TfyP CHI NGHIEN CU'U Y HOC — "
CHAN DOAN MLPC DO AC TJNH CUA U THAN KINH DEWI T R U a C PHAU THUAT SLF DUNG CONG HU'O'NG TU PHO DA T H ^ TfCH
N g u y i n D u y H u n g \ P h a m C h u H o a n g ^ , B i l l V a n G i a n g ^ D d n g V a n He' 'Ben/7 vien Viet Birc, 'Tru&ng Dai hoc Y Ha Nqi,
Nghien c&u dwac tiin hanh voi muc tieu s o sdn/j cac chi si chuyin hoA Iron cdng hw&ng tw pho da the tich va danh gia gia trj cua phuang phap nay trong chin doan mire do ac tinh cua u thin kinh dem tren mo benh hqc. Tw thing 01/2015 din 06/2018. 55 tru&ng hpp u nao dwac chup cong hwang tw thw&ng quy va cong hwang tw phi da thi tich. duac phiu thuat hoac sinh thiet va co kit qua mo benh hqc la u than kmh dem tai Benh vien Viet Due Dinh Iwong ndng do cac chit chuyin hoa dwac tinh toan tai tram lam vi$c, dwang cong receiver operating charactenstic (ROC) duac s u dung de xac dinh va tinh ngwong cua chit chuyin hoa tot nhit trong chin doan mire do ac tinh u than kinh dem. Trung binh n&ng dq va ty 1$ c^c chit chuyin hoa giu'a vung u va vung lanh, giwa vung quanh u va vung lanh co sw khac biet co y nghTa thing /ce VOT'P < 0,01. Tyle Cho/NAA co dien tich du&i duang cong l&n nhat Ngir&ng Cho/NAA 2.37 cho dqnhayva dp dac hieu la 89,86% va 88% trong chin doan bac u thin kinh dem Cong hwang tw phi da thi tich vaity le Cho/N/kA c& gia tri trong chin doan mwc do ac tinh ciia u thin kmh dem trwac phiu thu$t
TO khoa: u thin kinh dem, cdng hudng tO pho da t h i tich, mOc do ac tinh I. OAT VAN DE
U thin kmh dem chilm khoang 40 - 70%
cac u nguyen phat ndi so va duac phan thdnh 4 bdc theo To chOc Y t l The gidi f l j . Hien nay, cdng hudng tO duac eoi la phugng phdp t i t nhlt trong chin doan trudc phlu thuat va cung e l p eae thdng tin quan trong eho viee len k l hoach dieu tn vdi nhOng benh nhan u nao Mac du cdng hudng tu thudng quy vdi chuli xung T l trudc va sau tiem thule d l i quang tu da chOng minh vai trd trong viec xac dmh dac dilm u thin kmh dem, tuy nhien lai khdng hieu qua va khdng dac hieu trong phan loai va phan bac u [2, 3] Sinh thilt dmh Vj thudng duac sO dung d l chan doan md benh hoc eua
•Dia chi lien h$ Nguyen Duy Hung. Bo mon Chan doan hinh anh, Truong Dai hoc Y Ha N6i
Email nguyenduyhung_84@yahoo com Ngaynhan 25/11/2016 Ngay duoc chap tt\uan 26/2/2017
u Phuang phap can thiep xam lan nay cd ty le tai bien 3,6%, ty ie chay mau 8% va ty le \.u vong len den 1,7% [4, 5]
Cdng hudng tO phd bao gom phugng phap dan the tieh va da the tich la phuang phap ehln doan khdng xam nhap giup danh gia su thay doi chuyen hod trong cdc ton thuang ndi so Trong benh ly u nao pho Cho- line (Cho) la chit chl diem cho hoat dong cua mang te bao tang, phd NAA duac eoi la chat chl diem neuron hay chi chi dilm mat dd va su' sdng cdn eiia neuron giam MOc dd tdng Clio hay giam NAA cd hen quan den mOc do ac tinh va tham nhiem eiia u [2, 6 - 8] Mdt vai nghien cOu gan day eho thly cdng hudng tiJ' pho cd kha nang phan biet mOc do ac tinh ciia u than kmh dem, tuy nhien, cae nghien eOu nay chi tap trung vao mdt ho$c vai nhdm u va khdng chOng minh duae s u khac bidt rd rang v l chuyen hoa giua eae nhom u [1, 2; 9; 10]
TCNCYH 106(1)-2017
- TAP CHI NGHiEN CU'U Y HOC Chinh vl vay, nghien cOu cua chiing tdi nhlm
so sdnh cac chi sd chuyin hoa tren edng hudng t u pho da t h i tich vdi mOc do ac tinh eua u t h i n kinh dem tren md benh hgc va danh gia gia tn ciia phuang phap nay trong chin doan mOc do ac tinh ciia u thin kmh dem
tl. D 6 | TU'O'NG VA PHU'aNG PHAP
I . D d i tipgng
55 benh nhan duae phlu thuat hoae smh thilt, ed k i t qua md benh hoe la u t h i n kinh dem, dwac chup cdng hudng tO 1 5T vdi cac chuli xung cong hudng t u ca ban va chudi xung phd da t h i tich (MRSI - MR spectros- copy imaging) t u thang 01/2015 d i n thang 06/2016 tai Benh vien Viet DOe
2. Phu'ang phap
2.1. Thi&t ki nghien CIJ'U: md ta c i t ngang.
2.2. Quy trinh nghien cieu
Cac benh nhan duac chup edng hudng tu 1 5T tren may Ingenia, Philips hoac Avanto, Siemens. Cae chudi xung thudng quy dwac ap dung bao gdm axial T1W trudc tiem, axial FLAIR, Diffusion, axial T2GE va 3D T1GE sau tiem ddi quang tO
Anh FLAIR hoac anh T l sau tiem thulc duoc su dung d l dat chudi xung pho da t h i tich 144ms Vl tri duae lua chgn la vimg u cd kich thudc Idn nhlt va v i l n tang tin hieu tren FLAIR rdng, tranh vung chay mau, hoai tO, sat xuang va cac mach mau Idn DO heu thu dugc duac xO ly tren tram lam viSc ciia Sie- mens va Philips Chimg tdi xac dmh nong do eua cac chit chuyen hoa eg ban gdm Cho, NAA, Creatin (Cr), ty le Cho/NAA, NAA/Cr va
Cho/Cr cung nhu su xuat hien ciia Lipid va Lactate tai viing u, vung quanh u va vung lanh. Trong dd, vCing u la vung ed tin hieu t l chuc trudc tiem vdi cac u t h i n kmh dem bac thlp, vung co nglm thulc sau tiem vdi eac u t h i n kmh dem bae cao, viing quanh u la viing nhu md nao tang tin hieu tren FLAIR, khong n g l m thulc sau tiem va vung lanh la viing d l i aien vdi t i n thuang hoae vung khdng tang tin hieu tren FLAIR
2.3. Phan tich so lieu
Chung tdi xac dinh chi s6 trung binh ciia ndng do va ty le eae ehlt chuyen hoa theo vung u, vung quanh u va vCing lanh va theo k i t qua mo benh hoe Thuat toan Mann Whit- ney vdl p < 0,01 duac su dung d l danh gia su khac biet giua cac nhdm nay Dudng cong ROC (Receiver operating characteristic) danh gia m i l lien he ciia n l n g do Cho, NAA va cac ty le Cho/NAA, Cho/Cr, NAA/Cr vdi bac ciia u tren mo benh hoe, trong do, dien tieh dudi dudng eong > 80% duac coi la tit, 70 - 80%
la kha tdt va < 70% la khdng tdt Chl s l cd dien tich duai dudng cong Idn nhat duac lua chon a l xac dinh diem c i t Dd nhay, dd dac hieu trong chin doan phan bac u thin kmh dem tai diem e l t duae xae dinh.
2.4. Xie ly so lieu: s l heu duac xu ly blng phln mem SPSS 23 0,
3. Dao dOc nghien cuu
Nghien cuu tuan thii t i t ca eac tieu chuin v l dao due trong nghien euu y smh, benh nhan t u nguyen tham gia nghien cuu, cac thdng tin duoc giu bi mat Cac dO lieu thu thap dugc ehi duac su' dung cho muc dich nghien cuu, nang cao kha nang chan doan cho ngudi benh
TCNCYH 106 (1) ' 2017
TAP CHi NGHIEN CLfU Y HpC
III. K ^ T Q U A vung quanh u vS vung lanh du-ffc the hifen d bang 1 va bang 2, co s y khac biet co y nghTa th6ng ke giOa cac vung 6wac so sanh vm p < 0 , 0 1 .
Trong s6 55 benh nhan nghien ou-u CO 30 u thin kinh dem bac cao (13 u b§c III vS 17 u bac IV), 25 u th§n ktnh dem bac thap (3 u
b|c"l va 22 u bac II) tr6n mo benh hcc theo Theo mo benh hoc, tmng binh ty le Cho/
phan loai cua To chftc Y te T h j gioi (WHO) NAA giu-a nhom u bac thap 2,82 ± 4,32 va nam 2007, vol nhom tu6i trung nien (40 - 60 nhom u bac cao 4,00 ± 2,23 co su khac biet tu6i) chiSm ty le cao nhat 45,4% (25/55 tru-ong '='5 » "S^'a »i°"S ke Khong cb su khac biet v4 hop), Trung binh nOng 36 va ty le cac chjt "Sng do cac chat chuyen hoa cung nhu cacty chuyen hoa gitta vCng u va vung lanh, giOa '^ Cho/Cr va NAA/Cr giQ'a 2 nhom nay.
Bang 1. Trung binh cac c h t t chuy4n hoa giiPa vung u va vung lanh
Cho NAA Cr Cho/NAA
Cho/Cr NAA/Cr
Viing u 3,45 ±2,58 1,30±1,17 1,22 + 0,90 3,76 + 3,55 3,44 ±2,57 1,30±1,17
Viing lanh 1,84 ±0,96 3,26 ± 2,78 1,64 ±0,75 0,65 ±0,21 1,18±0,55 2,06 ±1,45
P*
<0,01
<0,01
<0,01
<0,01
<0,01
<0,01
" Cho-Choline; NAA N-acetylaspartate; Cr Creatine.
Dudng cong ROC eho thly ty le Cho/NAA cho dien tich dudi dudng eong Idn nhat 83,31%, nong dd cac ehlt chuyen hoa Cho, NAA, Cr va ty le Cho/Cr, NAA/Cr d l u cho dien tieh dudi dudng ceng < 60%. Diem e l t Cho/NAA = 2,37 cho do nhay, do dac hieu ciia eong hudng tO phi trong ph&n bac u t h i n kmh dem lln luat la 89,66% va 88%
Bang 2. Trung binh cac c h i t c h u y i n hoa giua vung quanh u va vung lanh
Cho NAA Cr Cho/NAA
Cho/Cr NAA/Cr
•Cho-Choline. NAA
Vung quanh u 2,35 ±1,32 2,15±2,14 1,51 ±0,70 1,43 ±0,79 1,76 ±1,67 1,75 ±2,51
N-3cetyl3spart3te; Cr Creatin Viing lanh 1,84 ±0,96 3,26 ±2,78 1,64 ±0,75 0,65 ±0,21 1,18 ±0,55 2,06 ±1,45
e
P*
<0,01
<0,01 0,06
<0,01
<0,01
<0,01
TCNCYH 106(1)-2017
• T;\P CHi NGHIEN CLfU Y HOC Bdng 3. Trung binh cac chat chuyen hoa t^i vung u theo md benh hoc
Bac thap ( n , = 2 5 ) Bac cao (n; = 30)
P*
Cho 3,73 ±2,89
3,19 + 2,38 0,66
NAA 1,62 ±1,96
1.07 ±1,20 0,19
Cr 1,32 ±0,93
1,17 ±0,92 0,31
Cho/NAA 2,82 ±4,32
4,00 ±2,23
< 0 , 0 1 * Cho/Cr 3,99 ±4,43
3,86 ± 2,32 0,27
NAA/Cr 1,30±1,32
1,27 ±1,08 0,97
* Mann-whiney test, Cho' Choline; NAA' N-acetylaspartate, Cr Creatine
^ 1^
t-00 0 25 0 50
1 -Speciliciiy Cho ROC area 0 464Q
• - ChoyNAA ROC area 0 8331 Cho/Cf HOC area- 0 5876
0 75
NAA ROC ar NAA/Cr ROC Role re nee
1-0
a 0 3966 area. 0 4869
Hinh 1. Dudng cong ROC vdi ndng do va ty le cac chat chuyin hoa trong chan doan bac cua u thin kinh dem
IV. B A N L U A N
Chan doan ehinh xac bae eiia u t h i n kmh dem trudc phau thuat r l t quan treng giiip len ke hoach dieu tn va tien luang bdi nhdm u bSc cao duac d i l u tn khac vdi nhdm bac t h l p Nhdm u b$c cao bj n h l m l l n vdi nhdm bgic thlp se duac d i l u tn kem tich cyc va ngugc lai nhdm u bac t h l p bj n h l m l l n vdi nhdm b^c cao dwcfc dieu tn tieh cyc hgn muc can thilt, Ca hai d i l u nay d l u gay tang ty le tai biln va
tO vong cho ngudi benh Nhdm u bac cao cd kha ngng phlu thuat hoac khdng ed ehl dinh p h l u thuat can dugc d i l u tn xa tn hoae phli hap ho^ xa tn Tuy nhien, vdi nhdm u t h i n kinh d&m bac thlp, p h i u thuat va hoa xa tn di kem duac khuylnh khich d cae trudng hgp u bac II ehi p h l u thuat lly u 1 phln hoac nhOng b$nh nhan trfen 40 tuoi khdng tinh d i n kha nang l l y bd duae u [11],
TCNCYH 106(1)-2017 67
TAP CHI NGHIEN CU'U Y HOC • Nhilu nghien euu cho thay cdng hudng tO thudng. quy cd ty Ig c h i n doan ehinh xac bgc cua u thin kmh dem t h l p tO 55 - 83,3% [1; 2, 8] Cac d l u hieu tren cpng hudng tO thudng quy nhu hieu Ong khli. hoai tO hay hinh anh nglm thulc sau tiem deu khdng ed tinh chat dac higu U t h i n kinh dem bae cao cd the bi chan doan n h l m khi chi gay phii nao nhe, -khdng-hoai tu, ngoai ra, cac u nay co t h i tham nhiem doc theo kenh maeh mau ciia ehlt trlng khdng gay pha vd hang rao mau nao va khdng hoac it nglm thulc sau tiem
Cdng hudng t u phd cung e l p thdng tin v l su thay d l i ciia cac ehlt chuyen hoa tai vimg u va viing quanh u, trong dd Cho dwac coi la chit chi diem chuyin hoa cua mang te bao, NAA ia ehlt ehi d i l m neuron hay chi chi dilm mat do va su sdng cdn ciia neuron va Cr tham gia vao qua trinh tao nang iuang chuyin hoa eua t l bao [12] Trong nghien cOu nay, chiing tdi thly ring cd su khac biet cd y nghTa thing ke v l trung binh cac chit chuyen hoa cQng nhu ty ie cac chit chuyin hoa giOa viing u va vimg lanh, cac nghien cOu khac eiia eung cho kit qua tuang tu [2, 13] Dieu nay ed the duae giai thich do tai vi tri u, cac t l bao u tang smh, tang phan bao va tang hoat dgng cua mang t l bao, ddng thai gay pha huy eac t l bao thin kmh binh thudng d i n den nlng do Cho tang va NAA giam Ndng do Cr thudng duoc sO dung nhu la chit tham chilu danh gia su thay doi ciia eae chit chuyen hoa khac do it thay d l i trong cac tinh trang smh iy va benh iy Tuy nhien, tren thuc t l nlng do Cr thay doi theo tung vijng, tOng ca the, giam trang u do u ting hoat ddng chuyen hoa, dong thdi ban than Cr khdng b i t ngudn d nao ma duoc tdng hgp tO gan va than vi vay cac benh he thing (benh ly than) cd t h i anh hudng d i n nlng dd ciia Cr trong nao [14]
U than-kmh dem ed tinh chat tham nhilm rdng ra nhu md nao lan can. Viee xac dinii duac vimg thSm nhilm eiia u khdng chi giiip ehan doan phan bigt giOa u t h i n kmh ddm vdi cac ton thuang ndi sg khac nhu di can, ap xe ma cdn rat c l n thilt giiip len k l hogch phau thuat va xa tri, S u khac biet cd y nghTa thing ke v l nlng-do va ty le cac chit chuyln-hoa giOa vLing qugnh u va vCing lanh duae chung tdi ghi nhan qua nghien cOu, Theo cac nghien cOu, ty le Cho/Cr d viing quanh u' tang a nhdm u ed dp ac eao, ty le NAA/Cr it thay doi do u cd tinh c h i t tham nhilm, it pha huy cac t l bao t h i n kmh hay cd su khac biet v l ty le Cho/NAA giOa viing quanh u vS vimg lanh, cac ty 1$ Cho/Cr va NAA/Cr khae biet khdng cd y nghTa thdng ke f1, 9]
Lien quan vdi do md hgc eua u. ehiing tdi ghi nhan su khae biet cd y nghTa thing ke ve ty le Cho/NAA giu'a nhdm u bac thlp va nhdm u bac eao, cac ndng dd va ty le giOa cac chit chuyin hoa cdn lai khdng ed su khac biet, Ngoai ra, ty le Cho/NAA cQng cho dien tich dudi dugng cong Idn nhlt 83,3% tren dudng cong ROC. Nhilu nghien cOu cung khlng dmh su quan trong cua ty le Cho/NAA trong du bao dd md hoc va d i l u nay dugc giai thich do ndng dp NAA thudng giam va nlng do Cho thudng tang trong u nao, d i n g thdi, ed su liSn quan giua ndng dd Cho va Ki - 67 la chi-s6 tang smh t l bao [1, 2, 9] MOc do tang sinh te bag tang len theo muc do ac tinh eua u dudc the hien la sy tang ndng do Cho trSn eong hudng tO pho [3, 15] Th§m vao dd, ty le Cho/
Crcho dd nhay cao 97,5%, tuy nhien do dac hieu thlp 12,5% ty le NAA/Cr khdng cd gia tn phan dd u t h i n kinh dem [1,10]
Chl so ngudng Cho/NAA trong nghien cOu eiia ehiing tdi la 2,37 cho do nhay va do dac hieu l l n lugt la 89,66% va 88% Trong cac
68 TCNCYH 106(1)-2017
• TAP CHI NGHIEN CU'U Y HOC nghign cOu khae chi sd nay dao ddng tO 0,8 -
2,49 vdi dd nhay va do dae higu dao ddng ian lugt to 72,73- 100% va 62,5-95,8% [1, 2; 7;
9] Nguygn nhan cua s u khdng dong nhlt giOa cac nghien cOu cd the do su khac bidt v l k? thuat chup cdng hudng tO pho, vi tri do, sd luong m i u , ty le cac nhdm u Mac dii vay, cac nghign cOu cOng khlng dinh ndng dd Cho va mOc dd ac tinh cua u cd lien quan chat che.
chinh vi vay cac ty le ciia Cho {Cho/NAA va Cho/Cr) cd gia tn trong c h i n doan phan bac u thin kinh dem [7, 9].
V. K^T LUAN
Nghien cOu nay eho t h l y edng hudng tO pho da the tieh la phuang phap chan doan khdng xam nhap giiip c h i n doan va danh gia tinh e h l t tham n h i l m eiia u t h i n kmh dem trudc p h i u thuat. Chi sd ngudng Cho/
NAA cb gia trj trong e h l n doan phan biet giOa nhdm u t h i n kinh dem bac cao va bac thap,
Lo'i c a m e n
Chiing tdi xm gOi Idi cam an d i n ban lanh dao, tap t h i bac sy, ky thuat vien Khoa C h i n doan hinh anh Benh vien Huu nghi.Vidt DOc da tao dieu kien eho chiing tdi hoan thanh nghien cOu nay
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TAP CHi NGHIEN CU'U Y HOC •
11. Li, C (2010) Susceptibiiity-weighted scopie imaging: clinical relevance imaging in grading brain astrocytomas Eur J 185(3), 675 - 686.
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Summary
PREOPERATIVE GLIOWIA GRADING USING MULTIVOXEL PROTON MR SPECTROSCOPY
The objective of this study was to evaluate the difference in the parameters derived from multivoxel proton MR spectroscopy and histological glioma grading and to elanfy the usefulness of this technique in the grading of glioma From 01/2015 to 06/2016. a descnptive cross - sectional study was conducted on 55 patients (30 high - grade glioma and 25 low - grade glioma cases) undenvent preoperative conventional MR Imaging, multivoxel proton MR spectroscopy and histo- pathologically who were determined gliomas after stereotactic biopsy or partial resection For quantitative analysis, the metabolite data of gliomas were estimated on workstation. Receiver operative characteristic (ROC) curve analyses were also performed to assess which metabolite parameter was optimal for discrimination of glioma grading Statistically significant differences were found between tumor area, adjacent tumor area and normal brain tissue for Choline (Cho), NAA, Creatine (Cr), Cho/NAA, NAA/Cr and Cho/Cr Cho/N/\A ratio provided 83 3 1 % area under the ROC curve The cut-off value was taken as 2 37 in the Cho/NAA ratio provided sensitivity, specificity of 89,66% and 88%, respectively In conclusion, multivoxel proton MR spectroscopy was useful in the preoperative assessment of the histopathological grade of gliomas Keywords: glioma grading, multivoxel proton MR spectroscopy
TCNCYH 106(1)-2017
