Nhan xet dac diem lam sang mot so di chiing sau xa trj cac
, r
bat thuong mach mau va cac bien phap khac phuc
Late Effects Following Radiotherapy for Vascular Anomalies and Plastic Surgery
J. r w - l -i-.
Do Dinh Thuan, Tran Thiet Son Truong Dgi hoc YHa Noi
Tom t i t
Xa trj cac u mach mau tr^ em van con dugc sU dung rgng rai d Viet Nam, mac du viec dieu tri nay da dugc bai bd d hau het cac nude phuong Tay. Muc dich nghien cUu n h i m mo t l cac dac diem lam sang cua mpt so di chUng sau xa tri v^ danh gi^ ket q u i dieu tri nhUng di chUng n i y b i n g phau thuat. Nghien cUu bao gom 30 benh nhan cd di chUng mupn sau xa tri cac bat thudng mach mau dugc dieu trj tai Benh vien Viet Nam-Cu Ba va benh vien Saint Paul tU01/2005-12/2010. Ket q u i : ton thUOng da bao gom teo da (90% benh nhan), thay doi sic to (77,6%), gian mao mach (33,3%). Cac ton thuong khac: teo to chUe dudi da (83,3%), teo co (53,3%), thieu san vu (4 benh nhan), cham phat trien xUOng (8 benh nhan). Oieu tri phau thuat bao gom hau het cle ky thuat trong phau thuat tao hinh. Nhieu lan phau thuat dugc doi hdi trong phan ldn cac trudng hgp (62%). Tuy nhien, ket q u i phau thuat trung binh va xau chiem 40% cac trUdng hgp. Kit ludn: cac di chUng sau xa trj cac bat thudng mach mau la da dang va nang ne. Viec dieu trj nhUng di chUng nay thudng khd khan, tham chi khong the sUa chUa dugc trong mgt so trUdng hgp. Vl vay, chi djnh xa tri nen dugc xem xet lai va nen than trgng d mgt so it trudng hgp chgn Igc vi no trd nen khong can thiet va tham chi co the co hai.
TUkhda: u mach mau, bat thudng mach mau, xa tri, di chUng.
Summary
Background: In Vietnam, irradiation of infantile hemangiomas is still used in some hospitals, although this treatment was largely abandoned in most Western countries. Objective: To describe the clinical aspect of somes late radiation effects following childhood radiotherapy and to evaluate the results of treatment of these sequelae by plastic surgery.
Patients and Methods: The study consisted of 30 patients of late effects following radiotherapy for vascular anomalies and surgically treated in Vietnam - Cuba Hospital and St Paul Hospital from 01/2005 to 12/2010. The clinical aspects, methods and results of treatment are hereby evaluated.
Results: Skin damage was found in most patients (atrophy 90 %, pigment disturbances 76,6%, teliangiectasia 33,3%).Other damages included hypotrophy or atrophy subcutanous tissues (83,3% ), muscular hypotrophy (53,3%), breast hypoplasia or aplasia (4 patients), retardation of the growrth of bones (8 patients). The surgical treatment included almost au techniques in plastic surgery. Multiple operations were required in majority of cases (62%). However, the results of treatment are not satistattoy in 40% of cases.
Conclusion: The late effects following radiotherapy for vascular anomalies are severe and variable. The treatment of these sequelae are difficult, even irrepairable in many cases. Radiotherapy therefore should be reconsidered and be careful in very few selected cases since it had turned out to be unnecessary and, furthermore, could be harmful.
Keywords: hemangiomas, vascular anomalie, radiotherapy, late effects.
Phin bien khoa hoc: PGS.TS. NGUYEN BAC HUNG
1. Oat van de
NhUng b i t thudng mach mau la nhUng benh ly rl't hay gap d tre em, bao gdm 2 nhdm chinh la d e u mach mlu (Hemangiomas) va elc dj dang mach mau (Vascular Malformation) theo p h i n loai eua Mulliken va Hiep hdi nghien cUu d c bl't thudng mach m l u the gidi ggi t i t la ISSVA (International Society for Study of Vascular Anomalies) [10].
Xa trj elc khdi u mach m l u tr^ em da dugc sU dung phd bien d cle nUde phuong Tly trong nUa dau the ky 20. Phan Idn tr^ dugc dieu trj vdi 226Ra, mdt sd it nhan lieu p h i p tia X tiep xue, ddi khi b i n g elc tam I p P32. Tuy nhien, viee dieu trj n i y hau nhu da dugc bli bd sau khi nhUng nguy co ve l l u d l i eua xa tri v l die tinh t h o i i lui t u phat cua d e u mach mlu duge ghi nhan [1, 3,4, 5,8,9].
d Viet Nam, mdt sd co sd dieu trj van edn chi djnh xa tri rdng rli cho mgi loai bl't thudng mach mlu, v l tren l l m sang d l gap khdng it d e di chUng sau xa tri.
Chinh vi vay, ehung tdi dat van de nghien eUu de t i i " Nhan xet d i e diem l l m sang mdt sd di chUng sau xa tri d e bat thudng mach m l u v l d e bien phip khac phuc bang phau thuat" nham 2 muc tieu:
Md t l cle hlnh thai l l m sang mdt sd di chUng sau xa trj cac bat thudng mach m l u .
Oinh g i l d c ket q u i dieu tri phau thuat khic phuc elc di ehUng.
2. Doi tugng va phiTcrng phap nghien cuTu
Bao gdm 30 benh nhan cd di ehUng do xa tri d e bat thudng mach mau, dugc kham va dieu trj tai d c Khoa Phau thuat Tao hlnh benh vien Viet Nam-Cu Ba, Benh vien Xanh-Pdn, tU 01/2005-12/2010.
Tat el cac benh nhan deu dugc thdng ke theo mgt mau thdng nhat vdi d c chi tieu can nghien cUu:
hg ten, tudi, gidi, thdi gian xa trj, thdi gian xuat hien di chUng, vj tri, kich thUdc tdn thUdng, hlnh thai lam sang, phuang phap dieu tpj, sd lan phau thuat, ket qui phau thuat.
Cac benh nhan dugc kham xet danh gia hlnh thai va mUc do cac di chUng, lap ke hoach, va tien hanh phau thuat.
Cac tdn thuong da cd kich thude nhd ed the tien h l n h elt bd t o i n bd tdn thuong v l tao hinh ddng khuyet da true tiep. Odi vdi nhUng tdn thuang ldn ban ed the elt b i n phan nhieu lan lien tiep, dat tui bom g i l n da, sU dung d c vat da ke can hole ghep da d l y toan bd tU t h i n .
Odi vdi elc tdn thuong td chUe dudi da, ed the lUa chgn d c ehl't lieu ddn b i n g vat trung bi-md, vat d n lay tU vung l l n can, ghep md tU do, ddn chat tro, ddi khi phii sU dung den d e vat ddn td ehUc ed ndi mach vi phau.
NhUng tdn thUOng ket hgp da v l td chUe dudi da dugc elt bd v l ket hgp tao hinh che phu va tao hinh ddn b i n g d e vat td chUe phUe hgp nhU vat da- cln, vat da-co, ddi khi sU dung ky thuat vi phau.
NhUng tdn thUOng xUong duge khic phuc bing d e h ghep ddn vdi chat lieu xUang tU t h i n , xuong ddng loai hole ghep chat tro.
Ket q u i phau thuat dUgc phin loai tdt, khi, trung binh va kem dUa tren hinh I n h ehung cua vung dugc phau thuat, sU eli thien ve ehUe ning, tham my va sU b l i Idng eua benh nhin.
3. Ket q u i nghien cuTu
Chung tdi cd 30 benh nhin vdi di ehUng sau xa tri d c bat thudng mach mau, trong dd ed 24 nU v l 6 nam. Cic tdn thUong gap ehu yeu d vung dau mat cd (24/30 = 80 %), vung ngUe cd 4 benh nhin (13,3%), d ehi ed 2 benh nhin (6,7%).
Cle hlnh t h i i tdn thUdng da va niem mac sau xa trj hay gap nhat I I teo da hole niem mac d 27 benh n h i n (90%), thay ddi sle td da d 23 benh nhan (76,6%), gian mao mach d 10 benh nhin (33,3%).
Kich thudc d e tdn thuong da tU 4 cm^ - 100 cm^
trung binh la 20 cm^
Cac tdn thuang td chUc phan mem Khac bao gdm: teo mdt phan hole toan bd td chUc dudi da gap d 25 benh nhan (83,3%), teo cd d 16 benh nhan (53,3%), teo tuyen vu d 4 benh nhin. Cle tdn thuang xuang cung gap d 8 benh nhan dudi dang thieu dudng xUong ham dudi, xUdng d mat, xugng b i n chan va cang chan.
Cae tdn thuong phdi hgp tU 2 thanh phan td chUc trd len (da-td ehUe dudi da, da-td ehUe dudi da- ea...) gap d 27 trudng hgp (90%). Cd 14 trUdng hgp tdn thuang x l m ehiem nhieu don vj tham my, trong dd ed 8 trudng hgp tdn thuong nang dUdi dang teo lep nUa mat.
Tao hinh che phii dan thuan sau elt bd tdn thuong di chUng xa trj chu yeu phii sU dung den d e vat da va niem mac, trong do cd 4 vat lan can, 4 vat g i l n to chUe, 2 trUdng hgp cit-khau nhieu thi lien tiep, 1 trudng hgp ghep da.
Cle bien p h i p tao hinh ddn don thuan khic phuc teo lep td ehUe phan mem bao gdm: 2 trUdng hgp ghep md kieu Coleman, 3 vat d n t h i i dUdng, 2 vat da-can (dugc bdc bd ldp bieu bi) tU do cd ndi
mach vi phau, 1 trUdng hgp ghep trung bi-md, 4 trudng hgp ghep chat lieu tro.
Cle bien phap tao hinh ket hgp vUa che phu vUa ddn bao gdm: 4 vat da-ein tU do ed ndi mach vi phau, 3 vat niem mac-co, 1 vat da-co cudng lien.
Chi cd 1 trudng hgp thieu sin xUOng h i m dUdi sau xa trj dUgc tao hinh ddn b i n g chat tro (san hd).
Cd 18 benh n h i n (62%) phii t r i i qua nhieu lan phau thuat (trong dd ed 1 benh n h i n md 3 lan, 1 benh n h i n md 4 lan). Cle bien ehUng sau md bao gdm: 2 trudng hgp Id tui g i l n da, 1 trudng hgp hoai tU vat da tU do, 1 trudng hgp t h i i trU m l n h ghep tro.
Ket q u i xa sau phau thuat d 20 benh n h i n kiem tra
dugc: tdt: 3 (15%), k h i : 9 (45%), trung binh: 6 (30%)/nl^.
k^m:2(10%). i 4. Ban luan
4.1. Bin luin ve cic hinh thii lim sing cua cic di chdng sau xa tri cic bit thU&ng mach mau
Chung tdi g i p d c di ehUng mudn sau xa trj cac bat thudng mach mau vdi d e hinh t h i i llm sang phong phu va da dang, vdi day du d c mUc do ton thuang ve chieu rdng (dien tieh tU 4 -100 cm^) cung nhu chieu slu (da, td chUe dudi da, cd, xUong). Ton thuang hay gap nhat la d da, ehu yeu II teo da (90
%) v l thay ddi sle td da (76,6 %).
Phan Idn d e trudng hgp (90%) cd sU phdi hop tdn thuang nhieu thanh phan td chUe, trong do co 8 trudng hgp tdn thuong nang lan tda dang teo lepca nUa mat. Oac biet cd trudng hgp, khdi u ban dau co kich thudc rat nhd khoing 1 -2 cm ma di ehUng de lai sau xa trj la mdt su teo lep nUa mat vdi tdn thuong c l da, td chUe dudi da, co, xuong. Chung tdi cung ghi nhan t i e ddng cua xa trj den sU p h i t trien cua tuyen vu eua be gai d 4 trudng hgp, trong dd eo 2 trudng hgp teo h o l n toan tuyen vu. Cac trUdng hgp
nay hau nhu deu cd bien dang teo hole thay doi sk td quang-num vu. Ve di chUng xuang, chung tdi gap ehu yeu tdn thuong d xuang ham dudi. Ole biet co trudng hgp n g i n e l xuang ban chan, d n g chan sau xa tri mdt khdi u mach m l u nhd d mu b i n chan.
A B C
Hinh 1 . Oi chUng sau xa trj d c bat thudng mach mau. A: rdi loan sic td da, B: teo da, td chUc dUdi da, teo cd va xUdng vung quanh hdc m i t t r i i , C: teo da, rdi loan sic td da va teo tuyen vu trai toan bd.
Nhdm benh n h i n eua chung tdi khdng bao gdm toan bd d e di ehUng cd the gap sau xa trj cle bl't thudng mach mau. Mdt sd di chUng khIe nhu sU xua't hien d e khdi u tren nen xa trj ehung tdi khdng gap, ed the do d e benh nhan nay thudng den d c CO sd u budu hdn II d e trung t l m phau thuat tao hinh. Mae du vly, ket q u i nghien eUu cung da chi ra tinh ehl't da dang v l mUe do tram trgng eua d c di ehUng do xa trj, ddi khi ldn ban nhieu so vdi tdn thuong ban dau.
Nhieu nghien eUu tren the gidi cung d l ehi ra tinh ehl't phd bien v l da dang eua elc di ehUng mudn sau xa tri d e bat thudng mach m l u . Lindberg da nghien eUu 126 u mach m l u tren 100 benh nhin dugc xa trj bing 226Ra trong n i m 1945. Lieu xa trj thong thudng II 800 900 R. Sau 13-16 n i m theo ddi, tie g i l thi'y ring tdn thuong da gap trong phan Idn elc trudng hgp: teo da (85%), rdi loan sle td (80%), giln mao mach (30%), mat Idng (10%), cham phit trien xuong va td chUe tuyen vu cung dugc ghi nhan trong mdt vai trUdng hgp [9]. Tie g i l cung d l tien hlnh mdt nghien eUu rdng Idn tren 11807 benh nhin vdi u mach m l u dUgc xa trj tU 1930 -1965 tai Thuy Oien, vdi thdi gian theo ddi tU 1958 -1989, da chi ra mdt sU t i n g len d i n g ke tan suit ung thu trong sd d e benh nhan nay, chu yeu d 3 vj tri: he thdng than kinh trung uong, tuyen g i l p , va d e tuyen ndi tiet khac (tuyen can g i l p , tuyen yen ...) [8]. Nhieu nghien cUu khic cung ehi ra ket q u i
tuong t u ve d e t i e ddng lau d l i sau xa trj d c u mach mau d tr^ em [2,4,5,6]. Ngoai ra, d e bao d o ve nhUng ea rieng le cung da ghi nhan ve d e ung thu da xuat hien tren nen xa trj sau 10-50 n i m [3,11].
4.2. Ban luin ve kit qui dieu trj phau thuit khic phuc cic di chdng
Viee dieu trj phau thuat phuc hdi d e di chUng sau xa trj thudng gap nhieu thich thUc do tinh ehl't lan rdng va mUe do tram trgng eua d c tdn thuong, nhat II d e tdn thuong x l m ehiem nhieu don vj tham my va lien quan den nhieu thinh phan da, td chUe dudi da, co, xUOng. Hau het d c ky thuat tao hinh da dugc sU dung, trong dd chu yeu II d e vat da dan thuan hole phUc hgp, vat giln td ehUe, vat d n , d y ghep md. Cle ky thuat don giln nhU eat- khlu mdt thi hole nhieu thi lien tiep, ky thuat ghep da t u do rl't it dugc sU dung. Nhieu trudng hgp ehung tdi phii sU dung den d e ky thuat tao hinh phUe tap nhu d e vat phUe hgp da-cin, da-co cd ndi mach vi phau. Nhieu lan phau thuat la can thiet trong phan Idn d e trUdng hgp (62%). Tuy vly, ket q u i tao hinh thu dugc khdng eao, ket q u i trung binh v l xau chiem khoing 40% d e trUdng hgp. Tat el 8 trudng hgp di ehUng xuong eua ehung tdi d l that bai hole khdng dugc dieu tri.
NhUng thach thUe trong viee phau thuat tao hinh d c di ehUng sau xa trj cung dugc de cap bdi d e t i e g i l khic [7,12].
Hinh 2. Phau thuat sUa chUa di chUng teo lep nUa mat phai sau xa tri u mach mau nho mdi tren phai bang tao hinh don vdi vat d n thai duang nong va sau.
^n
H i n h 3. I'h.'ui thuat si'f,) (liu',i di < hifiu] leo lep niciii nwic va ca moi rhrai i a u Xd III buny vdt iiieiii iiidc ca m u t hai ben.
5. Ket luan
Cle di ehUng m u d n sau xa tri e l c bat t h u d n g mach m l u ed c l e hinh t h i i l l m s i n g da dang v l nang ne, t i e d d n g den hau het d e t h i n h phan t d ehUe tU da, t d chUe dudi da, ca, xuong, tuyen vu, ed the lan rdng x l m chiem nhieu vung g i l i phau k h i c nhau, tham chi gay teo lep c l nUa mat, g l y I n h h u d n g tram t r g n g den chUe n i n g , thI'm my, t l m ly va su hda nhap eua tr^. Viee dieu tri k h i c phuc d e di chUng nay gap nhieu khd khan, t h a m ehi khdng the sUa chUa dugc t r o n g nhieu t r u d n g hgp. Vdi sU hieu biet s l u sle hon ve d i e tinh t h o i i trien tU p h i t cua d e u mach m l u tr^ e m , ehung tdi eho r i n g viec chi d j n h xa trj nen dugc xem xet lai v l d n n h l e , khdng nen ehi djnh rdng r l i eho mgi u mach m l u , n h u hien nay d m d t sd cd sd dieu trj dang lam, de t r l n h gay ra nhUng di chUng d i n g tiec khd phuc hdi.
Tai lieu t h a m k h i o 1.
2.
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Dondon MG, Vathaire F, Shamsaldin A. Cancer mortality after radiotherapy for a skin hemangioma during childhood. Radiother Oncol 2004;72:87-93.
Eggers G, Flechtenmacher C, Kurzen H, Hassfeld 5.
Infiltrating basal cell carcinoma of the neck 34 years after Irradiation of an haemangioma in eariy childhood. A case-report. Journal of Cranio- Maxillofacial Surgery (2005) 33,197-200.
Fragu P, Lemarchand-Venencie F, Benhamou S.
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radiotherapy for skin angiomas: a Frencii retrospective cohort study. Eur J Cancer 1991;27:1215-22.
5. Furst CJ, Lundell M, Holm LE. Radiation therapy of hemangiomas, 1909-1959: a cohort based on 50 years of clinical practice at Radiumhemmet, Stockholm. Acta Oncol 1987;26:33-6.
6. Furst CJ, Lundell M, Ahlback SO, Holm LE. Breast hypoplasia following irradiation of the female breast in infancy and early childhood. Acta Oncologica 1989;28:519-523.
7 Kdrlof B, Ponten B, Skoog T. Treatment of Radiation Injuries by Plastic Surgery. Acta Oncologica 1964;
2(61:423-442.
8. Lindberg S, Karisson P, Arvidsson B, et al. Cancer incidence after radiotherapy for skin haemangioma during infancy. Acta Oncol 1995;34:735-40.
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From active treatment to radiation risk estimates.
Radiat Environ Biophys (2001) 40:179-189
10. Mulliken, J. B., and Glowacki, J. Hemangiomas and vascular malformations in infants and children: A classification based on endothelial characteristics.
Plast. Reconstr. Surg. 69:412,1982.
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