MAH T-: Y HOC VIET NAM THANG 11 - SO 2/2010
CHi DINH VA KET QUA SINH THIET TIEN LIET TUYEN QUA NGA TRlfC TRANG
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TRONG NHUNG TRlTONG HOP PSA < 4NG/IVIL.
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TOMTAT ' :'"•' ;-• i':^br...:.;;.i Mac tieu: Trong bai nghien cffu nay chiing tor l<hao sat nhffng trUdng hgp PSA thap ma ket hdp vdi lam sang, can lam sang va chan doan hinh anh nghi ngd ung thU tien liet tuyen.
iiiTatleu va phuUng phap nghien cii'u: Tff nam 2007 den 2010 tai Medic tiep nhan 30 trUdng hdp sinh thiet tien liet tuyen ma cd PSA < 4 ng/ml. Chung tdi danh gia nhffng chi djnh va ket qua sinh thiet tien liet tuyen xem cd lien quan '•
den lam sang va can lam sang khdng. Tat ca benh nhan deu phai cd it nhat mgt trong nhffng dau hieu sau: cd nhan echo kem viing ngoai vi tien liet tuyen, kham trUc trang bang ngdn tay cd nhan cffng, ti le f/t PSA < 20%, PSA velocity >
0.75 ng/ml. chung tdi loai trff nhffng trUdng hdp ung thff tien liet tuyen da dieu trj co PSA thap.
Ket qua: Trong sd 30 benh nhan cd 4 ngffdi dffdc chan doan la ung thff tien liet tuyen chiem 13.3 %. Trong sd 21 benh nhan cd echo kem viing ngoai vi tien liet tuyen thi cd 3 benh nhan ung thff tien liet tuyen chiem ti le la 14.2 %.
Co 3 benh nhan sinh thiet la ung thff tien liet tuyen trong so 7 ngffdi cd nhan cffng khi kham trffc trang bang ngdn tay. Trong sd 7 benh nhan CO ti le f/t PSA < 20% thi chi cd mgt trffdng hdp sinh thiet dffdng tinh. Chung tdi cd mgt trffdng hdp cd PSA velocity > 0.75 ng/ml nhffng sinh thiet am tinh.
Kit luan: Ung thff tien liet tuyen xay ra d bat ky ngffdng PSA nao. Tuy nhien xet nghiem PSA van la xet nghiem cd ban khong the thieu trong tam soat ung thff tien liet tuyen. Ngoai PSA cdn
Le Tuan Khue , Le Thanh Chuong , Nguyen Minh ThienV Nguyen Tuan Vinh , Phan Thanh Hai
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- M . . / ; J : phai dffa vao iam sang va chan doan hinh anh de khdng bd sot ung thff tien liet tuyen.
Tu'khoa: ev'^i::
Sinh thiet tien tuyen qua nga trffc trang trong nhffng trffdng hdp psa < 4ng/ml.
Tff Viet tat:
- PSA: prostate specific antigen - Ng/ml: nanogram tren mi li lit - TLT: tien liet tuyen ^ ' ' ' - f/t PSA: free PSA/ total PSA '-''"
- TRUS: transrectalultrasound.
- DRE: digital rectal examination
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ABSTRACT
PROSTATE BIOPSY BY TRANSPERINEAL APPROACH AT A PSA LEVEL LOWER 4 NG/ML: INDICATION AND RESULT
Afe/ivoricf*/Prostate biopsy by transperineal
approach. '"
'- ' - PSA: prostate specific antigen ' - Ng/ml: nanograms per milliliter ' - DRE: digital rectal examination
' -' TRUS: transrectalultrasound '•'•'^' f/t PSA: free/total PSA '' ''
Purposes: In normally, prostate cancer investigated in the men who had the PSA level upper 4.0 nanograms per milliliter. However prostate cancer still detecte at a PSA level of 4.0 nanograms per milliliter or less. In this study, we describbed prostate cancer biopsy at a PSA threshold lower than 4 nanograms per milliliter with the suspicion of digital rectal examination (DRE), transrectalultrasound (TRUS), PSA
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HOI NGHI KHOA HOC LAN THLf IV • HOI TIET NIEU - THAN HOC VIET NAM velocity, free/total PSA.
Material and methods, from 2007 to 2010, there were a 30 cases of prostate biopsy at a PSA level lower than 4 nanograms per milliliter with retrospective study. We evaluate the relation between result and indication of prostate biopsy at a PSA threshold of 4 ng/ml.
Results: Among 30 men, prostate cancer was diagnosed in 4(13.33 percent). The prevalence of prostate cancer was 14.2% percent among 21 men with hypoechoic lesions in peripheral zone of transrectalultrasound (TRUS), 42.8 percent among 7 men with hard nodule in digital rectal examination, 14.28 percent among 7 men with the free PSA test at 20 percent or lower, 42.8 percent among 7 men combine the hypoechoic lesion and hard nodule.
Conclusions: Prostate cancer present at any PSA threshold. However a PSA test is still standard test for screening for prostate cancer.
I. Md OAU
Trong nhung nam cudi thap nien 1980, xet nghiem PSA dugc dung rdng rai d My de tam soat ung thu tien liet tuyen d giai doan sdm. Tuy nhien xet nghiem PSA van khdng chffng minh gidm nguy co tff vong do ung thu tien liet tuyen va khdng phai tat cd ung thu tien liet tuyen dugc tdm soat bang PSA deu lien quan den lam sang. Ngoai ra nhung xet nghiem can lam sdng khac nhu f/t PSA, PSA velocity va sieu am qua nga true trang cung hudng den nghi ngd ung thu tien liet tuyen'. Do vay trong bai nghien eim nay
chung tdi khao sat nhung trudng hgp PSA thdp ma kit hgp vdi lam sdng, can lam sdng va chdn dodn hinh dnh nghi ngd ung thu tien liet tuyen.
II. MUC TIEU NGHIEN CQU:
- Ddnh gid nhung chi dinh sinh thilt tiln liet tuyin ddi vdi PSA thap.
- Ddnh gid kit qua sinh thilt tiln liet tuyen xem cd lien quan den chi dinh sinh thiet vd lam sdng khdng.
III. o 6 l TUdNG VA PHUONG PHAP NGHIEN CIJlU 3.1. Doi tuong nghien cmi:
Tff nam 2007 den 2010 tai medic tiep nhdn 30 trudng hgp sinh thiet tien liet tuyen ma cd PSA < 4 ng/ml. Tat ca nhiing benh nhan cd xet nghiem PSA thap ma cd kem theo nhirng dau hieu sau:
- Kham true trang bang ngdn tay cd nhan cung.
- Sieu am qua nga true trang cd nhdn nghi K.
- PSA velocity tang > 0.75ng/ml/ndm.
,'..•,., Ti le Free PSA/Total PSA< 20%.
Chung tdi loai nhffng trudng hgp ung thu tien liet tuyen da dieu tri cd PSA thap.
3.2. Phuong phap nghien cuu:
Bang phuang phdp tien cuu, tat cd benh nhan dugc sinh thiet tien liet tuyen 6 mdu qua nga tang sinh mdn dudi hudng ddn dau dd sieu am qua nga true trdng.
IV. KET QUA VA BAN LUAN:
4.1,Tu6i:
- Tudi trung binh Id 65.03; tudi cao nhdt la 82; tudi thap nhdt la 45.
4.2. Nhimg tru'dng hgp PSA thap ket hgp voi TRUS co nhan echo kem vung ngoai vi*
- Cd 21 trudng hgp khi sieu am cd nhdn echo kem nghi ngd dugc sinh thilt, trong dd
3 trudng hgp. ., CO
Y HOC VIET NAM THANG 11 - SO 2/2010
(ITinh 4.1: nhan echo kem vung ngoai vi tien liet tuyen)
(ITinh 4.2: Sinh thiet vdo vung ngoai vi tien liet tuyen)
TRUS CO nhan KQ sinh thiet (+)
TrUdng hdp 21
3
Tile 7 0 % 14.2%
Bdng 4.2.1: Ti le sinh thiet khi TRUS cd nhdn.
- Khi TRUS cd nhdn nghi k, ti le ung thu khdng cao.
- Khi cd nhan echo kem thi kit qud sinh thiet cd the Id: ung tbu, lao, viem cap, viem man hoac Idnh tinh^'^
- TRUS cd gid tri trong hudng dan sinh thiet tien liet tuyen.
4.3. Nhirng truong hop PSA thap ket hgp voi DRE co nhan cung:
- Tham khdm true trang bdng ngdn tay phdt hien nhdn cung cd 7 trudng hgp nhung khi sinh thiet ket qud cd 3 trudng hgp ung thu tien liet tuyen.
DRE (+) KO sinh thiet (+)
TrUdng hdp 7 3
Tile 23.3%
42.8%
Bdng 4.3.1. Ti le sinh thiet khi DRE (+)
Khi thdm khdm true trdng bdng ngdn tay thdy cd nhdn cung ti le duong tinh cao.
DRE(+) hdu bet K TLT d ngoai vi va thi tich nhdn cffng phai >0.2ml.
HOI NGHj KHOA HOC LAI^THLT IV • HOI TIET NIEU - THAN HQC VIET NAM
-|, DRE(+) >50% xam lan vd bao. , .x - Nhung trudng hgp DRE {+), ma sinh thilt dm tinh la do sdi tidn liet tuydn, nang tien liet tuyen.
- Nhan xet: Theo A. Heidemeich va cdng su khi DRE (+) ti le CaP phu thudc vao chi sd PSA
Table 2: PSA value and risk of CaP PSA ng/mL PPV for cancer
0-1 2.8-5%
1I2.5 10.5-14%
2-5-4 ''''''";:^f*;"j/;2" - 22-30%
4-10 "•'••"• '"" 4 1 %
> :u •,:,,.„.,...., . 69% -...
PPV = positive predictive value;
PSA = prostate-specific antigen.
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4,4. Nhiing truong hop PSA thap ket hop vdi ti le f/t PSA < 20%.
^rong 7 trudng hgp ti le f/t PSA thap <20% thi cd 1 trudng hgp sinh thiet duong tinh.
f/t PSA
KQ sinh thiet ( + )
TrUdng hdp T i l e
23.3%
14.28%
SflHg'^.^.7. ti le sinh thiet khi f/t PSA < 20 ng/ml.
- Trong 7 trudng hgp ti ie f/t PSA tff 10-20 %. d ngudng ti le nay ciing nam trong vffng
nghi ngd ung thu cho nen thay rang do chuyen biet khdng cao. . - Theo Campbell-walsh Urology'* (Prostate Cancer Tumor Markers) \
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^•j afiofbl v'^^ fjfuf '^f >:!',>[ 'rhn nMn 63:3U3T '><i2A - . •• Aim fini:;i uBprt nem
O - I O " . 10—15=0 1 5-aO°/o 20—25°/o ^as^/o „
' — ' . . . - %fPSA '^^ ^•«'-''" '''•--"• 4\^»i gRtrarsI wffOrfi^'- .^.|.
Biku dd 4.4.1''. ti le ung thu tren benh nhdn cd f/t PSA < 20ng/ml
- Cho nen dua vdo ti le f/t PSA chdn dodn ung thu tien liet tuyen cung khdng chdc chdn.
4.5 Nhfrng tru-ong hgp PSA thap nhung PSA velocity tang > 0.75% / nam.
- Cd 1 trudng hgp dugc de nghj sinh thiet nhung ket qua am tinh. ^ u ,i - Theo Campbell-walsh Urology
PSA velocity > 0.75ng/ml ndm CaP 45%. :; nogn gncd gmit -xm tnmU mmli Iri..:
PSA velocity < 0.75ng/ml ndm CaP 11 %. • BV i^^ iBo§n d T,IT 'ji thd dd (+)a>!a
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Y HOC VI^T NAM THANG 11-50 2/2010
4.6. Nhiing tru^g hop PSA thap ket hop voi TRUS co nhan va DRE (-I-):
- Qua thdng ke cd 7 trudng hgp vua cd TRUS (+) vua cd DRE(-H), khi sinh thidt cd ddn 3 trudng hgp ung thu tidn liet tuydn.
KethdpTRUS(+)DRE(+) KQ sinh thiet (+)
Tru'dng hdp Tile
23.3 % 42.8 %
•., ,
PSA THAP
Tru'dng hdp 30
KQ sinh thiet ( + ) 4
Tile 13.3%
Bdng 4.6.1. ti Id ung thu khi kdt hgp TRUS(+) va DRE(+)
- Khi cdng kdt hgp nhidu ydu td chan doan duong tinh thi ti le phat hien ung thu cao.
- Mffc PSA thdp < 4 ng/ml thi do dc tinh cao (4 trudng hgp thi cd 3 trudng hgp gleason 7,8,9. trudng hgp cdn lai gleason 5).
15J 4.7. Ket qua sinh thiet trong nhung truong hop PSA th^p: MMJI Ti.>l V - Co 4 trudng hgp sinh thidt duong tinh trong 30 trudng hgp PSA thdp nghi ung thu tidn liet tuydn.
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5fl«^ ^. 7./. Ti Id ung thu trong trudng hgp PSA thap. ^
•5;,i;}r;T j Theo Thompsou et al: 15 % K TLT cd PSA < 4 ng/ml. : • rj§v ^.n-iidH .oa:) i>n.BO uril ^au
• ' Cd ledo cdmaunhd (n= 30) '" • ' ' • r..i < r i -r - Theo Thompson et al muc PSA < 4 ng/ml khdng sinh thiet thudng quy ma khi sinh thidt phdi phdi hgp them nhirng ydu td khde ggi y nhu: DRE {+), fit PSA, PSA velocity, TRUS cd nhan nghi ung thu vung ngoai vi. imH.n MAl-l i UpJ i/VI - Mdt nghien cixu ngdu nhidn d 2950 dan dng cd PSA < 4ng/ml trong do tudi 62-91.3 I , - Table 3: Risk of CaP in relation to low PSA value
•Jy PSA (ng/mL);,., Risk of CaP ,,
m nsyi.'aij ;;i'tii)*:iqi; oUitemq ,,.,0-0.50.6-1 1.1-2 2.1-3 3.1-4
W wiiliilsm i S ^ .a[ier_T0.1%
17.0%
• 23.9%
26.9%
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Guidelines on Prostate Cancer (A. Heidenreich, G. Aus, CC. Abbou, M. BoUa, S. Joniau, V. Matveev, H-P. Schmid, F. Zattoni)
- Lidn quan gifta ung thu tidn liet tuydn va PSA'*: (Campbell-walsh Urology)
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HOI NGH! KHOA HOC LAN THlf IV • HOI TIET NIEU - THAN HOC VIET NAM
Table 94-4 - Relative Risk of Subsequent Prostate Cancer Diagnosis after an Initial Baseline Prostate-Specific Antigen (PSA)
Relative Risk of Cancer (95% Confidence Interval) s • • -'•• •-' • - Baseline PSA (ng/mL) Gann et al, 1995 Antenor et al, 2004 ; i ,; " ' ' i v ';i <"; I ' ! ;
1 0 ' • • • ' " " ' • ' : ' • • : , " ' "
4.3(3.0-5.3) _^ ._
8.8(7,0-10.8) I •(.^•; «n,:;j; ; ,.-»v;j-(TQOf<
14.9(12.3-18.0) •••{--' • • •' 23.3(19.0-28.7) ',
38.7(32.2-46.7) , . ' M ' : I ' ; ' " ' ' i ' '"'•••"•^^
104.2 (80.0-135.7)
From Antenor JA, Han M, Roehl KA. et at. Relationship behwen initial prostate specific antigen level and subsequent prostate cancer detection in a longitudinal screening study. J Urol 2004:172:90.
Bdng 4,5.2'' lien quan ung thu tidn liet tuyen vd ndng do PSA/mau
0,0-1.0 1.0-1.5 1,6-2,0 2,0-3,0 3.0-4,0 4,0-10,0 More than 10 0
1,0 2,2(1,3-3,6) 3,4(1,9-59) 5,5(3,3-9,2) 8,6(4,7-15.6) 22,2(12,9-38,2) 145,3(59 1-357.0)
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V. KET LUAN : ;; i A^ I a - Ung thu tidn liet tuyen xay ra d bat ky ngudng PSA nao^. Tuy nhidn PSA van Id xet nghiem co ban khdng thd thidu trong tdm sodt ung thu tidn liet tuydn^
- Cang kdt hgp nhidu ydu td lam sang, can lam sang va chan dodn hinh anh thi ti Id ung thu cdng cao. Nhung ydu td nay chi cd y nghia ho trg chdn doan, khdng quydt dinh dugc chdn dodn ung thu tidn liet tuydn.
:• , . • - ,'./q i-,i^u i\: r- i n>s] .V TAI UEU THAM KHAO
1. Catalona WJ, SmithDS, Ratliff TL, Dodds KM, Coplen DE, et al. Measurement of prostate specific antigen in serum at a screening test for prostate cancer. N engl J med 324:1156-1161.
2. Ethan J Halpern MD. Ultrasound-guided biopsy of prostate. Imaging of prostate.
3. H. Ballentine Carter, M.D. Prostate Cancers in Men with Low PSA Levels - Must We Find Them?. N Engl J Med 2004;350:2292-2294.
4. Matthew B. Gretzer, MD Alan W. Partin, MD, PHD. Prostate Cancer Tumor Markers. Campbell-walsh Urology, chapter 93.
5. Matthew d. Rifkin MD. Ultrasound of the prostate. Imaging in the diagnosisand therapy of prostate disease.
6. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level of
< 4.0 ng per milliliter. N Engl J Med 2004;350:2239-2246.
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