Y HOC VIET HAH THANG 1 1 - s d CHUYEN pg-2015
NGHIEN CUTJ HQI CHU'NG CAN UNG THU"
(r BENH NHAN UNG THU" PHOI NGUYEN PHAT TAI TIIUNG TAM HO HAP - BENH VIEN BACH MAI
Le Hoan*, Bang Thanh Do**, Vii Van Giap*, Bang Hiing Minh*, Ngo Quy Chau*
T6M TAT
D^t van de; Hpi chiing (HC) can ung thu cd val trd quan trong trong chan doan, dieu trj va Uen luang benh nhan ung thU phoi. O Viet Nam cho den nay chi cd mgt vai nghien cuU ve hdi chuhg nay. Muc dich: md ta mgt sd dSc diem lam sang va can lam sang ciia ung thu phdi nguyen phat va md ta cac hdi chiing can ung thu thuftig gap trong ung thu phoi nguyen phat.
961 tu'dng va phu'dng phdp nghien ciiti: hdi dhi md ta tren 77 benh nhan dUdc chan doan ung thu phdi nguyen phat cd hol chuhg can ung tiiU tai Tmng tam Hd Hap- Benh vien Bach Mai tir 01/01/2012 den 31/12/2013. Ket qua va ket lu|n: ti le nam/nO' la 4,5/1; 87,0% benh nhan tir 50 tuoi trd len, do tuoi trung binh 62,16 ± 11,32;
72,7% benh nhan cd hut thuoc la; trieu chiing dau ngUc 66,2%, ho keo dai 61,0%, kho thd 40,3%; gay siit can 45,5%; ti Id HC can ung thu trong ung thU phdi la 8,7%; trong dd HC Pierre- Marie chiem a le 35,1%, HC Schwartz- Bartter 33,7%, HC tang tteu cau 21%, HC tang canxi mau 13,0%, HC vii to d nam gidi 2,6%.
Tittthoa; ung thU phot, hpi chiiiig can ung ttlU.
SUMMARY
PARANEOPLASTIC SYNDROMES IN PRIMARY LUNG CANCER PATIENTS
IN RESPIRATORY CENTER
• Trung Idm Hd hdp - Bfnh vifn Bgch Mai
" .linh vien Y6 • Dgi hpc Y Hd Npi 2009-2015 Chju trach nhipm chinh: Le Hoan
Email: [email protected] Ngiy nhan bai: 17/9/2015 Ngiy phin bipn khoa hpc: 16/10/2015 Ngiy duypt bii: 23/10/2015
OF B A C H M A I HOSPITAL Purpose: Review clinical characteristics, subclinical characteristics of primary lung cancer and frequent paraneoplastic syndromes of primary lung cancer . Subjects and Methods:
descriptive study of 77 patents were conflnned primary lung cancer .with paraneoplastic syndromes in Respiratory Center at Bach Mai hospital from 01/2012 to 12/2013. Results and conclusions: Male/female 4.5/1; average age 62.16 ± 11.32; 87.0% patients aged over 50 years old; 72.7% patients are smokers; primarily respiratory symptoms: chest pain 66.2%, chronic cough 61.0%, shortness of breatti 40.3%, cachexia 45.5%; Incidence of paraneoplastic syndromes of primary lung cancer is 8.7%;
include Pierre- Marie syndrome 35.1%, Schwartz- Bartter syndrome 33.7%, thrombocytosis 21.0%,
gynecomastia 2.6%.
Keywords; lung syndromes.
hypercalcaemia 13.0%, cancer, paraneoplastic
I. OAT VAN o l
Ung thu phdi la ung thu phd bien tiong nhieu thap ki qua va eho den nam 2012, udc tinh ed 1.825.000 trudng hgp mdi mic, chiim 13.0% tdng sd ttudng hgp ung thu mdi phat hipn. Ung thu phdi cung la loji ung thu ed ti I? hi vong hang dau vdi khoang 1.590.000 ca ttr vong, chiim 19,4% tdng sd eatu vong do ung thu nam 2012 [1].
Trong sudt chieu dai ljch su nghien ciiu va diiu tri cac bpnh ly ac tinh ndi ehung va ung thu phdi ndi rieng. ngudi ta da nhgn ra mdi lien he gitta ung thu va mdt sd bieu hipn toan than ma khdng lien quan tdi sir xam lin 117
CHAO M 0 N G H Q I NGHj KHOA HOC THUdNG NIEN HOI HO HAP VIET NAM
hay di can cua kh6i u, tir do ra dai thuat ngu
"HC can ung thir" [2]. Ciing vai viec phat hien ra mgt loat cac hormon cua ca the, ca ch^ cua hgi chung nay cung dan dan sang to.
Cac r6i loan ngi ti8t gay ra HC can ung thu dugc nghien cuu nhieu nhat co the ke den nhu HC vu to a dan ong (HC vii to) lien quan d6n HCG, HC tang canxi mau c^n ung thu (HC tang Ca) lien quan din PTH, HC ha natri mau can ung thu (HC Schwartz- Bartter) lien quan din ADH... [3] Ngoai ca chl npi tilt, cac HC nay con do ca che tir khang thi va ca chl tac dgng len chuyin hoa cung da duac nghien ciru nhilu tren thi giai [4].
HC c ^ ung thu g^p trong ung thu ph6i voi ti 1? khoang 10% [5]. NhGng bilu hien cua no CO vai tro quan trgng trong ca chan doan, dieu tri va tien lugng benh nhan ung thu ph6i. HC can ung thu co the bieu hien s6m truac cac dau hieu cua ung thu, luc nay viec n h ^ dinh dung cac trieu chung do se giup b?nh nhan dugc chan doan va dieu trj ung thu a giai doan sam han [6]. Dong thofi dua vao HC can ung thu xudt hi?n a b^nh nhan ung thu phoi co the giup bac sT djnh huong dugc loai tl bao u, huang dieu tri cung nhu tien lugng dap i^g vai dieu tri ciia benh nhan. Doi khi, nhung anh huang ciia HC can ung thu co kha nSng gay nguy hiem din cugc sing han la ban than kh6i u. Mac dil v^y, hgi chung nay van chua dugc cac th^y thuic lam sang quan tam mgt each thuc SIJ trir truang hgp b?nh nhan chju anh huang qud n$ng. Tren ca so do, chiing toi tiln hanh nghien cuu nay voi hai muc tieu:
/. Mo td mgt so dde diem ldm sdng vd can ldm sdng cita ung thu phoi nguyen phdt.
2. Mo td cdc hgi chung cgn ung thu thudng gap trong ung thu phoi nguyen phdt.
II. DOt TU'ONG VA PHirONG PHAP NGHIEN COU 2.1. Doi tirgng nghien cihi
77 benh nhan ung thu phoi co bieu hien HC can ung thu trong tong so 887 benh nhan dugc chan doan ung thu phoi tai Trung tam Ho hip Benh vien Bach Mai tir 01/01/2012 din 31/12/2013.
2.1.1, Tiiu chuan chgn benh nhdn
• Benh nhan dugc chan doan xac dinh ung thu ph6i CO bang chiing rao benh hgc va/hoac te bao hoc
- Co bieu hien ciia HC can ung thu.
2.1.2. Tieu chudn logi trir bfnh nhdn - Benh nhSn ung thu phoi thii phat.
- Khong CO bieu hien hgi chung c£tn ung thu 2.2. Phirong phap nghiSn cuu: Nghien ciru hoi cuu, mo ta cat ngang.
III. KET QUA
3.1 D^c diem chung cua nhom nghien ciVu
- Giai; ti le nam/nO la 4,5/1
Tu6i: 87,0% benh nhan tir 50 tuli tro len, do tuoi trung binh 62,16 ± 11,32
72.7% benh nhan co hiit thuoc la.
Trieu chiing ho hap: dau nguc 66,2%, ho keo dai 61,0%, kho tho 40,3%.
Trieu chiing toan than: giy siit can 45,5%.
T6n thuang mo benh hgc: UTBM tuyln 57,1%, UTBM tl bao nho 16,9% va UTBM ll bao vay 15,6%, va mgt so type te hko khac.
- Giai doan ung thu: giai doan Illb va giai doan IV chiem 68,3%.
3.2 Dac diem ciia cac h9i chirng c?n ung thir
Ty ie HC can ung thu trong ung thu phoi la 8,7%.
- Ty le timg HC c^n ung thu
118
Y HQC VIET NAM T H A N G 11 • SO CHUViN BE • 2015
ff i : Ty le rung HC can ung thu HC c$n ung thir HC tang canxi mau HC Schwartz- Bartter
HC vii to d nam gidi HC Pierre- Marie HC tang tieu cau
n 10 26 2 27 21
%
13,0 33,7 2,fa 35,1 27,3 Nhan xet: HC Schwartz- Bartter va HC Pierre- Marie pho bien han cac HC khac Lien quan giQ-a mgt s6 HC c ^ ung thu va giai doan img thu
H$i chihig
HC Pierre- Marie HC Schwartz- Bartter
HC t ^ g canxi mau HC tang tieu ckn
<IIla (giai do^n khu trii v(H UTBMTB nhd)
n 8 4 0 2
%
30.8 15,4 0 11,1
>IIIa (giai doan lan rong vdi UTBMTB nho)
n 18 22 10 16
%
69,2 84,6 100,0 88,9
T6ng
26 26 10 18 Nhgn xet: ckc HC c^n ung thu gap vai ty 1? cao han a giai doan mugn
IV. BAN LU$N
4.1. Ti If cdc HC cSn ung thir Trong nghien ciiu cua chiing toi g?lp 8,7% benh nhan co HC can ung thu, ket qua nay thip han so vai n h ^ x^t cua Spiro SG vk c^ng sy [5], ty 1? gap HC cgn ung thu trong ung thu phdi khoang 10%. Nguyen nhan do chiing toi chi thing ke cac HC can ung thu da dugc y vkn dk cgp nhilu nhit va da dugc hiiu bilt kha rQ vl ca chl benh sinh bao g6m: HC Piene Marie, HC vu to, HC Lambert- Eaton, HC Gushing, HC Schwartz- Bartter. HC tang canxi mau. HC tang tiiu ciu, HC da. Trong do, HC tang canxi mau la kit qua tuang dii vi khong phai tat ca cac dii tugng nghien ciru diu dugc lam xet nghi?m djnh lugng canxi mau (chi co 704/887 b^nh nhan).
Trong nghidn cihi ciia chiing toi HC Pierre Marie vk HC Schwartz- Bamer la hai
HC gap nhieu nhat trong cac HC can ung thu lien quan den ung thu phoi. Ket qua nay ciia chiing toi cung tucmg ty nhu nhan xet ve su thuang g^p cua cac HC nay theo Dong Khac Hung (1995) [7]. Trong t6ng s6 77 b?nh nhan co HC c^n ung thu, 35,1% truang hgp CO HC Pierre Marie, tiep den la HC Schwartz-Bartter chiem 33.7%. HC tang tieu cau chiem 27.3%. HC tang canxi mau va HC vii to gap it han vol ty 1^ lan lugt la 13,0%
va 2,6%.
4.2. Lien quan giua m9t so HC c|in ung thu va giai doan ung thu
Trong bon HC deu co ty le BN o giai doan > llla (hoac giai doan lan rgng vai UTBM te bao nho) chiem da so.
Ty le BN co HC tang canxi mau a giai doan ung thu lan rgng chiem toi 100%, cao han so vai ly le 87.7% trong nghien ciru ciia Hiraki va cgng su tren 65 b?nh nhan [8]. Dii
CHAO MCTNG HOI NGHj KHOA HOC T H U 6 N G HitU HOI HO HAP VIET NAM
chi voi 10 BN c6 HC tang canxi mau, ty le 100% trong nghien cvm cua chiing toi chua thi dai dien cho nhom BN co HC tang canxi noi chung, nlu ca mlu lan han, rat c6 the ty le nay se thay doi, nhung hien nay nguoi ta thiy ring HC tang canxi mau xay ra nhieu han a ckc BN ung thu phoi giai doan mugn.
Su c6 mgt cila HC nay a BN ung thu phii la mgt ylu tl tien lugng xiu, khong chi bai ban than tinh trang tang canxi mau co the gay biln chirng vai b?nh nhan, ma con vi tinh trgng nay con co moi tuong quan vai cac giai dogn mugn cua ung thu phii [9].
Trong cac BN co HC Schwartz- Bartter, CO 10/26 BN la UTBM te bao nho, trong so nay co 8 BN a giai dogn ung thu lan rgng (80%). Ket qua nay tuong ly vai mgt. s6 nghien ciru cua cac tac gia khac: theo Hainsworth va cgng sy, ty 1? UTBM tl bao nho o giai dogn lan rgng la 72,2% [10], theo Gross va cgng sy, ty le nay la 85,7% [11], Cac nghien ciiu vl HC Schwartz- Bartter ci b?nh nhan UTBM te bao nho cung ghi nhgn BN UTBM tl bao nho co HC Schwartz- Barrter co thai gian song ngin hon va dap ling vai h6a tri kem hon so voi BN UTBM tl bao nho khong co HC nay [10], [11].
HC Pierre- Marie co 18/26 BN (69,2%) a giai doan > llla. Kit qua nay tuang tu vai nghien ciiu cua Qiaii Xinyu (n=115), ty le b?nh nhan 6 giai dogn > Ilia chiim 76%
[12], va nghien cuu cua Takeo Ilo (n=19) li I^ nay la 73.7% [13].
Nhu v4y, cung gilng nhu ung thu phii noi chung, da so benh nhan ung thu phii co HC can ung thu di kham 6 giai dogn mugn.
Dilu nay anh huang khong nho tai kha nang dilu tri b?nh, thai gian sing ctia b?nh nhan.
Mgt sl HC can ung thu nhu HC tang canxi m^u. HC Schwartz- Bartter co thi gay nguy
kich tai tinh mang benh nhan neu khong dugc phat hien kip thoi.
4.3. Lien quan giua mot so HC c^n ung thu vfri ton thmrag mo benh h9c
4.3.1. HC Pierre- Marie
Trong 27 benh nhan co HC Pierre- Marie, UTBM tuyln c6 ti le cao nhit vai 66,7%, tilp theo la UTBM tl bao vay 14,8%.
Ket qua nay tuang tu v6i nghien ciiu cua Qian Xinyu (lin lugl la 48% va 23%) [12] va Takeo Ito (lin lugt la 53% va 21%) [13].
4.3.2. HC Schwartz- Bartter Co 26 b^nh nhan c6' tinh trang ha nalri, trong do gap nhieu nhat la UTBM te bao nho, chiem 38,5%. Kel qua nay phii hgp vai nhan xet ciia Schwartz va Bartter tir nam 1970 khi nghien ciiu tren 120 truang hgp UTP thay ring cac loai UTBM te bao nho thuang hay gay hgNa [14].
4.3.3. HC tang canxi mdu
Ve moi lien quan ciia HC tang canxi mau voi te bao hgc cua khoi u. cac lac gia tren the giai deu kel lugn HC nay gap chu yeu a UTBM te bao vay [8]. Trong nghien ciiu ciia chung toi, ty Ie UTBM tl bao vay la 50%, luang ty vai cac ket lugn tren. Tuy nhien 50% benh nhan con lai la UTBM tuyen, khong CO CO type te bao khac. Dieu nay khong phil hgp vai kit qua nghien ciiu ciia Hiraki va cgng su (2004) tren 65 b^nh nhan CO HC tang canxi mau: ro 51% UTBM vay, 23% UTBM tuyln va 15% UTBM tl bao nhd [8], Nguyen nhan co the do sl Iugng benh nhan co HC lang canxi mau trong nghien ciru ciia chiing toi khong nhieu, chi 10 b?nh nhan, va trong nghien ciiu cua chiing toi chi co 704/887 b?nh nhan dugc Iam xet nghi?m canxi mau. Ty 1? nay co the khac di nlu tit ca cac benh nhan dugc lam xet nghiem canxi mau vi day la each chinh xac nhit dk chin doan HC nay.
Y HQC V I | T NAM THANG 11 • SO CHUYEN DE - 2015
V. Kfr LUAN
- Dac diem chung cua nhom nghien cuu:
ti le nam/nO; la 4,5/1; 87,0% benh nhan tir 50 tuoi tro len, do tuli trung binh 62,16 ± 11,32;
72,7% benh nhan co hiit thuoc la; trieu chung dau nguc 66,2%, ho keo dai 61,0%, kho tho 40,3%; giy siit can 45,5%.
- Dac diem cua cdc HC can ung thu: ly 1$
HC can ung thu trong ung thu phoi la 8,7%;
trong d6 HC Pierre- Marie chiem ty Ig 35,1%, HC Schwartz- Bartter 33,7%, HC tang tiiu ciu 21%, HC tang canxi mau 13,0%. HC vii to d nam giai 2,6%; mli lien quan vol t6n thuong mo b?nh hgc: HC Pierre- Marie: UTBM tuyln 66,7%, UTBM lb vay 14,8%; HC Schwartz- Bartter: UTBM ll bao nho 38,5%. UTBM tuyln 34.5%: HC tang canxi mau: UTBM te bao vay 50%, UTBM tuyln 50%; HC tSng lilu ciu: UTBM tuyln 61,9%.
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