Hinh thai hoc ung thir bieu mo tui mat

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Tap chi GAN MAT VIET NAM s6 15-2011 2 5

Hinh thai hoc ung thir bieu mo tui mat

Morphological Study of the gallbladder carcinoma

TRAN VAN HOP*, HA THI THU HIEN ^{C X T * *}

Tom tat:

Ung thu bieu mo tiii mat thuong dugc phat hien muon va co tien lugng xau. Nghien ciiu hinh thai hgc c6 gia tri trong dieu tri va danh gia tien lugng benh.AfMc tieu: Mo ta hinh thai dai the va phan loai tip mo benh hgc ung thu bieu mo tiii mat.;0^/ twang vd phieangphdp nghien cmi: doi tugng la 111 benh nhan phau thuat cat tiii mat dugc mo benh hgc xac dinh la ung thu bilu mo tui mat; phuong phap: ve dai the xac dinh vi tri, kich thudc,tip dai the; ve vi the xac dinh ti le tip mo hgc theo WHO 2000. Kit qua:

Sumary

Background'. Gallbladder carcinomas have been diagnosed in the late stage so the patients are usually in the poor prognosis. Morphological study of the gallbladder carcinoma plays an important role in the treatment and the prognosis of the disease.

Objectives: to study the gross features and the histopathological classification of the gallbladder carcinomas.

Methods and materials: descriptive study on 111 operated patients diagnosed gallbladder carcinomas by histopatholggy. To study the location, size, gross type and the histopathological classification of the gallbladder carcinomas basing on the WHO 2000.

Results: age average 62.3 ±11.9, F/M: 1.7/1.

1. Dat v i n de.

Ung thu bilu mo tui mat la loai u ac tinh

n F F 1 \

khong pho bien, benh tien tnen tham lang, nen thuang dugc chin doan muon. Ti le mac ung thu bilu mo tui mat co su khac nhau giira cac khu vuc tren thi gidi va ngay ca giiia cac viing, giiia cac chung toe trong eiing mot qu6c gia.

tuoi tmng binh 62,3±11,9. Ti le nii/nam: 1,7/1.

Dai thi: u thudng a than va day tiii mat(46,8 va 25,2%); u CO kich thuoc Ion l-5em chilm 68,5%;thl sui-49,5% va 80,2% cac traong hgp CO soi tiii mat kem theo. V.e vi the: 63,8%) la tip bieu mo tuyen, do biet hoa vua ehiem 55,9%; di can hach 19,8%); xam lan gan 22,5%. Ket luan:

ung thu bieu mo tiii inat hay gap d than va day tiii mat, u d giai doan muon c6 kich thudc Idn,

F t •* F

chu yeu d the sui va tip bieu mo tuyen.

The location: gallbladder carcinomas located the most frequent in the body and the bottom 46.8%, 25.5% respectively. The tumor size l-5em accounting for 68.5%), the polypoid tumor 49.5%) and the tumor accompanying the gallbladder stones 80.2%. The histopathological classification: adenocarcinoma accounting for 63.8% and 55.9% of these classified as intermediate differ- entiation. The proportion of lymphatic node metastasis 19.8%, hepatic infiltration 22.5%.

Conclusion: gallbladder carcinomas located the most frequent in the body and the bottom of the gallbladder, most of the tumor appeared as the polypoid type and the histopathological classification basing on the WHO 2000 shows that the predominant type is adenocarcinoma.

Cac nude My la tinh nhu Chile, Mexico, Bolivia co ti le benh cao nhit. 6 Chau A Nhat Ban CO ti le trung binh. C) My moi nam c6 khoang 6.600 trudng hgp benh mdi dugc chan doan va so tii vong ciing gan tuong tu. Theo T6 chiic Y t l thi gidi (WHO 2000) ti le ung

*Dai hoc Y Ha N6i,**Benh vien him nghi Viet-Dirc.

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thu bilu mo tiii mat chilm khoang 0,17% trong tit ca cac loai ung thu dii voi nam va 0,49%

dii vdi nil (14).6 Viet Nam ung thu tui mat it gap, nhung eo xu hudng ngay cang tang va p h k Idn CO kit hgp vdi benh ly soi tiii mat (4,5,6). Cae nghien ciiu eho th4y benh gap d nii nhilu hon nam tu 3 din 5 ihn va d nhdm ngudi cao tuli thudng chilm ti le cao (2,5,7,10,11,).

Ngay nay nhd nhung tiln bg trong chin doan dae biet la cac phuong phap chan doan hinh anh da phat hien dugc nhung trudng hgp chua c6 bilu hien lam sang. Tuy nhien ung thu tiii 2. Ddi tuotig va phuong phap nghien cuu.

2.1 Ddi twang.

Nhiing benh nhan eo benh ly tiii mat dugc phau thuat ck bo tiii mat tai Benh vien Viet- Diic va dugc mo benh hgc chan doan xac dinh la ung thu bieu mo tu thang 1 nam 2002 den thang 6 nam 2009.

2.2 Phuang phdp nghien cmi..

- Lam sang: xac dinh tuoi, gidi benh nhan Dai thi: Mo ta vi tri u (el, than, day tui mat)

Do kich thudc u: < 1 cm, 1- 5 em va > 5 cm.

mat vin la benh cd tien trien nang ne va c6 tien lugng x4u. Thdi gian song trung binh 5 nam sau phlu thuat chi ehiem khoang 5%) (12).Ci Viet Nam da cd mot so nghien cuu ve lam sang, ve chan doan va dieu tri, song chua co nghien ciiu v l hinh thai hgc vdi so lugng Idn benh nhan ung thu tui mat da dugc phlu thuat. Bdi

F

vay nghien cuu nay dugc tien hanh vdi muc tieu: Mo ta hinh thai dai the va xac dinh ti le cac tip mo benh hgc ung thu bieu mo tiii mat theo phan loai cua T6 chiic Y t l Thi gidi (WHO) nam 2000 (14).

Mo ta tip dai the: polip, siii, xam nhap, lan toa.

Xac dinh soi tui mat: c6, khong.

- Vi thi: c i t 2 - 3 manh d trung tam u , viing ranh gidi u va vung ngoai u doi vdi u Idn

F F F

, cat ngang qua u doi vdi u nho. Cae manh cat dugc e l dinh trong formol 10%, chuyin, viii nin, cit lat 4 |xm va dugc nhugm Hematoxilin - Eosine (H & E). Phan tich mo benh hoc theo WHO 2000 (14).

3. Ket qua nghien cmi.

Bdng 1: Tuoi, gi&i benh nhdn Tiioi

Nam Nii- Cong

<50 n 5 12 17

%

4,5 10,8 15,3

50-59 n 14 24 38

%

11,6 21,6 34,2

60-69 N 12 18 30

%

10,8 - 16,2

27,0

>70 N 10 16 26

%

9,0 14,4 23,4

Cdng n

41 70 111

%

36,9 63,1 100 Nhan xet: tuoi thip nhit 18, cao nhit 86, tuli trung bkih 62,3±11,9

Hiu hit benh g|p d tuoi > 50 (84,7%), ti le nam/nii =1,7/1 O mgi nh6m tuoi nir dlu nhilu hon nam.

Vitri Solugng

%

Co tiii mat 16 14,5

Bdng 2: Vi tri u Than tui mat

52 46,8

Day tui mat 28 25,2

Lan toa 15 13,5

Cong 111 100 Nhan xet: U d than tui mat eo ti le eao nhit sau dd la day tui mat.

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Tap chi GAN MAT VIET NAM so 15-2011 2 7

Nhdn xet: U nhd nhit 0,5em Idn nhit 7,5em; trung binh 2,75+1,35em Hiu hit u CO kich thudc Idn tren 1cm, u <lem c6 ti le thip

Kich thude u

So lugng

%

< 1cm 21 18,9

Bdng 3: Kich thu&c u l<u<5cm

76 68,5

>5cm 14 12,6

Cong 111 100

Bdng 4: Cdc tip dai the

Tip dai the

So lugng

%

Dang polip 23 20,7

Dang sui 55 49,5

Dang tham nhiem 33

29,8

Cong 111 100

Nhdn xet: Dang siii la tip hay gap nhat

F

Bang 5. Uphoi hap v&i soi tui mat

Soi tui mat

n

%

Co 89 80,2

Khong 22 19,8

Cong 111 100

Nhdn xet: Phan Idn ung thu tiii mat c6 soi kem theo

Bdng 6. Cdc tip mo benh hoc

Tip mo hgc

UTBM tuyen UTBM tuyen nhii

F

UTBM tuyen vay UTBM tuyin nhiy

UTBM tl bao vay UTBM te bao nhd UTBM te bao sang

Cgng

... ^

70 n 18 8 7 5 2 1 111

%

63,1%

16,2 7,3 6,2 4,5 1,8 0,9 100

Nhan xet: ung thu bieu mo tiii mat chii yeu la tip tuyen.

Bdng 7. Do mo hoc

Do mo hgc

Biet hda cao Biet hda viia Biet hda kem Khong biet hda

Cgng

n 41 62 6 2 111

%

36,9 55,9 5,5 1,8 100

Nhdn xet: Do biet hda vira ehiem ti le cao nhat, tip khong biet hoa it gap

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F

Bdng 8. Do xam Idn cua u

T N

%

Tis 0 0

Tla 6 5,5

Tib 22 19,8

T2 58 52,3

T3 25 22,4

T4 0 0

Cgng 111 100

Nhdn xet:\J xam lan d miic do T2 ehiem ti le eao nhat,Tla it gap

Bdng 9.Di cdn hach, xam lan gan Di can hach: 22/111 trudng hgp, chilm 19,8%

Xam lin gan: 24/111 trudng hgp, ehilm 22,5%

Anh 1.Dang polip. Anh 2. Dang tham nhilm.

Anh 3.Dang polip, 2 polip. Dang sui loet.

nphylantda cd soi kem theo.

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Tap chi GAN MAT VIET NAM s6 15-2011 2 9

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%:

Anh 6.Ung thu bieu mo tuyen nhii. Anh 7.Ung thu tuyen biet hoa eao.

Anh 8,Ung thu bieu mo te bao nhd. Aiih 9.Ung thu bieu mo tuyen nhay.

Anh 10:M6 u xam lan gan. Anh 11: Mo u di can vao hach.

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4. Ban luan 4.1 T\i6i, gidi.

Trong ngien ciiu chung toi gap tuli thip nhit la 18, tuli cao nhit la 86,tuli trung binh la 62,3 ± 11,9 va nhan thiy ring benh eo xu hudng tang din theo tuli. CI tuli < 50 gap 15,2%, tuli 50-59 chilm 34,2% va d tuli > 60 chilm 50,6%. Dilu nay nhan thiy d ea nam va nu benh eiing tang din theo tuli (bangl). Theo nghien ciiu cua mot s l tac gia trong nude ung thu bilu mo tiii mat c6 tuli trung binh la 52 va 65 (7). Nghien ciiu cua cae tac gia nude ngoai tuli trung binh ciia benh nhan ung thu tiii mat la 72,2% eao hon d nude ta (14).

v l gidi: cac tac gia trong nude eiing nhu d nude ngoai deu nhan thay ung thu tiii mat gap d nil nhieu hon nam. Van Tan va Duong Van Hai nghien ciiu 113 benh nhan ung thu tiii mat c6 81 la nu (72%) va 32 nam (28%) (7), cac tac gia nude ngoai deu eo nhati xet ti le nu nhieu hon nam (8). Nghien ciiu cua chiing toi d 111 benh nhan ung thu tiii mat c6 70 benh nhan nii ehiem 63,1% va 41 benh nhan nam chilm 36,9%, ti le nu/ nam la 1,7/1. Nhu vay kit qua eiing tuong tu nhu eua cac gia tren la ung thu tiii mat gap d nir nhieu hon nam.

4.2 Vi triu, kich thir&c u:

-Vitri:

Nghien ciiu ciia Saavedra thiy gin 60%) ung thu d day tiii mat, 30% d than, 10% e l tiii mat va mot so it d thi lan toa toan tiii mat (13).

Mot nghien ciiu khac tren 734 trudng hgp ung thu bilu mo tiii mat gap d vung day 13%, than 17%,d cl tiii mat 13% va tip lan toa ehilm tdi 53%.Klt qua nghien ciiu eua chiing toi eo khac mot ehiit la u d vi tri than tui mat gap nhilu hon chilm 46,8%, tilp din la vung day tui m^t - 25,2%, eon d vung co va thi lan toa c6 ti le thip hon (14,5% va 13,5%).

-Kich thudc u:

Qua tham khao cac tai lieu chiing toi khong thay cac tac gia d l cap tdi kich thude cua u.

Trong nghien ciiu cua ehiing toi u nhd < 1cm chi gap 21 trudng hgp chilm 18,9% dieu nay cho thiy ung thu bilu mo tiii mat thudng dugc

chin doan muon. Nhung u eo kich thudc >1 va

y F t

<5em gap nhieu nhat vdi 67 trudng hgp ehiem ti le 65,8%. Nhung u Idn >5cm va lan toa toan tiii mat it hon nhung cung ehiem ti le dang kl -

F F

12,6%.U nho nhat 0,5cm, u Idn nhat 7,5cm ,kich thudc trung binh cua u la 2,72±l,35em.

4.3 Cdc tip dai the:

Denis. S phan ehia cae tip dai the thanh ba tip: tip dang polip, tip dang sui va dang tham nhiem. Dang polip bieu hien dudi dang khIi co cuong de rung, dang siii thudng eo eae nu sui d tren be mat niem mac, dang tham nhiem xam nhap thanh tiii mat lam thanh tiii mat day len co the gay ra hep d than hoac d day tiii mat. Dua

F

tren phan loai ciia Denis, trong so 111 trudng hgp ung thu bieu mo tui mat chiing toi gap dang sui nhieu nhat vdi 55 trudng hgp ehiem

F F >ud

49,5%, tiep den la dang tham nhiem 33 trudng

F F

hgp ehiem 29,8%, dang polip c6 ti le thao hon 23 trudng hgp ehiem 20,7%. Kit qua cua ehunh toi eiing tu vdi tac gia nude ngoai the sui ehiem tdi 70%.

Mot diem dae biet la trong nghien ciiu ciia ehiing toi gap 80,2%) ung thu tiii mat eo ket hgp vdi soi tiii mat va 66,3%) cd s l lugng soi >5

f F

Vien Mot so tac gia trong nude eiing cho thay ung thu tui mat cd soi kem theo chilm tren 70% (1,6). Nhieu nghien cuu cua eae tac gia nude ngoai cho thiy tren 80%) ung thu tiii mat cd kit hgp vdi sdi.Nhu vay soi mat dugc xem

F F 7

nhu la yeu to nguy co eao vdi ung thu bieu mo tiii mat. 6 nhung ngiidi cd soi tiii mat co ti le ung thu tui mat cao hon nhung ngudi khong bi

• f \ F

SOI mat. Quan diem cho rang cat tiii mat c6 soi la bien phap phong ung thu tiii m|,t la cd co so eua nd.

4.4 Cdc tip mo hoc vd dp mo hgc.

- Cac tip mo hgc: ap dung phan loai mo hgc eua TCYTTG nam 2000 (14) chung toi tiln hanh phan loai cac tip mo hgc, kit qua cho thiy ung thu bilu mo tuyin gap nhilu nhit vdi 70/111 trudng hgp chilm 63,1%, ung thu bilu mo tuyin nhii gap 18 trudng hgp chilm 16,2%.

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Tap chi GANMAT VIETNAM s6 15-2011 31

Cac tip khac cd ti le thip nhu img thu bilu mo tuyin vay 7,3 %o, ung thu bilu mo tuyin nhiy 6,2%, t l bao vay 4,5% va ehi co 2 trudng hgp la ung thu bilu mo t l bao nho ehhilm 1,8%.

F ^

Ket qua nay cung phu hgp vdi nhieu nghien cuu cua eae tac gia khac ung thu tiii mat tip bieu mo tuyen hay gap nhit chilm 67,9%) din tren 76% (9,13).

- Do mo hgc: dua tren tieu ehuan phan do biet hoa cua TCYTTG nam 2000 chiing toi thay rang ung thu bieu mo tui mat do biet hoa viia ehiem ti le cao 47,8%, sau do la biet h6a eao 45,9%, loai kem biet hoa va khong biet hoa ehiem ti le thip 4,5% va 1,8%. Tuong tu cac

F •>

tac gia khac cQng nhan thay ung thu bieu mo tiii mat chu yeu la loai biet hda cao va biet hoa viia.

4.5 Muc do xam lan vd di cdn.

/ F

-Miic do xam lan eua u: bang 3.8 cho thay u

F F

chu yeu d giai doan T2 ehiem 52,3%), tiic la u da xam nhap qua Idp eo ra den dudi thanh mac

F

va sau d6 la u d giai doan T3 ehiem 22,4%, u da vugt qua Idp thanh mac xam nhap true tiep vao gan hoac cae eo quan lan can nhu da day, dai trang,ta tuy, mac noi Idn, dudng mat ngoai gan.

U d giai doan Tla , mo u khu tru d niem mac, ha niem mac va u d giai doan Tib - mo u mdi 5. K i t luan.

5.1 Dai thi:

F

-Vi tri u hay gap nhat la than tui mat (46,8%), sau dd la vung day tiii mat (25,2%),viing co va the lan toa toan bg tiii mat chilm ti le thip hon (14,5 va 13,5%o).

-Kich thude u: lem< u <5em ehiem ti le eao(68,5%), sau do la u <lem (18,9%) va u

>5cm(12,6%).

9 F

- U the sui thudng gap hon ca (49,5%), tiep den la thi tham nhiem (29,8%), the polip it gap hon (20,7%).

5.2 Tip mo hpc, dp mo hgc, di cdn vd xam lan.

t r r

Tip mo hgc: ung thu bieu mo tuyen ehiem

xam nhap vao Idp eo ehiem ti le thap 5,5% va 19,8%.

Chiing toi khong gap u o giai doan T4 nghia la u xam nhap vao tmh mach cua hoac dong mach gan hoac vao nhieu co quan ngoai gan.

Mot so tac gia eiing c6 ti le tuong tu u d giai doan T2,T3 ehiem ti le eao hon ca.

-Di can hach , xam nhap gan.

Di can hach chiing toi gap 22/111 trudng hgp chilm ti le 19,8% , chu ylu la ung thu bieu

F F

mo tuyen biet hda viia va kem biet h6a. Thue te

F r F F X

so hach tim thay trong cat tiii mat la rat it, dieu nay cd the cho thay trong qua trinh phau thuat, phau thuat vien khong tim vet hach hoac la nhiing trudng hgp khong dugc chin doan trude mo la ung thu tiii mat.Theo mot sl tac gia chan doan ung thu tiii mat trudc m l khoang 10%o, eon lai 50- 75% dugc chan doan trong mo va sau m l va di can hach eiing ehi khoang 38%) (9). Xam nhap gan chiing toi gap 25 trudng hgp ehiem 22,5%.

Tim hieu moi lien quan giiia do biet h6a u va di can hach, xam nhap gan ,

chiing toi nhan thiy u biet hoa viia va thap, dae bi?t la loai khong biet hoa thudng eho di can hach va xam nhap gan cao hon loai c6 do biet hao cao.

ti le cao nhat (63,1%), tilp din la tuyin nhii (16,2%)), tip tuyen vay, tuyin nhiy, tip t l bao

F r F r

vay ehiem ti le thap, loai te bao nhd te bao sang hiem gap.

F

Do mo hgc: u chu yeu d do biet hoa viia (55,9%), sau do la biet hoa cao (36,9%), loai kem biet hoa va khong boet hoa chilm ti le

F

thap.

-Xam lan va di can: u chu ylu d giai doan T2 (52,3%), sau do la T3 (22,1%), Tla va Tib chilm ti le thip (5,5 va 19,8%)). Di can hach chilm 19,8%, xam nhap gan 22,5%'

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Tai Ueu tham khao.

1. Do Tuin Anh, Trin Dinh Tho, Doan Thanh Tung (1997). Ung thu tui mat, dii chilu lam sang tin thuong benh ly, sl 3 fr 27-35.

2. Truong Phu Hai (2008). Nghien ciiu d|c dilm lam sang, can lam sang, giai phiu benh ly va kit qua dilu fri phlu thuat ung thu tiii mat. Luan van tit nghiep Bac sy chuyen khoa II.Dai hgc Y Ha Noi.

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F

trong noi soi. Ngoai khoa, so 5, tr.37-43.

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108.

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F 1 ts)

(2005). Mot so dae diem dich te hgecua ung thu dudng mat. Tap chi Y hoc Viet Nam, chuyen de ung thu dudng mat. tr.

26-34.

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Oncology, Vol. 9, pi-4.

9. Kinjiro Sumiyoshi., Eshi Naga et al (1991). Pathology of carcinoma of the gallbladder. World J. Surg. 15, p.315- 317.

10. Kowalewski K. and Todd E. F.(1971).

Carcinoma of the gallbladder induced in hamstprs by insertion of cholesterol pel- lets and feelding dimethylnitrosamine.

Proc. Soc. Exp. Biol. Med., 136, p. 482- 486.

11. Nishihara K., Nagai E., Izumi Y. et al (1994). Adenosquamous carcinoma of gallbladder a clinicopathological immunohistochemical and flow-eytomet- ric study of twenty cases. Jmp. J. Cancer Res. 85, p. 389-399.

12. Roger L.F., Lastra M. P., Lin K.T., Ben- nett D. (1973). Calcifying mucinous adenocarcinoma of the gallbladder. Am. J.

gastro-enterol. 59, p 441- 445.

13. Saavedra J.A., Henson D.E., Klimstra S.D (2000). Tumor of the gallbladder, extrahepatic bille ducts and ampulla of Vater. Afip atlas of tumor pathology amer- ican registry of pathology, p. 51-169.

14. WHO histological classification of tumour of gallbladder and extrahepatic bile ducts (2000). In pathology and genet- ics of the tumour of the dygestive system.

Edited by Stanley R. Hamiton, Lauri A.

Aaltonen. lARCPress Lyon 2000, p 204-