Le Phong Thu vo Dtg Tap chi KHOA HOC & CONG NGHE 164(04): 2 0 1 - 2 0 5
TONG QUAN DAP UTVC MO BENH HQC UNG THU" VU SAU DIEU TRI HOA CHAT TIEN PHAU
Le Phong Thu'", Nguyen Thu Thuy', Tg Van Td^
' Trudng Dgi hgc YDugc - DH Thai Nguyen, ^Benh vien K Hd Noi TOM T A T
Sau dieu hi hoa chit tien phlu, danh gia dap ung mo b^nh hgc tren benh pham phau thuat dong vai tro quan trgng. Muc dg dap ung mo benh hoc hen quan den dieu tn va tien lugng. Co nhieu he thong phan logi dip dng mo bgnJi hgc dugc dua ra ciing vdi cac tieu chuin danh gia mdc do dap ling, Tuy nhien, vif c dinh gia dap ung mo bgnh hgc chua dugc tieu chuan hoa. Khai ni^m dap ung mo b?nh hgc hoan toin khac nhau giira cac hg thong. Hau het, sy bien mat hoan toan te bao ung thu Uen b?nh pham phau thugt dugc coi la dap ung mo b?nh hgc hoan toan. Mgt so he thong lai xIp c i nhdng trudng hgp con thanh phan ung thu ngi ong vao nhom dap iing hoan toan. Nhung theo bat cd cich xic djnh nao, dap ung mo b?nh hgc hoan toan bao gid cung tien luong tot ban dip dng khong hoan toin,
TiJ kh6a' phdn logi ddp ting, dap irng mo binh hpc, hda chdt tiin phdu. ung thu vw, ung thu biiu mo.
DAT VAN DE
Ung thu vd li bSnh phd bien dung hing thu 2 tren thS gidi, li bSnh ung thu pho bien nhat d nir gidi. LTdc tinh 1,7 trieu ca ung thu mdi mic dugc chin doan nam 2012 (chilm ti le 25% tit ci cac loai ung thu). Ung thu vd ph6 biln d ci nhdng nude phat trien va kem phit hien [12].
Tnrdc day, phac dd hda chat tien phlu chi dugc chi dinh cho nhung bgnh nhan ung thu vii giai doan 111 khdng m6 dugc. Hien nay, tren the gidi cung nhu tai Vigt Nam, xu hudng dilu tri hda chit tiln phiu dugc md rdng ddi vdi ung thu vd giai doan sdm [13]. Mdc dp dap ung mo benh hgc vdi dieu tri cd sy khac nhau giua cic trudng hgp. Da cd nhieu h£ thdng phan dp dap ting md benh hgc vdi dieu trj hda chit tiln phiu dugc dua ra [2], [3], [7], [14].
Trong mdi mgt h? thdng phan dp dap ung deu dua ra cac tieu chuin de danh gia. Cac tieu chuin dinh gia chd ylu dua vao sa sinh quan thi tl bao u trudc vi sau dilu tri, dua vao muc dp giim hogc het hoan toin te bao u.
Tuy nhien, cac tieu chuan cua cac he tlidng phan loai dap dng niy chua dugc tieu chuin hoa. Tieu chuin danh gia khac nhau anh hudng din ket qua danh gia dap dng vdi dilu
tri tu nhiing nghien cdu giii phiu benh khic nhau tren cung quin the benh nhin, Chinh vi vgy, viec dinh gia dap ling m6 benh hgc vdi dieu tri can dugc tieu chuan hoa, thdng nhit, Mac du vay, hiu het cac he thong phan loai dap ling vdi dieu tri da cho thiy lien quan giua mdc do dip iing vdi thdi gian sdng cua benh nhan.
Ti£u chuan danh gia dap iing mo benh hoc Hien nay, co rat nhieu tieu chuin mo benh hgc dugc dua ra de dinh gia dap iing vdi dieu tri ung thu vu. Du vay, cac phin logi dap dng md benh hgc chua dugc tieu chuan hda. Hiu hit cac tieu chuan xep vao 2 nhdm chinh: Dap ling hoan toan vi khdng dap iing, dua vio viec edn hay hit hoan toin te bao u tren benh phim phiu thugt sau dieu tri. Mgt sd phan logi dugc chia lam nhieu nhdm dua vao muc dp thay ddi cda te bao ung thu vi ti le cac vung bien ddi [2].
Mgt so he thong danh gia dap iing mo benh hoc
He thong phan logi ddp irng mo benh hgc theo Hiep Hpi ung thu vii Nhgt Bdn ndm 2007 - Do 0: Khong dap iing: Gin nhu kh6ng cd thay ddi d te bao ung thu sau dieu trj.
' Tel- 0976 888 383; Email:[email protected]
Le Phong Thu vd Dtg Tap chi KHOA HQC & CONG NGHB 164(04): 201 - 205 - Do 1: Dap irng mot phan
+ Dg la: Bdp ung nhe: Thay doi nhe d te bao ung thu vi/hoac thay d6i ro nhung it hon 1/3 te bao ung thu.
+ Bg lb: Bdp ung vua: Bien ddi ro 1/3 - 2/3 tS bao ung thu.
- Dg 2: Dip ung rd ret.
+ Do 2a: Thay doi ro ret: > 2/3 tl bao ung thu so vdi te bio ung thu cdn lai.
+ Dg 2b: Thay doi ddc biet ro rft: Thay d6i dap ling gan hoan toan chi con vii tl bio ung thu cdn lai.
- D5 3: Dip dng hoan toan, Hogi td vi/hoac het tl bao u va/hoac thay thS cac te bao ung thu bdi md hat va xa [2].
Theo hS thdng phin loai dap iing niy, dip ling hoan toan (Dp 3) bao gdm ci nhiing trudng hgp con thanh phin ung thu bieu m6 dng tgi chd.
Theo nghien ciiu cua Mukai va cdng sy, phin loai theo he thong eua Hiep Hdi Ung thu vu Nhit Ban cho kit qui: Dg 0: 5,2%. Do la:
39,7%. Dp lb: 21,4%. Dp 2a: 15,6%. Dp 2b:
3,1%. Dp 3 cd ung thu bilu m6 dng tai chd:
6,6%. Dp 3 khdng cd ung thu bieu md dng tai cho: 8,4%. Su khic biet cd y nghia thdng ke ddi vdi mdi nhom dap dug ve thdi gian song khong benh. Ti le song khdng benh sau 5 nam doi vdi dp 3 li 88%; 95% dg 2b; 80% dp 2a;
73% dp lb; 67% do la; 59% do 0 [4]. Cung theo he thdng phan loai nay, nghien cihi cda Le Phong Thu va cs tren 68 benh nhan ung thu vu giai doan III cd dieu tn hda chat tien phiu cho kit qua dp 0: 26,5%; dg I: 27,9%;
Dp 2: 25,6% vi d6 3: 20,6% [1].
Theo hudng dan thuc hanh ung thu vu nam 2013 dugc xuat ban bdi Hiep hdi Ung thu vu Nhit Bin, dap dng mo bgnh hgc vdi dilu tri can dugc danh gia sau dieu tri hda chit tien phiu nhu mpt vigc thudng quy.
He thong phan logi ddp ung theo NSABP B- 18 (National surgical Adjuvant Breast Project) bao gdm 3 nhdm sau:
- Dip ihig hoan toin: Hoan toin khdng. con te bao ung thu xam nhap.
- D5p ung m§t phin: Cic tl bio ung thu cdn lgi sap xep rieng le hoac thanh timg dam xen ke m6 dem xa hoac kinh hda.
- Khong dip u-ng: Tl bao u khdng cd thay ddi gi nhu da neu d tren.
NSABP B-18 la nghien ciiu Idn nhat so sanh dieu tri hda chat tien phau va hoa chit bd trg.
Dl can hach dugc phin tich rieng. NghiSn cuu niy cd liSn quan vdi sdng toan bp va song khdng benh [14].
Hf thong phan logi ddp ung Chevallier - Nhom 1 (Dip ling hoan toan): Cac te bio u mat hoan toan
- Nhom 2 (Dap iing hoan toan): Con c6 carcinoma dng tgi chd, khdng cdn cac te bao ung thu xam nhap va hgch im tinh.
- Nhom 3 (Dip ling mdt phan): Cdn co te bio ung thu xam nhap trong md dem cd sy bien doi.
- Nhom 4 (Khong dap ung): Cd rit it biln dli cua md u.
He thdng nay phan loai dip dng dieu tn cho 45 bgnh nhin ung thu vu the viem. Cic tic gia tach nhung trudng hgp ung thu vu the dng tai cho khdi nhom khdng cdn te bio ung thu [7], He thdng phdn logi ddp ung cda Miller-Payne - Do 1 (Khdng dip iing): Kh6ng co thay dli hoic thay ddi rat it d mOt so tl bao ic tinh nhimg khdng lim giam tren toan bg quan the t6 bio.
- Dg 2 (Dap ung mgt phin): Cac tl bao u bi mit mgt phan nhirag tren toan bd quin the te bio u vin cao, so lugng te bio mat khoang 30%.
- Dg 3 (Dap dng mgt phan): Cac te bao u bj mit udc tinh trong khoang tu 30-90%i.
- Do 4 (Dap dng gin hoan toan): Cac tl bao u bi mat mpt each rd ret, chi cdn lai nhiing dam nhd hoac cac te bao u hi phin tan rieng rS.
Cac te bio u bi mat tren 90%i.
- Do 5 (Dap dng hoan toan): Hoin toan khong con tl bao ac tinh tren benh phim ml. Chi
Le Phong Thu vd Dtg Tgp chi KHOA HOC & CONG NGHE 164(04): 201-205 thiy md dem xa mach, thudng thiy dgi thuc
bio. Tuy nhien, co thi thiy thanh phin ung :thun6i6ng[5], [10].
Phin loai dap ung dugc chia lam 5 do trong do cd so sanh quin thi tl bao u trudc dieu tri vi sau dieu tri, co lien quan vdi sdng toan bg va s6ng kh6ng benh. Tuy nhien, trong he thing phan loai cua Miller-Payne khdng dl cap den viec danh gia tinh trgng di can hgch.
He thong phan logi ddp ung theo Pinder vd cpng sir [8]
- Dap ung mo bSnh hgc hoan toan: Hoan toan kh6ng cdn te bao ung thu xim nhap nhung CO the cd thanh phan ung thu dng tgi chd.
- Dap ung mgt phan:
+ Dip ling gan nhu hoin toan, cdn rat it te bao u (<10% te bao u con lai)
+ Dip ling vdi dieu tri nhung cdn tu 10-50%
te bao u.
+ Dip ling it vdi dieu tri, cdn >50% te bao u khi so sanh vdi mau sinh thiet kim trudc do, mac du cd the nhan thay mpt sd dac diem dap img vdi dieu tri.
-Kh&ng CO bieu hiln dap ung vdi dieu tri.
Hf thong phan logi Sataloff[9]
-Mdu:
+ T-A: Toan bp hoac gan nhu toan bd dap dng vdi dieu tri (Dip dng md benh hgc hoan toin).
+ T-B; Tren 50% tl bio u dap ung vdi dilu tri nhung it hon la toan bp hoac gin toin bd.
+ T-C- Dudi 50% t l bao u dip ung vdi dieu tri nhung co bieu hien dip dng (dap dng mgt phan).
+ T-C: Khdng dap ung vdi dieu tri - Hach:
+ N-A: Cd bilu hien dap iing vdi dieu tri, khdng cd di can.
+N-B: Khong cd di can hach hay dap dng vdi dieu tri.
+ N-C: Cd bilu hien dap dng vdi dieu tri nhung cd di can hach.
+ N-D: Di cin hgch, kh6ng dip iing vdi dilu tri.
He thing niy phan logi dap ung dilu tri tren 36 benh nhan bao g6m ca khdi u nguyen phit va tinh trang hgch. K6t qui nghien cuu cho thiy nhiing benh nhan nhdm T-A co thdi gian sdng sau 5 nam tdt hem 3 nhom khic nhung kh6ng cd su khac biet vdi nhdm dip iing mgt phin [9].
HethdngRCB (Residual Cancer Burden) [11]
- RCB-0: Diem = 0. Kh6ng cdn te bio ac tinh tren md vd va bach.
- RCB-I: Diem 1,36, Dap iing mgt phan, -RCB-ir. Diem 1,36 - 3,26. Dip iing mgt phan.
- RCB-III. Dilm tren 3,26. Khing hda chit.
He thdng nay phat trien dua tren su tinh toan te bao_u con lai tren md vd d 382 benh nhan trong 2 nghien ciiu thuan tip khic nhau de du doan thdi gian s6ng khong benh va tai phat.
He thong nay sd dyng cic te bio u con lai tren toan bp nen mo u, so hach di can vi kich thudc khoi di can Idn nhat ket hgp tinh toin, xac dinh chi sd vao trong 4 nhdm (RCB-0 den RCB-III). Viec tinh toan niy dua vio phan mlm CO sin. (http://www.mdanderson.org/
breastcancerRCB) [II],
Nghien ciiu cda Patel va cs theo phan loai nay cho kit qui: RCB-0: 14%, RCB-I: 2%, RCB- II: 30%, RCB-III: 54% [6],
KET LUAN
Qua tieu chuin phan loai dap iing md benh hpc cda cic he thing tren cho thiy, khii niem dap ung mo benli hpc hoin toan khic nhau giua cic he thdng. Hau het, sy bien mat hoin toan tl bio ung thu tren benh phim phlu thugt dugc coi li dip iing mo benh hpc hoan toan, Theo phuong phap Sataloff, dap iing md benh hpc hoan toin bao gdm ca trudng hgp gin nhu hoin toan khong con te bao ung thu xam nhap tren md vu, Theo he th6ng phan loai cua Hiep Hpi Ung thu vu Nhat Ban xac dinh dip dng m6 benh hoc hoan toan khi hoin toan khong thiy tl bio ung thu vu xam
203
Le Phong Thu va Dtg Tgp chi KHOA HQC & CONG NGHE 164(04): 201 -205 nhap nhtmg lai bao gdm ca nhiing trudng hgp
ung thu vu tai chd vi cd di cin hgch. Trong phuang phap Chevallier, nhdm 1 dugc xac dinh la mit hoin toin te bao u, bao gdm ca cic tl bao ung thu xam nhgp, ung thu bieu m6 tai chd va hgch liln quan. Tuy nhien, theo bat cd cich xic dinh nao thi dip iing md benh hpc hoan toan bao gid ciing tien lugng tdt ban dap ung khong hoin toan,
TAI LIEU THAM KHAO 1. Le Phong Thu, Ta Van To (2015), "Dap dng mo b?nh hgc Carcinom tuyen vu giai doan III sau dieu trj hoa chat tien phau", Tgp chi ung thu hpc Ki#//V(im, 04, tr. 332-336.
2. Kurosumi M. et al. (2008), "Histopathological criteria for assessment of therapeutic response in breast cancer (2007 version)". Breast Cancer, 15(1), pp. 5-7.
3. Marchio C, and Sapino A, (2011), "The pathologic complete response open question in primary therapy", J. Natl Cancer Inst. Monogr.
(43), pp. 86-90.
4. Mukai H, et al, (2015), "Suatilying the outcome afler neoadjuvant treatment using pathological response classiflcation by the Japanese Breast Cancer Society", Breast Cancer, 23(1), pp 73-77,
5. Ogston K. N. et al. (2003), "A new histological grading system to assess response of breast cancers to primary chemotherapy: prognostic significance and survival". Breast, 12(5), pp. 320-327.
6. Patel T., Gupta A , and Shah M. (2013),
"Pathological predictive factors for tumor response in locally advanced breast carcinomas treated with
anthracyclin-based neoadjuvant chemotherapy", / . Cancer. Res. Ther. 9(2), pp, 245-249, 7. Penault-Llorca F. et al. (2008), "Comparison of the prognostic significance of Chevallier and Sataloffs pathologic classifications after neoadjuvant chemotherapy of operable breast cancer". Hum. Pathol. 39(8), pp. 1221-1228, 8. Pinder S. E. et al. (2007), "Laboratory handling and histology reporting of breast specimens from patients who have received neoadjuvant chemotherapy", Histopathology, 50(4), pp. 409-417.
9. Sataloff D, M. et al. (1995), "Pathologic response to induction chemotherapy in locally advanced carcinoma of the breast: a determinant of outcome", J Am. Coll. Surg. 180(3), pp. 297-306.
10. Smith I. C. et al. (2002), "Neoadjuvant chemotherapy in breast cancer: significantly enhanced response with docetaxel", J. Clin.
0«co/. 20(6), pp, 1456-1466
11. Symmans W, F, et al. (2007), "Measurement of residual breast cancer burden to predict survival after neoadjuvant chemotherapy", J. Clin. Oncol.
25(28), pp, 4414-4422.
12.Torre L, A, et al. (2015), "Global cancer statistics, 2012", CA. Cancer J. Clin. 65(2), pp.
87-108
13 Van der Hage J. A. et al, (2001), "Preoperative chemotherapy in primary operable breast cancer:
results from the European Organization for Research and Treatment of Cancer trial 10902",/
Clin. Oncol. 19(22), pp. 4224-4237
14.Wolmark N. et al. (2001), "Preoperative chemotherapy in patients with operable breast cancer; nine-year results from National Surgical Adjuvant Breast and Bowel Project B-18", J. Natl.
Cancer Inst. Monogr., (30), pp. 96-102,
Le Phong Thu va Dtg Tgp chi KHOA HQC & CONG NGHB 164(04): 201 - 205
S U M M A R Y
R E V I E W P A T H O L O G I C A L R E S P O N S E OF B R E A S T C A N C E R F O L L O W I N G N E O A D J U V A N T C H E M O T H E R A P Y
Le Phong Thu'*, Nguyen Thu Thuy', Ta Van To^
'University of Medicine and Pharmacy - TNU, ^Ha Noi K Hospital After neoadjuvant chemotherapy, assessment of pathological response in surgical speciments plays an important role in diagnosis and prognosis. The level of pathological response associates to treatment and prognosis. There are some systems to classify pathological response with standards were issued. However, pathological response assessment has not been standardized yet. The theory of pathological complete response is different among systems. Most of all, complete disappear of tumor cell in surgical specimens is considered as pathological complete response. According to any identification, pathological complete response always has better prognosis than non pathological complete response.
Keywords: classification response, pathological response, neoadjuvant chemotherapy, breast cancer, c
Ngdy nhgn bdi: 05/4/2017; Ngdyphdn bi4n; 10/4/2017; Ngdy duy?t dang; 27/4/2017 ' Tel: 0976 888 383; Email: [email protected]
