V H p c T P . H b C h i M i n h * T a p 18 * P h u b a n a i a S b 1 * 2 0 1 4 N g h i e n ciru Y h p c
NHAN 500 TRl/ONG HQfP UNG THU" VOM MUI HONG
Nguyen Trgng Minh*, Ddo Duy Khmth*
T O M T A T
Giai thiiu: Ung thu vom dugc md td dau tiin bai hai tdc gid khdc nhau la Regaud vd Schmtncke vdo ndm 1921. Ung thie vom thi hie'm gap tqi Hoa Ky nhung plio biih tqi chdu A vd Viet Nam Id mgt trong nhieng qud'c gia c6 ty li ung thir vom cao do, ung thu vdm Id loqi binh khdng diphdt hiin. Diiu in diinh cho ung thu vom diii nay vdn la xg tri, hda tii hode kei hgp cd hai loqi ndy. Theo to'chiec y tethi'gidi thi ung thir vom cd the dugc chia ldm 3 loqi: 11 Ung tebdo vay cx) tqo sieng; 2/ Ung thu te'bdo khong simg hda;
3 / Ung thu tebdo khdng biet hda bao gom cd lymphoepithelioma. Ung thu ndy thieang xuat phdt tir cdc thdnh cita vdm hoac tran vdm, neri gan voi tOn sg, viing khau cdi. hd'c mui hoac vimg hgng hau. Sau do ung ihu xdm Id'n de'n viing hach ldn can vd di can xa.
Do'i tugng: Bdi bdo ndy diiing ioi xin gidi tiiieu 500 tntang hgp K vom iqi phia nam vd dugc chan dodn xdc dinh la k vom tqi phong khdm TMH - BVCR trong 3.5 ndm qua.
Chd't liiu & Phucmg phdp nghiin aiu: Phieang plidp tien cdu: Chitng tot xin gidi ihiiu 500 trmnig hgp ung thu vdm song a cdc iinh phia mam. diegc phdt hiin trong thai gian 3.5 ndm (4l2iX)7 - 10/2010) thdng qua sinh tbiil vdi phuang tiin Id ngi soi Chung idi xin dira ra vdi kei qud vd nhan dinh budc (ffiu ve tinh litnh ung ihu vdm tqi cdc ttnh phia nam trong thdi gtan qua.
Kei qud: Trong thai gian 3.5 ndm vai 500 ca ung thu vdm dugc xdc dinh dieang tinh, diung tdi ghi nhdn ty li ung thu a nH giai c^ xu hudng tdng (2:1,12), binh nhdn ung thu vdm co xu heang tie (49 tuoi so vdi 55,60 hoac 65 tiidi a cdc nudc khdc), Imii hii trong sohg dai khdm khi binh dd a giai doqn tii hode qud tii (> 90%), 1 ca dttgc chdn dodn I'di iim gian qiid ddi (4 ndm) vdlcabj tdi phdt qud iihanh(lthdng sau xq tri).
Kei luam Npi soi vom dung ldc, dung doi tugng Idmdt phuang phdp rdt quan trgng tien dung, an todn ding vai su xdm lah tdi thieu (sinh thai) nhmi khi se giup phdi hien chinh xdc benh ly vd cuu mgng dw nhmi ngieai dang mang hoac mdi bj can berOi khung kiiiip ndy. Su kii ligp tdi giiea cdc chuyen Idwa Tai MQi Hgng, Gidi plidu binh m Ung buau trong diah dodn, dOu tri vd iheo ddi sau xq tri se giup dugc rdi nhieu dw nhieng benh nhdn k vom ^Idhq thdp tij li tie vong vd tdng thai gian sdhg ciia benh nhdn.
TH khoa: Ung thit vdm miii ligng (NPC), Sinh Uiiei u vom, Budu nguyin plidi, Tebdo vay, Sirng hda vd Idiong sitng hoa, Ung ihu khong biit hoa, Di can
A B T I I A C T S
NASO - PHARYNGEAL CARCINOMA (NPC) (500 CASES)
N g u y e n T r o n g M i n h , D a o D u y Khanh
* Y H o c TP. H o Chi M i n h * Vol. 18 - S u p p l e m e n t of N o 1 - 2014:83 - 88
Background: Nasopharygeal carcinoma was first described as a separate entity by Regaud and Schmincke in 1921 Nasopharyngeal carcinoma is rare in the United States. In other parts ofthe world specifically Asia and Viel Nam is one of these countries, nasopliaryngeal carcinoma occurs much more frequently. Nasopharyngeal carcinoma is diffiailt io detect early, probably because the nasopharynx isn't
easy io examine and symptoms of nasopliaryngeal carcinoma mimic those of many other conditions. The
•Khoa Tai Mui Hpng, BV Chp R | y **Khoa Kham Benh, BV Chp Ray
Tdc gid lien lac: TS. Nguyen Trong Minh D T 0903677164; Email, drnguyentrongminhig gmail.com
Chuyen De Tai Miii Hpng 85
Nghien cuu Y hpc Y Hoc TP. H b Chi M i n h * Tap 18 * P h u ban o i a Sb 1 * 2014
main treatment options for nasopharyngeal carcinoma are radiation therapy, chemotherapy or a combination of ihe tum. Three subtypes of NPC are recognized in ihe World Health Organization (WHO) classification: 1) squamous cell carcinoma with keratin production. (SCO; 2) non-keratinizing carcinoma (NKC); 3) undiffereniiaied carcinoma including lyinphoepiihelioma (UC) He tumor can extend within or out ofthe nasopharynx to tlie other lateral wall and/or posterosuperiorly to the base of tlie skull or the palate, nasal cavity or oropharynx and then typically metastases to cervical lymph nodes and metastasis Objectives: This report introduces 500 naso - pharyngeal carcinoma (NPC) patients who have lived at ihe South of Viet Nam and had been diagnosed at the ENT clinic of Cho Ray hospital - HCM city during 3.5 years.
Materials and Methods: Prospective stiidy. Betiveen April 2007 io October 2010, 500 NPC patients received eruioscopic nasopharyngx and had been biopsied arui they are confirmed NPC patients. We uiould like to introduce our cases who have lived at the south of Viet Nam and had been diagnosed NPC at ihe ENT dinic. Cho Ray hospital during 3.5 years with some first key points
Results: During 3.5 years wiih 500 cases have confinned NPC show ilmi thefrnmle patient is rising (2:1.
12), and ENT patient have more and more younger than before (average 49 year old), most of them came to see Docter um late or too late (> 92%), 1 case was diagnosed 4 years afier first symptom appear, and 1 case was recurrent just one month Imd finished radiotherapy.
Conclusion. Appropriate endoscopic nasopharynx is a minimally invasive, safe, and more convention for biopsy with encouraging short-term outcome and saves NPC patients life wlw suffering or lias just contaminated this Iwirible disease. The good co-apa-ation in diagnosis, ti-eatment and follow up aftei' radioilierapy betweai depariments such as ENT, pathology and oncology will be benefit for NPC patimts arui help to make down the mimber qf mortal rate and raise ihe number of survival rate.
Key words: Nasopharyngeal cardnoma, Nasopliaryngeal tumor biopsy. Primary tiimor. Squamous cell.
Keratinizing vd non-keratinizing. Undifferentiated carcinoma: Metastases
TONG QUAN Tubi 40 -50 la dp tubi bi nhieu nhat, rat hiem dubi 20 tubi tuy nhien ciing cb bao cao ghi n h ^ hrrbng hpp dubi 5 tuoi, nam nhieu hon nii theo ty le 2,5 : 1 . Gap nhieu o Trung quoc, dac bi?t 6 cac tinh phia nam nhu Quang Dbng, Phuac Kieh, dao Hai Nam va dac khu Hong Kbng la Tren 40 nam trubc ung thu vbm con dupc
gpi la ung tfiu Quang Dbng (Cantonese cancer) vi tinh nay ciia Trung Quoc cb ty le b^nh cao nhat the gibi"-"'*'. Tai cac qubc gia Au - My va
chau Phi thi ty le 6 nhiing nguoi da hang va da , ^^ , ~- , ,-^ ,~- ,. , ,
. , . , , , , . , „ , , . « . , _ ^ cao nhat the gioi, ke den la khu vuc Dong nam A den bl bpnh nay thap hon nhieu, o nhung quoc , - - , ; . „
• J- iJv. . , - , . , . , . trong do cb Viet nami^l.
gia do phan dong trong so nguoi bi ung thu vom °
hpng cung thubng la nhimg nguoi Tmng Hoa di ^°^ ^ g thu nay chiem 18% trong tat ca loai cu hogc con chau ciia ho, d^c biet con chau " " S ^h" ^ ^ " 8 Kbng, nhung chi chiem tu 1- nhung ngubi di cu tir tinh Quang Dong tii mpt 2% b Hoa Ky. Ty le tai phat ciia ung thu vbm vai the he tmoc den nay bi ung thu vom vln ^^° ^ ^ ^ ^ S ^^ ^ ^ " 50% sau 5 namW, chiem ty le cao hon nhung ngubi ban dja*^". Theo WHO thi su di can aia ung thu vbm Dich te *h^° ^ dubng la bach huyet den vimg cb va theo
^ , dubng mau den cpt song cb, phoi va san^'^.
Theo hiep hpi chong ung thu the gioi (Union
Intematinale Centre le Can«r - UICC) loai ung ^irfi Wet la dieu bat bupc phai lam va cung thu nay cMem 1% cua tat ca cac loai ung thu (a ' * ' ' " ) ' " ^ ^ -SS co chan doan chinh xac Chau Au)i«.
Chuyen D e Tai Miii Hpng
Y Hpc TP. Hb Chi Minh * Tap 18 * Phu ban cua Sb 1 * 2014 Nghien cmi Y hpc Nguyen nhan
Cho d&i tan ngay nay nguyen nhan tfipc su cua ung thit vom van khbng dupc biet mpt cadi chinh xac, mac dii cb nhieu gia thuyet ve nguyen nhan nhu co su hien dien ciia vi-nit Epstein-Barr (EBV), hiit thubc la hoac thubng hep xuc vbi khbi nhang, dac biet che dp In man, an db khb, an do chay (thbi quen an uong ciia cu dan vimg duyen hai Trung hoa va cac nuoc giap Trung hoa trong db cb VN), ihuong xuyen sii dung nubc tuong, dau hao (chiia chat 3-MPCD va 1,3 DCP dupc cho la chat sinh ung thu), hot vit muctt, nho khb, tao tau khb, rau qua dbng hop de lau v.v.
Tai viet Nam nhiing yeii to thuan loi dang ke sau day ciing dupc de cap nhu:
Hut tfiubc la va uong rupu nhieu (khoang 20% trong sb ca ung thu vom)
Moi trubng 6 nhiem, sir dung tran lan Ihuoc kich thich tang trubng vbi thpc vat va v | t nubi, thpc phain che biSi khbng an toan vi cb nhieu chat dpc hai va thiic an nhanh cb qua nhieu chat beo v.v.P*
Phan l o ^ ung thtr vom*^^"
Keratinizing squamous cell carcinoma (Ung thiT te bao gai simg hoa)
Nonkeratinizmg carcinoma (Ung thu te bao gai khbng simg hba)
Undifferentiated carcinoma (Ung thu khbng biet hba; hoac ten gpi khac la Lymphoepithelioma)
Theo lb chiic y te the gibi (WHO) lo?d 3 ciia ung Ihu vbm la loai hay ggp nhat b Trung Quoc va mpt so qubc gia 6 Dbng Nam chau A trong db cb Viet Nam. Hien nay gibi khoa hpc dang tap tnmg nghien ciiu ve sa tac dpng qua lai gjiia nhiing yeii tb co dia (host factors), su nhiem vi nit EBV va che dp an nhu da neu b tren.
Xep giai doan^'*
Qaidoanl:Tl,K0,M0
Giai doan 2: Tl, Kl, MO hoac T2, Nl, MO
Giai doan 3: T3 bat chap N, MO hoac N2 bat chap T va MO
Giai doan 4: T4 bat chap N va M hoac bat ky T nhung N3 hoac bat ky T va N nhung Ml DOITUtJNG&IHU'CNG PHAPNGHIENCUlJ Dbi tirpng ngluen cuu
500 trubng hpp dupc chah doan ung thu vbm.
Nhung tnrong hpp nay thubng cb cac tripu chiing sau day:
Dau (Nhuc dau, dau vimg m^t, dau tai, dau trong mat
Hach cb nbi mpt ben la trieu chiing rat thuong gap, hach ciing kich thubc cb the tii 2- 3cm den 7- 8cm, xung quanh khbng cb dau viem nhiem nhu sung, nong, db va dau, ban dau hach di dpng sau db thi dinh vao to chuc xung quanh, vi tri thubng la goc ham, ben cb.
Dpt nhien chay vai gipt mau miii roi tu ngung, cb th§' sau db chay nhieu Ian, moi lan vai gipt.
Nghet miii la thubng gap, liic dau mpt ben sau cb the nghet ca hai ben, chay chat nhay tir miii nhung khbng cai thien sau khi dimg thubc khang sinh, u tai hoac nghe kem, dau trong tai, dau vung thai duong hoac dau nua mat, te vimg ma.
Le hoac liet van nhan ciia mot ben mat v. v.
Tieu chuan loqii trU
Benh nhan chay mau miii do than thuong ham m|t hoac sp nao
Da dupc npi soi mtii xoang kiein tra nhung van ton tai mpt vai trieu chung
Da dupc chan doan xac dinh mpt benh ly TMH
Phuongphdp n^ienc ciiu Tien Cliu
Trong thbi gian 3,5 nam (4/2007 -10/2010) Chiing tbi da trpc tiep tham gia bMn sinh thiet cho 500 ca / 3000 lupt benh nhan co lien
Chuyen De Tai Miii Hpng
Nghien cuu Y hpc Y Hpc TP. Hb Chi Minh * Tap 18 ' Phu ban cua Sb 1 * 2014 quan den K vbm, tiic la bao gom ca so benh
nhan kiem tra sau xa.
Tieu chuan ddnh gia
Tix ket qua giai phau benh cua khoa giai phau benh - BV Chp ray
Phirong lien nghien cuu Phuang tien xet nghiem
CT Scans xoang & vimg dau co va trung that PET - CT loai tru khoi u da di can XQ phbi.
Phbi hpp voi cac chuyen khoa nhu: than kinh, mat, huyet hpc de loai trir mpt so benh cb lien quan.
Phuang tien thifi: hien May nbi soi Sinh thiet vom
Hitdi 1. Bd mdy ndi soi Phuong tipi chan doan
Thpc hien ket hpp vbi khoa giai phau bpnh ciia BVCR
\%^
Hinh 2 Mau mo ung thu vom di can liach co
Hinh 3. Loqi ung thu vdm klwng hiit hda KETQUA
Bdng 1. Gi&i tinh Gioi tinh Nam
64%
Nir 36%
Ty if Nam/Nir 2:1,12 Bdng 2. Turn
Tudi ntio nhit 16
Tu6i Ion nhSt 82
Tuoi trung binh 49 Bang 2. E>ia phuong
Tp Ho Miidi
Oii Campuchia
2,8%
Phli yin
0%
Bdng 4. So'ca ndi soi mui xoang vd sinh thi^ vdm Benh miii xoang
dipgrc noi soi 10,000 ca
Lirq^ bfnh lien quan Kvom 3O00ca (bao gom sau xa trj)
Sd ca sinh thiit 500 ca (3.5 nam) | BdngS. So'ldn sinh ihiii
Sd ca/ngay 4ca
Sinh thiit lJin1 100%
(500 ca) Sinh thidt
2 20%
Sinh thiit 3 3%
Ket qua 80% {+)
Cac dang ton thuong thirang thay a vom:
Tham nhiem:ll% (55 ca)
Khbi u & Siii; La dang hay gap nhat vbi 68%
(340 ca)
Loet & h o ^ tm 21% (105 ca)
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Y Hpc TP. Hb Chi Minh * Tap 18 * Phu ban cua Sb 1 * 2014 Nghien cuu Y hpc Bang 6.
STT 1 2 3
Dqng ton thuang Ton thiFong Tham nhilm U&sui Loet & Hoai tu
Soca 55 340 105
%
11 68 21 Bang 7. Triiu chunf;SIT 1 2 3
, ••
k P '
Te
Trifu chiing n6i b|t Dau (Olu, m^t, tai va mat)
Chay vai giot miu mui Nghet mui, diay nhay miii
Hachc6 M^ben Hai ben 0 tai, chay mu tai M^t (L6, li^t van nhan)
100%
%
50 52 92 68 32 20 8 BANLUAN
Ty lp benh nhan ung thu vbm cb xu hubng tang: Neu so sanh vbi so lieu tai BV Binh Dan trong 14 nam thi chi phat hien 613 ca, tiic la 43 ca/nam, trong khi chi ri&ig phong khamTMH - BVCR la 91 ca/nam, ttic tang > 2 ran)(^.
Gap 6 nhieu nhom tuoi, cu the la tii 16 deh 82 tura.
Ty le b|nh nhan ung thu vbm la nii (2:1,12) hong bao cao aia chiing toi co xu hubng tang vi theo cac tb chiic WHO, AJCC va UICC tlu ty le giiia nam va nii la 2:1; theo Gs Nguyen Chan Himg (1982) fhi ty le nay la 2:0,87P^-«.
Ty le benh nhan ung thu vom co tubi doi cb xu hubng tre (49 tuoi), neu so sanh vai tb chiic y te tile gibi hoac mpt so tb chiic ung ^ u cb uy tin khac nhu WHO: 55-70 tubi; Mayo clinic: >55;
AJCC > 55 tubi va UICC >50)f"-5>.
Ty le benh nhan ung thu vom d&i kham tre rat cao (ty le % c6 hach co: > 92% va a vbm hpng CO ton ttiuong dang sui va loet khoang 90%).
Benh nhan dupc chan doan tre nhat la 4 nam, ke tir khi bi dau dau, sau do bi u tai va cuoi cimg la liet than kinh van nhan, Ie trong mit P va benh nhan ung thu vbm cb xu hubng tai phat som, hubng hpp bi tai phat sbm nhat sau xa tri lal thang
Hinh 5. Khoi u vdm dugc phdi hien sau 2 ndm vd 4 ndm
Giai phau benh cho thay lo^ ugn ttiu khong biet hba (undifferentiated Ca) la hay gap nhat trong nhiing benh nhan ung thu vbm aia Viet nam nbi chung va mien nam noi rieng va d^c diein ciia Ioai ung Ihu nay la logi nhay tia nhung Cling la loai ung thu cho di can sbm nhat vi vay ly lp thanh cong ciia dieu tri thap va ty lp % song sau 5 nam la thap
Can ling dung hon nira ky thuat ho trp chan doan: PET- CT (lea)
Ty le sbng sau 5 nam tai VN hien nay la bao nhieu?
Chuyen De Tai Mfii Hpng
Nghien cuu Y hpc Y Hpc TP. Hb Chi Minh * Tap 18 * Phu b a n o i a Sb 1 * 2014 Theo WHO: Ty le sbng b cac quoc gia khac la
20-30% trong thap nien 70's, 40-60% thap nien 80-90's, >90% tii?p nien 2000's
Vbi giai doan: 98% stage 1; 95% stage H A-B, 86% stage m va 73% stage IV.
KETLUAN
Hien nay xa tri van chiern vai tro chii dao aia loai ung thu nay, chinh vi vay ma viec dupc thbng tin, hieii ve benh nay la quan trong nhat, vi nhu vay benh nhan se chii dpng di kham sbm.
Theo chiing tbi thi bac si tai miii hpng can tich cue trong viec thbng tin cho benh nhan ve benh ly nay tren nhieu phuong tien, mpi luc va mpi nai cb the.
Phuong hen npi soi la dac biet quan trpng trong viec tam soat ung ttiu cac vung cua Tai mui hpng, sinh thiet ket hpp vbi giai phau benh CO y nghia quyet dinh trong viec chah doan va giiip benh nhan dupc dieu tri sbm diing vbi benh trang aia minh (xa t4, hba tri hoac ket hpp giira X? tri va va phau thuat).
Su ket hpp tot trong chan doan, dieu trj va theo doi sau xa tri gjiia cac chuyen khoa nhu tai miii hpng, giai phlu benh va ung buou se gjiip kiem tra sau xa, phat hien nhiing trubng hpp tai phat va de dieu tri bb sung, giup keo dai tiibi gian sbng cho benh nhan.
TAI LIEU THAM KHAO
1 Couch ME (2010). History, physcal examinadon and the preoperative evaluaticm Cunutungs Otolaryngology Head &
Neck Surgery, 5(h ed IMadelphia, Pa. Mosb)' Elsevier. 2010 http-y/wvm-jndconsidteoin/book/player/book. pp298]
2 Caranoma. http:/Avl\^v.uptodate com/hpme/indexiitinl.
Accessed June 14,2010
3 Head and neck cancers. Fort Washington <2010), Pa.: National Compreiiensive Cancw Ket^vork.
http-j'/www.'.ncm.org'prDfesMonals^yaaan.gls/PDF/head- and-neck.pdf Accessed June 2,2010.
4 Hui EP (2010), et al. Epidemiology, etiology and diagnoas of
nasophaiyngeal caranoma.
httpy/www.uptodate.com/home/indexJitml Accessed June 14 2010.
5 Nasi^Jiatyngeal cancer treatment National CaiKer tishlute (3)10)
httpV/www.cancer.gov/cancertcpic^jdq/treatment/nasophaiynge alyhealtfiprofessional/allpages. Accessed June 2,2010 6 NguylnChanHiing."Uii5ftir!wmftiiH" Ung Ihu hpc lam sang.
Tap n, Trang 83-88
7 Nguyin Trpng Minh. "Oufii rforfii vng ihu vom bStig ky IhuSt nSi soi va CT scaiif", T9p chi y hpc TP.HCM, Tnjcmg D H Y-Dugc TPHCM, so dac bi?t chuyen d e u n g b u u hoc, Phv ban so. Tap 5, 2001. Trang 77-80
8 Nguyen Trgng M m h "L/rjg tliirvbm mm liong". Tap clii Y-Hgc TP H o chi MJnh,T|p 8, so 1,2004. Trang 84-88
9 Tan I_ et al (2010). Benign and malignant himors of the nasopharynx. In: Hint PW, et al Cummmgs Otolaryngolog}' Head & Neck Surgeiy. 5th ed. Philadelphia, Pa; Mosby Elsevier;
2010. httpv'/www.mdconsultcomAiook/player/book June 2,2010
Ngdy nhan bdi bdo:
Ngdy phdn biin nlidn xet bdi bdo:
Ngdy iToi bdo dirac dang:
22/11/2013 16/12/2015 10/01/2014
Chuyen De Tai Mui Hpng
