DIENDAN Y HOC
Chuyen de trong thang
He thdng xep giai doan ung thu" phoi mdi
Hoang Hdng Thai*, NguySn Quang Dgi*
T()M TAT
Viec xac dinh giai doan la mgt vdn dS quan trong khi dat chdn doan xac dinh d benh nhan ung thu.
Hiep hoi kidm soat ung thu qudc td(UlCC) va Lien Uy ban ung thu Hoa Ky (AJCC) da dua ra dmh nghla, xem xet dinh ky, cai tidn nhdng he thdng phan giai doan. He thdng phan loai lin thd 7 dugc dua ra nam 2009 da dugc chinh thdc ap dung.
Dd lieu sd dung dd danh gia, dua ra ban phan giai doan ung thu phdi lin nay dugc thu thip td 81015 trudng hgp sau khi da loai ra nhdng trudng hgp khdng du tieu chuin. Trong sd nay, ung thu tdbio nho (SCLC): 16% va ung thu phdi khdng tdbio nho (NSCLC): 84%. Chico NSCLC dugc dung dd phin chia T, N, M vi xdp nhdm giai doan. Dd lieu dugc thu thip a 4 chiu luc, trong dd Chiu Au: 58%, Bac My:
21%, Chiu A: 14%, Chiu Uc: 7%. VS diiu tri, phiu thuit dat: 41%, xa tri: 11%, hda chat: 23%, cdn lai la cac bien phap diiu tri kdt hgp.
1. Lieh sir he thong xep giai doan quoc te ve ung thu phdi
He thong xep giai doan TNM cho ung thu phoi ban dau dugc de xuat bdi Bic sT Clifton Mountain va da dugc AJCC thong qua vio nam 1973, UICC thong qua nam 1974. Sau do dugc Lien iiy ban xep giai doan ung thu Hoa Ky sir dung de dua ra khuyen cao xep giai doan lam sing cho ung thu phdi khong te bio nho (NSCLC). Miic do ciia benh dugc mo ta theo khoi u tien phat (T: primary tumor): T0-T3, tinh
trang hach (N; nodal status): N0-N2, vl co hay khong di can (M: metastasis): MO-Ml.
Nam 1985, AJCC, UICC, cle nha khoa hoc Dire va Nhat Ban da dS xuat danh gil lai he thong xep giai doan quoc tS cho ung thu phoi dya tren phan tich 3 753 benh nhan. Trong phan loai nly, xuat hien them phan nhom T4 vl N3 vdi dac diem:
- T4: khoi u xam lan vao nhirng cau trtic ciia trung that hoac mot hoac nhiSu can true ciia than dot song hoac tran dich mang phoi lc tinh.
* Khoa Ho hap Benh vien Bach Mai
** Khoa Ho hap Benh vien Da khoa tinh Hal Dwcfng
1 2 IY HOC LAM SANG Sd 45 (Thang 10/2009)
- N2: gidi han cho cac hach trung that va bach dudi cua khi quan (carina) ciing ben, N3:
hach thugng ddn, hach rdn phdi, hach trung that ddi ben.
Bang phan giai doan ung thu phoi nam 1997 dua tren dtr lieu ciia 5 319 benh nhan bj ung thu phdi tien phat dieu trj tai trung tam ung thu Anderson tu 1975 den 1988. He thdng xep giai doan ung thu phoi nam 1997 co mot so diem mdi: (1) chia giai doan I thanh IA va IB, (2) chia giai doan II thInh IIA vl IIB (3) chon khoi u ve tinh d ciing thuy phoi vdi khoi u tien phlt phan thanh T4, (4); nhirng khdi u tien phat vdi mot hoac nhieu tSn thuong dong thdi d khac thiiy nhung cting bSn dugc xep vao nhom di can M l .
Han che ciia he thong phan loai nly la so lugng benh nhan it, trong bdi canh thdi gian dai, nang ve nhiing benh nhan dugc diSu trj phau thuat.
2. Nhihig nguyen t2c co" ban trong he thong xep giai doan ciia UICC/AJCC
Bang phan loai giai doan NSCLC dua tren he thdng TNM, dugc sir dung rgng rai cho hau hSt cic loai ung thu, trong do: T: khoi u tiSn phlt. N: bach lympho, vl M: dnh trang di can.
He thong xep giai doan chi dya tren mdt yeu to duy nhat do la pham vi giai phau ciia benh, nhiing ySu to khac chang ban nhu trieu ehung lam sang, dac diem sinh hgc phan tir ciia khoi u khong dugc dnh den, sy gia tang miic do T phan Inh khdi u ldn hoac sy xam lan nhiSu hon d ngoai vi (Vi du: mang phoi tang, thanh nguc) hoac nhieu hon d trung tam (phe quan goc hoac phe quan thuy, trung that). Trong ung thu phoi, giai doan hach tuy thupc vao vj tri hach co di can (tuang phan vdi so lugng cila bach). Giai doan lam sang dugc bieu thj bdi tien to "c", giai doan to chiic hoc dugc bieu thj bdi tien td "p", ngoli ra, UICC con dinh nghTa he thong phan loai cho sy xuat hien hoac vang mat phan ton du ciia khoi u sau dieu tri.
Bdng 1. Xep loai cua ddnh gid giai doan Tign t6
c P y r a
Ten Lam sang (Clinical) T5 chuc hoc (Pathology) Xep lai giai doan (restaging) Tai phat (Recurrence) Mo tir thi (Autopsy)
Djnh nghla
Thuc hien truac dieu tri. Sir dung tat ca cac thong tin lam sang hien co (ke ca noi soi trung that).
Sau khi cat bo, dira tren danh gia 15 chuc hoc.
Sau mot phan hoac tat ca cac bien phap dieu tri dugc ghi nhan.
Xep giai doan tai thai diem tai phat.
Xep giai doan dugc xac dinh bdi mo tu thi.
Bdng 2. Phdn cdn lai cua khdi u sau dieu tri Ky hieu
RO
RI R2
Ten
Khong con u
Con u dang vi thg Con u dang dai the'
Djnh nghla
Khong the xac djnh dugc khoi u con lai, bd phau thuat am dnh.
Bd phau thuat duong tinh ve vi the nhung khong nhin thay khoi u con lai bang mat thudng.
Khoi u con lai lo (nhin thay hoac sd thay).
DIEN DAN Y HOC
Chuyen de trong thang
3. Djnh nghTa cac ky bieu trong be thdng xep giai doan quoc te TNM mdi ebo ung thu phdi cda AJCC va UICC nam 2009
Bdng 3. Dinh ngliia ky hieu T, N, M
Ky hieu T TO Tl Tia Tib T2
T2a T2b T3
T4
N NO Nl N2 N3
M M Mia
Mlb
Dinh nghTa
Khdi u tien phdt'" (Primary tumor) Khong CO u tien phat
U< 3cm, duac bao boc boi pho'i hoac mang ph6i tang, khong gan han phe quan thuy U<2cm
U > 2cm nhung< 3cm
U >3cm nhung < 7cm hoac u co bat ky dac diem: '"
Xam lan vao mang phoi tang, ton thuang tai phe quan g5c nhung each carina >2cm, xep phoi/viem phoi tac nghen lan den ron phoi nhung khong ton thuang toan bo phoi.
U > 3cm nhung < 5cm U > 5cm nhung <7cm U > 7cm.
Hoac xam lan true tiep vao thanh nguc, vom hoanh, than kinh hoanh, mang phoi trung that.
hoac mang ngoai tim.
Hoac u a phe quan goc each carina < 2cm '"".
Hoac xep phoi/viem phoi tac nghen toan bp phoi.
Hoac CO nhCmg khoi u khac d ciing thijy.
U CO dudng kinh bat ky xam lan vao tim, mach mau Idn, khi quan, than kinh thanh quan quat ngugc, thuc quan, than dot song, hoac carina.
Hoac CO nhihig khoi u khac d thiay phoi khac ciing ben.
Hach Lympho viing Khong di can vao hach vung
Di can vao hach lympho quanh phe quan va/hoac hach quanh ron phoi cijng ben va nhung hach trong phdi, ke ca tdn thuang xam lan true tiep.
Di can vao hach lympho trung that va/hoac dudi cariana
Di can vao hach lympho trung that ddi ben, hach rdn phdi ddi ben, hach ca bac thang cung hoac ddi ben, hoac hach lympho thugng ddn.
Di can xa (Distant metastasis) Khdng cd di can xa
Cd khdi u khac d thiJy phdi ddi ben
Hoac u vdi nhung ndt(nodes) d mang phdi hoac su lan tran mang phdi ac tinh (dissemination) '•''
Di can xa
Dudi nhdm'"
Tia Tib
T2a T2b T3>7 T3 xam lan
T3 trung tam T3trung tam T3 ve tinh T4 xam lan
T4 khac thiiy, ciJng ben
Mia ndt ddi ben Mia lan tran Mlb Nhirng tinh huong dac biet
TX, NX, MX Tis TID
Trang thai T, M, N khdng cd kha nang danh gia.
Ung thu khu tru tai chd
NhiJiig khdi u vdi bat ky kich thude Ian d6n bS mat nhung ti6p giap vdi thanh khi quan hoac phe quan gde.
Tis Tlss
/. Khoi u vdi duang kinh ldn nhdt.
2. Tieu de dudi nhom khong ditac xdc dinh trong dn bdn ciia lASLC nhtmg duac them vao day di thuan tien cho viec bdn luan ro rdng.
3. Nhung khoi u T2 vdi nhung dac diim ndy cting dtrac phdn loai nhu T2a niu u < Sent.
4. Nhung khoi u lan den be mat khong phd biin, a dudng tha trung tdm duac phdn loai nhu TL 5. Trdn dich mdng phoi duac loai trie neu te bdo hoc dm tinh, khong cd mdu, dich tham, vd ddnh gid lam sdng khong phdi do ung thir.
1 4 IY HOC LAM SANG Sd 45 (Thang 10/2009)
Ky bieu T
Uy ban quoc te xSp giai doan ctia lASLC da phan tich dudng kinh kh6i u mot each chi tiet.
Ngudng dudng kinh 3cm dugc xac dinh la diSm cat (outpoint) co y nghTa va dugc su dting de djnh nghTa T l ' v l T2. Them vao do, diem cat khac co y nghTa cting da dugc xac dinh II 2cm, 5cm, 7cm. Nhtrng khoi u > 7cm c6 thdi gian song sot tuong ty vdi nhtrng djnh nghTa khlc ciia T3 (xam Ian hoac khu tru d trung tam) va do do dugc xSp vao cung nhom.
Nhirng diem cat 2cm v l 5cm dugc thSm vao dudi nhom ctia Tl (Tl a va Tl b) va T2 (T2a vl T2b). Ngoai ra, s5 Itrgng khoi u ngoai khoi u nguyen phlt (additional tumor) cting co gia tri tiSn Itrgng, chang han benh nhan co them nhtrng khoi u ve tinh (sattelite) d cung thuy vdi khoi u tiSn phat cd thdi gian song sot
tuang ty T3 va bay gid dugc phan loai nhu T3 (trudc day la T4). Thdi gian song sot ctia nhtrng benh nhan T3 ve tinh cao ban mot each CO y nghTa so vdi nhirng benh nhan co khoi u T4 bdi su xam Ian chu yeu vao nhtrng cau true ctia trung that (T4 xam Ian). Tuy nhien, tiSn lugng nhtrng benb nhan T4 xam lan khong co sy khac biet co y nghTa so vdi nhirng benh nhan co them khoi u khac d khac thuy cting ben vdi khoi u tien phat (T4 not khac thtiy Cling ben). Do do, nhung khoi u khac thtiy Cling ben nay bay gid dugc phan loai nhu T4 (trudc day dugc phan loai nhu M l ) . Trai lai nhirng benh nhan co lan tran mang phoi (Pleural dissemination) c6 thdi gian song sot thap hon mot each c6 y nghTa so vdi T4 xam lan va T4 not khlc thuy, bdi vay nhirng benh nhan nay dugc phan loai nhu Mia.
Ky bieu N
Giai doan 0 Giai doan la Giai doan lb
Tis NO
K b\iu m6
tai ch$ T i a NO
T i b NO TL.NO
\.^ V UbSmattai
\ <ia6ng tha
Lan tai ban nay khong co sy khac biet ve phan loai hach so vdi tai lieu tai ban Ian thir 6.
Tuy nhien, so vung hach bj ton thuang co anh hudng den tien lugng, benh nhan chi co mot viing bach bi tSn thuang Nlco thdi gian s5ng dai ban nhirng benh nhan c6 nhieu hach vung N2 (ly
T2aN0
xam \Sn, trung tam
T2a NO
(>3 £.5 cm)
le song sot sau 5 nam tuang ting la 48% so vdi 35%, p< 0,09). Tuong ty, nhtrng benh nhan chi CO hach ton thuang N2 co thdi gian song sot dii hon nhirng benh nhan co nhieu vung hach ton thuang N2 (ty IS song sot sau 5 nam tuang trng la 34% so vdi 20%, p< 0,001).
DIENDAN Y HOC
Chuyen de trong thang
Giai do^n lla
T2bN0
(>S s7 em)
Ngudi ta cting can nhac ky ky hieu MO va Ml (di can xa), than trong doi vdi nhtrng benh nhan bj trin dich ming phoi ac tinh hoac co them nhtrng khoi u d phoi. Nhirng benh nhan c6 them khoi u d cung thtiy vdi khoi u tien phat hoac khlc thtiy nhung cung ben dugc dinh
T l a N l T l b N l
T2aNl
<>3 £5 cm)
nghTa lai vdi hinh thai khlc ciia ky hieu T. Thdi gian song sot khlc nhau dan den viec phan loai thanh 2 dudi nhom M i a (Mia ndt doi bSn hoac Mia lan tran mang phoi: tham nhiem ming phoi hoac co khoi u d phoi doi ben) va Mlb vdi di can xa.
T3 NO
trung tam
T3 NO xdm lln T3.,N0
Giai doan lib
T2b,5,-,N1
Mac dti nhan ra co nhieu nhom nho mdi trong cac ky hieu T vl M nhung nhom giai doan da khong dugc thSm bat ky nhom nho mdi nao. Tuy
T3 NO
v& tinh
nhien, dinh nghTa nhtrng nhdm giai doan da trd nen phtrc tap ban bdi thSm nhung dudi nhom ciia ky hieu T v I M .
1 6 IY HOC LAM SANG Sd 45 (Thang 10/2009)
Giai do^n HIa
T4 NOJ
T3 Nl]
T3.,NI T3 N2
T3 Nl
v6 tinh
T 4 NO T4 N l
N5t khac thDy cCing t&fi
Giai d o a n Nib
T 4 N 2 xdm l3n
T N 3
bStkjr T 4 N 2
N5t khiic thCiy cCing bdn
Bang 4. Nhimg dac diem TNM trong phdn nhdm giai doan Phan nhom giai
doan la lb Ua
Ub Ilia
Hlb IV
T Tla,b
T2a Tla,b
T2a T2b T2b T3 Tl-3
T3 T4 T4 Tl-4 T bat ky
N NO NO Nl Nl NO Nl NO N2 Nl N0,1
N2 N3 N bat ky
M MO MO MO MO MO MO MO MO MO MO MO MO Mla,b
Benh nhan, % (lam tron so)
15 13 2 4 4 2 14 20 6 2 1 3 14
Chii thich: ky hieu % cho tat ca c l e trudng hgp
DIENDAN Y HOC
Chuyen de trong thang
Bdng 5. Phdn nhdm giai doan theo ky hieu TNM vd dudi nhdm T/M
T l T2
T3
T4
M l
DuxH nhom T i a
T i b T2a T2b T 3 , , T3 xam lan T3ve tinh T4 xam lan
T4 not khac thtiy, cung ben M i a not doi ben
M1 a lan tran mang phoi M l b
NO la la lb Ila lib lib lib Illa Ilia IV IV IV
N l Ila Ila Ila lib Ilia Ilia Illa Ilia Illa IV IV IV
N2 llla llla Ilia llla llla Ilia Ilia Illb Illb IV IV IV
N3 Illb Illb Illb Illb Illb Illb Illb Illb Illb IV IV IV Bdng 5. Phdn nhdm giai doan theo ky hieu TNM vd dudi nhdm 1
2R.
2L 3a 3p 4R.
4L.
Vung hach thirang don Hach CO thap, thirong don, dau tren xirong ire
Hach trung that tren hach canh khi quan tren (phai) Hach canh khi quan tren (trai) Truac mach mau
Sau khi quan
Hach canh khi quan thap (phai) Hach canh khi quan thap (trai)
5 6 7 8 9 10 11
Hach quanh dong mach chu Duoi dpng mach chu
canh dpng mach chii (doan DMC xuong hoac hoanh)
Hacli trung that trinyc Hach diroi carina
Canh thirc quan( carina thap) Day chiing phoi
R5n phoi Lien thuy Vung ngoai vi
thiJy-O, phan thiiy-I4, ha phan thuy TAI LIEU THAM KHAO
L Etingger DS (2007). Lung cancer and other pul- monary neoplasms. In Goldman: Cecil medicine, 23rd ed. Chapter 201, Saunders.
2. Giroiix DJ, Rami-Porta R, Chansky K, et al (2009).
The lASLC Lung Cancer Staging Project: data ele- ments for the prospective project. J Thorac Oncol;
4:679-683.
3. Goldstraw P, Crowley J (2006). The International Association for the Study of Lung Cancer International Staging Project on Lung Cancer J Thorac Oncol; 1:281-286.
4. Mountain CF (1986). A new international staging system for lung cancer Chest; 89,225-231 s.
5. Mountain, CF (1997). Revisions in the International System for Staging Lung Cancer Chest 111, 1710-1717.
6. Union Internationale Contre le Cancer (2002). TNM classification of malignant tumours. 6th ed. New York, NY: Wiley-Llss; 272.
7. Zielinski M, Rami-Porta R (2007). Proposals for changes in the Mountain and Dresler mediastinal and pulmonary lymph node map. J Thorac Oncol;
2:3-6.
8. Frank C. Detterbeck, Daniel J. Boffa and Lynn T.
Tanoiie (2009). The New Lung Cancer Staging System. Chest; 136; 260-271.
Chu viet tdt: AJCC: American Joint Committee on Cancer; lASLC: Internationcd Association for the Study of Lung Cancer; NSCLC: non-small cell lung cancer; SEER: Surveillance, Epidemiology, and End Results; UICC; Union Internationale Contre le Cancer
1 8 IY HOC LAM SANG Sd 45 (Thang 10/2009)
