdc mo thi eo 95.'1 va 2%'tru'dng hdp chan doan Ianh tfnh tru'dc mo.
. . 100.0 , i) la dffdng tmh, 2.6% trffdng hdp nghi ngd
VIETHAM MEDICAL JOURHAL N^l - JANUARY - 2017
- Chan doan mo benh hoc sau mo
Bang 3.10. Chan doan mo benh hoc sau mo (theo WHO 1982) Loai md benh hoc
Un5 thu' bieu mo tai cho UTBM ong xam nhap UTBM onq xam nhap co thanh phan noi onq
UTBM tieu thuy xam nhap UTBM the nhav
UTBM the tuy UTBM the nhu trrBM the ban huy
The di san Tong so
So benh nhin (n=195) 4
155 7 8 13 2 4 1 1 195
-'.
Tyli o/o 2.1 i 79.5 < 1
3.6 4.1 6.7 1.0 2.1 0.5 0.5 100.0 Nhin xei: UTBM dng xam nhap la the giai phau b|nh hay gap nhat chiem 79,5 % sd benh nhSffj sau do den UTBM the nhay chiem 6,7%, con iai la cac the giai phau benh khac.
IV. BAN LU$N
* Bac diem lam sang - Phin bfflda tudl mic UTV
Nghien ci!ru cua chung toi cho thay trong so 195 b|nh nhan cao tuoi bj UTBM tuyen vu thi lua tuoi tir 60 - 69 tuoi chiem ty le cao nhat vdi 74,9% va giam dan khi lu^ tuoi cang cao. Ket qua cua chung tdi phu hdp vdi mpt so tac gia nghien cu'u UTV d phu nu' cao tuoi nhu*: Popovici R va Seung P. NhU vay, ty le UTBM tuyen vii d ngu'di cao tuoi cd dac diem la ty le nghjch vdi lua tuoi, tire la tuoi cang cao thi ty le bj UTBM tuyen vu cang thap. Nhu'ng van de nay can dUdc nghienciJu vdi so lu'dng Idn hdn de khang djnh, VI ty le ngu'di cdn song d lija tuoi cang cao thi cang thap hdn so vdi lua tuoi it hdn.
- Thdi gian tit khi phii Men binh den dieu tri
_^Thdi gian tCr khi phat hien benh den khi dUdc dieu trj tu' 1 - 3 thang chiem t/ ie cao nh^t (53,8%) va ty le dUdc dieu trj sau 12 thang van cdn kha cao vdi 31/195 trUSng hdp chiem 15,9%.^ Nhu vay, cd the thay d cac bSnh nhan caotuoi bi UTV thu'dng den kham va dieu trj mupn, khi cac bleu hien lam sang da ro rangl Nhanxet nay cua chiing tdi phu hdp vdi tac gia Nguyen Van qui [4].
- Cic benh ly kei hdp
Trong 195 benh nhan UTV dUdc nghiSn ciJu, benh ket hdp chlem ty 1$ nhieu nhat la benh ly tim mach (20,5%) va benh dai thao dudng (16,4%). Conj bo ciia Pham Khue [3] cho thay d ngu'di cao tuoi thi benh hay gap nhat la benh ve tieu hda (26,37%) va thif hai la benh ve tim mach (18,4%). Day cung la van de khd khan trong
lua chon phu'dng phap dieu tri cung nhu tien lu'dng cho benh nhan bj UTV co benh ly ket hdp.
' Ly do vao viin
Ket qua cho tliay ty le vao vien vi td phat hien CO khoi u viing vu chiem cao nhat chiem 83,07%, sau dd la dau viing vii vdi 13,84%, chay djch bat thu'dng 6 niim vii chi la 3,07%. KSt qua nay phii hdp vdi mot so tac gia khac nhif fa Xuan Sdn [5] va Nguyen Minh Khanh [2]. Khi benh nhan da tif phat hien ra khdi u hoac da co chay djch bat thu'dng d num vii thi da khong c6n d giai doan sdm cua UTV, nhu vay van de dat ra la cong tac kham, sang Ipc phat hien sdm ufv'd ngu'di cao tud'i cdn chua du'dc chu trpng.
- I f tri khdi u tai tuyen vti
Ung thu' d ben vii trai la 51,3% tUdng du'dng vdi ben vil phai la 48,7%; vj tri khoi u chiem ty le cao nhat la 1/4 tren ngoai (34,4%), dutig thif 2 la vj tri 1/2 tren (29,8%). Ba so cac nghien cifu ve_UTV d cac lifa tuoi khac nhau deu cd ket qua thong nhat la vj tri hay gap nhat ciia khoi ung thu vii la 'A tren ngoai, dieu nay phii hdp vdi sif phan bo so lu'dng ong tuyen d cac plian khac nhau ciia tuyen vu.
- Bac diem khdi u
Jrong so 195 tru'dng hdp, so IUdng 1 khoi u chiem ty le cao nhat (95.4%), kich thu'dc khoi u tir 2 - 5cm (T2) chiem ty le cao nhat (62.6%), u,;
> 5cm (T3) chiem 25,6%, khoi u cd ranh gidi.
kh6_ng ro chiem 75,4%, be mat khoi u go ghe • chiem 74,5%, mat do khoi u chac hoac cifng;
chiem 96,4%. Ket qua nay phii hdp vdi tac gia Phi Thuy Du'dng [1]. Trong nghien ciili ciia Chung toi van cdn cd ty le kha cao (25,6%) benh nhSn di kham khi kich thu'dc u da Idn (T3), dS S giai doan mupn. Nhu' vay, van de sang loc, phat hien sdm UTV can chii trpng ngay ca vdi ngiiSI!
JJiP CHJ Y HOC VlgT HAM TAP 450 - THAHG 1 - S6' 1 - 2017 cao tuoi.
- PhathiSn hach nach ben lam sang Ty le phat hien hach nach cun§ ben rat cao vdi 154/195 benh nhan chiem ti le la 79.0%, Idiong cd trffdng hdp nao cd hach nach ddi ben.
Nhu" vay, Tren lam sang, I<hi Itham phat hien ed tthcn u d vu va hach nach to cung ben tht kha nang bj UTV la rat cao, nhffng cung dong nghla vdi benh nhan cd the d3 d giai doan mugn.
- Giai doan lam sdng
Trong 195 benh nhan nghien effu thi ket qua chan doan giai doan lam sang ehiem t/ le cao nhat la giai doan I I (70,8%), tiep theo la giai doan III (20,3%), giai doan I chiem ty le thap nhat (6,2%). K^ qua nay phu hdp vdi Nguyen Nhat Tan [6] va Nguyen Van Qui [4]. Nhu* vay, d Viet Nam ty le benh nhan den kham d giai doan sdm cdn thap, van de nay lien quan trffc tiep den ket qua dieu tr| UTV d tat ca cac lu^ tudi, dac biet vdi ngu'di cao tuoi khi ma toan trang
^ung ngay cang kem hdn.
* Dac diem can lam sang
- Chan doan UTV bang X guang tuyen vu tia mem
Trong 195 benh nhan nghien cffu cua ehiing toi, ket qua ehan doan du'dng ti'nh chiem ty le cao nhat (67%), tiep theo la chan doan nghi ngd (22,3*%), ehan doan am tinh chiem ty le thap nhat (10,7%), Ket qua nay cao hdn Nguyen Nhat Tan [6] vdi ty le dffdng tinh chi la 46.4%, Theo Buseman S [1] thi X quang tuyen vu tia mem ehan doan UTV ehinh xac den 90%, ed vai trd sang igc va ehan sdm.
- dian dian t^ljao hge bang kim nho (FNA) Trong nghien cdu cua chung tdi, ty l | FNA Chan doan UTV rat du'dng ti'nh eao (95,4%), cd 2,6% benh nhan cd ket qua nghi ngd thi dffde chan doan xac djnh bang sinh thied tffc thi, 2%
benh nhan cd ket qua am tinh khi cd ket qua mo binh hoc sau md la UTV thi da du'dc phau thuat Patey cai bien.
FNA la xet nghiem hang dau trong viec phat hien, dian doan UTV giai doan sdm d mgi Iffa hJoi. Theo Demay R. thi ehan doan UTV bang FNA ed dp nhay va gia trj dff bao am b'nh deu rat cao la 92% VA 94%, Cd ty Ie nhd chan doan lanh tfnh va nghi ngd ac ti'nh ed the do ky thuat lay benh pham, nhupm va lam phien do.
- Chan doan mo benh hge
Ket qua cho thay: UTBM dng xam nhap la the giai phau benh hay gap nhat (79,5%), ket qua nay phu hdp vdi eac nghien cffu cua cac tac gia
trong nude va tren the gidi nhff Ta Van Td [7], Berg va CS, Popovici R, cac tac gia deu thong nhat UTBM ong xam nhap la loai md benh hoc chiem ty le cao nhat, khdng phan bi$t Iffa tuoi.
V. KFT LUAN
- Mpt sd dac diem iam sAng
+ i'i le mac UTV d phu nff cao tudi ty le nghich vdi lu^ tuoi.
+ Vi tri khdi u pho bien la 1/4 tren ngoai (34,4%) va d vi tri 1/2 tren (29,8%).
+ So Iffdng mot khoi u d mot ben vu chiem t/
le cao nhat'(95.4%).
+ Cd hach nach cung ben la 79,0%.
+ Giai doan lam sang: da sd d giai doan I I (70,8%).
- Mgt sff dae diSm can lam sang + Chup vu tia mem od I ^ qua dffdng b'nh la 67%.
+ Choc hut te bao kim nhd tru'dc md cd ty \%
dffdng tinh la 95.4%.
+ The md iDenh hpc sau mo hay gap nhat la UTBIVI dng xam nhap (79,5%).
TAI UEU THAIVI KHAO
1. Phi Thuy Du'dng (2008), ''Danh gia ket qua ^iu tii ho tid bang Anastrozoi (Arimidex) cho benh rihan ung tiiu' vu glal doan II, III da man kinii cd thu die ngi tiet dudng ti'nh", Luan van Thac sT y hoc, Oai hpc y Ha Npi.
2. Nguyin Minh Khanh (2004), "^Danh gia ket qua phau thuit bao ton irong dieu tii ung thu' vu d nU giai doan I-II tai binh viin K", Luan van thac si Y hoc, Trui&ng dai hoc Y Ha Ngi.
3. Pham Khue (1993), Benh hge tuoi gia, Nha xuat ban Y hpc. Ha npi
4. Nguyen Van Qui (2007), "^Nghiin cuV chan doan va dieu tii ung thu" vii giai doan I - III dphu ndtai binh viin da khoa CSn Thd", Luan an Tien sT Y hoc, Tru'dng Dai hoc Y Ha Ngi.
5. Ta Xuan Sdn (2009), ""iVghien cuV phiu tiiuat bao ton dieu tri ung tiiu" vu nd glal doan I, li', Luan an tien sT Y hoc, Hpc vien Quan y.
6. Nguyen Nhat Tan (2004), "^Nghiin cuV mgt sd dac diem iam sang, can lam sang va ket qua phiu thuat Patey trong dieu tri ung thti vu giai doan I, II, Illa te/ benh viin K Ha Noi", Luan van tot nghiep bac sy chuyen khoa cap II, Tru'dng dai hoc Y Ha Ngi.
7. Ta Van Td (2004), Nghien cuii hinh thai hoc, hoa mo mien dich va gia tri tiin IWdng cua chung trong ung thu" bieu mo tuyen vu, Luan an tien sT Y hpc, Tru'dng i3ai hpc Y Ha Ngi.
