Tap chl Tai MOI Hpng Vijt Nam -Volume (58-16). N°4- June, 2013
DO! CHIEU T 6 N T H U O N G TREN CT vOl LAM SANG CUA UNG THU" MUI XOANG
Phung Quang Tuan **, Li Cong Bjnh *, Nguyen Dinh Phuc' T6M TAT
Ung thu mui xoang gap khong nhiiu. nhung kho de quyil dinh phuong phap chan doan scrm, CT scan c6 gia Iri quyet dinh phuong phap mo va lien lufmg. Muc tieu: 1) Mo Id chdn dodn CT. 2) D6i chiiu CT va lam sang Boi tu^tg ,PPNC: Nghien cim timg truang hap tren 38 UTMX( 2007-200). Chdn dodn lam sang CT, MBH, HMMD. Kit qua.Tudigap nhiiu a>40-60 (55.27%), ly le narn/nH Id 1,52/1. So sdnh vai CT: c6 biiu hien tren Idm sang Huang Ian vdo trong co 86.95%, Ian ra ngoai 70%, Ian rci Irudc 75%
Ian len tren 50%. Dac biet la huong Ian ra sau chi co 1/3 benh nhdn co bieu hien trieu chung tren Idm sang. Chi co CT Scanner cho phep danh gia hu&n^ Ian Iran sdu vdo day so, ndo. Kit luan: CT Scanner rdl co gid tri danh gia chinh xac ton thuang khi con nho, hay a sdu, Ian tran ddy so.
Tir khoa: Ung thu miji xoang, CT scan.
SUMMARY
In cancer naso-sinusal, CT is used to deled a tumor, provide information about the extent of the disease, help plan treatment. Ojective : The description a lesion on the CT scan and compare with the clinical of the naso-sinusal cancer. Materials and Methods:
Case study of 38 patients operateds at Hospital ENT central (2007-2009). Diagnostic clinical, CT scan (and contrast given), histopathologics of HE, PAS and immuno- hislopathologic. Results and discussions: The advantages of CT is provide information about the extent of the base cranial and brain. The direction of the extent on the clinical is di sanguis only : the inner 86,95%o. in front 75%. outside 70%, upper 50%,behind 33%.
Conclusion is used to detect a tumor, provide information about the extent of the disease.
Key words: naso-sinusal carcinoma. CT scan.
1. DAT VAN D E ^^'- ^ ^ ' ' W ^^ ^'^^ "^^8 vimg mat thi benh nhan mai di kham \a chan doan dupe.
Ung thu mui chi chiem khoang 0,2- u,i \^ tran len day sp phai co chin doan 0,8% tong so cac ung thu, va khoang 3% |,inh anh mai co thi xac dinh chinh xac. DS cac ung thu viing dau co [7]. Trieu chiing ,^1 " B Q I CHIEU TON THUONG TREN lam sang kin , tham lang, bi che day nhu cT Vdl LAM SANG CUA UNG THU cac viem mui xoang thong thuang, it di can ^ U I XOANG" n h t a vao 2 muc tieu: 1) hach CO. Chi o giai doan da Ian rpng vao ^^ ,g ^^ jii„, ,S„ thuang tren CT, 2) B6i
chiiu tdn thuang tren CT vdi Idm sang, de
*Tniong DHY Ha noi ^^, jh„/l nghiem cho chdn dodn .
• • BV VTnh phiic. ' Nhan ngay 25.2 Duyet in 10.3.2013
Tap chl Tai MQi Hpng Vi^t Nam - Volume (58-16). N°4-June, 2013
2. D 6 I TU'ONG VA PHU*ONG PHAP NGHIEN c u t !
2.1.G6m 38 benh nhan gap tai BVTMH TU tir 2007-2009, co chdn doan xac dinh boi mo benh hpc.
2.2. Phuong phap mo ta timg ca, can thiep.
2.3. Su dung npi soi va tham kham lam sang mo ta hinh thdi ton thuong. Su dung may chup CLVT xoan 6c (Siemens Somatom Emotison) de chup 2 tu th^ cat ngang, diing ngang va dung lunh dung doc voi dp day 3inm de danh gia ton thuong va doi chieu voi lam sang.
3. KET QUA
1.1. Danh gia t^D thutmg tren CT scan l.Ll. Vi tri ton thieomg
Bang 1. T6n thuang trfen CT scan Vi tri ton thuang tren CT scan Xoang ham dan thuan Xoang sang dan thu^n c a sang ham Ca h6c mOI va xoang
n 11 4 22 21
%
28,95 10,62 57,89 55.26
1.1.2. PhSn ting ton tbumig tteo Sebileau
Bang 2. Phan t i n g ton t h u a n g theo Sebileau Phan
tang n
%
Tang trSn 4 10,52
Ting gitta 11 28,94
Tang d u a l 1 2,63
Ca hai tang
22 57,89
1.1.3. Chdn dodn phan loai khoi u (T).
Bang 3 Phan loai khoi u (T), Kh6i u T
n
%
T1 0
T2 0
T3 26 68,42
T4 12 31,58
1.2. Doi chieu ton thircmg tren lam sang va CT ( N=33 )
1.2.1. Boi chieu Ian tran tren lam sang vdCT(N=33)
Bang 4. Doi chieu Ian trSn tren ISm s^ng va CT {N=33)
T6n thuang trSn CT scan Lan I6n trdn Lan vao trong Lan ra sau Lan ra trub'c Lan ra ngoai
n
Ton thuang tr&n lam sdng Phu hap
5 20 1 3 7 36/50 (72%)
Kh6ng phu hap
5 3 2 1 3 14/60 (28%)
n
10 23 3 4 10 60= 100%
1.2.2. Boi chieu hwdng lan tran tren trong giua Idm sang vd CT
Bang 5. £>6i chieu hu-b-ng lan tran tr6n trong giija lam sang va CT (N=33)
Ton thu-ong trSn CT scan Khuy^t xu'ang bo du-oi 6 m M Phd huy tran Scinq Pha huy vSch mCii xoanq
n
Ton thuong lr6n ISm sang Phu h{?p
5 1 20 26/33 (78,8%)
Khong phu hp-p
4
3 7/33 (21,2%)
n
9 1 23 33=100%
11
Tap chl Tai Mui Hpng Vi^t Nam - Volume (58-16). N''4- June, 2013
1.2.3. Bdi chieu lan tran Iru&c, sau, ngoai giira Idm sang vd CT
Bang 6, D6I chieu lan tran trudc, sau, ngoai giOa lam sSng va CT ( N=33 )
T6n thu'ong trfin CT scan
Ph^ huy thSnh tru'P'c xoanq h^m PhS huy thSnh sau X.
hcim, vSch bu'dm sSnq
Pha huy thSnh ngoSi
xoanq h^m Pha huy th^nh ngoai X ham va goc
nqoai 6 m l t n
T6n thu-ong trfin Idm s^ng Phu hpp
3
1
5
2
11/17 (64,8%)
KhPng phu hpp
1
2
1
2
7/17 (35,2%)
n
4
3
6
4
17=100%
4. BAN LUAN
4.1. Hinh thai ton thvong tren phim CT Scanner
So voi phim XQ kinh dien, phim CT Scanner co nhieu uu diem noi trpi. Hai tu the chup thuong diing de danh gia tinh hinh lan tran cua u do la tu the Axial va tu the Coronal .Tu the Coronal cho phep danh gia tot ve cac ton thuong trong xoang, cac m6c giai phau nhu manh sang, bo trong va bo d- uai cua 6 mat, cua cac xoang, dac biet la xoang sang va xoang ham. Tu thS nay rat quan trong trong ung thu sang ham. no cho phep danh gia dupe su xam lan, de day ciia
u v^o cic thanh 6 m$t, thanh ngoai hoc mui, n^n sg, khau cai la cac hu6ng lan co ban cua loai ung thu nay.Cac lop cat theo tu the n^y c3n dugc lay tir bo truoc xoang tran d^n bo sau cua xoang buom v<!ri tu the chyp b?nh nhan ngua co toi da.Tuy vay, trong ung thu sang ham, tu the Axial ciing CO mpt vai tro quan trgng nhat la doi voi cac t6n thuong lan theo chieu truac sau:
cac t6n thuong lan ra mat truoc xoang ham hay phia sau xoang buom, xoang sang.
Them nua, trong c^c trucmg hgp benh nhan khong the ngua dau bet c5 nhu tniong hgp benh nhan co dSt ong npi khi quan, benh nhan co tat a dot song, benh nhan co ton thuong cot song c6... Ta can chup bang tu the Axial sau do co the dung hinh lai tu the Coronal neu can.
Phim CO the cho thay u tu khi con rSt nho moi chi khu tni 6 1 thanh trong xoang, nho do ta co the chan doan benh 6 giai doan som. Khi u da phat then, tren phjm ta CO the thay dupe \'i tri u con khu tni a mpt xoang hay da lan tran sang cac bp phan lan can, nhat la khi chua co cac trieu chiing bien dang 6 mat hay co cac trieu chitng tren lam sang. To chuc ung thu xam lan moi chi de day cac thanh xuong hay da an mon, pha huy cac thanh xuong ciia xoang {vach mui xoang, thanh truoc, thanh sau, thanh ngoai, thanh trong xoang ham, xuong giay, san 6 mat, trin sang. Nhimg ton thuong nay thuong khong ro tren phim XQ thong thuong 6 giai doan som.Co th^ thay hinh anh pha vo mgt hay nhilu vach xuong tren cimg mpt benh nhan.Tren phim cCing co the quan sat duoc su tham nhilm, xam 1^ cua
Tap chl Tai MQi Hpng Vi$t Nam - Volume (58-16)- N°4 - June, 2013
u vao cac to chiic xung quanh nhu ho chan buom ham, 6 mat, xoang buom, vao nao.
Trong nghien cuu cua chiing toi co den 15 truong hgp (chilm ty 1$ 39,47%) da co bieu hien u xam lan vao 6 mat. Day la vi tri hau nhu khong the chan doan dupe tren phim XQ thong thuong. Tren phim CT Scanner c6 the danh gia muc dp lan tran cua u voi dp chinh xac 85%[10]. Phun CT Scanner con cho phep chung ta danh gia chinh xac vi tri va kich thuoc cung nhu mat do cua u, biet dugc miic dp lan tran ciia u vao cac to chuc lan can. Nho CT Scarmer ta CO the danh gia, du kien dpc nhiJng phuong phap phlu thuat mpt each toi uu cho benh nhan va tien lugng dupe ket qua.Theo doi benh nhan sau phau thuat dinh ky, co chup CT Scanner se giiip cho viec giam sat va theo d6i tien trien cua benh sau dieu tri. Ty le benh nhan ung thu sang ham c6 chup phim CT scanner tang nhanh. Thdi ky 1991 -1996 ty le benh nhan ung thu sang ham c6 chup phim CT Scanner khoang 17%, thdi ky 1996 - 2001 ty le nay khoang gSn 43%
Ngo Ngpc Liln [5] va hien nay tat ca cac benh nhan ung thu sang ham deu chup phim CT Scanner de chan doan va tien luong benh.
4.2. BOI CHIEU T 6 N T H U ' O N G LAM SANG VOfI CT SCANNER
Dk so sanh cac ton thuang phat hien duac vdi CT Scanner, chung toi xep ton thuong theo cac huong lan tran ciia benh.
4.2.1. Lan len tren
Lan vao 6 mat, vao nao; Tren lam sang bilu hien cac tri$u chiing sung ne mi dudi.
loi mat, cac tri?u chung than kinh khu trii.
Tren phim CT Scanner thay cac dau hieu ton thuong cac vach xuong cua xoang, dau hi^u xam lan cua u vao 6 mat, nao... Trong nghien cim co 10 truong hgp u lan len tren dugc phat hi?n tren phim CT Scanner nh- img chl CO 5 truong hpp co bieu hien tren lam sang.
Nhu ta da bi8t, viec phat hien huong lan tran len tren trong cac ung thu sang ham CO vai tro rat quan trgng trong dieu tri ciing nhu trong tien lupng cac truong hgp ung thu sang ham, khi ung thu sang ham da lan len nao thi phlu thuat se khong co ket qua va khong dugc chi dinh phau thuat nua.
Do do neu su lan tran ciia u vao viing nay dugc biet truoc se giup benh nhan tranh dugc mpt cugc phau thuat it ket qua.
Con trong truong hop u lan vao 6 mat, viec phat hien truoc mo tinh trang nay se giiip cho ngudi thay thuoc co the tien lugng truoc phau thuat, tham khao y kien cua cac dong nghiep chuyen khoa Mat. ban bac va giai thich vdi gia dinh ngudi benh... nhat la trong nhung trudng hgp con lai mpt mat duy nhat, vi d nhimg benh nhan nay se phai cat bo u va nao vet 6 mat phoi hpp.
4.2.2. Lan ra tru'O'c
Qua CT Scanner thay cd 4 trudng hpp u pha vo thanh trudc xoang ham lan vao viing ho nanh, phong ranh lai moi. Trong phau thuat ung thu sang ham viec phat hien tinh trang tham nhiem cua u ra phia trudc la kha quan trpng. No giiip ta tien lupng trudc viec tao hinh vimg mat trong va sau khi mo.
T9P chl Tai MQi Hpng Vi6t Nam - Volume (58-16). N°4 - June, 2013
4.2.3. Lan ra sau
T6n thuang tren CT Scanner la ph^
huy xuong thanh sau xoang ham, vach xoang buom, xam lan vao trong xoang, thudng dugc phat hi?n tic sdm. Trong nghien ciru, co 3 trudng hgp u lan ra sau dupe phat hien dpc tren CT Scarmer (100%). Lan ra sau vao ho chan budm ham, gay CO that nura mat kbit ham, dau, te rang nua ham tren ben benh (cac trieu chung lam sang thudng ngheo nan va xuat hien mugn khi u da Idn). Tren lam sang chi co 1 trudng hpp cd trieu chimg te bi rang ben benh chiem ty le 1/3.
4.2.4. Lan vao trong
U pha thiing vach mui xoang, Ian vao trong hoc mui gay ra trieu chung ngat mui.
Trudng hpp u qua Idn co the pha thimg vach ngan lan tran sang ben doi dien. Cac benh nhan deu den d giai doan mugn, t6 chuc ung thu da lan tran nhieu vao trong hoc mui. Day la trieu chung gap nhi^u nhdt va la ly do benh nhan den kham. Khi do, thudng chi can quan sat tren lam sang ciing CO the thay u da xam lan vao viing hoc mui.
Vi vay tren 23 trudng hgp phat hien co tdn thuong xuong vach miii xoang qua phim CT Scanner deu da dugc phat hien tir trudc qua lam sang.
4.2.5. Lan ra ngoai
U pha vd thanh trong 6 mit lam sung ne goc trong 6 m4t, 16i mat, nhin doi hoac pha vd thanh ngoai xoang ham lam sung nk niia mat.Thanh trong d mit r4t mong vi vay rat de bi u xam lin. Tren phim CT Scanner phat hien 6 trudng hgp pha huy xuong
th^nh trong b mat va 4 trudng hpp pha th^nh ngo^i xoang ham. Trong khi do tren lam s^g chi cd 4 trudng hpp co trieu chimg sng n^ g6c trong 6 mSt, loi mat va 3 trudng hpp sng ne nira mat. So sanh tri^u chimg lam sang va cac ton thuong phdt hipn dupe tren CT Scanner ta thay trong nhieu trudng hpp mac du cd su pha huy thanh xuong cua xoang nhung do to chuc ung thu chua xam lan nhieu nen tren lam sang chua thay c6 cac dau hi^u co nang va thuc the, ngay ca tren phim XQ thong thudng cac dau hieu pha huy xuong cung khong thay bieu hien r6 net. Tren lam sang chi khi u pha huy xuong, lan tran nhieu mdi CO bieu hien trieu chung. Do do ta thay rang CT Scanner rat co gia tri trong danh gia ton thuang d sau.
5.KET LUAN
1. So sanh vdi CT: Hudng lan vao trong cd 86,95% cd bilu hien tren lam sang, lan ra ngoai 70%, lan ra trudc 75%
lan len tren 50%. Dac biet la hudng lan ra sau chi CO 1/3 benh nhan co bieu hien trieu chimg tren lam sang.
2. Phim CT Scanner cho phep danh gia hudng lan tran ciia u ( nhkt la vdi lan len tren - vao day sp, nao). Khi bilu hieu trieu chiing tren lam sang rat mugn va ngheo nan thi CT Scanner lai giiip chan doan sdm, chinh xac.
Tap chl Tai MQi Hpng Vi^t Nam - Volume (58-16). N°4 -June, 2013
TAI LIfU THAM KHAO 1. Le van Bich, Pham Khanh Hoa
(1969), " Nghien ciru tren 60 u ac tinh sang ham gap tai khoa TMH benh vien Bach mai tir 1960-1968", A^pi san TMH, sS 1-2, trang 73-79.
2. Nguyen Manh Cuong (1978), Nhimg bieu hi?n lam sang, to chuc benh hpc, dien quang ciia 52 trudng hgp ung thu bieu mo khoi sang ham", Luan van tot nghiep CK 11 chuyen ngdnhTMH, Dai hoc YHa noi.
3. Pham Van Hau (2004), " Nghien cuu dac diem hinh anh chup cat lap vi tinh trong chan doan ung thu sang ham ", Luan van tot nghiepthgc sy Y hoc, chuyin ngdnh chdn dodn hinh dnh , Bgihoc Y Hdnoi.
4. Tr3n Thi Hgp (1996), " Gop phan chan doan va diSu tri ung thu sang ham . Nhan xet qua 174 ca ung thu sang ham tai BV TMH va benh vien K ha noi tir ", Luan van tot nghiep CK II chuyen ngdnh Ung thir, Bgi hoc Y Hd nQi.
5. Ngo Ngpc Lien (2002)"Tinh hinh ung thu sang ham t^ Vien Tai Mui Hgng trong 15 nam 1986-2001", tap chi y hpc thuc hanh, s6 431, tr 299-305.
6. Anton N (1984), " CT of tumor and tumor - like conditions of the paransal sinus" Radiologic clinics of North Americ, Vol 22, Noi, pl9-30.
7. Barnes L, Everson J, Reichart P (2005), Worid Health Organization classification of tumors: pathology and genetics head and neck tumors. Lyon, lA RC, Press.
8. Bouijat P. and al,(1993), "Tomoden simetrie cervicofacial", Masson,p 42- 47.
9. Cerilli L, Hoist V, and al.(2003),
"Sinonasal undifferanciated carcinoma profie and genetics head and lack of EBV association. Am J Surg Pathol, 25,156-163.
10. Popovic D. (2004), Malignant tumors of the maxillary sinus. A ten years experience", Med. And Biology, Vol 11, No l,p 31-34.