TAP CHl Y HOC VIET NAM TAP 459 - THANG 1 0 - S O 2 - 2017
DANH GIA HIEU QUA DIEU TRI NANG VA TON THU-QNG DANG NANG
LANH TINH TUYEN GIAP BANG PHU'O'NG P H A P TIEM CON TUYET DOI
Dum HiraNG DAN CUA SIEU AM
Nguyen Thi Thu Duyen*, Ngo Le Lam*, Pham Minh Thong*
I. OAT VAN OE
Nhan giap lanh tinh la ton thu'dng dang khoi khu tru trong tuyen giap. Sieu am c6 the phat hien du-dc 1 9 - 6 8 % [1][2]. Phan Idn nhan tuyen giap la nhan hon hdp gom ca phan dich vaphan dac. Khi phan djch > 50% the ti'ch nhan gpi la ton thu'dng dang nang. Khi phan dich > 90% the tich nhan, goi la nang ddn thuan. Neu nang khong Idn len va gay ra bat ky tneu chCrng nao thi CO the khong can dieu tri. Tuy nhien, khi nang gay ra cac van de ve trieu chu'ng va anh hu'dng den tham my thi nen dieu tri. Tru'dc kia phu'dng phap dieu trj hut dich ddn thuan da du'dc ap dung. Nhu'ng theo bao cao ty le tai phat cua phu'dng phap nay la 80% nen hien nay khong con ap dung. Sau khi_ phu'dng phap hut dich ddn thuan that bai EA da du'dc thCr nghiem va dat du'dc ket qua tot. [3],[4],[5]. 6 Viet Nam phu'dng phap nay con it va chu'a c6 bao cao ve hieu qua dieu tri trong nang ddn thuan va ton thu'dng dang nang c6 khac nhau khong. Vi vay Chung toi tien hanh nghien cu'u de tai: "Danh gia bleu qua dieu tri nang va ton thu'dng dang nang lanh tinh tuyen giap bang phu'dng phap tiem con tuyet ddi dddi hu'dng dan cua sieu am", vdi muc tieu nghien ciTu: danh gia hieu qua ciia phu'dng phap tiem con tuyet doi trong dieu tri nang va ton thu'dng dang nang lanh tinh tuyen giap.
II. €)6l TLTONG VA PHUaNG PHAP NGHIEN CLTU 1 . Doi tUdng nghien cu'u: Co 56 BN du'dc Ilia chpn gom: 42 nQ', 14 nam cd do tuoi tu' 20- 83, dUdc dieu trj bang EA tai khoa Chan doan hinh anh Benh vien Bach Mai tu" thang 4/ 2016 - 9/ 2017. Tat ca cac benh nhan deu c6; Ton thu'dng dang nang vdi phan dich> 50%, khong CO dau hieu ac tinh tren hinh anh sieu am. Co trieu chtTng hoac cac van de tham my. Nong do hormone tuyen giap trong gidi han binh thu'dng.
Choc te bao du'di hu'dng d i n sieu am cho ket qua ton thu'dng lanh tinh
2. Phu'dng phap nghien cu'u: Nghien cu'u can thiep khong doi chu'ng.
2.1. Ky thuit: Cac ky thuat du'dc tien hanh tren cd sd ngoai trii, khong benh nhan nao du'dc tiem tinh mach thuoc an than hoac thuoc giam dau tru'cfc hoac trong lam thu thuat.
T O M TAT
Muc tieu: Danh gia hieu qua cua phifOng phap tiem con tuyet doi trong dieu trj nang va ton thu'dng dang nang lanh tinh tuyen giap. Phu'dng phap nghien culi: Nghien cuU tien cuii can thiep khong doi chijtig. 56 benh nhan jBN) chan doan nang va ton thu'dng dang nang tuyen giap, dieu trj bang phu'dng phap tiem con tuyet doi (EA) du'di hu'dng dan cua sieu am tai benh vien Bach Mai tiT thang 4/2016 den 9/2017. Danh gia hieu qua, bang thay doi the tich nang, tneu chCrng, diem tham mytru'dc va sau EA 1 ttiang, 3 thang. So sanh hieu qua ciia EA trong ton thUdng nang ddn thuan va ton thu'dng dang nang.
Ket qua; The tich nang giam tif 7,8±5,26 mixuong 2,18 ±3,69ml sau 3 thang (the tich giam trung binli 79,00 ± 19,18%) va ty le thanh cong 87,5%. Hieu qua cua EA trong nhom nang ddn thuan tot hdn nhom ton thu'dng dang nang. Ket iuan: EA c6 hieu qua trong dieu tri nang va ton thi/dng dang nang lanh tinh tuyen giap. Tronq do hieu qua tot hdn trong nhom nang ddn thuan so vdi ton thu'dng dang nang.
Tif khoa: Nang tuyen giap, ton thu'dng dang nang, tiem con tuyet doi.
SUMMARY
TREATMENT EFRCACY OF ETHANOL ABLATION OF CYSnC AND PREDOMINANTLY
CYSTIC THYROID NODULES Objectives. The purpose of this study was to evaluate the efficacy of ethanol abiation (EA) of cystic and predominantly cystic thyroid nodules. Methods.
From April 2016 to September 2017, a total of 56 thyroid nodules were treated with EA. Nodule volumes, symptoms and cosmetic scores were evaluated before and after EA. EA efficacy in treating cystic and predominantly cystic nodules was compared. Results Mean nodule volume decreased from 7,8± 5,26 mito 2,18 ± 3,69ml (mean volume reduction, 79,00 ± 19,18%) andthe therapeutc success rate was 87,5% at last follow-up. EA was significantly more effective in cystic than predominantly cystic nodules. Conclusions. EA is effective in both c/stic and predominantly cystic nodules.
Key words: Thyroid cystic, predominantly cystic thyroid nodules, ettianol ablation,.
*Benh vien Da khoa dnh Ha Nam
**Benh vien Bach Mai
Chiu trach nhiem chinh: Nguyen Thi Thu Duyen Email: [email protected]
Ngay nhan bai: 18/8/2017 Ngay phan bien khoa hoc: 10/92017 Ngay duyet bai: 25/9/2017
VIETNAM MEDICAL JOURNAL H''2 - OCTOBER - 2017
2.2. Chi tieu nghien cu'u:
The tich nang: V = nabc/6 (V la the tich, a la Rich thu;dc Icfn nhat, va b va c la kich thu'dc con lai. Ton thu'dng nang c6 phan dac <10%:
nang ddn_ thuan. Phan dac: 10- 50% du'dc xep vac cac ton thu'dng dan gnang
Tu'di miu: dddc phan loai thanh bon mdc 0- I I I (khong tu'di mau; tu'di mau chi c6 d v6; tu'di nnau thanh phan dac < 5 0 % ; tu'di mau ben trong> 50%).
Thi'm my: do bac sy tham kham va ghi lai: 4 dp O-III (khong sd thay khoi; sd thay khoi, nliu'ng khong nhin thay; Nhin thay khi nuot; binh thu'dng ciJng nhin thay)
Lip lai EA hoac RF d nhuhg benh nhan:
TheJ:ich giam < 50%, trieu chiihg chu^ du'dc glai quyet, van de tham my chu'a du'dc giai quyet, phan dac con lai tang tu'di mau tren sieu am.
2.3. Xiflysdlieu: So lieu sau thu thap, du'dc nhap vao may ti'nh bang phan mem Epidafei3.b, phan tich bang phan mem thong ke SPSS 22.0 d\ia theo phu'dng phap thong ke y hoc.
III. KET QUA NGHIEN CU'U
Nghien cdu trong 56 BN trong do cd: 20 BN nhan nang ddn thuan va 36 BN ton thu'dng dang nang tuyen giap. Ket qua thu du'dc nhu' sau:
Bang 1. Bac diem Chung Dac diem Chung Tuoi TB (min-max) Nhom tuoi
Gidi Danq nanq
• < 19
• 20- 39
• 40- 59
• >60
• Nij-
« Nam Nanq ddn thuan Ton thu'dng danq nanq Tham my TB+SD f m i n - m a x )
BoO Do I 06 II Do I I I Do IV Mii'c mach mau ( m i n - m a x ) Mach mau
Trieu Chiang
MLTCO MlJcI MffcII Mii'c I I I
Co Khong Chung
So lu-Onq 1 Tv le ( % ) 49,38+12,17 (20-83)
0 10 38 6 42 14 20 36
0 17,9 67,9 14,2 75,0 25,0 35,7 64,3 2,73±0,52(l-4) 0
1 14 40 1
0 1,8 25,0 71,4 1,8 l,43±0,83(0-3) 8
20 24 4 40 16 56
14,3 35,7 42,9 7,1 71,4 28,6 100 Nh$n xet:JuQ\ trung binh cua
ty le nU/ nam= 3 / 1 . Ty le nang chu'ng va tham my dp I I I .
Bing 2. Hieu qui dieu tri
nhom DTNC 49,38±12,17. Ty le nu" gidi mac benh nhieu hdn nam, ddn thuan it hdn ton thu'dng dang nang. Cd 71,4% BN c6 trieu
N = 5 6
N = 2 0
N = 3 6
The tich T h j tich(ml) The tich giam Tham my Trieu chu'ng; Co
Khong The tich(ml) The tich giam Tham my Trieu chu'ng: Co
Khong The tich Cmi)
Tru'dc di'eu tri ( 1 ) 7,81±5,29 2,73+0,52 40 (71,4) 16 (28,6) 6,98±2,93 2,45+ 0,60
11 (55,0) 9 (45,0) 8,26±6,22
Sau dieu tri 1 thang ( 2 )
2,42+4,03 75,50+21,08
1,16+0,89 2 (3,6) 54 (96,4) 0,79+1,42 90,11+11,39
0,60+ 0,82 0 20 (100) 3,34+4,67
Sau dieu tri 3 thang ( 3 )
2,18+3,96 79,00+19,18
0,86+0,88 0 ( 0 ) 56 (100) 0,73+1,61 91,35+12,99
0,25 ± 0,55 0 20 (100) 2,98+4,62
Pl2
<0,01
<0,01
<0,01
<0,01
<0,01
< 0 , 0 1
< 0 , 0 1
<0,01
TAP CHI Y HOC VIET NAM TAP 459 - THANG 10 - SO 2 - 2017 The tich giam
Tham my Trieu chu'ng: Co
Khong
2,89 ± 0,4 29 (80,6) 7 (19,4)
67,37+20,93 1,47 + 0,77 2 (5,6) 34 (94,4)
72,14+18,73 1,47 ± 0,77
0(0) 36 (100)
<0,01
<0,01 IVhan xet: The ti'ch trung binh, tham my, trieu chLfngtri/dc va sau dieu tri khac nhau c6 y nghta thong ke p< 0,01.
Bieu do 1 . Ket qua dieu t r i t r o n g n h o m DTNC
Nhinxet:!^ le thanh cong nhom nang ddn thuan cao hdn nhom ton thu'dng dang nang (p< 0,01).
Bang 3. Bang so sanh the tich trung binh, giam the tich trung binh va ty le thanh cong cua nang ddn thuan va ton thUdng dang nang.
The tfch TB nang{TB + SD) Giam the tich TB (%)(TB + SD)
Thanh cong
Nang ddn thuan{n= 20) 6,98+2,93 91,35+12,99
95%
Dang n a n g ( n = 3 6 ) 8,25+6,22 72,15+18,73
83%
P 0,93
<0,01
<0,01 Nhan xet: Khong c6 si/ khac biet ve the tich trung binh giiJa nang va ton thUdng dang nang (p>
0,05). NhUng c6 sir khac biet va SLT giam the tich cua 2 nhom ton thUdng (p< 0,01). Ty ie thanh cong ciia nang ddn thuan la nhieu hdn cua ton thu'dng dang nang (p< 0,01)
Bang 4. Cac yeu to anh den hieu qua dieu tri
— — ; . _ _ l < e t qua Bac diem — - . , _
The tich Thanh phan dac
Mii'c mach mau Chung
<5 5-10
>10 Nang ddn thuan
(10-50%) Danq nang (<10%)
OdO O d I 06 I I Bo I I I
Thanh cong 25(100) 19 (90,5) 5 (50,0)
19(95,0) 30 (83,3)
8(100) 19(95%) 20(83,3) 2 (50,0) 49 ( 8 6 , 8 )
Khong thanh cong
0 ( 0 ) 2(9,5) 5 (50%)
1 (5,0) 6 (16,7)
0(0) 1(5,0) 4(16,7) 2 (50,0) 7 ( 1 2 , 5 )
Chung 25 21 10 56 20 36 8 20 24 4 56
P 0,003
<0,01
0,03
Nhan xet: Cac yeu to, the tich ban dau, thanh phan dac trong khoi, mdc mach mau va ty le thanh cong, khong thanh cong khac biet cd y nghta (p< 0,05).
IV. BAN LUAN
1 . Oac diem chung: Tuoi trung binh cua nhom £)TNC49,38±12,17, nhom 40-59 chiem phan Idn (67,9%). Ty le niJgidi mac benh nhieu hdn nam, t / le nu'/ n a m ^ 3 / 1 . Ty le nang ddn thuan 35,7%, ton thu'dng dang nang 64,3%, Phan Idn benh nhan c6 van de ve tham my va trieu chuYig.
2. Hieu qua dieu trj bang phu'dng phap tiem con tuyet doi: Klil nghien cu'u 56 benh
nhan, chung toi thay rang ty le thanh phan dac la mot du' doan cho hieu qua EA. Do do chung toi chia nhijng ton thu'dng nang tuyen giap thanh 02 nhom, nang ddn thuan va ton thu'dng dang nang.
The tich trung binh cua nang tru'dc dieu trjtu' 7,81+5,29, sau dieu trj 3 thang the tich TB giam con 2,18±3,96 (p<0,6l). Trung binh the tich giam79,00±19,18% den lan theo doi cuoi ciing.
£)iem so trung binh ve tham my cung du'dc cai
VIETNAM MEDICAL JOURNAL WZ - OCTOBER • 2017 thien dang ke (p< 0,01) va khong BN nao con
trieu chu'ng den lan theo doi cuoi ciJng. Ty le thanh cong trong nghien cuU la 87,5%, Hieu qua ton thu'dng giam dan theo thc^i giam theo doi. Cd tac gia cho rang do phan dac trong ton thu'dng nang hap thu con tuyet doi va tac dung xd hoa keo dai nen the tich giam dan sau nhUng lan kiem tra[3].
3. Cac yeu tci anh hu'dng den mu'c g i a m the t i c h : trong nghien cu'u mu'c giam the ti'ch phu thuoc vao cac yeu to: the tfch ban dau, ty le phan dac trong khoi (ton thu'dng nang ddn thuan hay dang nang), mii'c tang sinh mach cua ton thu'dng. Cac nghien cuXi tru'dc day da bao cao, nang ddn thuan EA hieu qua 95- 9 6 , 1 % , ton thu'dng dang nang hieu qua dieu tn 82,2%. EA it hieu qua trong ton thu'dng cd the tich ban dau >
10ml va mii'c tang sinh mach do I I , I I I . Cac tac gia cho rang thanh phan dac lam han che khuech tan ciia con tuyet doi dan den tac dung giam, con mach mau tang sinh d i n den tang liap thu con vao mau, giam lu'dng con trong nang, giam hieu qua dieu tri[3][5].
4 . So sanh hieu qua ciia EA t r o n g n h o m nang ddn thuan va ton thu'dng dang nang:
The tich trung binh cua nang ddn thuan va ton thu'dng dang nang khac biet khong c6 y nghTa (6,98+2,93 so vdi 8,25+6,22, p=0,93), nhu'ng sau dieu tn sd giam the ti'ch trung binh cua nang ddn thuan so vdi ton thu'dng dang nang khac biet mang y nghla thong ke (91,35+12,99 so vdi 72,15+18,73, p< 0,01). Ty le thanh cong trong dieu tn nang ddn thuan la 95%, trong ton thu'dng dang nang la 83% (p= 0,01). Cac tac gia cho rang khong the xac dmh bat ky yeu to nao lien quan den hieu qua cua EA trong ton thu'dng nang ddn thuan, EA la hau nhu" luon luon hieu qua trong viec dieu tn cac ton thu'dng nang ddn thuan, bat ke tru'dc do c6 cac yeu to nguy cd anh hu'dng den hieu qua dieu tri cua EA. Oieu nay cung cap them bang chu'ng ve viec SLT EA trong dieu trj ton thu'dng nang ddn thuan la phu'dng phap dau tay[3][6]
Bieu tt! bo xung da du'dc thiTc hien sau 1 thang vdi 1 BN lap lai EA trong nhom nang ddn thuan, 6 BN lap lai EA va 3 BN dot song cao tan tuyen giaptrong nhom ton thu'dng dang nang.
5. Mu'c do dau, tac dung phu va ton thu'dng: Nghien cu'u cho thay diem dau TB d nhom ton thu'dng dang nang (2,83±1,38) cao hdn nhom nang (1,65±1,18) (p<0,01). Phan Idn BN khong dau, cd 11 benh nhan dau nhe trong qua trinh lam thu thuat ma khong can dijng thuoc giam dau. Chiing toi thay rang tiem
ethanol bang each choc kim xuyen eo giam thieu cac bien chu'ng. Cac each tiep can xuyen eo cho phep kim xuyen qua nhu mo tuyen giap du de khong lam thay doi doi vi tri ciia cac miji kim trong khi nuot hoac noi chuyen, cung nhu" ngan chan ethanol ro ri ben ngoai tuyen giap. Cach tiep can nay cung da du'dc su' dung cho EA cung nhu'cho RFA ciia nhan giap[3][5i[6]
V. KET LU^N
Phu'dngphap tiem con tuyet doi dieu tri nang tuyen giap du'di hu'dng dan ciia sieu am la phu'dng phap dieu tri an toan, hieu qua, de thi/c hien va tiet kiem chi phi dieu t n .
The tich trung binh sau dieu tn giam 79%, ty le thanh cong 87,5%. Diem tham my tru'dc va sau dieu trj giam cd y nghTa (p< 0,01) va khong CO BN nao sau dieu tri con trieu chu'ng. Cac yeu to anh hu'dng den ket qua dieu tri: thanh phan dac, mii'c mach mau, the tich ban dau.
Mac du EA la hieu qua va an toan cho ca hai loai nang va ton thu'dng dang nang, nhutig hieu qua hdn cho ton thu'dng nang ddn thuan trong van de thanh congtrong dieu tri va dieu tri bo xung. Ty le thanh cong trong dieu tri nang ddn thuan la 95%, trong ton thu'dng dang nang la 83% (p= 0,01). Co lOBN can dieu tn bo xung.
Trong do nang ddn thuan IBN, ton thu'dng dang nang 9 BN.
TAI LIEU T H A M KHAO
1. HaugenB.R et al (2016). American Thyroid Association Management Guidelines for Adult Patiento with Thyroid Nodules and Differentiated Thyroid Cancer; The American Thyrciid Assodation Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 26(1); p.1-133.
2. Gharib H et 3^2016^.American Association of Clinical Endocrinologists, American College of Endocrinology, and Assodazione Media Endocrinologi Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules2016 Update. Endocr Prad. Vol.
22. 2016. 622-39.
3. KimYJ et aj[2012).Cysdc versus p^ominantly cystic thyroid nodules: efficacy of ethanol ablation and analysis of related fedars. Eur Radiol. 22(7): p. 1573-8.
4. Ferreira MC, C Piaia, and AC Cadore ^016), Percutaneous ethanol injection versus conservative treatment for benign cystic and mixed thyroid nodules. Arch Endocrinol Metab. 60(3): p. 211-6.
5. Sung jy et ai (2008). One-step ethanol ablation of viscous cystic thyroid nodules, AJR Am J Roentgenol. 191(6): p. 1730-3.
6. Jang SWetai (2011) How to manage the patents with unsatisfactory results after ethanol ablation for thyroid nodules; role of radiofrequency ablaton. Eur J Radiol. doi:10.1016/].ejrad- 2011.02.039
