Y HQC VIET NAM THANG 3 - 3 0 2/2015 Nghien eiiu eua ehung tot da chi ra eong eu
SGA CO do nhay va dp dac hieu cao de xae dinh cac tre em suy dinh duSng, dang ed nguy ed suy dinh dudng. Ap dung eong cu SGA trong sang Ipc va danh gia tinh trang dinh duSng, giup eho eong tae ho t r d dinh dudng sdm nham giam t y le suy dinh dudng, giam eae bien chu'ng lien quan den dinh du@ng.
V. K ^ L U A N
Phu'dng phap danh gia tlnh trang dinh du@ng theo rang cu SGA ddn gian, co do nhay va dp dac hieu cao de phat hien dung cac tru'dng hdp suy dinh duQng va khong suy dinh du@ng. Cdng eu SGA can du'dc thyc hien d cac benh vien de sang Ipc, danh gia tinh trang dinh du^ng eua tre em
TAIUIUTHAMKHAO
1 . Baker JP, Detsky AS, Wesson DE, e t al (1982). Nutritional assessment: a comparison of dinical Judgment and objective measurement.
New EnglandJoumal of Medidne. 306,969-972
Detsky AS, McLaughlin JR, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN (1987). What is subjective global assessment of nutritional status? JPEN J Pa/vnter Enteral IVutr,mi),8-13.
Elmore MP, Wagner DR, Knoll DM, et al (1994). Developing an effective adult nutrition screening tool for a community hospital. J Am Diet Assoc. 94(10), 1113-8
Kenneth EC (2002). Malnutrition and bad oucome. J Gen Mem Med. 17(12), 956-957 Seeker D3, Jeejeebhoy K (2007). Subjective Global nutrition assessmnet for children. Am J Oin Nutr. 85,1083-9
Thoresen L, Fjeldtad I , Krogstad K, e t a l (2002). Nutrition status of patient with advanced cancer; the value of using the subjective global assessment of nutritional stetus as a screening tool. Paliiat Medicine. 16,33-42
WHO (2006). Child growth standards. Geneva:
World Health Organization. Available at:
http;//www.who.int/ehildgrowth/standards/en/,htt p://www.who.inVchildgrowth/standards/tedinlcal _reporVen/index.html
NGHitU Ciru VAI TRO CUA SIEU AM NOI TRITC TRANG
B A N H GIA GIAI DOAN UNG THU- TRirC TRANG
T6MTAT
Mvc tISu nghien cihi:
1. Dinh gia vai trd cOia sieu am nol tri/c trang Chan dodn glal doan kh5l u va dl cSn haeh (uT- uN) ung thu tn/c b-ang
2. Tim hieu mot s5 yeu to lien quan tdi ket qua eOa sl§u 3m nOl trut trang
Phu'dng ph^p: Dinh gia mot phUdng phip eh^n doin- den cu\j
60 b#nh nhSn ung thu* tn/c trang du'dc lam sieu I m npi tri/c tring trude mo danh gii glal doan sau dd du'dc phSu ttiuSt triet cSn v i so sanh vdi ket qui giii phau benh sau m6 (ty le chan doin dicing glai doan T v i N, do nh^y, do d$c hl^u)
* Khoa ngoai T i n trieu - Benh vlen K Chiu trich nhiem chinh: Pham Vin Binh Email: [email protected] Dt: 0904145909 Ngiy nh$n b i i : 4.2.2015
Ngiy phin blen khoa hpe: 30.2.2015 Ngiy duyet b i i : 5.3.2015
P h ^ m v a n B i n h * , T r 4 n D i n h T S n * Ket qua: 25 (41,6%) BN nam, 35 (58,4%) BN nff-Tufil trung binh 59,6. 40 (66,7%) ea u tn/e tring thap, 17 (28,3%) ca tmng binh, 3 (5%) ca u tn/c tring cao, 12 (20%) ca u chiem 1/3 chu vl, 48 (80%)ca u chiem tren VJ chu vi. Ty le chan doan dung cua sieu am nol trut tring giai doan khoi u 66,7%, dl cin h^di 56,6% (do nhay l i 94,1%, dp die hi§u 79%)
K ^ tu^n: sieu am npi trut trang danh g i i glai doan ung thu' trUc trang i p dung tai Benh vlen K e61^' le ehan doan di^ng: khoi u 66,7%, di cin hach 58,3%
(dp nhay 94,1%, dp die hieu 79%). The tich ehu vi khoi u va kinh nghiem ciiia bic sy lam sieu i m c6 khi ning anh hudng tdi ket qua cua sieu i m n$l true tring.
SUMIVIARY
THE ROLE OF TRANSRECTAL ULTRASOUND I N THE EVALUATION
OF RECTAL CANCER STAGING Objectives:
1, Assess the role of transrectal ultrasound in the diagnosis of T and N staging (uT - uN) of rectal cancer
Y HOC VIET NAM THANG 3 • SO 2/2015 2. Rnd out factors effected on result of
transrectal uftr^sound.
Methods: Evaluate value of diagnostic test.
Prospective study on 60 patients with rectal cancsr undergoing preoperative transrectal ultrasound for staging and then radical surgery. Outcome of transrectal ultrasound were compared to postoperative pathology results (sensitivity, specificity, accuracy rate value)
Results: 25 (41.5%) male patients, 35 (58.4%) female padents. Average age is 59.6y. 40 (66.7%) cases with low rectal cancer, 17 (28.4%) cases with middle rectal cancer, and 3 (5%) cases wlUl upper redal cancer, 12 (20%) one tiiird drcumferentlal involvement, 48 (80%) over a half drcumferential Involvement Tlie rate of accuracy diagnosis of bansrectal endoscopic utoasound Is 55% for T stage, and 56.6% for N stage (sensitivity 94.1%, specificity 79%)
Conclusion; Transrectal ultrasound in evaluation of T and N stage of rectal cancer at K Hospital has accuracy rate Is 66.7% and 58.3% respectively (sensitivity 94.1%, specificity 79%). Circumference of the tumor Involvement and experience of the doctors performing transrectal uibasound affect the outcome of bansrectal utosound.
I.CATVXNCI
Ung thu dai trUc tilng (UTDTT) la nguyen nhin giy tir vong dirtig hang thii" 3 trong cae b|nh ly ung trin till gidi. Nam 2012 td chii'c y t l the gidi thdng bao UTBTT chilm 10% eae trudng hpp ung thu mdi mac va ty le tU vong la 8% trong eae benh ung thu. Ung thir true trang (UTTT) chiem khoang 1/3 sd UTDTT.Tiieo tilu ehuan eiia vl|n nghien edu ung thu quoe gia Hoa Ky UTTT dUde ti'nh la ung thu trong do?n true tiang 15 em tinh tU ria hau mdn trd len. U'dc tinh d l*ly nam 2013 cd khoanp 40340 benh nhan UTTT mdi mie v l tal Chau Au ty II mac UTTT II 50/100.000 dan vdi 80.000 ea tU vong moi nam [1],[3]. Oieu til UTTT la mdt trong nhOtig benh ly dien hinh dieu tii da md thUe: phau thuat - hda chat-tia xa. De ed phac dd dieu trj phii iipp phai dUa vio ehan doln glal doan UTTT. Trong Chan doln giai doan UTTT cd nhieu phudng tiln chan doln hinh anh ditdc ap dung nhu cpng hudng tu (MIU), chup eit Idp (CT), tuy nhiln sliu am ndi sol (SANS) ngay eing dupe irtig dung ring rai.
Cac nghlen cihi gan day trin t h i gidl cho thay SANS Chan doan glal doan khdl u (T) ehinh xae tu 70% den 90%, di can haeh diing den 60- 80% so vdl kit qui glai phau benh sau mo [7].
a Vl|t Nam SANS da dUde Ip dung d eae benh vi|n trudng dai hpc Idn tiding chan doln glal
doan UTTT, tuy nhien chUa ed nhieu bao cao ve ITnh vUc nay. Tai Benh vien K trong 1 nam trd lai day da ap dung sieu am npi trUc trang (SANTT) dau do ciilig (rigid transrectal ultrasound), de danh gia ket qua ciia phUdng phap nay chiing toi tien hanh nghien cud vdi myc tieu:
1. Danh gii vai trd cua sieu am noi trut trang chan doan glai doan khdi u va di ein hach (uT~ uNJ ung thw trWc trang (so vdi ket qua giai phau benh sau md'pT, pU)
2. Tim hieu mdt sd yeu td lien quan tdi kit qui eua sieu im ndi trWc tring: vl tn khS u, kich thwdc ehu vi khdi u, kinh nghiem eua bac sy SANS...
II. edi TirpNG vA PHycnviG PHAP NGHIEN COU 2.1. eoi tUOng nghiin cii'u
Cae benh nhan LfTTT dUde SANTT dinh gia glal doan sau dd phau thuat triet can vl phSu tich benh pham tai khoa ngoai Tan trieu ^ 1/1/2014 den 15/08/2014
- Tilu ehuan ehpn benh nhin
Benh nhan d\i:dc chan doan xae djnh UTTT (bi^u md tuyen Adenocarcinoma) bang kit qua npi sol sinh thiet, ed ehi djnh phau thuat trilt can.
SANTT trUdc mo danh gia giai doan UTTTi glal doan xim lan khdl u (T) va glal doan di can haeh (N) theo phan loal AJCC 2010.
Oanh gia ket qua gial doan LTTTT sau mo (pT) va di can hach (pN) theo phan loal AJCC 2010.
-Tilu ehuan loai trd: benh nhan UTTT ed dl can xa (Ml) hay da xam lan eae tang lan can (T4b);
UTTT ban hoac tae rupt; LTTTT hoa xa trj trUdc mo, UTTT tal phit.
2.2. PhUOng phap nghiin cii'u: danh gia mpt nghiem phap ehan doan - tiln aid
Cdng eu Hen hanh nghien cirti; may sieu Im ALOCA, dau dd ndi soi true trang dng ciihg dp phan giai eao 10 I4Hz.
Ope kit qua glai phau benh (glal doan pT- pN] sau mo tai khoa glai phau benh Benh viln K.
Phau thuat true trang triet can tai lihoa ngo?l Tan Trilu; eat doan, eat cut trUe trang
Thu thap sd lieu theo mau benh an vdl cac chi^tllu nghlen cUu da dinh san: lay kit qui gill phau benh sau md (pT- pN) la tilu ehuan ving de danh gia gia trj chan doan diing do xim i n khdi u va dl can hach eiia SANTT. Xd ly sd lieu theo cac thuat hian tiidng ke: hSnh mire dp chin doan dung (%) glai doan khdi (u'T) va di ein
Y HOC V l | T NAM THANG 3 - SO 2/2015
hach (uN) ciia phudng phap SANTT so vdi ket qua giii phau benh sau mo (pT-pN).
2.3. Chi tieu nghien cii'u:
Tudi - gidl:
- Chan doln glal phau benh trUde md xae djnh UTTT bleu md tuyen.
- Vj trd khdi u true tring: eao - trung binh - thap
- ed xam lan cua khdi u trin SANTT (Tl, T2, T3, T4a)- so sanh vdi ket qua giai phau benh sau md (giai doan pTl- pT2- pT3, pT4a) - Ty II di can hach tren SANTT (N+) - so vdi ket qua glal phau benh sau mo (giai doan pN+)
lac yeu td anh hudng tdi kit qua eua SANTT:
vj tri khdi u, kich thudc ehu vi khdl u, kinh nghiem cua bdc sy SAI^TTT ...
III. KfrQUANGHieN CIJ'U
- 60 benh nhan UTTT dUde lam SANTT va phau thuit triet can tal khoa ngoai Tan Trieu: 25 (41,6%) BN nam, 35 (58,4%) BN nil'. Tudi trung binh la 59,6 .
Bleu dS I; vj tri khdl u trUe tring
40 20 0
UTTTUi?p UTTT trung UTTT cao binh
BiSu dS 2: The tich u v l ehu vi true trang
60 40 ' 20 • '
0 •
Uchi?ml/3 Uchi?mtren chuvi 1/2 chu vi
Bing 1 / So sanh kit qua glai doan khdi U(uT
SANTT (uT) C/o)T l 0 T2 7 (11,6%)
T3 35(58,4%) T4a 18 (30%)
Tonq 60 (100%)
qvia SAf^TT va qial phau benh
Giai phau benh (p'HC/o)T l 0 T2 4 (6,6%) T3 36(60%) T4a 20 (33,4%)
60 (100%)
Ty 14 chSn doin dung ehung eho de giai doan khdi u la (40/60) 66,7
Y HOC VI^T NAM THANG 3 - s 6 2/2015
Bing2;{>o nhay v l do dac hieu di can haeh (uN) ciia SANTT so vdi
ShKn dUdnq ti'nh SANTT am b'nh
Tdnq
GPB du'dng tinh
16
1 17
GPB am tinh
9 34 43
giai phau benh pN
Tong25
35 60 Dd nhay = 16/(16+1) = 94,1%
do die hieu = 34/(34+9) = 79%
Ty le sdbenh nhin chan doan dung di can haeh cua SANTT ii 58,3%(35/60) IV. BAN LUiiLN
SANS true tiang ed tiie UiUc hien bang 2 phudng phip: dau rd ndi true trang dng eirtig (rigid tiansreetal ultiasound -TRUS) thudng dUde ap dung bdi cle bae sT di|n quang hay phau thu|t vlen dai tii/c trang v l sliu am dau rd ndi true bang dng men (flexible video echoendoscopes) dUpe thiet k l gidng nhU dau rp sliu Im ndi sol dudng Ueu hoa tiln. Mpt tiong nhifng han che eiia SANTT la khd thUe hi|n ti^n b|nh nhan u tiife tiang chit hep Idng true trang.
Trong nghiin eiiU nay chiing tdi diing SANTT dau rd dng cirtig va khdng ehi djnh cho nhiitig benh nhin u vdng nhan gay chit hep Idng tiUe trang.
Savldes.TJ cho rang khoang 95% i m T II ung thu blen md tuyen xuat phit tU nilm mac, hinh Inh khdi u true trang trin SANTT thudng ed hinh Inh khdi giam am (hypoeehpic) va tuy theo miit dp xam lan khi cd hinh anh pha vd sU lien tgc aia 5 Idp ciia thinh bue tring nhu Idp nilm mac, dudi niem mac, ed niem... ma ta phan loal dupe giai doan khdl (uT). Trong nhDtig ttiap ky gan day khoa hpc edng ngh| chan doln hinh Inh da cd nhiitig budc Hln Idn dUde ap dung trong ehan doan giai doan UTTT nhU MRI 3 Tesia- coil npi true tiang, CT da ray, PET [2],[4],[6] ... vay SANTT dang duHc xep d vj tri nao?
Puli.SR et al ding tiln tap chi Surgical Oncptogy nam 2009 mdt nghiin eirti thdng k l tat c l d c bli bio Viet ve SANS tn/c trang tren cac t?p ehi Idn: MEDLINE, OVID, Cochrane, Pubmed tir nim 1980 din 2008, 3630 bai bio ed 42 nghlen cifti vdl 5039 benh nhan dUdc SANS trUc tring danh gia giai doan ung thu. Kit qua tinh gdp lai lan lUdt la: giai doan T l ty II ehan doan diing II 87%, T2 80,5%, T3 90,2% va T4 la 95,4%. Tie gia kit luan SANS tii/e trang la mpt Ipa ehpn tdt de danh gia glal doan khdl u va khdl u eang xam lan nhieu cac Idp ciia thanh trUc
trang thi dp chinh xae eiia SANS cang eao. COng mdt nghiin ciid khae tai Benh viln Bang Minnesota eho thay ty II chan doan dung glai doan khdl u la 69%. Khi ket qua eiia SANTT khdng tUdng xirtig so vdl kit qui glai phau benh thi thudng cd su hudng ehan doan qua glai doan (overstage cancer) bdi khdng the phan bllt du?c viing td ehUc vien xung quanh khdi u vdi gidi han xim lan ciia ehinh khdi u va thudng Idiii phan dinh glQ^ T2 va T3. Trong nghiin ciiti eua ehiing tdi SANTT cd ty II ehan doan dung khdl u la (40/60) 66,7% tiong dd glal doan T2 c6 3 trudng hdp (7/60) qua giai doan so vdl gill ph^u b|nh (4/60). Vdi T3 va T4 thi ngUiJc lai SANTT dudi giai doan so vdl gial phau benh (58,3%- 60%) va (30%-33,3%) (Ba.ngl).
Ahuja.NK et al nghiin eUu hoi cud tai 4 b|nh viln d^i hpe Hoa Ky trong 2 nam vdl 86 b^nh nhan SANTT danh gia glai doan thly ty I? dl/
bio am tinh dp xam nhap khdl u II 83,7%, ty le Chan doln diing dp xam lan khdi u la 77% vl tae gia cung dUa ra nhan xet la danh gia sal giai doan eiing thudng xay ra glQa T2 v l T3 [1].
Phan Idn eae nghlen eUu v l SANS true trang tren the gidi deu cd nhan xet rang thdng thudng khdng nhin thay hinh Inh haeh quanh trUe trang tren SANTT, nIn khi cd tiat ky hinh anh haeh nao quan sat thay deu dUde eho la hach dl d n ciia UTTT v l dUde tinh la N+ [5]. Hinh anh h?ch lympho dl ein quanh tiUe trang ed hinh tron giam am so vdl eau triic md quanh trUc tring.
Tuy nhiln cung cd tae gll lai dUa ra quan diem kich thudc hach phai tien Smm, hinh trdn cd cau triic giam am mdi dUde cho la haeh dl d n de phan bllt vdl haeh viem hinh oval eau true tang Im (hyperechogene)[4]. Trong thUc t l lam sing ed nhutig nghiin cud phau .tich benh pham UTTT sau mo thay cd tdi 30% den 58% hach dl dn ung thu ed kich thudc < Smm, vi vay t?i thcfi
J
Y HOC VlfT NAM THANG 3 - 3 0 2/2015 diem h i l n nay xep loai di can hach trong UTTT
tren SANS cae t i e gia van thdng nhat khi quan sat thay ed hinh anh hach quanh trUe trang [ 5 ] . Savide.Ti bao d o t r i n 545 UTTT dUpc lam SANTT dau rd eirtig ty I I ehan doan dung haeh di d n quanh true trang la 6 4 % . Cung theo b i o d o eiia Gleeson nam 2009 vdl 76 benh nhan ung t h u true trang dupe lam SANTT, ty I I chan doan diing hach dl d n la 6 8 % t 5 ] . Krajewski KM tdng hdp d c nghlen cUu ve SANS true tiang tai My bao d o n i m 2009 t y I I ehSn doan dung di d n hach til 6 4 % den 8 0 % , dp nhay 8 0 % - 9 0 % , do d i e h l | u 8 4 % - 9 2 % [ 7 ] .
Vdl 60 b|nh nhan LTTTT eiia chung tdi ty le Chan d o l n diing hach di d n so vdl giai phSu benh sau md chi dat (35/60) 58,3%, tiong d d dp nh^y la 9 4 , 1 % dp d | c hieu 7 9 %
Nhin iai k i t qua 60 benh nhan trong nghiin cuti cua chiing tdi SANTT cd ty I I danh g i i dung gial doan x i m lan khdi u va dl can haeh quanh tn/c tiing thap hdn d e t i e g l l nude ngoai (66,7% va 58,3%) vay nhirtig n g u y i n nhan nao anh hudng Idi k i t qua SANTT nay? Da ed nhii'ng nghiin eiitj so s i n h g i l l trj ciia SANS true trang vdi MRI, CT va phan tich cae yeu t d I n h hUdng tdi k i t qua ciia SANTT n h u sau d i l u trj tan bd trp hoa x ; trj, sU chit hep khdl u d long tr\tc bang gay khd khan eho U l p d " dau rd vao khdi u, v i l m tay quanh u , u true t r i n g tai phat tal cho v l m$t yeu t d quan trpng nu;a la kinh nghiem eiia b l e sy l l m SANTT [ 5 ] . Nghiin cUU ciia ehiing tdi vdi d c benh nhan dUdc dieu tri h o i xa tri trUdc mo, benh nhan ed dau h i | u ban t i e rupt hay UTTT t i l phat deu dUdc loal trir khdl nghiin cud. Trong 60 benh n h i n cd 66,7%
(40/60) I I u true trang thap chi cd 5% (3/60) u trifc ti'lng eao (Bleu do 1) va 8 0 % (48/60) benh nhan cd khdl u tide tiang ehiem t r i n 'A chu vi bve bang ( B i l u do 2), day cd Hie la yeu t d anh hudng tiii nhieu am khi dau rd dng cdng H i p can bS mat khdi u. Cac t i c gia ed neu nhan xet khi vj tii khdl u d tr^Tc trang eao gan n i p gap van trUc t r i n g t t i n thi anh hudng tdi dp chinh sac Mil danh g l l x i m lan khdl u cung nhu tim hinh I n h dl d n hach do nhieu am, tuy nhien chiing tdi chi ed 3 benh nhan u trifc trang eao.
Trong n g h i i n cifu ciia chiing toi day la giai doan dau ap dung SANTT vao chan doan gial doan LTTTT nen nhdm n g h i i n ciili van d n thdi gian va sd lUpng benh nhan nhieu hdn eho mdi bae sy lam SANTT de dat dupe ket qua chan doan dung giai doan cao hdn.
V . KET L U A N
Qua n g h i i n euU SANTT tren 60 benh n h i n UTTT so sanh vdi k i t qua giai phau benh tai Benh vlen K chiing tdi rut ra mpt sd k i t luan sau:
- Ty I I Chan doan dung glal doan xam lan khdi U I I 66,7%, ty le ehan doan diing di d n haeh la 58,3% (dp nhay 9 4 , 1 % , dp dae hieu 79%) - The tich ehu vl khdl u ( 8 0 % sd benh n h i n cd u ehiem t r i n '/2 ehu vi Idng true trang) va kinh nghi|m ciia ngUdi lam SAI^iTT la d c yeu t d ed kha nang anh hudng tdi k i t q u i eiia SANTT.
T A I L i f U THAIVI KHAO
1 . Ahuja.NK, Sauer.BG, Vifang.AY et al (2014)
"peifomiance of endoscopic ultrasound In staging rectal adenocarcinoma appropriate for primary surgical resection". Clinical gastroenterology and hepatology. Vol 1, No 6, pp 1-7
2. Blomqvlst.L, Machado.M, Rubio.C et al (2000)
" Rectal tumour staging: MR imaging using pelvic phased- array and endorectal coil vs endoscopic ulbasonography" Eur Radiol .10,653-660 3. C r a v c M , Rodrigues.T, Ouro. S et al (2014) "
i4anagement of rectal cancer: Times they are changing". Ge J port Gastrenterol 1-9 4. Giovannini.M (2007). " Echographle endorectale
et cancer du rectum". Acta Endoscopla, vol 37, No 1, pp 15-25
5. Gleeson.FC, Clain.3E, Papachristou. G I et al (2009). " Prospective assessment of EUS criteria for lymphadenopathy associated with rectal cancer". Gastrointestinal Endoscopy. Vol 69, No 4, pp 896-903
6. Kim.JC, Kim.HC, Yu.CS et al (2006) " Efficacy of 3- dimensional endorectal ultrasonography compared with conventional ultrasonography and computed tomography in preoperative rectal cancer staging". The American journal of surgery 192: 89-97
7. Krajewslii. KM, Kane.RA (2008). ' Uibasound staging of rectal cancer". Semin Ultrasound CT MRI. Elsevier Inc 29: 427-432
