NGHIEN CUtJ D^C DIEM HINH ANH FDG - PET/CT Cf BfNH NHAN UNG THU* TUYEN GIAP BIET HOA CO NONG DQ
THYROGLOBULIN HUYET THANH CAO VA XA HINH TOAN THAN 1-131 AM TINH
LE NGQC HA, LE MANH HA LE DUY HUNG, NGUYEN THANH HUdNG
Khoa Yhgc Hgt nhdn-B?nh vi?n TT/QD108
Summary
Objectives: the purpose of this study was to assess clinical characteristics and FDG PET/CT findings in differentiated thyroid carcinoma (DTC) patients with negative radioiodine scan and high serum thyroglobulin (Tg) concentration.
Methods: 26 DTC patients with negative radioiodine scan and elevated serum Tg concentration were enrolled in the study. Whole body and bead-neck dedicated PET/CT scan was performed 60 min after injecting 0.16-0.22 ^iCi/kg of 18F-FDG.
Results: FDG PET/CT imaging revealed recurrences or metastases in 17 of 26 DTC patients (65.5%) including local recurrences (23.1%), cervical lymph node metastases (50%), distant metastasis (30.8%). FDG PET/CT is helpful for exactly detecting and precise localization of metastatic lesions, particularly lymph node metastases for surgical treatment.
Conclusions: FDG PET/CT can be used for detecting and localizations of recurrences and/or metastatic lesions but also impact in management of DTC patient's subset with elevated serum Tg and whose 131-1 whole body scans were negative.
Tu- khda: ung thu tuyin gidp biit hda, xg hinh I-I31 todn thdn, thyroglobulin, FDG PET/CT
I. DAT VAN DE
Ung thu tuyen gidp (UTTG) la mgt ung thu ngi tidt thudng gdp, chiem 90% so benh nhan (BN) va 70% tit vong a cac BN ung thu ngi tilt. Theo phan loai mo benh hgc, UTTG the biet hoa (differentiated thyroid carcinoma) chiem hon 90% cac BN UTTG. Sau phau thuat, UTTG bi6t hoa thu6ng t^ phdt tai cho, di cSn bach c6, trung thit, ph6i, xuong ... Tuy nhien, do dac tinh bat gift I-131, cac b^nh n h ^ (BN) UTTG biet hoa co tien lugng kha quan, ty le tdi phat va bi vong gidm ro ret neu dugc di^u tri bang 1-131 sau phau thuat cat giap hodn todn. Theo nghien ciiu cua Mazzaferri EL vd cs, ty le song sau 10 nam cua cac BN UTTG the nhii va the nang Id 93% vd 85%. Ty le tu vong do UTTG biet hoa giam 20% tai Hoa Ky trong giai doan ttr 1973 den 1996 nho su tien bg trong chin dodn, di^u tri vd dac biSt id nho viec ap d\ing phuong phap phau thuat cdt giap thich hgp tiiy thugc vdo giai doan benh, dieu tri bang 1-131 vd sit dung hormone tuyhn gidp thay thi. Hon 10 ndm qua, khoa Y hgc h?t nhan, benh vi^n TWQD 108 da nhdn dieu tri 1-131 va theo doi tren hon 6000 BN UTTG biet hoa sau phau thuat cit gidp hoan toan hoac gdn hoan todn theo qui trinh dya tren cdc kiln thiic cap nh|it va hi?n dai dang dugc ling dung tren thi gioi. Tuy nhien, nhieu BN UTTG bi?t hoa giam biet hoa (dedifferentiated thyroid cancer), gidm va mit khd ndng bdt giii 1-13 Itrong qua trinh dieu tri, vi vay, chyp xa hinh I-131 toan than Idiong co khd ndng phdt hi?n di can va ^ l u tri bdng I-I31 ciing trcr nen kem hi?u qud. Mgt so nghien cihi gdn day da cho rdng ca che cua hi^n tugng nay la do gidm bieu
552 Hgi nghi Khga hgc vd Cdng nghe hgt nhdn todn quic lan thi IX, Ninh Thugn 18-19/8/2011 hien gen NIS (Sodium/Iodide Symporter) co rfu|m vu van chuyin qua ming va bat giu: lot cua t6 chiic ung thu. Trong thuc hanh lam sang diSu tri I-13I a BN UTTG bi?t h6a sau phlu thujt, nhieu truong hgp khong phat hiSn tai phdt, di can tren hinh 4nh x? hinh I-I31 toan than nhung thyroglobulm huyet thanh cao (bing chOmg co tai ph4t hojc/vi di c5n ft b$nh nhan ung thu tuyen giap). Nhom BN UTTG nay co tiln luong xiu do mdt kha nang bit gift I-13I, tinh tr^g tai phat va di can khong phat hien dirge tren x^ hinh 1-131 toan than va BN khong dap ung viH dilu tri I-13I. D6ng thai, ngucri ta cung thay cac t6 chijfc ung thu giam biSt hda ft nhom BN nay CO tang bieu hien gen chuyen hoa glucose nhu GLUT-1, hexokinase I va II. Chinh vi v^y, chyp PET/CT sii dung F18 - FDG co gia tri chin doan cao va thuftng dugc chi dinh g nhom doi tugng BN nay. Tai Viet nam, FDG PET/CT moi dugc ling dung trong lam sang vk chua co nghien ciiu nao da de c^p den van d6 niy. Muc tieu cua di tdi nky nhim nghiSn ciu ddc diim ldm sdng vd hinh dnh FDG - PET/CT a benh nhdn ung thtr tuyin gidp bi$t hda c6 ning do thyroglobulin huyet thanh cao vd xg hinh todn thdn 1-131 dm tinh.
II. DOI TUONG VA PHUONG PHAP:
1. D6i tvgng nghien curu
Cac BN UTTG biet hoa da dugc dieu trj bing 1-131 sau phlu thugt cit giap hodn toan hoac gan hoan toan t?i Khoa Y hoc Hat nhdn (YHHN), Benh vi?n TUQD 108 tir 1/2009 - 1/2011.
Tieu chuan lira chgn:
- Benh nhan UTTG co ket qua mo b|nh hgc la UTTG biet hoa
- Benh nhan dugc theo dSi va dilu tri I-I31 sau phlu thudt tai Khoa YHHN theo qui trinh dua theo Huong dan thuc hanh cua Hoi YHHN Hoa K^ vl dilu tri I-I31 o benh nhdn UTTG biet hoa sau phlu thuat.
- Khong phat hien m6 giap con lai va di can xa trSn xa hinh toan than bing 1-131 sau dieu tri (xa hinh I-131 toan thdn dm tinh).
- Nong do Thyroglobulin huylt thanh cao > 10 ng/ml tai thfti dilm dang sii dung hoac ngung hormone tuyin giap
2. Phuong phap nghien cihi
- Tdt ca benh nhan dugc theo doi va dilu tri 1-131 sau phau thudt cit giap hoan toan theo qui trinh dua theo Huong din thuc hanh cua H6i YHHN Hoa Ky. Ho so nghien ciiu dugc thu thdp theo mau thing nhdt.
- Chup FDG PET/CT: BN dugc sil dung F-18 FDG, lilu 0,16 - 0,22 FDG (iCi/kg can nang tiem tinh mach sau khi nhin an It nhdt 4 - 6 h. Chup PET/CT toan thdn 2,5 phiit/1 vj tri giudng va protocol chuyen bi?t vung ddu - c6 tiln hanh sau 60 phiit, thvc hien fren may Discovery STE ciia hang GE.
- Hinh anh FDG PET/CT toan thdn dugc phdn tich djnh tinh va djnh lugng boi 2 bdc sj*
y hoc hat nhdn. Hinh anh bit thuang dugc djnh nghTa la nhung tin thucmg khu ttu tang bdt giu FDG cao hem t l chiic binh thuong xung quanh hoac khi gia trj hap thu chuin (standardized uptake value: SUV) > 3. Hach c6, trung thit co du&ng kinh idn nhit >10 mm hoac/va SUV > 3 dugc cho la so di can. Hinh anh FDG PET/CT dugc dii chilu vol kit qua cac phuong phap hinh anh khac nhu xa hinh SPECT Tc99m-sestamibi, xa hinh 1-131 sau dilu trj, CT scanner, xg hinh xucmg ...
- Phdn loai vj tri hgch c6 theo 7 vimg ciia Vien Phlu thudt Tai Hgng va Ddu - Cl Hoa Ky (The American Academy of Otoraryngology Head and Neck Surgery).
Hdi nghj Khoa hgc vd Cdng nghi hgt nhdn todn qudc lan thir IX, Ninh Thudn 18-19/8/2011 553
- Chyp xa hinh toan thdn 1-131: tien hdnh sau 2 ngdy u6ng 5 - 1 0 mCi 1-131 sau khi ngiing hocmon tuyin giap dl dat TSH > 30 ml/I. Chup xa hinh todn than tu thi truoc vd sau dugc thyc hi?n tren may gamma camera 2 dau Nucline Spirit cua Hang Mediso hoac Millennium MG ciia Hang GE. Sii dung truong nhin rgng, collimator phdng, nang lugng cao, Clia s6 nang lugng 20% quanh dinh 364 keV, toe do bdn lm/15 phiit. Hinh anh xa binh 1-131 toan than dugc phan tich boi 2 bac sy y hgc hat nhan.
- Dinh lugng thyroglobulin huyet thanh (Tg) va khdng thi khang thyroglobulin huylt thanh (ATg) theo phuong phap dien hoa phat quang, tien hanh tren may Elecsys - Nhat Ban tai Khoa Sinh hoa, Benh vien T U Q D 108. Gid tri Tg cao khi > 10 ng/ml.
- Chan doan xac djnh di can: dua vdo ket qua mo benh hgc tren cdc BN dugc phdu thu^t. So BN con lai dua vao dua vdo su doi chieu voi ket qud chgc hiit te bdo, theo doi vd d6i chieu voi cac phuong phdp chan doan khdc nhu sieu am, CT scan.
- Chien thuat dieu tri BN UTTG biet hoa co nong do thyroglobulin huylt thanh cao va xa hinh toan than 1-131 am tinh: Dua tren hinh dnh PET/CT, chiln luge dilu tri BN dugc thuc hien nhu sau: (1) Ton thucmg kich thuoc Ion, khu tni, co thi phau thuat: BN dugc chi djnh phau thuat; (2) Ton thuong kich thuoc Ion, o nhilu vi tri, khong thi phau thuat triet dl: kit hpp phau thuat va/hoac xa tri ngodi; (3) T6n thuong kich thuoc nho (<10 mm), 6 cac vi tri kho phau thuat, hinh dnh PET/CT am tinh: xem xet dieu tri 1-131 b6 sung 1-131 hoac theo doi (Wait & Watch).
2.3. Xii ly so lieu: Cac so lieu nghien ciiu dugc xu ly theo cac thuat toan thing ke y hgc bang chuong trinh phdn mem SPSS 18.0. Cdc biln Hen tuc dugc bilu diln duoi dang s6 trung binh
± do lech chudn {X± SD) voi a = 0,05. Sii dung Student t-test so sdnh cac gia tri trung binh, su dung X^ test so sanh cac ti le. Gia tri p < 0,05 tinh todn trong cac phep so sanh kilm djnh dugc coi la co y nghTa thong ke.
111. KET QUA
Bdng 1. Mdt sd dgc diem ldm sdng, xet nghiem cita cdc benh nhdn Mot so ddc diem ldm sdng
Tuoi trung binh (nam) Gioi tinh: Nu
Nam
Type mo benh hgc: Thi nang Thenhii The nhii - nang So dgt dieu tri trung binh Lilu 1-131 trung binh/dcrt (mCi) JTongJilu trung binh/benh nhan
Ning do Tg huylt thanh (ng/ml) Khi dang sii dung thyroxin Sau khi da ngimg thyroxin
si benh nhan (n=2S) Ty IS (%) 45,6 ±15,2
19 7 2 22 2
73, 1%
26, 9%
7,7 % 84, 6%
7,7 % 4,0 ±2,12 ( 2 - 6 )
139,9±21,1 554,8 ±289,8 49,9 ± 152,55 (eao nhit 754) 241,7±280,31 (cao nhit 1000)
554 Hdi nghj Khoa hgc vd Cdng nghe hgt nhdn todn qudc idn thir IX, Ninh Thudn 18-19/8/2011 Tuoi trung binh cua cac BN Id 45,6 ± 15,2, gdn V* s6 BN Id nu gioi. UTTG thi nhu va nhii - nang chiim tren 90%. So dgt dieu tri 1-131 trung binh la 4 Idn voi tong lieu 554,8 ± 289,8 mCi. N6ng do Tg huylt thanh trung binh la 49,9 ± 152,55 khi dang sii d\mg hormon va 241,7 ± 280,31 sau khi ngCmg hormon.
Bdng 2. Ty li vd vj tri tdi phdt, di cdn a cdc benh nhdn nghiin ciru Vi tri tdi phdt, di cdn
Khong di can Tai phat tai ch6, di cdn
Tai phat tai cho
Dican Hach CO
Trung that
si Itrong (n = 26) 9 17 6 13 8
Tylf(%) 34, 5%
65,5%
23,1%
50, 0%
30, 8%
Trong s6 26 BN UTTG biSt hoa Tg cao va xa hinh 1-131 toan thdn dm tinh, 9 BN (34,5%) khong phat Men tin thuong, 17 BN (65,5%) co tin thuong di can tren FDG PET/CT.
Di can hach cl chiim ty le cao nhit (50%), hach trung thit 30,8% va tai phat tai cho 23,1%.
Bieu do 1. So sdnh ndng do Tg huyet thanh a cdc nhdm benh nhdn khi dang si dung vd sau khi ngirng thyroxin
Ning do Tg huyet thanh tang ro ret tit 3,46 ng/ml khi dang sir dung thyroxin len 113,1 sau khi ngimg hormon a nhom BN co hinh anh PET/CT dm tinh (p = 0,028) va tang tit 77,8 ng/ml len 309,8 ng/ml 6 nhom PET/CT duong tinh (p = 0,007).
Hgi nghi Khoa hgcvd Cdng nghe hgt nhdn tgdn qudc Idn thi IX, Ninh Thudn 18-19/8/2011 555
Bieu dd 2. Vi tri hgch cd di cdn tren hinh dnh FDG PET/CT
Hach el thuong gap nhdt Id nhom VI (76,9%), nhom IV (53,8%), nhom II (28,5%), nhom 111 (15,4%) va nhom I (7,7%).
Kichthu'c'ch^ch/CT
Bieu do 3. Phdn bd SUV vd kich thudc hgch cd tren FDG PET/CT SUV max trung binh 8,7 ± 6,4 (Ion nhit 28), hach kich thuoc trung binh 11 ± 4,0 mm (max 26 mm). Trong so 33 hach co tren PET/ CT, 14 hach (42,3%) co SUV > 3 nhung kich thuoc nho hon 10 mm. 16 hach (48,5%) co ca SUV > 3 va duong kinh > 10 mm. Dua vao tieu chuin chin doan hach di can tren PET (SUV > 3) vd tren CT (hach > 10 mm), he s6 kappa = 0,14 (phii hgp thip).
556 Hgi nghi Khoa hgc vd Cdng nghe hgt nhdn todn quic lin thi IX, Ninh Thugn 18-19/8/2011
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Bieu dd 4. Phdn bd SUVvd kich thuac hgch cd a nhdm di cdn vd khdng di cdn xdc dinh bdng kit qud md benh hgc
Trong so 15 bach dugc doi chieu vol ket qua mo b?nh hgc, SUVraax trung binh 11,5 ± 7,9 (lom nhdt 28), kich thuorc trung binh 12 ± 5,0 mm (Idn nhdt 26 mm). 13/15 hach di cdn, 2 hach CO ket qua mo benh hgc la hach viem (I hach SUV = 10mm; SUV 6,5 - duong tinh gia va mgt bach duong kinh 11 mm, SUV max 1,7). Tat cd hach di can co SUV > 3, trong do co 6 bach di can co kich thuoc < 10 mm nhung SUV > 3.
Bdng 3. Thay ddi chien thudt diiu tri a cdc BN UTTG sau khi chup FDG PET/CT Phitang phdp
Phau thudt
Phau thuat ket hgp xa trj ngodi Phau thudt ket hgp dieu tri I-131 Theo del (Wait & Watch)
So benh nhdn (n=26) 9 2 2 13
Tyl((%) 34,6 % 7,7 % 7,7 % 50%
Chien thuat dieu trj thay doi dua fren ket qua PET/CT cr 13 BN (50%>). Trong do, phdn thuat don thuin 9/26 (34,6%i) vd kit hgp phdu thuat vcri dilu tri xa tri ngoai hoac 1-131 bl sung.
IV. BAN LUAN
Cho den nay, chup xa hinh 1-131 toan than va djnh lugng Tg huylt thanh la nhirng xet nghiem co gia tri hang ddu da dugc sir dung de theo doi tai phat, di can 6 benh nhdn UTTG biet hoa dieu trj 1-131 sau phdu thudt. Tuy nhien, a nhGng BN UTTG biet hoa kem va giam tinh biet hoa, to chirc ung thu tai phdt hoac di can mdt khd nang bat gift lot. Vi vdy, xa hinh 1- 131 todn thdn tro nen dm tinh vd khong co khd nang khing djnh BN khong bj tai phdt hoac di can. Trong nhOng nam truac ddy, nguai ta thuang su dung chup xa hinh Th-201, Tc99m- tetrofosmin vd Tc99m-sestamibi a nhom BN ndy. Tuy nhien, do do phdn gidi cia cac may gamma camera khong cao, khoang 25% ton thuang tai phdt, di can sg khong phat hien dugc.
De khic phuc van dl nay, FDG - PET da dugc nghien ciiu sji dung dl theo doi b?nh nhdn UTTG biet hoa. Joensuu vd Ahonen da co nghien cim cong bo ddu tien ve khd ndng bit gift cua FDG trong UTTG biet hoa. Sau do, nhilu tac gia da thay co hien tugng thay dii khd nang bit gift 1-131 va FDG cua UTTG biet hoa ("flip-flop" phenomenom). Ngucri ta da nghien ciiu thdy hien tugng nay thay dii til 31 - 74% s6 BN. Ngucri ta cho ring t l chiic UTTG bit gift I-
Hgi nghi Khoa hgc vd Cdng nghe hgt nhdn todn qudc lin thi IX, Ninh Thugn 18-19/8/2011 557
131 nhung khong bit gift FDG thirong la logi ung thu tuyin giap co mirc do bi?t h6a cao. Trai lai, khi tl chute UTTG tdng chuyin hoa FDG ma khong bit gift 1-131 thuang Id tl chirc ung tiiu giam, mit tinh bi?t hoa (dedifferentiation). Do mit kha nang bit gift 1-131, tinh trang tai phat vd di can khong phat hi^n dugc tren xg hinh 1-131 todn thdn va BN khong dap img vol dilu frj 1-131. Ngdy nay, nhilu nghien cuu da chung minh co ehl cua hien tugng ndy Id do giam bieu hien gen NIS (Sodium/Iodide Symporter) - mgt gen co nhiem vu van chuyin lit qua mdng vd tang mftc do bifiu hi?n cac gen van chuyen, chuyin hoa glucose nhu GLUT-1, hexokinase I va II. Moi lien quan ngugc ndy the hien sir gidm, mdt tinh biet hoa cua tl chirc UTFG. Ben cgnh do, ngucri ta cung thdy tang tdn xudt dot biln gen BRAF - mgt bilu hien tien lugng xau a BN UTTG. Vi vdy, FDG PET da dugc coi Id chi djnh co gid tri trong phdt hien tai phdt vd di can ft cdc BN UTTG bi^t hoa co nong do thyroglobulin huylt thanh cao va xa hinh todn thdn 1-131 dm tinh. Peine va cs nghien ciiu so sanh FDG PET vol xg hinh 1-131 toan than frong theo doi o 41 BN UTTG biet hoa. Khi kit hgp gifta 2 phuong phap chdn doan, do nhay len toi 95% trong phdt hi?n tdi phat va di can. 90% BN co dang thay dii bit gift phong xa(xahinhl-131 dmtinh nhung FDG-PET duong tinh hoac 1-131 duong tinh va FDG PET am tinh). Ben cgnh d6, miie dg bit gift FDG con la ylu tl tien lugng xiu ft BN UTTG.
Lotty Hooft vd cs phdn tich sl Ii$u tren 156 BN xg hinh 1-131 todn thdn dm tinh vd Tg cao 6 11 nghien curu da thiy 82% co kit qud FDG PET/CT co diu hieu tdi phdt va di can.
Trong sl 26 BN UTTG bi$t hoa Tg cao va xa hinh 1-131 toan than am tinh thugc nghien ciiu ciia chung toi, 17 BN (65,5%) co diu hieu tin thuang tdi phat tai cho hoac/vd di cdn hgch khu vuc, di cdn xa. Nghien ciiu da trung tdm cua Grunwals vd cs da so sdnh do nhgy, dac hieu cua FDG PET, xg hinh 1-131 todn than va Tc99m sestamibin'hal-201. Do nhgy cua FDG PET, xa hinh 1-131 todn thdn vd Tc99m sestamibi/Thallium-201 lin lugt Id 75%, 50% vd 53% vd do dac hifu Id 90%, 99%> vd 92%. D$ nhgy chung ciia FDG PET frong phdt hien di cdn trong UTTG biet hoa Id 75% nhung se tang len 85% ft nhom BN UTTG biet hoa eo xg hinh 1-131 am tinh, Nghien curu cua Holger Palmedo vd cs (2006) da phdt hien 127 tin thuong tren PET/CT ft 40 BN UTTG co xg hinh 1-131 dm tinh. Do chinh xdc ciia FDG PET vd FDG PET/CT lin lugt la 78% va 93%. PET/CT ldm thay dii chiln thudt dilu tri ft 48% BN.
Nghien ciiu cua chiing toi o 33 bach cl nghi ngo di cdn fren PET/CT, 14 hach (42,3%,) co SUV > 3 nhung < 10 mm. 16 hgch (48,5%) co cd SUV > 3 va ducmg kinh > 10 mm. Su phii kip chan doan vl tieu chudn hgch di can dua vao SUV > 3 vd kich thuac > 10 mm tren CT rit Ihap (kappa = 0,14). Doi chilu vfti kit qud mo benh hgc tren 15 hach thiy 13/15 hach di can, 2 hach CO kit qud mo benh hgc la hgch viem (1 hach SUV = lOmm; SUV 6,5 - duong tinh gid va mgt hach duong kinh 11 mm, SUV max 1,7). Tat cd hach di can co SUV > 3, trong do co 6 hach di can co kich thuac < 10 mm nhung SUV > 3.
Trong nghien ciiu ciia chiing toi, 26 benh nhdn diu co ning do Tg huylt thanh cao tren lOng/ml. Nhilu BN co mirc Tg cao tren 100 ng/ml, dgc biet co BN nong do Tg > 1000 ng/ml.
Nong do Tg huylt thanh tang co y nghia thing ke ft cd 2 nhom BN co hinh dnh PET/CT am tinh (p = 0,028) vd duong tinh (p = 0,007). Mi-Yeon Choi vd cs (2006) da thiy FDG PET co dp nhgy cao han djnh lugng Tg huylt thanh trong phat hien tai phat, di can ft BN UTTG biet hoa. Voi nhung BN co kit qua FDG PET duong tinh, tac gid thiy do nhgy cua Tg huylt thanh ttong phdt hien di can hach cl Id 69% va so vfti Tg, FDG PET phdt hien them nhilu tin thirong di can hgch co. Dietlein va cs da nghien ciiu thay mirc do bdt gift FDG bien doi ft cac CO quan khac nhau vd muc dg bat gift cao nhit o hgch cl va thip nhdt trong di can kich thuoc nho o phoi. Vi dilu trj 1-131 kem hieu qua vol di cdn hach cl do kha nang bit gift 1-131 kem, phau thudt vet hgch thuang dugc chi djnh. Nghien cuu cua chung toi khdng djnh FDG PET/CT CO vai fro rdt quan trgng trong viec phdt hien vd djnh vi di cdn hach co truoc phlu thuat neo vet hgch. Trong nhom 32 BN UTTG co ning do Tg cao nhung xa hinh 1-131 dm linli, Altenvoerde vd cs da tiln hanh chup FDG PET tren 12 BN. FDG PET duong tinh ft 6/12
558 Hdi nghi Khoa hgc vd Cdng nghe hgt nhdn todn quic lin thiIX, Ninh Thudn 18-19/8/2011
BN. N i n g do Tg huylt thanh cao hem o cac BN FDG PET duong tinh (23 - 277 ng/ml) so voi nhom FDG PET dm tinh ( 1 , 5 - 1 7 ng/ml). T i n g hgp cdc nghien cuu ft Diic ndm 2000, dg ddc hieu ciia FDG PET phdt hien tdi phat vd di cdn ft BN UTTG co n i n g dg Tg cao nhtmg xa hinh I-131 am tinh la 85 - 94%, do ddc hieu 9 0 - 9 5 % .
Dua tren ket qua FDG PET/CT, chiing toi da quylt djnh thay d i i chiln thudt dilu tri 6 13 BN (50%). Trong do, phuang phdp dugc lira chgn chu y l u la phau thugt co kit hgp voi dieu tri xg trj ngoai hogc 1-131. Trong nghien ciru cua Schluter va cs v l dnh huftng ciia FDG PET d i i voi ijilu tri ft 64 BN UTTG, 44 BN co hinh anh FDG PET duong tinh (34 duong tuih that, 7 duong tinh gia, 2 ung thu thii phat vd 1 danh gid dugc) va 20 BN co hinh dnh FDG PET am tinh (5 dm tinh that, 15 dm tinh gid). Theo ket qua nghiSn cuu ndy, gig tri du bao am tinh Id 83%, gid tri du bdo dm tinh 25%i, chien luge di^u trj thay d i i ft 19 trong s l 34 BN duong tinh that. Su ra doi ciia PET/CT da cho phep djnh vj t i n thuong t i t han, giam ty le duong tinh gid, cai thien do tin cdy ciia FDG PET/CT. Nghidn ciiu ciia Ong va cs da thiy do nhgy cug FDG PET/CT Id 88,2%, Nahas va cs nghien cuu dnh huftng cua PET/CT len viec dilu trj 33 BN tai phat do UTTG t h i nhii. FDG PET/CT cung c i p nhung thong tin b l sung dan toi thay d i i viec dilu tri ft 67%. s l BN, do chinh xac cua PET/CT Id 70%, do nhay 66%, dp dac hieu 100%, gid frj du bao duang tinh 100%,. Khi PET/CT duong tinh, no la phuong tien chdn dodn xdc dinh chinh xdc vj tri t i n thuong tdi phdt cua UTTG t h i nhii. Cdc tac gia kit ludn PET/CT c6 gid tri nhit trong phdt hien vd dilu tri BN UTTG t h i nhii co Tg huylt thanh Ion hon 10 ng/ml. Nghien ciiu ciia Peter Lind vd cs da khing djnh PET/CT chinh xac han PET hogc CT don dgc, kit qua chup PET/CT lam giam ty le phat hien nhOng t i n thuong khong ro rang, tang do tin cdy, dem lai thong tin b l sung o 4 5 % s l BN va lam thay dii qua trinh dieu trj ft 17%, BN (nhu thay doi truong chieu xg, xg tri thay vi phdu thuat, xa trj ngoai . . . ) . Holger Palmedo cung thiy PET/CT lam thay d i i chiln thudt dilu tn a 4 8 % BN.
KET LUAN: FDG PET/CT la mgt phuong phap c6 gid trj cao trong chin doan phdt hien tai phat vd di can ft cac b?nh nhan ung thu tuyen gidp biet hoa co xg hinh 1-131 todn than dm tinh va thyroglobulin huylt thanh cao. 65,5%, s l BN co d i u hieu t i n thucmg tai phdt tai ch§
hoac/va di can hgch e l , di can xa. FDG PET/CT giiip thay d i i chiln thudt dilu trj o 50%
nhom BN UTTG biet hoa ndy.
TAI LIEU THAM K H A O
[1] Domonique Delbeke, R, Edward Coleman et al. (2006). Proceduce guideline for tumor imaging with 18-F FDG PET/CT 1*. SNM 2006.
[2] James W. Fletcher et al. Recommedation on the use of 18-F FDG PET in Oncology. J Nucl Med 2008; 49: 480 - 508.
[3] Holger Palmedo, Jan Bucerius, Alexius Joe et al. (2006). Integrated PET/CT in differentiated thyroid cancer: Diagnostic accuracy and impact on patients management. J Nucl Med; 47: 6 1 6 - 6 2 4 .
[4] Hui Wang, Hong Liang Fu, Jia Ning Li et al. (2008). Comparison of whole-body 18F- FDG SPECT and posttherapeutic 1-131 scintigraphy in the detection of metastatic fliyroid cancer. Clinical Imaging 32: 32 - 37.
[5] Mi-Yeon Choi, June-Key Chung, Ho-Yeong Lee et al. (2006). The clinical impact of 18F - FDG PET in papillary thyroid carcinoma with a negative 1-131 whole body scan: a single-center study of 108 patients. Annals of Nuclear Medicine 20 (8): 547 - 552 . [6] Lotty Hooft, Otto S. Hoeksfra et al. (2001). Diagnostic Accuracy of 18F-
Fluorodeoxyglucose Positron Emission Tomography in the Follow-up of Papillary or Follicular Thyroid Cancer. J Clin Endocrinol Metab 86: 3779 - 3786.
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[7] Peter Lind, Susaime Kohlfrst (2006). Respective roles of thyroglobulin, radioiodine imaging and positron emission tomography in the assessment of thyroid cancer. Semi Nucl Med 36: 194-205.
[8] Steven M. Larson, Richard Robbins (2002). Positron Emission Tomography in thyroid cancer management. Seminar in Roentgenology, 37 (2): 169 - 174.
[9]HaT.T. Phan, PieterL. Jageretal. (2008). Comparison of C-11 methionine PET and 18F- Fluorodeoxyglucose PET in differentiated thyroid cancer. Nuclear Medicine Communication, 29: 711 -716.
