MUc dp liet tiiy theo the lam sang Ddng y. Nhdm triing phong tang phii- kinh lac: triing phong tang phii cd sd benh nhan Net d mifc dp rat nang chiem ty le cao (liet dp IV 45,14%, Net dp V 49,31%), triing phong kinh lac sd benh nhan Net mUc dp nhe lai chiem Uu the (liet dp III 152,78%):
nhdm chimg thuc - hu : chimg hu cd sd benh nhan Net d mUc dp rat nang (Net dp IV 42,85%, Net dp V 50%), chdng thuc cac mUc dp liet cd ty le tuong dd'i ddng deu (Net dp III 28,13%, liet dp IV 35,42%, liet dp V 31,25%).
TAI UEU THAM KHAO
1. Nguyin Van ChUdng (2005), Dai cuang dot quy nao, Thuc hanh lam sang than kinh hoc, Nha xuat ban Yhoc, tap 3, tr 4-34.
3.
4.
Nguyen Minh Hien (1995), Gop phan nghien cUu cac yeu to tien tugng nang va mgt so yeu to nguy LdDuTc Hinh va nhom chuyen gia (2007), Tai bien mach mdu ndo: hu'dng dan chin dodn va xdtra, Nh xuat ban Y hpc, tr. 20-45.
Kim Quy yeu lupc (1996), Mach chdng va each chOa benh trung phong, Nha xuat ban Y hpc, tr.
68 - 82.
Dang Thi Huyen Nga (2003), Nghien cOu bien doi dien nao, luu huyet nao tren benh nhan liet do nhoi mau nao duac phuc hoi bSng dien mang cham. Luan van thac sy y hpc, tm'dng dai hpc Y Ha npi.
Vu Thu'dng SOn (2004)\, Nghidn cub dien chdm phuc hoi chut nang van dgng trdn benh nhdn liet nda ngu'di do tai bien thieij mdu ndo cue bg, Y dupc hpc qu5n sU, so 5, tr. 114-121.
Nguydn Tai Thu (1994), Mdt sd nhan xet 120 benh nhan liet do DQN duac phuc hoi tai Vien cham cUu, Tap chi cham cUu Viet Nam sd 14, tr.15-16.
U.K.
VMI OSO or-
NGHIEN Cliu KET QUA DIEU TRI 53 BENH NHAN DA U TUY
TOM TAT
Qua nghien cUu 53 benh nhan da u tuy xUdng, dieu tri ban dau bang phat do hoa chat Mp, VMCP, VAD. Cho ket qua sau:
Ty le giam dau chiem 71,11%, trong dd 31,11%
giam dau hoan toan, 28,89% khdng giam dau.
Dap Ung dieu tri 73,6%, trong dd dap Ung hoan toan 32,1%, dap Ung khdng hoan toan 41,5%, ty le sdng 4 - 5 nam la 13,6%. Thdi gian sdng trung binh 25,6 thang.
Nong dp HST tang tU 74,6 ±22g/l len 93,5±21,6 so lupng plasmocyt trong tuy xUdng giam tU 30,93±16,46 xuong 13,67±8,0. Trong 24 benh nhan rdi loan chUc nang than vdi creatinin >130(.imol. Sau dieu tri c6 10 benh nhan (41,7%) phuc hoi chdc nang than, nong dp protein giam nhanh tU 106,57±25,9 xuong 90,47±22 Albumin mau tang tU 31,87±7,7g/llen24,7±7,1g/l.
Tom lai, da u tuy xUdng la benh ly tUdng bao ac tinh toan than khong the dieu tri khdi.
Nguyen Trung Chinh*
•.. ..,:_ y'er'} ofto uuo .•
SUMMARY
RESEARCH OF TREATMENT RUSULTS FROM 53 KAHLER PATIENTS
After researching 53 Malignant tumor in bone marrow (Kahler) patients, who have treated initially with chemical diagram Mp, VMCP, and VAD. The results are:
Rate of relieving pain accounts for 71.11% in which relieving pain totally account 31.11%: and rate of not relieving pain is 28.89%.
Rate of demanding treatment account 73.6%, in which rate of demanding totally account 32.1%, rate of not demanding totally account 41.5%. Rate of alive from 4 - 5 years account 13.6%. Time of living averagely is 25.6 months.
Concentration of HST increases from 74.6 '22g/l till 93.5± 21.6. Number of plasmocyt in bone marrow decrease from 30.93±16.46 till 13.67 '8.0. For 24 patients of disordering kidney function with creatinin >130|imol. After treatment, there are 10 patients (41.7%) to improve kidney function.
Y HOC VIET NAM THANG 12 - SO 1/2010 concentration of protein decreases rapidly from
106.57+25.9 till 90.47±22. Albumin in the blood increases from 31.87+7.7g/l till 24.7±7.1g/l.
Inclusion, Malignant tumor in bone marrow (Kahler) is phathology with multicellular, malignant for all over and it can not be cured.
Oe gdp phan nang cho chat lupng dieu tri, chiing tdi tien hanh nghien cuU de tai nham muc dich:
1. Danh gia dap Ung lam sang sau dupc dieu trj ban dau
2. Danh gia nhung thay ddi can lam sang sau dieu tri
I. OAT VAN OE
Benh da u tu^ xuong la benh ly huyet hpc it gap chiem khoang 10% va chiem 1% benh ly ung thu.
Benh da u tu;/ la su tang sinh cd tinh chat ac tinh cOa ddng tuong bao trong tuy xuong. Benh gay nen rdi loan tang tiet globulin midn djch don ddng, khdng binh thudng ve sd lupng va chat lupng. Dac trung ndi bat la thieu mau, tdn thuong xuong, rdi loan chifc nang than, tang canxi mau, nhilm triing... Benh cam lam sang va bien chUng rat da dang. Viec chan doan va dieu trj gap nhieu khd khan. Vi vay phai xac djnh sdm benh de mang lai hieu qua dieu trj thiet thuc cho ngudi benh.
Da cd nhieu phac do phd'i hpp dieu trj da u tuy, dupc nghien cUu va ap dung. Tuy nhien moi phac dd cdn phu thude vao benh nhan va giai doan benh. Cd gan 50% benh nhan khdng dap img vdi dieu trj ban dau. Tai phat cdn la van de nan giai vdi benh nhan va thay thudc.
III. KET QUA NGHIEN ClfU i
3.1. Danh gia thay doi lam sang sau dieu trj
3.1.1. Danh gia muc dd giam dau sau dieu trj n = 45 Bang 3.1.1 Ty le giam dau sau dieu trj
II. OOI TUONG VA PHUONG PHAP NGHIEN ClJfU 2.1. Ddi t u p n g nghien ciiru
Gdm 53 benh nhan dupe chan doan va dieu trj tai Benh vien 108 va benh vien Bach Mai Ha Ndi
Tieu chuan loai trU: cae trudng hpp benh ly tuong bao ac tinh khac
2.1. PhUOng phap nghien ciiru
- Nghien cifu hdi cull ket hpp tien ciru cat ngang va theo ddi dpc
- Phac dd dieu trj
MP (melphalan, prednisoeon)
VMCP (vincnistin, melphalan, cyclophosphamide prednisolon)
VAD (vineristin, doxorubicin, Dxamethazon) - Danh gia dap ifng dieu trj: Dap img chii quan, dap Ung khach quan
- Xii' ly sd lieu: sd lieu dupc xur ly theo chuong trinh phan men SPSS1.
~~~ •—.-___^^^ Ket qua Mirc do ^ __
Giam dau hoan toan Giam dau mdt phan
Khdng giam
SdBN 14 18 13
Ty le % 31,11 40,00 28,89
Nhan xet: Trong 53 benh nhan dupe theo ddi dieu trj cd 45 benh nhan (84,9%)) cd dau xUOng. Sau dieu trj 6 dpt hoa chat 71,11% benh nhan giam dau, trong dd 31,11% giam dau hoan toan; 28,89%
khdng giam dau ^ ; , : .r , .J ; r ./ ' \ i . • ' 3.1.2. Tyle dap ung sau dieu trj ban dau
Bang 3.1.2 Ty le dap ifng sau dieu trj ban dau Miirc dp
Dap irng Hoan toan
Khdng hoan toan Khdnq dap Ung
Tdng
Sd BN(n=53) 17 22 14 53
Ty le % 32,07 41,51 26,42 100,00
Nhan xet: Dap img hoan toan sau 6 dot hoa chat la 32,07%, dap img tUng phan la 41,51% va khdng dap img la 26,42%
3.1.3. Thdi gian sdng sau dieu trj Bang 3.1.3 Thdi gian sdng sau dieu trj
Thdi gian song (thang)
>2-6 7-12 13-24
2536 27-48 49-60 Tong
So BN (n=22) 3 4 3 8 1 3 22*
Ty le % 13,6 18,2 13,6 36,5 4,5 13,6 100,0
* Cd 2BN loai ra khdi nghien cUu vi tirvong ngay sau dieu trj 1 thang
Nhan xet: - Sau 1 nam dieu tri chi cdn 69,2% benh nhan sdng, trong dd 3 benh nhan (13,6%) chet trudc 6 thang
- Sau 2 nam ty le cdn sdng la 55,6% ' ' ' - Sau 3 nam ty le cdn sdng la 19,1% - ' - ^
- Sau 4 nam ty le cdn sdng la 13,6% ;'' - Chi cd 3 benh nhan (13,6%) sdng sau 4-5 nam
3.2. Danh gia nhifng thay doi can lam sang sau dieu trj 3.2.f. Thay dd'i cdng thuc miu
Bang 3.2.1 Thay ddi cdng thUc mau CacchlsdXN
Huyet sac td XN
Bach cau (G/L)
Tieu cau (G/L)
TrUdc dieu trj
74,6±22
6,5±2,4
161,6±78,3
Sau dieu trj 1 dpt
83,57±20,8
5,59+2,9
188,9+109,6
Sau dieu trj 3 dot
87,38±22,1
5,2+2,5
189,3±94,7
Sau dieu 6 dpt
93,50±21,6
4,87±2,5
164,5+88,5
So sanh P (pi, P2p3) P1 =0,001 P2 = 0,0001 P3 = 0,0001
PI = 0,001 P2 = 0,001 P3 = 0,0001 PI = 0,031 P2 = 0,028 P3 = 0,0756 P I : So sanh trudc dieu trj vdi sau dieu trj 1 dot hoa chat
P2: So sanh trUdc dieu trj vdi sau dieu trj 3 dot hoa chat P3: So sanh trUde dieu trj vdi sau dieu trj 6 dpt hoa chat
Nhan xet: - Lupng huyet sac td tang len rd ret sau moi dot dieu tri, tif 74,9g/L trUdc dieu trj len 93,5g/L sau 6 dpt hoa chat (vdi p = 0,001 - 0,0001)
- Sd lupng bach eau giam dan tif 6,5g/L xudng 4,87g/L sau 6 dpt dieu trj (p = 0,01 - 0,0001).
- Sd lupng tieu eau khdng cd sU khae biet rd ret sau 6 dpt hoa chat vdi p>0,05; cd the do vai trd cOa cac cytokin (IL-1, TNF p, IL-6) cdn cd hieu lUe va do hieu qua cua cortieoid trong phac dd dieu trj.
3.2.2. Thay dd'i sd lugng tebao tuy va ty le piasmocyle sau dieu trj Bang 3.2.3 Sd luong te bao tuy va ty le % plasmocyt trUdc va sau dieu trj
TrUdc dieu tri Sau dieu trj (6 ddt)
So lupng te bao tuy (G/L) 44,95+39,69 39,45+46,18 0,645
% plasmocyt tuy 30,93+16,69 13,67+8,0 0,002
Y HOC VIET NAM THANG 12 - SO 1/2010
"" Nhan xet: - Sd lupng te bao tuy sau 6 dpt dieu tri cd giam hon so vdi trUdc dieu trj nhung khdng cd U khac biet (p>0,05)
- Ty le % plasmocyt tuy giam rd ret sau dieu tri (p < 0,05) '' 3.2.3. Thay dd'i sinh hoa trudc va sau dieu trj
Bang 3.2.3 Thay ddi xet nghiem sinh hoa trUdc va sau dieu tri Thanh phan
Creatinin (|.imol/L) LDH (U/L) kxit uric Canxi
Protein toan phan (g/L) Albumin (g/L
TrUdc dieu trj 165,1+137,1 534,3+297,5 567,6+700,2 2,38+0,61 106,57+25,9
31,87+7,7
Sau dieu tri 1 ddt 122,8+53,1 508,3+238 392,2+152,78
2,09+0,35 94,07+24,2
32,02+3
Sau dieu trj 3 dpt 112,2+53,1 425,9+216 417,4+123,3
2,08+0,32 90,47+22 33,07+7,5
Sau dieu 6 dpt 125+113 473,9+243 398,8+160,2
2,1+0,28 90,32+21 34,7+7,1
So sanh P (Pl,p2p3)
0,028 0,3 0,71 0,002 0,0001
<0,05 P: So sanh trUdc dieu trj va sau dieu trj 6 dpt
Nhan xet: - Ndng dp Creatinin giam dan sau cac dpt dieu trj (tU 165,1+137,1 xudng 125+113) vdi p<0,05.
- LDH, axit uric, giam so vdi trudc dieu trj, song khdng cd y nghTa thdng ke vdi p<0,05.
- Sau 6 dpt dieu tri hoa chat, ndng dp canxi mau, protein toan phan giam dan, ndng dp albumin tang dan (p<0,05)
3.2.4. So sanh t Nong do creatinin
< 130 nmol/L
>130 |imol/L Tong
y le thay doi nong a 0 Greahmin truac va sau dieu tn TrUdc dieu tri
SdBN 29 24 53
Ty le % 54,7 45,3 100,0
Sau dieu tri So'BN
39 14 53
Ty le % 73,6 26,4 100,0 Nhan xet: Sau dieu trj, cd tdi 10/24 benh nhan (41,7%) phuc hdi chifc nang than. SU khac biet nay cd y nghia vdi p < 0,05.
3.2.5. So sanh ty IS thay doi ndng do canxi trudc va sau dieu trj Bang 3.2.5 So sanh t^ le thay ddi ndng dp canxi trUdc va sau dieu trj Nong do canxi
(mmol/L)
<2,5
>2,5 Tdng
TrUdc dieu tri SoBN
32 17 47
Ty le % 65,3 34,7 100,0
Sau dieu tri So'BN
42 4 46
Ty le % 91,3
8,7 100,0 '• Nhan xet: Sau dieu trj, ty le benh nhan ed
ndng dp canxi mau > 2,5 giam so vdi trudc dieu trj (tu 34,7% cdn 8,7%). SU khac biet nay cd y- nghTa vdi p<0,05.
IV. BAN LUAN
Dau xuong va thieu mau la nhifng trieu trimg ehii yeu trong da u tuy xuong ddng thdi la trieu chimg quan trpng anh hudng de'n chat lupng cudc sdng ngUdi benh.
Nghien ciru ve ket qua giai doan qua bang 3.1.1 chiing tdi nhan tha'y ty' le giam dau hoan toan la 14/45
benh nhan (31,11%) giam dau mdt phan dat 40%, t^
le khdng giam dau sau dieu trj la 28,89%
Dd'i chieu tieu chuan dap img dieu tri eiia vien ung thU Hoa Ky 1993, ty le dap img toan bd ciia chimg tdi la 73,57%; trong dd 32,07% la dap img hoan toan; 41,51% dap img mdt phan. Thdi gian sdng tmng binh la 25,45 trong dd ty le sdng 2 - 3 nam chiem 36,5%. Sau 4 nam ty-le cdn sdng la 13,6%. Ty' le phii hpp nghien cuU ciia La Van Tafdng (2002).
Nghien ciiU ciia J.Bila, L.Elezovie cd 20% dap img hoan toan, 60% dap img mpt phan thdi gian sdng tmng binh ciia nhdm la 24 thang.
Ket qua nghien cifu qua eae bang 3.2.1, 3.2.2., 3.2.3 3.2.4 cho tha'y nd hieu qua sau dieu tri hoa chat.
Ndng dp HST tang len rd ret sau mpt dpt hoa chattU74,6+22g/l trUde dieu tri len 93,5+21,6 sau 6 dpt hoa chat, HST tang la yeu td quan trpng cai thien chat lupng cudc sdng cho benh nhan.
Muc tieu dieu tri lam giam khdi lUpng u plasmocyte, giam SLTB plasmocyt tuy xudng ket qua cho thay ty le % plasmocyte giam dang ke', sd lupng tu 30,93+16,6g (trUdc dieu trj) cdn 13,67+8,0 (sau dieu trj 6 dpt). Day la mue tieu danh gia ket qua dieu tri
Ket qua nghien cdu bang 3.2.3, 3.2.4 chiing tdi tha'y ndng dp creatimin, canxi, LDH, a.uric benh nhan rdi loan chUc nang than vdi creatimin
>130iimol, sau 6 dpt dieu trj cd 16 benh nhan (41,7%) phuc hdi chdc nang than. Nghien cifu ciia Blade (2003) ty le nay la 29% cdn vdi M.Baeda (2003) ty le phuc hdi suy than sau 1 nam la 66,7%.
Ndng dp protein toan phan giam nhanh tU 106,57+25,9 xudng 90,47+22 sau 6 dpt dieu trj
Ndng dp Albumin mau tU 31,87+7,7g/l tang len 34,7+7,Ig/I sau dieu trj.
Ket qua bang 3.2.5 cho tha'y ndng dp canxin mau ciia 17 benh nhan (76%) eho sau dieu trj trd ve mirc binh thudng.
V. KET LUAN
Dieu trj lieu trinh ban dau benh da uy tu^
xuong bang phac 66: MP, VMCP va VAD ket hpp dieu tri hd trp giup cai thien chat lupng cudc sdng cho benh nhan ty le giam dau hoan toan la 14/45 benh nhan (31,11%) giam dau 1 phan dat 40%, ty le khdng giam dau sau dieu tri 28,89%. Dap img dieu trj 6 dpt hoa chat ban dau la 73,6%
trong dd dap img hoan toan la 32,1%, dap img
khdng hoan toan 41,5%. Ty le sdng 4-5 nam 13,6% thdi gian sdng trung binh 25,6 thang
Ndng dp HST tang rd ret sau dieu tri tU 74,6+22g/l len 93,5+21,6 giiip cai thien thieu mau cho benh nhan.
Ty le plasmocyte trong tuy xUOng giam dang ke trudc dieu trj 30,93+16,6g, sau dieu trj con 13,67+8,0. Cd 24 benh nhan rdi loan chUc nang than vdi creatimin > 130|.imol. Sau dieu trj cd 10 benh nhan (41,7%) phuc hdi chUc nang than ndng dp protein toan phan giam nhanh tU 106,57+259 xudng 90,47+22. Albumin mau tang tU31,87±7,7g/l len 34,7+7 ed 17 benh nhan (76%) sau dpt dieu tri canxi mau trd ve mirc binh thudng.
Nhu vay sau 6 dot dieu trj hoa chat ban dau, ket qua benh nhan dupc cac cai thien chat lupng cudc sdng, ddi sdng dupc keo dai them.
TAI UEU THAM KHAO
1. NguySn Thj Minh An (2002), "Benh Kahler (Multiple myeloma)", Bai giang Benh hgc ndi khoa, Nha xuat ban y hpc, tr.181 - 189.
2. Tran Van Be (1998) "Da uy tuy va cac benh gammaglubulin ddn dong". Lam sang huyet hgc, Nha xuat ban Y hpc
3. Pham Hoang Phiet (1994), "Benh da u tuy". Bach khoa thu benh hgc, tap 2, tr.53-57.
4. Le Que', Nguyen Anh Tri (1998), "Mpt sd nhan xet lam sang va can lam sang d 15 benh nhan da u tuy XUdng gap tai Benh vien HUu Nghj tU 1980 - 1992" Yhgc Viet Nam, tap 2, tr.119-123.
5. Durie B., Giles F. (1999), "Multiple myeloma", Postagraduate Hematology, 4"^ Edition, pp.462-478.
6. Gonzalez-Fralle M.L., GarciaSanz R. (2003),
"Prognosis in multiple myeloma (M.M) under conventional chemotherapy. A multivarite analysis of series uncluding 644 patients". Hematology Journal,
7. Hoffbrand A.V., Pettit (1993), "Multiple myeloma and related disorder", Essential Hematology Oxfort, 3'" Edition, pp.273-285.
