JOURNALOFIOS-CLINICALMEDICINEANDPHARIVIACY Voi.ll -N"4/2016
Ket qua dilu tri ung thir ti bao day vung mui bang piiiu tliuat Molis tai Benli vien Da lieu Trung uong
Treatment of basal cell cancer in the nose by Mohs surgery at the National Hospital of Dermatology - Venereology
Nguyen Hmi Sau, Nguyin Phmmg Hoa Tnrang Bgi hoc YHa Ndi
Muc tl^u: Oanh gia ket qua dieu tri ung t h u te bao day vung mui bang phau t h u l t iVlohs tai Benh vien Da lieu Trung Udng tCr 1/2010 den 9/2015. Bdi tuang vd phuong phdp: 54 benh nhan mac ung thu te bao day vCing mui dUdc phau thuat IVlohs theo quy trinh sau khi da duoc h6i chan. Ket q u i danh g i i dua vao so Idp cat Mohs, tao hinh phu tdn khuydt va sir tai phat sau phau t h u a t Ket qud: Co 53,7% benh nhan het t6 chC^c ung t h u sau 1 lan cit, 35,2% c i t 2 t i n va 11,1 % b^nh nhan sau 3 lan. Do s l u khuyet den Idp md d vung song mui/sudn mui chiem 11,1%; d canh mui la 3,7%. Trong so khuyet s l u den x u d n g / sun chiem 40,7%. Co 90,7% ton khuyet dUdc tao hinh bang vat da tai cho, 9,3% trUdng hdp g h ^ p da. Tl l§ tai phat la 3,7%. Ket lugn: Dieu t n ung t h u te bao d l y vung mui bang phau thuat IVlohs co t l le t i i p h l t t h i p , tiet kiem dUdc to chdc da lanh xung quanh tii do CO the phu ton khuyet bang vat tai cho de d i n g .
TUkhda: Ung t h u t ^ bao d l y , ung thU da, phau t h u l t IVlohs.
Summary
Objective: Evaluate the results of treatment for nasal basal cell carcinoma (BCC) by IVlohs surgery at the National Hospital of Dermatology - Venereology from 1/9/2010 to 2015. Subject and method: 54 patients w/ith BCC of the nose were treated by Mohs surgery. Results wrere accessed by layers o f Mohs, the reconstmction of the defects and recurrence rate after surgery Mohs. Result: 53.7% BCC was completely removed after one cutting, 35.2% after the second cutting and 11.1 % after the third time. The depth to the fat layer defects in nose slopes accounted for 11.1%; 3.7% In nose wing. The depth to bone/cartilage defects was 40.7%. 90.7% loss skin area was recontructed by local flap, 9.3% by skin graft. Relapse rate of BCC was 3.7%. Conclusion: Mohs surgery should be the treatment of choice for nasal basal cell carcinomas because of low recurrence rate and saving healthy surrounding tissue so that t h e defects could be easily reconstructed by local flaps.
Keywords: Basal cell carcinoma, skin cancer, Mohs surgery.
1 . C a t v i n ai dac biet v i i n g canh m u i va dau m u i [9]. Benh thudng Ung t h u te' bao day (Basal cell carcinoma) <;^'"'rien cham.^co t h « xam lan t d chdc x u n g quanh t h u d n g gap d vung da hd, noi tie'p xiic vdi anh sang L'" " ^ " ^ " ^ ' * ' ^""^ ^'^^ ' ° " " ^ ' ™ '^"^ " ' "
mat trdi, n h u da v u n g dau - mat - c6 (chiem t d i 70% - ='?"S - " " ' • ^ n h h u d n g t h a m my va r6i loan chiic ), t r o n g d d viing mui la hay gap n h j t (25% - 30%) nang ciia mOi [7].
Cd n h i l u p h u o n g p h i p dieu trj khac nhau co t h e I p d u n g d ^ dieu trj u n g t h u t e bao d l y ndi Phan bi?n khoa hoc: PGS.TS. DANG VAN EM chung. Bdi vdi viing mui, phau thult Mohs 112
TAP CHi Y DUOC L A M SANG 108 Tap 11-564/2016
(micrographic surgery) la phUcmg phap eho k ^ t q u a dieu trj tdt, vdi t^ le tai phat thap [4], [6], giiip cho viec tiec kiem tdi da t o ehdc da lanh xung quanh, tao di^u kien t d t cho viec tao hlnh phCi ton khuydt. Cho d^n nay d Viet Nam, phau thuat Mohs mdi chi duge tien hanh d Benh vien Da lieu Trung ucmg va van chiia co mot cong trinh nao danh gia ket q u i di^u tri ung t h d t e bao day vung mui bang phau thuat Mohs.
2. Doi tUtfng va phiftfng phap
Nghien cdu t i ^ n eiJu theo doi doc tren 54 benh nhan dUde ehan doan mSc ung t h u te bao day v u n g miji dua vao lam sang va xet nghiem mo benh hoc, tai Benh vien Da lieu Trung Udng td 1/2010 den 3. Ket qua
9/2015. Benh nhan d u o c ISm b e n h an, kham lam sang vh lam xet n g h i e m m o b e n h hpc. Benh nhan dugc phSu t h u ^ t Mohs t h e o d d n g quy t r i n h sau khi da ducfc hpi chan. Ket qua dUcfc danh gia dUa t h e o vao sd Idp eat Mohs, lien quan giijra sd Idp e l t Mohs vdi t h e m o benh hoc va t h e l^m sang, lien q u a n dau hiSu loet va so Idp c i t Mohs, phan bo ty' 1^ g h e p da ~ sd d u n g vat tai cho de tao hlnh sau Mohs va sU tai phat sau p h l u t h u $ t Mohs. So lieu dUpc phan tfch trdn phan m e m SPSS 16.0. Cac t h o n g t i n cOa b e n h nhan t r o n g qua t r i n h nghien cdu dupe giu" bi mat va ma hoa tren may vi t i n h t r o n g qua t r i n h xCf ly s6 l i ^ u , dam b i o khong Ip t h o n g t i n .
Bang 1 . Lien quan the m d benh hoc va so Icrp phau t h u a t Mohs
The mo b@nh hoc
The u Idn The u nho T h i x d The Adenoid Th^ hon hop - xam nhap
Tdng
So ldp phau thudt Mohs 1
n 18 5 2 4 0 29
%
33,3 9,3 3,7 7,4 0,0 53,7
2 n 12 2 1 2 2 19
%
22,2 3,7 1,9 3,7 3,7 35,2
£ 3 n 3 2 1 0 0 6
%
5,6 3,7 1,9 0,0 0,0 11,1
Tong n 33 9 4 6 2 54
%
61,1 16,7 7,4 11,1 3,7 100
Nhdn xit: Trong so 54 ung t h U te bao day v u n g mui, the u t h u d n g gap nhat (77,8% t r o n g d o 6 1 , 1 % t h ^ u Idn va 16,7% t h ^ u nh6). Co 53,7% benh nhan
phau t h u a t Mohs 1 lan, 35,2% phau t h u i t 2 lan va 11,1% benh n h i n can eat lan t h d 3 m d i h€t t 6 chdc ung t h u .
BSng 2 . D o sau khuyet sau phau t h u a t va phdn bo v| trf ung t h u t e bao day v u n g mui
Vjtrf
Sdng mui - sudn mui Bau m u i - g d e mill Tru mui Canh mui
Tdng
06 sau khuyet ton thUcmg MS
n ( % ) 6(11,1%)
4 (7,4%) 1 (1,9%) 2 (3,7%) 13(24,1%)
Caned n ( % ) 1 (1,9%) 1 (1,9%) 0 (0%) 5 (9,3%) 7113%)
CO n ( % ) 4(7,4%)
0(0%)
Xlfdng - sun n ( % ) 3 (5,6%) 2 (3,7%) 0 (0%) 1 2 (3,7%) 8(14,8%) 15(27,8%) 12(22,2%) 1 22(40,7%)
TSng n ( % ) 14(25,9%) 7(13,0%) 3 (5,6%) 30 (55,5%) 54(100%)
JOURNAL OF 108 - CUNICAL MEDICINE AND PHARMACY Vol.11-N°4/2016
Nhdn xit: D o s l u khuyet den l d p m d 6 vOng song m u i / sUdn m u i chiem 11,1%; t ^ \i nay d c i n h m u i chi la 3,7%. Trong so khuyet s l u den x d o n g / sun chiem t ^ le rat cao: 40,7%.
B i n g 3. Sir phSn bo t y l i ghep da - sA dung v a t t a i cho sau phau t h u a t Mohs PhUdng phap tao hinh
Ghep da Vattaicho
Tdng
SolifOng 5 49 54
%
9,3 90,7 100
Nhdn xet. Sau phau t h u i t Mohs, 90,7% t o n khuyet dUpc tao hlnh bang vat da tai cho. S6 t o n khuyet phai ghep da chi chi^m 9,3%.
Bang 4 . T^ I f tai phat sau phau thuat Mohs Tai phat
Co Khong
Tong
SdlUtfng 2 52 54
%
3,7 96,3 100 Nhdn xit Trong so 54 trudng h p p phau thuat Mohs CO 2 trUdng hpp tai p h i t chiem ty le 3,7%.
4 . Ban luan
Phau t h u a t Mohs la m o t p h u o n g phap dieu trj hien dai, dang dUpc nghien eUu tri^n khai d m o t so nUdc tien tien. Ky t h u i t da tao ra dupe budc d o t pha t r o n g dieu t n ung t h u da, giup cho phSu t h u a t vien x i e ^ n h ngay dupc vl$c loai b o het dupc t o chufc ung t h u t r o n g qua t r i n h p h i u thuat, t l ^ t kiem dUpc t o chdc da l i n h xung quanh khoi u va giam toi da mu'c dp t i i phat ciJa benh. Ket q u i p h i n tich trong nghien c i ^ ei^a ehCing toi eho th^y t r o n g so 54 trUdng h p p nay co 29 t r u d n g h p p ehi can phau t h u a t 1 Idp Mohs, chiem 53,7% ( b i n g 1). So t r u d n g h p p p h i i p h l u thuat t i ^ 2 Idp Mohs t r d len la 46,3%. Theo Pham Cao Kiem t r o n g m o t nghien cUu ve ket q u i phau t h u i t Mohs vdi ung t h u te bao d i y , nhCfng t r u d n g h p p can tU 2 ldp Mohs t r d len chi gap 6 v u n g mui, m o i , m i ; trohg~do~mui co 7 trUdng h p p t h i eo t d i 5 t r u d n g h p p phai p h l u t h u i t tren 2 Idp Mohs (71,43%) [8]. Day la mot sukhac biet Idn eo y nghTa the hien su xam lan s i u va rpng cua ton t h u o n g ung t h u vung mui. Dieu nay cung phu h c ^ vdi nghien cdu eCia
Paoli J va e6ng sU khi hoi edfu 587 trUdng h p p ung thu t e bao day co tinh xam lan, vi t r i v i i n g ehuf H, tii 1993 d ^ n 2003 tai Khoa Da lieu Benh vien Oai hpc Salgrenska, Thuy Dien eho ket qua 87,9% nhOfng khdi u nay can (t nhat 2 Idfp phau t h u a t Mohs [5].
Khi dat van de v ^ d p s i u cOa khuyet t d n t h u w i g chOng t 6 i g h i nhan d p sau khuyet den Idp m d cf v u n g s6ng m u i / sudn m u i ehiem 11,1%; t y le nay d e i n h m u i chi la 3,7%, khuyet sau d ^ n xuang/ sun c h i ^ m t ^ le reit cao (40,7%). D i l u n i y cho thay so vdi cac v| tri k h i c , cau true vDng m u i rat de bj k h u y i t t h i e u , kho phuc hoi.
Trong so lieu cua chOng t o i , sau phau thuat Mohs, 90,7% t o n khuyet dUpc tao hlnh bang vat da tai cho. So t o n khuyet phSi g h I p da ehl ehlem 9,3%.
So lieu nay t h e hien Uu t h e cCia p h l u t h u i t Mohs t r o n g viec tao t i e n di t h u i n lpi cho tao hlnh. Mac du g h e p da la m o t phUcfng p h a p tao hinh dPn g i i n nhUng xet ve t h a m m y t h i it dugc ua ehuong do m a u da g h e p sau nay khac b i l t vdi mau da nen cilia v u n g phau t h u a t va t o chiifc x u n g quanh de bj co keo. Oieu nay dac biet can chO t r p n g d m d t dPn vj g i i i phau can t i n h t h a m m y cao nhU vOng mui. Qua t h u e t e p h o n g van b e n h nhan va quan sat k h i m lai seo m d vdi nhUng b e n h n h a n t r o n g n h o m phau t h u a t Mohs, hdn 8 0 % b i n h nhan hoan t o i n h i i Idng vdi k i t qua t h a m m y sau m 6 : Khong bj co keo seo va m i u sac v u n g da sau tao h i n h tUPng d o n g vdi vCing da x u n g q u a n h . NhOng b i n h nhan co m a u sac da va seo con Ip rd da sd la nhOng b e n h nhan m d i phau t h u a t , sU hinh t h a n h o n d m h seo chUa hoan toan.
Trong sd cae benh nhan n h o m phau t h u i t Mohs CO 2 benh nhan t i l phat, c h i e m tJ' I I 3,7%, c i 2 t r u 6 n g h p p n i y deu eo t h i m o b e n h hoc la the u, m o t t h e mo b e n h hpc n g u y c d x a m lan thap. Hai t r u d n g h p p b e n h nhan tai phat nay x u a t hien lai t6n thUPng lan lupt sau 2 nam va 3 n a m , m o i benh nhan deu da dugc phau t h u i t lai 1 lan va k h i m hien tai chua phat h i l n thay t 6 n thUPng t i i phat. Cac trUdng h p p benh nhan sau phau t h u a t Mohs deu cdn s6ng>
ehi CO 2 t r u d n g h p p da tiJ v o n g d o t u 6 i gia. Oieu nay chUng t 6 ung t h U t e b i o day c6 tien lUpng t o t v i it i n h h u d n g den t i n h m a n g cCia n g u d i b i n h . Oa s6 cac nghien edu deu dUa ra ty* le tai p h i t cua phau t h u a t Mohs t h a p hcfn so vdi p h l u t h u a t cat r i n g
TAP CHIY Dl/OC U M SANG 108 T a p l l - S o 4 / 2 0 1 6
t h o n g t h u d n g : Theo s6 lieu Van Loo E v i cong sU theo doi tai phat sau 5 nam cua ung t h u da sau Mohs 4,4% [10].
Yeu eau t i l n q u y e t cua m o t l i t e i t Mohs la manh m o d6 p h i i co t i n h l i l n tuc. Oieu nay l i kho ngay ca khi phau t h u a t d u p c tien hanh tren nhOfng vj tri giai phau t u o ^ g ddi b i n g phang hdn nhU ma, tran. Trong khi d o m u i lai la d o n vi giai phau co cac Idp t o chdc m o n g manh ( n h u song m u i , sudn mui) hoac XP chac (nhU e i n h mui) v i lai khong n i m t r l n eung m i t mat phang dan t d i kho d i m bao dp l i l n OJC cua manh c i t . Campell T. va cong sU da thUc hien m o t nghien edu khao sat m o i lien quan giUa ky thuat cOa phau t h u a t vien va chat lUpng cua t i l u ban vdi su t i i p h i t cCia khoi u sau phau t h u a t Mohs vc^ cd mau la 6208 t o n thUPng ung t h U da tai Oai hpc California. Hp dUa vao kiem d i n h cac yeu t o ; Sai sot ky thuat cOa phau t h u a t v i l n , sU h o n g / rach cOa manh mau, t h e mo benh hpc cua khoi u, va hp dUa ra ket l u i n day cung la 3 yeu t d quan t r p n g nhat dan den su t i i p h i t cua khoi u [2]. Hruza thUe h i l n phau thuat Mohs eho 2414 benh n h i n ung thU da cung ket luan rang 75% t i l p h i t la d o loi ky t h u a t bao gom: Ope tieu ban sai (25%), 1 ^ t h u i t labo sai (40%), that bai t r o n g v i l e lay hoan t o a n phan eon lai cCia khoi u ehi ehiem 10% [8].
Hon nOa, tac gia Van Loo E va cong su da t i l n hanh mot nghien cdu keo dai tu" t h i n g 10/1999 den t h i n g 2/2002 tai H i Lan vdi 408 t o n thUPng ung t h U te b i o day v u n g mat eo nguy co cao (vi tri v u n g chiJ H, mo benh hpc co t i n h xam lan). Ket q u i eho t h ^ y t y le t i i phat sau 5 nam la 56% vdi t o n t h u o n g u n g t h U te b i o day t i e n p h i t [10]. I'y le nay dac biet eao d i nhan manh rang ung t h u t i bao day eo nguy cP cao can thdi gian theo ddi lau d i i hem la chi t h e o doi trong 5 nam.
S . K ^ t l u a n
Nghien eUu ket qua phau t h u i t Mohs t r l n 54 benh nhan mac ung t h U t I bao day vung mui tCr 1/2010 den 9/2015, chung toi rdt ra m o t so k i t luan sau:
Co 53,7% b e n h nhan p h l u t h u a t Mohs 1 lan, 35,2% p h l u t h u a t 2 lan va 11,1% benh nhan can eat lan thO 3 m d i h i t t o chUc ung thU.
Cac k h u y i t t o n thUOng sau phau t h u i t Mohs t h u d n g s i u t d i xUOng/ sun t u y n h i l n t ^ le tao h i n h b a n g vat t o chUc tai ch5 rat cao (91,8%).
90,7% t o n khuyet dupe tao hinh bang vat da tai ch6. Sd ton Idiuyet p h i i ghep da chi c h i l m 93%..
Ty le tai p h i t sau phau thuat Mohs thap (3,7%).
Tai l i e u t h a m k h a o
1. Batra RSI, Kelley LC (2002) Predictors of extensive subclinical spread in nonmelanoma skin cancer treated with Mohs micrographic surgery. Arch Dermatol 138(8): 1043-1051.
2. Campell T, Armstrong AW, Schupp CW et al (2013) Surgeon error and slide quality during Mohs microghraphic surgery: is ^ere a relationship w/tft tumor recurrence?. J Am Acad Demriatol 69(1): 105-111.
3. Duriye Deniz Demirseren, Candemir Ceran, Berrak Aksam et al (2014) Basal Cell Carcinoma of the Head and Neck Region-A Retrospective Analysis of Completely Excised 331 Cases. Jounal of skin cancer.
4. Galimberti G, Ponton Montano A, Ferrario D et al (2010) Mohs micrograhpic surgery for the treatment of basal cell carcinoma. Actas Dermosifiliogr 101(10): 853-857.
5. John Paoli, Samuel Daryoni, Ann-Marie Wennberg et al (2011) S^fear recurrence rates of Mohs Micrograhpic surgery for aggresive and recurrent facial basal cell cardnoma. Acta Derm Venereol 91:689-693.
6. Li H, Yang SX va Wang B (2006) Study on cases of nasal tumor treated by dermatologic surgery:
analysis of 63 eases. Bejing Da Xue Xue Bao 38(5):
519-521.
7. Mohammed F, Solish N, Murray CA (2011) A challenging case of multiply recurrent nasal basal cell carcinoma. J Cutan Med Surg 15(5).
8. Pham Cao Kiem (2007) BUde ddu ddnh gid hieu qud dieu tri ung thu te bdo ddy d vung mat bdng phau thudt Mohs. Luan van thae sy Y hoc. TrUdng Oai h p c Y H a N d L
9. Uwe Wollina, Annett Bennewitz and Dana Langner (2014) Basal Cell Carcinoma of the Outer Nose:
Ovenriew on Surgical Techniques and Analysis of 312 Patients. J Cutan Aesthet Surg 7(3).
10. Van Loo E, Mosterd K, Krekels GA et al (2014) Surgical excision versus Mohs' micrographic surgery for basal cell carcinoma of the face: A randomised clinical trial with lOyear follow-up. Eur J Cancer.
