Y HOC VIET NAM THANG 3 - SO 1/2012
HIEU QUA GIAM KICH THVQC U Cff TRf/N TUT CUNG SAU CAN THIEP NOI MACH GAY TAC Q O N G MACH TUT CUNG
Le V a n Tru'dng*, £)6 Q u y e t * * , N g u y i n Van Ba,**
T O M TAT
Giam kich thiTdc u cd trdn tir cung ia mot trong nhiing tieu chi quan tipng danh gia hieu qua dieu tn ciia phu'Ong phap can thiep gay tac dpng mach tir cung, Nghien ciru tien hanh tren 100 benh nhan u cd trdn tir cung dUpc can thiep tac mach tai benh vien TWQD 108 va Benh vien 103 cCr thang 4/2003 den thang 10/2010. Ket qua nghien ciru ch9 thay: Ty le giam kich thu'dc va the tich u cd trdn tir cung trung binh sau 3 thang la 34.8 va 66,2%, sau 6 thang la 50.0 va 79.5%, sau 9 tliang la 55,5 va 83,7%, sau 12 thang la 69,1 va 86.6%. Co 25.9% bien mat hoan toan u cP tron tren sieu am sau 12 thang. U ca trdn tang sinh mach nhieu co ki'ch thUdc giam nhieu hon (37,9%
sau 3 tnang) so vdi nhiJng u cd trdn tang smh mach trung binh (giam 9,8% sau 3 thang), p < 0.05. U cd trdn nam trong thanh va dudi niem mac cung co mirc giam kich thu'dc sau 3 thang nhieu hdn dang ke (40.5%) so vdi cac u cd trdn nam dUdi thanh mac (9.7%), p<0.01.
Td /chda: U cd trdn tir cung, tac dpng mach tir cung, giam kich thu'dc.
SUMMARY
SIZE REDUCTION EFFECT OF UTERINE SMOOTH MUSCLE TUMOR POST UTERINE ARTERY
EMBOLIZATION
Reducing rhe size of smooth muscle tumors of the uterus is one of the important criteria evaluation of the effectiveness of uterine artery embolization (UAE).
Study was carried on 100 patients with utenne smooth muscle tumor was intravascular interventon by UAE in 108 military central hospital and 103 hospital from 4/2008 to 10/2010. The result showed that: rate of average size and 'volume reduction of the tumor after 3 months: 34.8% and 66.2%; after 6 months: 50.0 and 79.5%; 9 months: 56.5 and 83.7%; 12 months:
69.1 and 86.5%. 29,5% had no image of the tumor in ultrasound after 12 months. The tumor with much vascular proliferation more reduced in size (37.9% after 3 months) than vascular medium proliferation did (down 9.8% after 3 months), p<0.05. The tumor In the musculcir wall and mucosa also more decreased in size after 3 months significantly (40.5%) than the tumors underlying serosa (9.7%) did, p <0.01.
fCey words: uterine smooth muscle tumor, uterine arteiy embolization, size reduction.
I. OAT VAN £>E
Can thiep tac dong mach tir cung dieu trj u cd trdn tii cung (UCTTC) la phu'dng phap mdi ft xam nhap, dtrdc ap dyng rdng rai tren the gidi trong hdn 20 nam qua. 6 Viet Nam lieu phap mdi ap dung gan 10 nam, nhu'ng da the hien nhieu Lfu diem la ky thuat nhe nhang, an toan, hieu qua, bao ton du'dc tCr cung, mang iai chat lu'dng cudc sdng tdt hon cho ngu'di benh [1],
Hieu qua dieu tri ciia phu'dng phap du'dc the hien tren nhieu khfa canh: giam kich thu'dc u va tir cung, giam va het rdi loan kinh nguyet va trieu chiihg chen ep, cd thai va sinh de sau dieu tri.
Giam kich thu'dc UCTTC du'dc danh gia bang miic % giam du'dng ki'nh ldn ciia khdi u so vdi trtrdc dieu tri. MiTc giam kich thu'dc trung binh sau 6 thang dat td 40 - 6 9 % [2], [4], [6]. Cd the tfnh mirc giam the ti'ch UCTTC sau dieu trj thdng qua mirc giam du'dng kinh u, neu gia thiet UCTTC la hinh rau. Nhd giam kfch thu'dc cua u xd va toan bp t i i cung nen cac trieu chu'ng chen ep do khdi u gay nen cung giam dan, dat ty le 85-90% [3].
Nghien cu'u nay nham muc tieu danh gia hieu qua giam kfch thu'dc u cd trdn tiT cung sau can thiep ndi mach. Ket qua cua de tai la cd sd khoa hoc cho thay hieu qua ciia phu'dng phap trong dieu UCTTC.
II. oo'l TUONG VA PHUONG PHAP NGHIEN CUU 2 . 1 . £)dl tu'dng nghien cu'u
Tien hanh tren 100 benh nhan UCTTC du'dc dieu tri bang phu'dng phap tac mach tai benh vien TWQD 108 va Benh vien 103 tiy thang 4 nam 2008 den thang 10 nam 2010.
2.2. Phu'dng phap nghien cu'u 2.2.1. Thiet fee nghien cdu: Nghien cu'u md ta, cat ngang.
2.2.2. Ky thuat can thiep ngi mach - Vd cam: te tai cho, te tiiy sdng.
- Du'dng vao; OM diii phai hoac ca hai ben.
- Sii dung dng thdng 5Fr hay 3Fr.
- Chup dpng mach chau trong va dpng mach tLf cung chpn loc.
- Chat tac mach sir dung la PVA cd kfch thu'dc
* Benh vien 108, * * Benh vien 103; *** Hgc vien Quan y
Y HOC VIET NAM THANG 3 - SO 1/2012 355-500 am. Bdm tac mach du'dc thy'c hien dudi su'
kiem soat lien tyc tren man tang sang.
2.2.3. Theo doi dinh fey
Sau TDMTC, benh nhan du'dc kiem tra sieu am dinh ky 3 thang mdt lan trong vdng 1 nam de danh gia bien ddi kfch thu'dc UCTTC.
2.2.4. Cac chi tieu nghien cdu - Bien doi ki'ch ttiu'dc u: de danh gia dap iing cua khdi u thdng qua mu'c dp bien doi ki'ch thu'dc sau dieu tri, he thdng phudng phap mdi REQST da ap dung cong thu'c so do 1 chieu (unidimentional measurement) tCr nam 1999, thay vi 2 chieu (bldlmentlonal measurement) theo he thdng kinh dien ciia TCYTTG de xuat nam 1981.
% thay doi kich thu'dc khdi u = [( D l - D2) : D l ] X 100.
Trong dd: Dl la (tong) sd do du'dng kinh dai cua (cac) khdi u tru'dc dieu tn,
D2 la (tdng) sd do du'dng kfnh dai ciia (cac) khoi u sau dieu tn, dUdc xac dmh d cac thdi diem khac nhau trong qua trinh theo doi (3, 6, 9,12 thang),
Tuy theo cac gja tn do ma ta chia thanh ba loai dap irng ciia cac khdi u:
(1), Dap irng hoan toan: neu khoi u bien mat hoan toan,
(2), Dao irng mdt phan: neu khoi u giam diTcfng kinh > 25%.
(3). Khong dap irng: neu khoi u giam <25%
du'dng kfnh
- Bien ddi the tfch khdi u: UCTTC du'dc gia dinh !a hinh cau. The tfch bien ddi theo ty le lap phudng cua du'dng kfnh. Thdng qua mdc bien ddi du'dng kfnh chiing ta rut ra 6ddc miic bien ddi the tich u.
III. KET Q u A NGHIEN CCTU
3 . 1 . Bien doi kich thu'dc va t h e tich UCTTC sau dieu trj: Kfch thu'dc UCTTC trung binh tru'dc dieu tri la 5.8 cm, giam dan theo thdi gian vdi miTc giam dang ke, chi cdn 3.8 cm d thang t h i i ba, 3.0 cm d thang t h i i sau, 2.4 cm d thang t h i i chin va 1.9 cm d thang thiJ" mu'di hai sau dieu t n .
Bang 3.1. Giam kfch thu'dc va the tfch UCTTC sau dieu trf.
Cac tieu chi Kich thirdc UCTTC trung binh (cm)
% giam l<icli tfiirclc UCTTC
% qiam tlie ticli UGTC
Tri/drc dieu trj ( n = 1 0 0 ) 5.8±1.8
Sau 3 thang (n=S8) 3.8±1.6 34.8 (0-61) 66.2 (0-94)
Sau 6 thang (n=88)
a.oii.i
50.0 (0-73) 79.5 (0-98)
Sau 9 thang (n=74) 2.1±1.4 56.5 (0-75) 83.7 (0-98)
Sau 12thang
(n=57) 1.9±1.7 69.1 (0-100) 86.6 (0-100) Kiem dinh T vdi mau cap cho thay sd khac
biet ve kich thu'dc tai cac thdi diem sau dieu tri so vdi tru'dc dieu trj deu cd y nghTa vdi p < 0.01.
Xet ve ty le giam kich thu'dc va the tfch UCTTC sau dieu tri, chiing tdi nhan thay ty le giam du'dng kinh Idn cua khoi UCTTC dat 50%
(tu'dng du'dng giam 79.5% the tfch UCTTC) sau 6 thang va dat 6 9 . 1 % (tu'dng du'dng giam 86.6%
the tfch UCTTC) sau 12 thang.
3.2. Moi lien quan m o t so yeu to vdi mu'c do giam kich thu'dc.
3.2.1. Lien quan cua mdc do tang sinh mach UCTTC vdi mdc do giam fdch thu'dc sau diieu tri: Mirc dp giam kfch thu'dc ciia 86 benh nhan UCTTC tang sinh mach nhieu sau 3 thang dat tnjng binh 37.9%, trong khi dd ciia 12 benh nhan UCTTC tang sinh mach it chi dat 9.8%.
Hai gia trj nay d thdi diem 6 thang la 51.3% va 18.0%. Sif khac biet cd y nghTa thong ke vdi P<0.05 (kiem dinh ANOVA so sanh 2 so trung binh).
3.2.2. Lien quan cua vi tri UCTTC vdi mdc dp giam /dch thu'dc sau dieu trj.
Cac UCTTC du'di thanh mac cd miic gjam kich thu'dc sau 3 thang chi dat 9.7%, trong khi dd cac tru'dng hdp UCTTC trong thanh va du'di niem mac dat miic 40.5%. Hai gia tri nay d thdi diem 6 thang la 20.3% va 53.6%. Sd khac biet cd y nghTa thdng ke vd\ p < 0.01.
IV. BAN LUAN
De danh gia mu'c dp giam kfch thu'dc theo thdi gian, chiing tdi da theo doi bang sieu am tai cac thdi diem 3, 6, 9 va 12 thang sau tac mach, danh gia miTc do giam kich thu'dc theo ty le % so vdi tru'dc dieu tri. Kfch thu'dc UCTTC trung binh 5.8 cm (tru'dc dieu tri) da giam xuong cdn 3.8 cm sau 3 thang (giam 34.8% - dao dpng td 0 - 6 1 % tren 34 ca), cdn 3.0 cm sau 6 thang (giam 50% - dao ddng tir 0-73% tren 20 ca), cdn 2.4 cm sau 9 thang "(giam 56.5% - dao dpng tir 0-75% tren 13 ca) va cdn 1.9 cm sau 12 thang (giam 6 9 . 1 %
Y HOC VIET NAM THANG 3 - SO 1/2012 - dao ddng tir 0-100% tren 10 ca). Tfnh ty le
giam the tich u cd trdn (vdi gia dmh UCTTC hinh cau) theo ty le giam du'dng ki'nh, ket qua thu du'dc rat dang ke vdi 6 6 . 2 % sau 3 thang, 79.5%
sau 6 thang, 83,7% sau 9 thang va 86,6% sau 12 thang. Nhu' vay, tdc dd giam kfch thu'dc u cd trdn nhanh nhat trong 3 thang dau, nhu'ng van tiep tyc giam den het nam dau tien. Trong sd cac benh nhan theo doi tren 12 thang, chiing tdi kiem tra sieu am du'dc 57 tru'dng hdp, va thiiy rang UCTTC van cd the tiep tyc giam kich thu'dc den thang thir 15 - 18, xac nhan 23 ca (40,3%) bien mat hoan toan UCTTC (hinh 4,1). Oac biet cd 1 tru'dng hdp khdng giam ki'ch thu'dc sau 2 nam dieu trj, mac dii sieu am Doppler xac dinh tang sinh mach nhieu tru'dc dieu tri, theo ddi nhieu lan trong 24 thang thay rang UCTTC khdng
Hinh 4.1. Bien mat UCTTC sau dieu tri.
cdn mach mau, la 1 khdi dac, cd vien tang am bao quanh vdi dp day tang len theo thdi gian, nhu'ng hoan to^n khong thay ddi du'dng kfnh, mach TC hoan toan binh thu'dng va chu ky kinh nguyet khdng cd gi bat thu'dng (hinh 4.2).
Nghien ciru ciia Ravina tren 80 benh nhan cho thay sau 6 thang the tich UCTTC dat mirc giam 69% so vdi tru'dc dieu tri. Ket qua nay tu'dng du'dng vdi nhu'ng bao cao khac ciia Goodwin va CS.
la 64%. Nghien cifu ciia Spies JB. neu len miic giam the tfch UCTTC sau 12 thang la 78% [7]. Tac gia Hutchins va CS. tuy khdng dan chiTng miic giam kfch thu'dc UCTTC cu the, nhutig cdng bd ty (e het cac tneu chirng cd nang va thy'c the ciia khdi u chen ep (mass effect) sau 3 thang la 64%, sau 6 thang la 77% va sau 12 thang la 92% [3].
Tru'dcTDMTC. u cd trdn 4.1 cm, tang sinh mach. Sau 3 thang, u cd trdn 2.3 cm, vo mach
Sau 16 thana bien mat ucdtrdn, TC tra ve bmh thu'dng Cac nghien ciiu tren day danh gia bien dd'i
ve the tich, dy'a vao phan mem tfnh the tich ciia may cdng hu'dng tir. Nghien cifu ciia chung tdi dy'a vao ty le bien doi dij'dng kfnh ldn de suy ra ty le bien ddi the tfch, theo khuyen cao ve phu'dng phap do kich thu'dc 1 chieu (unidimension measurement cua he thdng REQST), da du'dc chu'ng minh la cd gia tri tu'dng du'dng. So lieu ve ty le bien doi the tfch bao gid
cung Idn hdn ty le bien doi du'dng kfnh theo he sd lap phu'dng, va cung chfnh sd lieu bien dd'i the tfch mdi phan anh het ban chat giam khdi lu'dng ciia UCTTC. Nghien ciTu ciia Spies va CS. [4] cho ket qua giam du'dng kfnh UCTTC sau 2 va 6 thang la 20 va 5 2 % ; ciia Laurent Brunereau va CS. [5]
sau 3, 6, 12 thang la 23, 43 va 5 1 % , tu'dng du'dng vdi ket qua cua chung tdi.
Y HOC VIET NAM THAHG 3 - SO 1/2012 Hinh 4.2. Khoi UCTTC khdng giam kfch thu'dc.
11. -^^s^msss^ss^^mz.
1. TrUdc dieu tn: u cd trdn 5.6 cm, tang sinh mach.
2. Sau 2 nam: u cd trdn khong giam ki'ch thu'dc, khong co mach, vo xd day bao q.uanh.
Ben canh viec danh gia chung cho ca nhdm nghien ciiu, chung toi da phan tich cac yeu to anh hu'dng den mu'c dp giam kfch thu'dc UCTTC sau dieu tri, nhan thay cac u cd trdn nam trong thanh va du'di niem mac cung cd mu'c giam kich thu'dc sau 3 thang nhieu hdn dang ke (40.5%) so vdi cac u cd trdn nam du'di thanh mac (9.7%), p < 0.01, (hinh 4.3). Chung tdi khdng tim du'dc cac thdng bao ve van de nay trong cac tai lieu khac. %d khac biet dd giiip chung ta ly'a chpn benh nhan tru'dc dieu tri va tien lu'dng sau dieu trj.
Hinh 4.3. MiTc giam kfch thu'dc khac nhau giCTa cac nhdm vj trf u cd trdn.
U cd trdn trong thanh, sau 6 thang g am dddng kmh 73 0%
V. KET LUAN
- Can thiep npi mach tac ddng mach tir cung la mpt phu'dng phap dieu tri u cd trdn tir cung khong md, co hieu qua. Ty le giam kich thu'dc va the tfch u cd trdn tir cung trung binh (lan lu'dt) sau 3 thang la 34.8 va 66.2%, sau 6 thang la 50.0 va 79.5%, sau 9 thang la 56.5 va 83.7%, sau 12 thang la 69.1 va 86,6%. Ty le bien mat hoan toan u cd trdn tren sieu am la 25.9% (14 trong 57 ca theo ddi > 12 thang).
- Kl'ch thu'dc u cd trdn tang sinh mach nhieu giam nhieu hdn (37.9% sau 3 thang) so vdi
nhUng u cd trdn tang sinh mach trung binh (giam 9,8% sau 3 thang), p < 0.05. U cd trdn nam trong thanh va du'di niem mac cilng cd miic giam kfch thu'dc sau 3 thang nhieu hdn dang ke (40.5%) so vdi cac u cd trdn nam du'di thanh mac (9.7%), p < 0.01.
TAI UEU THAM KHAO
1, Le'Van Tru'dng, Tran Ngpc Uyen (2004), "Bleu tn U xa td cung b^ng ptiuang phap tsc mach, phuang phap mdi khong mo - cO hoi lua chon hgp ly cho BN'. Tap chi thong tin y dUOc, sd 8/2004, Trang 14 - 17.'
Y HOC VIET NAM THANG 3 - SO 1/2012 Gary P. Siskin, Brian F. Stainken (2000),
"Outpatient uterine artery embolization for symptomatic utenne fibroids: experience in 19 patients", .lournal of vascular interventional radiology 11, pp. 305-311.
Hutchins FL Jr, Worthington-Kirsch R, Berkovtfitz RP. (1999), 'Selective uterine embolization for symptomatic leiomyomata uten".
Journal of Amencan Association in gynecological laparoscopy 6(3), pp, 279-284.
Jean-Pierre Pelage, Olivier Le Dref, Philippe Soyer (2000), "Fibroid-related menorrhagia:
treatment with superselective embolization of the utenne arteries and midterm follow-up". Radiology 215, pp. 428-431.5. Laurent Brunereau, Denis
Herbreteau, Sophie Gallas (2000), "Utenne atery embolization in the primary treatment of leiomyomas: technical features and prospective follow-up with clinical and sonographic examinations in 58 patients", American Journal of Radiology 175/pp. 1267-1272.
Ravina JH, Bouret ] M , Herbreteau D. (1997),
"Recount tu parHojIar adenal embolization In treatment of some utenne leiomyoma". Bull Acad Natl Med 181(2), pp. 233-243.
Spies JB, Sicalli AR (1999), "Initial results fmm uterine fibroid embolization for symptomatic leiomyomata", Journal of vascular interventional radiology 10(9), pp,1149-1157.
NGHIEM Ciinj TiNH TRANG XUAT HUYET DO GIAM TIEU CAU aBENHNHANLOXEMi CAP DONG TUY
Du'dng Doan Thien ( * ) , N g u y i n Ha Thanh (*
TOM T A T
Dat van de: Xuat huyet la mot bieu hien lam sang thu'dng gap va co y nghla tien lucfng trong IcJxemi cap dong tiiy, nguyen nhan chii yeu la do giam so lUdng tieu cau. Myc tieu: Danh gia tinh trang xuat huyet (chii yeu do giam tieu cau) d benh nhan lOxemi cap dong tity, Ooi tu'dng va phu'dng phap: nghien ciru mo ta tren 58 benh nhan Idxemi cap ddng tiiy dieu tn tai vien Huyet Hoc - Truyen Mau trung ircJng (Vien HH-TM Tl/) tif 1/2010 - 10/2010. Ket qua: Hau het benh nhan giam so iLTdng tieu cau (92,8%). Ty le xuat huyet do giam tieu cau 6 cac benh nhan Icfxemi cap dong tuy la 74,1%. Trong dd the M3 c6 ty le xuat huyet cao nhiit (100%), tiep den la cac the Ml (85,7%), M4 (81,8%), M2 (80,0%); thap nhat la the M6 (33,3%), Xuat huyet du'di da chiem ty le cao nhat (63,8%), CO 24,6% so benh nhan xuat huyet noi tang;
20,3% so benh nhan xuat huyet ca dUdi da va noi tang; miTc do xuat huyet phu thuoc vao mirc do giam tieu rau. Ket luan: Xuat huyet do giam tieu rau la mgt bieu hien thirdng gap trcing lOxemi cap dong tuy va mu'c do xuat huy^: phu thupc vao miic do giam sd lUdng tieu cau.
Tij' khoa: Idxemi cap ddng tiiy, xuat huyet do giam tieu cau
SUMMARY
STUDY OF THROMBOCYTOPENIC PURPURA IN ACUTE MYELOID LEUKEMIA Background; bleeding is a common clinical symptom of acute myeloid leukemia (AML) and has
prognostic significance. Mam cause of bleeding is thrombocytopenia. Purpose: To assess the situation with bleeding symptom (mainly thrombocytopenic purpura) m AML patients. Patients and methods:
descriptive study of 58 patients with AML treated in National Institute of Hematology and Blood Transfusion from 1/2010 to 10/2010. Results: Most patients have reduced piatelet count (92.8%). Overall percentage of thrombocytopenic purpura m AML is 74.1%, from which the M3 subtype has highest bleeding percentage (100%), following by subtypes Ml (85.7%), M4 (8.,8%), M2 (80.0%); M6 is the subtype with lowest bleeding rate (33,3%). Most common form of bleeding is subcutaneous purpura (63.8%); 24.6% patients has internal organ bleeding;
20.3% patients has both subcutaneous and organ bleeding; seventy of bleeding symptom correlates with severity of piatelet count decrease. Conclusion:
thrombocytopenic purpura is a common clinical symptom of AML and severity of bleeding symptom correlates with severity of platelet count decrease.
I.
DAT V A No f
Xuat huyet la mot trong nhu'ng trieu chu'ng dien hinh cua benh Idxemi cap dong tiiy. Xuat huyet cd the xay ra d nhieu vj t r i vdi cac mu'c do khac nhau, co nhii'ng tru'dng hdp roi loan nang do xuat huyet nao, xuat huyet du'dng tieu hda cd the lam benh nhan tir vong. Do dd bieu hien xuat huyet va miic dp giam tieu cau cdn la (*) Vien Huyet hoc - Truyen mau Trung i/cfng
(**) Bo mon Huyet hoc - Truyen mau - Dai hoc Y Ha Noi Phan bien khoa hgc: PGS.TS. Bach Khanh Hoa 38