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Tap cht Tai MOi Hong Vi$t Nam - Volume (60-25). N°1 - February, 2015
NGHIEN CUtJ IfNG DUNG VI PHAU THUAT THANH QUAN LASER C02 TRONG DIEU TRI UNG THlT THANH QUAN
GIAI DOAN SdM
LeMinh Ky\ Hodng Vu Giang*, Nguyin Tiin HUng**, Nguyen Quang Trung**, Tdng Xudn Thdng**, Nguyin Dinh PhUc**,
Vo Thanh Quang*, Trdn Thi Quang***
TOM TAT
Muc tieu : Ddnh gid hieu qua vi phdu thugt Ihanh qudn laser C02 trong diiu tri ung thu thanh qudn giai dogn sam. Doi tuang vd phuang phdp nghien cuu : nghien cim mo td tung truong hgp co can thiep. Bdi titmtg : 50 benh nhdn bi ung thu Ihanh qudn giai dogn Tl. T2, khong phdn biet tudi, gidi tinh dugc diiu tri bdng phdu thugt lu thdng 1.13 din thdng 5.14. Ket qud : 50 benh nhdn gdm 48 nam vd 2 nH, co 35 tru&ng hgp TlaNOMO, co 8 truong hgp TlbNOMO, cd 7 trucmg hgp T2N0M0; tdn thuang ddy thanh mot bin chua lan tdi mep trudc 29 truong hgp, cd 5 trudng hgp tdn thuang ddy thanh mot bin cd lan tai mep trudc, 7 trudng hgp tdn thuong ddy thanh hai ben co lan tdi mep trudc,4 trudng hgp CO tdn thuang lan din mep sau day thanh vd mdu thanh sun phiu, 5 truong hgp tdn thuang lan ra ngodi thanh mdn. Md khi qudn dugc tiin hdnh tren 10 trudng hgp chiim 20% trong do 6 trudng hgp cd khoi u lan ra mep sau, 4 trudng hgp do dien cdt rong. Kit qud ria vet cdt an todn tren 49 trudng hgp. Cd 2 trudng hgp ndo biin chung chdy mdu 16 md khi qudn. Kit luan : vi phdu thugt thanh qudn Laser C02 chung td budc ddu cd hieu qud trong dieu tri ung thu thanh qudn giai dogn sdm, benh nhdn trdnh dugc phdu thudt md, da sd trdnh dugc md khi qudn, hgu phdu nh? nhang, it biin chimg. Kit qud lau ddi cdn dugc theo doi Ihem.
SUMMARY
Objectives: To evaluate the primary results of C02 laser laryngeal microsurgery for laryngeal cancer at early stage. Methods : 50 patients with laryngeal cancer at Tl, T2 stage, age from 42 to 72, were treated by C02 laser laryngeal microsurgery, from jan.2013 to may.2014, at ENT National Hospital, Ha Noi. Results : There were 48 males and 2 females, 35 cases were at TlaNOMO stage, 8 cases TlbNOMO, 7 cases T2N0M0, the anterior commissure was involved in 5 cases, the two vocal cords were involved in 7 cases, the posterior commissure was involved in 4 cases. Tracheotomy was done in 10 cases (20%).
The marginal security was good in all cases, no severe complications such as haemorrhage, dispnea was noted. Gralunoma post-op was noted in 6 cases. One relapse in place was noted after 2 months and C02 laser laryngeal microsurgery was done again. Conclusion : C02 laser endoscopic surgery is initially effective and safe in the treatment of early glottic carcinoma not infiltrating the cartilaginous skeleton. The rate of tracheotomy was low. It could replace for open cordectomy 's operation in some indications.
' Benh vi§n Tai-Mui-Hpng Tnmg uong
" B6 m6n TMH- Tnrimg D^i hpc Y Wk Noi
Tap chi Tai l^ui Hong Viet Nam - Volume (60-25). N°1 - February. 2015
l.DATVANDE
Ddi vdi ung thu thanh quan giai doan sdm viec dilu tri phai dat duac muc dich loai bd khdi u nhung van giii lai duac chuc nang thanh quan. Chiic nang nay bao gdm ca chiic nang phat am va chiic nang nudt.
Sd dung tia xa va phdu thuat md c4t ban phSn thanh quan la cac phuong i)hap truyen thdng vSn duac ap dung trong dieu tri.
Nhd nhiing tiln bd ve cdng nghe laser trong nhfeig nam ghn day, phuang phap vi phau thuat ung thu thanh quan bing laser qua dudng mieng bat dau duac iing dung va ngay cang duac chap nhan nhu la phuang phap tri lieu cd hieu qua.
Nam 1967, Polanyi da thu laser C02 tren thanh quan ngudi chet, cho thAy kha nang gay thuang tdn it. Tii dd ngudi ta bat dSu nghien ciiu phat trien he thdng laser gan vao kinh hien vi. Nam 1972, Jako lan dau tiSn sir dung he thdng nay trSn tho.
Nam 1975 Strong Ian dau tien da bao cao 11 benh nhan giai doan Tl tang thanh mdn da duac phau thuat bang laser C02 dudi soi treo vi phau thuat[l]. Blakeslee va cdng su da sii dung laser C02 tren 68 benh nhan ung thu thanh quan giai doan Tl, ti le sdng sau 3 nam la 88%.
Nam 1978 Ossoff da su dung laser C02 phau thuat cho cac ung thu 1/3 giiia day thanh tren 25 benh nhan, 24 benh nhan van sdng sau 3 nam (96%)[2].
Ttr dd den nay, nhieu trung tam dieu tri benh ung thu thanh quan tren thi gidi da dua laser C02 vao phlu thuat ung thu thanh quan. Do Ipi ich cua phlu thuat biing laser C02 chinh xac, it lam tdn thuang, it phli ne td chiic ximg quanh, cd the gan vao kinh hien vi phau thuat dudi soi treo, ty le can phai md khi quan trong m6 thip, benh
nhan hdi phuc nhanh, chat lupng gipng t6t hon..., viec su dung laser C02 trong phSu thuat ung thu thanh quan ngay cang phi bien d cac nude tren the gidi.
Tuy nhien do phlu trudng hep, tia laser di thing, nen khd khan khi phlu thuat d cac ngach cua thanh quan, nhat la d viing mep trudc cua day thanh, ben canh dd laser C02 it cd tac dung cam mau nen ddi khi gay chay mau Iam khd khan trong khi md. Do dd viec danh gia vung cat an toan cho khoi u ddi khi khd khan hon so vdi phau thuat md, khdi u se bi tai phat tai ehd neu khong lay duoc het.
Vi vay, cho den nay van cdn m6t so ban luan ve cac chi dinh ciia phau thuat bang laser trong ung thu thanh quan, nMt la vSn de cd nen sir dung laser C02 phau thu|it cho cac khdi u da lan dSn mep trudc day thanh, cd nen chi dinh cho cac khoi u giai doan mudn hon T3 hay khdng? Laser cd thi thay the cho cac phau thuat md cat thanh quan ban phan truyen thong hay khdng?.... Day la nhiing van de cdn tiep tuc nghi6n ciiu.
Chiing tdi tiln hanh dl tM nghien ciiu ling dung laser C02 phau thuat ung thu thanh quan giai doan sdm nham budc dau danh gia hieu qua vi phlu thuat thanh qu^
laser C02 trong dilu tri ung thu thanh quan.
2. DOI TirONG VA PHLTONG PHAP NGHIEN C ^
2.1 Doi tirvng nghien ciru : 50 benh nhan bi ung thu thanh quan giai doan Tl, T2 dupc dilu tri phdu thuat tir thang 1/2013 din thang 5/2014.
-Tieu chuan lira chon:
Benh nhan duprc ch§n domi ung thu thanh quan, cd kit qua giai phlu benh la ung thu bieu md vay.
Tgp chi Tai IVIOi Hgng Vi$t Nam -Volume (60-25) N°1- February. 2015
Giai doan T1,T2N0M0.
Khdng phan biet mdi gidi.
Khdng bi benh ndi khoa man tinh nang, cd the gay me phlu thuat dupc.
2.2 Phirffng phap nghien cihi: nghien cuu tien Cliu, md ta tiing trudng hop cd can thiep.
3, KET QUA VA BAN LUAN 3.1 Tuoi va gidi
Benh nhan cd dp tudi tir 42 din 72, dp tudi gap nhieu nhat la tii 50-59. Nam gidi chi^m da sd cac trudng hap(48/50 trudng hpp). Dp tudi thudng gap ciia ung thu thanh quan phii hop vdi cac nghifin ciiu khac trong nude, day la dp tudi tich luy du lau cac yeu td nguy ca nhu thudc la, rupfu.
Khac vdi cac phlu thuat bao tdn md, ddi voi phau thuat bang laser cd the phau thuat duac cho cac benh nhan ldn tudi.
Trong nhdm nghien cuu nay, benh nhan ldn tudi nhat la 72.
3.2 Phan dp khoi u (T)
Tat ca benh nhan dupc phau thuat trong nhdm nghien ciiu nay deu d giai doan Tl, trong do chu yeu la giai doan Tia (37/50 trudng hpp).
Ty le ung thu thanh quan duac phau thuat tai BV tai Mm Hpng TU'(2004-2008) ddi vdi Tia va Tib la 7,4 v^ 13,7% ddi vdi
cac trudng hpp dupc phlu thuat[3].
Theo nghien ciiu ciia Rodel trSn 444 benh nhan phlu thuat bing laser C02 giai doan Tia cd 292 BN, giai doan Tib cd 50 Bn, giai doan T2a cd 102 BN[4].
That vay ddi vdi chiing tdi, budc dau nghien cuu, vdi kinh nghiem chua nhieu, trang thiet hi chua dly dii, chiing tdi chi gidi han chi dinh trong cac khoi u giai doan T2. Tuy nhien can than trpng timg budc de dam bao an toanve mat benh tich va ung thu hpc. Trong thdi gian tdi chung tdi se dan chi dinh rdng han cho mdt sd khdi u chon lpc d giai doan T2
3.3 Hirdng Ian khoi u
Trong nhdm nghien cuu cua chiing tdi, tdn thuang day thanh mdt bSn chua lan tdi mep trudc 29 trudng hpp, cd 12 trudng hap cd tdn thuong Ian den mep trudc day thanh trong dd : 5 trudng hap tdn thuong day thanh mot ben cd lan den mep trudc, 7 trudng hop tdn thuang day thanh hai ben cd lan den mep trudc; 4 trudng hpp cd tdn thuong lan den mep sau dSy thanh va mau thanh sun pheu, 5 trudng hpp tdn thuong lan ra ngoai thanh mdn.
Van de cd the iing dung laser C02 trong trudng hop ung thu lan den mep trudc day thanh cho den nay van cdn duac
Tap chi Tai Mui Hong Viet Nam - Volume (60-25). N°1- February. 2015
ban luan, cac phuang tien chan doan hinh anh vl dp lan sau cua u vao mep trudc nhu chup cat lop vi tinh, chup MRl deu khdng rd rang.
Chiing tdi chi dinh phlu thuat laser cat mep trudc day thanh khi tren phim CT ciing nhu MRl khdng cd hinh anh tham nhilm sun giap, nhung quan trpng nhat la dua vao kit qua soi thanh quan true tiep cd phdng dai dudi ndi soi.
3.4 Md khi quan
Md khi quan duoc tien hanh tren 10 trudng hpp chiem 20%, trong do co 4 trudng hpp khoi u lan den mep sau, 6 trudng hop do dien cat rdng.
Chiing tdi tien hanh md khi quan trong cac trudng hpp lan nhieu den mep sau vdi muc dich lam rdng rai phau trudng, ddng thdi tranh kha nang tia laser cd the ban vao Ing ndi khi quan. Cdn trudng hop thii 2 la khi dien cat qua rpng, kha nSng cd thi chay man sau md, md khi quan trong trudng hop nay cd tinh chat du phdng.
Cac trudng hpp md khi quan nay deu la tam thdi, chiing tdi deu nit duac canuyn an toan sau md.
3.5 Phu-omg phap ph3u thuat[5]
Phlu thuat cit co 1 day thanh don thuln chilm da sd cac trudng hpp : 15/25 trudng hpp.
Phlu thuSt type II cit 1 ben co day thanh va mep trudc chilm 7/25 trudng hop.
Phau thu^t cit 2 ben ca day thanh va mep trudc chilm 3/25 trudng hpp.
Ddi vdi khdi u lan vao mep sau day thanh, chiing tdi tiln hanh cit ra sau din hit mau thanh, tham chi cd thi cit hit 1 sun phlu.
3.6 Giai phau benh ly ria dien cat Trong tat ca cac trudng hpp, chiing toi deu lam giai phau benh ly ria dien cit tir 2- 4 mau, cd 1 trudng hpp ket qua ducmg tinh.
So sanh vdi ket qua nghien ciiu vl phau thuat ung thu thanh quan giai do?in Tl bang phau thuat md trong 50 trudng hpp, cd 3 trudng hpp ria dien cat duang tinh[6].
Ket qua nay chiing tdi cd the ndi tuong duong vdi phau thuat md cat day thanh theo dudng ngoai.
3.7 Theo ddi gan
Bien chiing : trong 50 trudng hgp phlu thuat chiing tdi gap 2 trudng hpp biln chiing chay mau Id md khi quan va khong gap trudng hgp nao chay mau dien cit sau md, day la bien chiing nguy hiem do chay mau vao dudng thd, nhat la khi benh nhSn khdng dugc md khi quan. Tuy nhien bien chiing nay khdng xay ra trong sd cac b?nh nhan nghien curu, budc dau cho thay tinh an toan cua phau thuat bang laser C02.
Td chiic hat phat trien d dien cat tren 14/50 ca, trong dd 2 ca phai cat lai td chiic hat, ket qua giai phlu benh ly lanh tinh.
Tai phat tai ehd 1 ca va phai phlu thu?t lai bang laser. Day la 1 trudng hpp da phau thuat cat u bang soi treo vi phau, sau do ket qua giai phau benh ly la ung thu. Chiing toi tien hanh cat lai bang laser, nhung cd thS da khdng kiem soat hit dien cit do kh6ng con xac dinh ro ranh gidi kh6i u.
3.8 Ket luan
Vi phau thuat thanh quan laser C02 chiing td budc dau cd hieu qua trong dieu trj ung thu thanh quan giai doan sdm. B?nh nhan tranh dupc phau thu|it md, hdu phau nhe nhang, da sd tranh dugc md khi quan, cd the thuc hien d benh nhan ldn tuoi, it
Tap chi Tai lUlui Hong Viel Nam - Volume (60-25). N°1- Febmary, 2015
bien chiing. Ket qua lau dai can dupc theo ddi them.
Cd the ndi day la each mang trong phlu thuat dieu tri ung thu thanh quan, chuyen tii phau thuSt md sang phau thuat kin.
1. Strong, M.S., Laser excision of carcinoma of the larynx.
Laryngoscope, 1975. 85(8): p. 1286-9.
2. Ossoff, R.H., G.A. Sisson, and S.M.
Shapshay, Endoscopic management of selected early vocal cord carcinoma.
Ann Otol Rhinol Laryngol, 1985. 94(6 Ptl):p. 560-4.
3. Nguyen Dinh Phiic Pham Thi Ku va cs, Ung thu thanh qudn vd hg hong : nhgn xet ldm sdng qua 58 benh nhdn dugc phdu thugt tir 1995-1998, in Ky yeu cdng trinh nghiin cicu khoa hoc
Hdi nghi Tai MUi Hong todn quoc 1999. 1999.
4. Rodel, R.M., et al.. Endoscopic laser surgery of early glottic cancer:
involvement of the anterior commissure. Head Neck, 2009. 31(5):
p. 583-92.
5. Remade, M., et al.. Endoscopic cordectomy. A proposal for a classification by the Working Committee, European Laryngological Society. Eur Arch Otorhinolaryngol, 2000.257(4): p. 227-31.
6. Pham Van Hiiu, Nghien cuu dgc diim ldm sdng, noi soi, kit qud dieu tri ung thu thanh qudn giai dogn sdm, Luan van tdt nghiep BSNT. 2008, Dai hpc Y Ha Npi.
