TAP CHl KHOA HOC T l 6 u H 6 A V 1 £ T NAM 2012 -'
K§'t qua brfdc d i u di^u tri ung thtf bi^u md te bao gan bang phtfchig phap hoa tac mach vdi hat vi clu tai hoa ch^'t
Preliminary results of TACE using drug - loaded microspheres for the treatment of hepatocellular carcinoma
THAI DOAN K Y ' , MAI H 6 N G BANG*. PHAM MINH THONG^ NGUYEN TI^N THINH'. VU V A N KHIEN', LE V A N TRLfdNG'. DUCJNG MINH T H A N G ' , TRINH XUAN HUNG', NGUYEN LAM TUNG'. NGUYEN CANH BiNH'. N G 6 THI HOAl', HOANG KIM NGAN'
'B^nh vi§n TUQD 108. ^B^nh vi^n Bach Mai
Abstract
Aims: To study the preiiminaiy effects and safety of TACE using doxorubicin -loaded microspheres for treatment of HCC. Subjects and methods: a prospective study involved 30 HCC patients (mean tumor
size: 55.8 ±24mm) underwent TACE using drug-loaded beads at the 108 hospital, from June 2011 lo May 2012. We used 1 or 2 from 3 different sizes of DC-Beads (100-300pm, 300-500pm and 500-700pm) loaded with 75mg doxorubicin per 1 procedure. Tumor responses were assessed at I month, 3 month and 6 month after the first procedure according to modified RECIST. Postembolization syndrome and complications were also recorded. Residts: A total 35 procedures were successful performed. The objective response rate according to modified RECIST was 86.6% at 1 month, 66.7% at 3 month and 61.1% at 6 month follow-up. Serum AFP levels were decreased significantly after treatment. Postembolization syndrome
was observed in 93.3% of cases but mild and recovered without any treatment. There were no case of doxorubicin -related systemic toxicities. The complication occurred in 1 cases (tumor abscess).
One death occurred within 6 months follow-up due to the progression of disease but there were no case of procedure-related death. Conclusion: DC-Beads TkCE is safe and effective treatment for patients with HCC.
Tom tat
Mi^c ti§u: D^nh gii hifiu quS h\S6c dau vh dp an to&n cOa phiTcfng phSp h6a t^c mach vc3i hat vi clu tai hoa chS't trong d i l u tri ung thu" bieu mo teb&o gan. Dd'i Ut(fng va phtftfng phap: Nghien cii^i tien ciJu g6m 30 benh nhSn chin doSn xSc dinh ung thir bieu mo Id' b^o gan trfin n l n gan xd vdi kich thifdc khoi u trung blnh 55,8 ± 24mm, du'dc dieu tri b^ng phUdng phdp h6a tSc mach v(3i hat DC-Beads tai Benh vien Tl/QD 108, th&i gian tir th^ng 6/2011 de'n thSng 5/2012. Sti dting 1 hoSc 2 trong 3 loai hat DC-Beads (100-300Mm, 300-50O|im v^ 500-700Mm), hkm ItTdng Doxorubicin trung binh75mg/lan can thiep. D^nh gid dSp iJng khQ'i u tai cdc thdi dilm 1 thdng, 3 thdng, 6 thdng dtfa theo tieu chuin ddnh gid ddp iJng kh6^i u cdi tid'n. Theo doi hOi chiJng sau tSc mach vd cdc bifi^n chtJng sau moi l^n can thiep.
Kfi't qua: Tdng c^ng c6 35 lan can thiep, ta't ch d i u th^nh cfing ve ky thuat. T;^ lfi ddp tJng kho'i u tai c^c thdi diem 1 thdng, 3 thdng vd 6 thdng sau can thi$p iln liTdt Id 86,6%; 66,7% v^ 61,1%. H^m lUdng AFP giim c6 ^ nghla sau d i l u tri. Hfii chd'ng sau t^c mach gdp S 93,3% s6' triTdng hdp nhtfng hau he't diu nhe vd h6i phuc khdng cin can thifip. Kh6ng gdp trirSng hdp ndo b i l u hifin dgc tmh todn than ciia
[ 9 0 8 TAP CHf KHOA HPC TifeU H 6 A V I ^ T NAM 2012 - T ^ P VII- s 6 29
doxorubicin. BiS'n chiJng gap 1 tritflng hcjp (dp xe h6a khefi u). Khdng c6 t* vong lien quan tin ky thuat. c6 1 truang h(?p t* vong trong v6ng 6 thdng do b^nh ti^n tri^n. KS't lu^n: Hda dc mach vdi hat DC-Beads li mOt phUdng phdp an toiln vi bltdc dSu cho thSfy c6 hi$u qud trong dilu trj b^nh ung thubi^u mfi tS'bao gan.
Tir khda: Ung thU bi^u mfi t6' bho gan, hda tSc mach
I. DSt va'n ai
Ung thu bi^u mfi tS' bio gan (UBTG) lit mOt trong nhffng loai ung thU phd bi^n nha't d nUdc ta [3]. PhSu thuat lit phirdng phdp dilu trj tffi iru nhtfng chl dp dung diTdc cho khoing 1/3 stf b^nh nhan do phSn ldn cdc trirdng hdp dUdc phdt hi§n bSnh d giai doan muOn. Hda tile mach qua dudng ddng mach tir lau d3 dlTdc cha'p nh&n rdng rai nhu la mdt phtfdng phdp dilu tri tam thdi cd bdn cho cdc tnrdng hdp ung thu bilu md td' bdo gan khdng cdn chi djnh ph§u thu^t, tuy nhiSn ty Id hoai til hodn toin khdi u thd'p vi dl gid vflng kit qud cin phdi thiTc hi0n nhilu lin. Hda tSc mach vdi hat vi cSu tdi hda cha't Id phudng phdp hda tdc mach cdi tiln. sij" dung cdc hat vi ciu (hat DC- Beads) vfla cha't mang thud'c vd gidi phdng thuoc mot cdch 6n dinh bdn trong mdi trirdng khd'i u, vira Id tdc nhdn gdy tic mach. PhiTdng phdp ndy da dfldc chflng minh trong nhieu thfl nghidm iam sdng td cd hidu qud hdn nhtrng it tdc dung phu hdn so vdi hda tic mach truyen thd'ng. O nfldc la chi mpt sd'cd sd y tlldn mdi bit diu iriln khai dp dung hda tic mach vdi hat DC- Beads Irong dilu tri ung thfl bilu md td' bdo gan.
Myc tidu;
- Ddnh gid hieu qui cira phfldng phip hda tic mach vdi hat DC-Beads ve ty Id ddp flng khdi u vd bien ddi hdm lfl(?ng AFP trong dilu tri UBTG.
- Ddnh gii tdc dung phy vd tai bien, biln chflng cda phfldng phip ndy.
II. Dd'i tflf/ng v^ phi/dng phdp
Dd'i tfl((ng nghien cd'u: g6m 30 b$nh nhin bi UBTG trdn nln gan xd, dilu tri nOi UTi tai Bdnh vidn TUQD 108, thdi gian tir thdng 6/2011 dd'n thing 5/2012.
• Wu chuSn IfCa chqn:
- Dfldc chin dodn xic dinh UBTG bSng tibdo hpc vd/hojlc mfi b^nh hpc.
-Tudi 18-80.
- Xd gan Child A. B. Giai dpan Okuda I.II - Khfing cd huyl't khdi thin linh mach cila - Khdng cd di cSn ngodi gan.
- Chl sfi' thi trang: ECOG 0-2 (theo WHO).
- Ty Id Prothrombin >=60%, Tilu ciu > 50 G/1.
Bach ciu > 4 G/1.
- Khfing cd bdnh ndng kit hdp (suy tim, suy thin, suy hd hd'p..).
• • Tilu chuin lofi trU:
- U gan lan tda, u gan nhieu khtfi (> 3 khoi), u gan kich thfldc ldn >15cm
- Xd gan Child C.
- ECOG 3-4 dilm.
- Cd di cdn ngodi gan. cd huyet khtfi thin hode nhinh chinh ttnh mach cila
Dang chdy mdu do vd gian tinh macb thflc quin.
- Rd'i loan ddng miu: ly 1^ prothrombin < 60%;
Tilu ciu < 50 G/1, BC < 4G/1.
- Cd benh ndng kd't h(Jp (suy tim, suy thdn, suy hd hd'p) hode b^nh nhin qui gid yd'u.
- Phy nff cd thai hode cho con bti.
- B^nh nhan khdng dtfng S phfldng phdp dilu tri dfldc chi dinh.
PhiAfng phip nghidn citu: tid'n cflu, can thi$p khdng dd'i chflng
• Ky thudt can thifp: Vl cdc bfldc cd bin tfldng tfl nhfl dd'i vdi hda tic mach truyin thd'ng. Hda chi't dfldc tii vdi hat DC- Beads trfldc 90-120 phdt nhim dim bio dfldc tdi vdi lilu Ifltjng ttfi da. Lilu hda chd't: Doxorubicin 75mg, sfl dung 1 hoic 2 trong 3 loai kich cd hat DC-Beads (lOO-SOOiim, 300-500|jm, 500-'700Mm).
^ i :
TAP CHl KHOA H(?C TIEU H O A VlfeT NAM 2012 - T A P Vlt - s 6 29
* Chl tieu nghiin citu: T^ 1§ ddp iJng kh6'i u (ddnh gid theo RECIST cdi tifi'n ndm 2008 ctia mp hOi Gan Mdt MJ- AASLD [8]) lgi cdc th&i dilm 1 thdng, 3 thdng, 6 thdng sau can thi$p diu tifin (dtra v^o hinh dnh chup cit ldp vi tinh da day, 3 thi); bifi'n ddi hdm Itfdng AFP trrfdc vd sau dilu tri, hgi chiJng sau tic mach, tai bifi'n, bifi'n chtfng ky thudt, tO: vong). Cdc xfit nghiem cfing thtJc mdu vd chiJc ndng gan thdn diTdc thu'c hi^n trifdc dieu tri, 1-3 ngdy sau can thi^p vd tai cdc thdi dilm theo doi.
* X&l^ sd'li$u: Sli dtang phin mIm SPSS 18.0.
III. Kfi't qua nghifin citu
30 BN diTdc tht/c hi$n ting cgng 35 iln hda tic mach vdi hJit DC-Beads, td't cd diu thdnh c(3ng vl ky thu^t. C6 1 triTdng hdp bi bien chiJng dp xe hda khfi'i u gdy Irdn dich mdng phdi phSi phdn iJng nhirng du'dc dilu tri In dinh, khfing tru'dng h^p ndo tiJ vong do ky thudt, 1 tru'dng h0p tt3* vong d thdng thiJ 4 sau can thi$p do bfinh tifi'n triln. Khdng cd tru'dng hdp ndo bilu hien tdc dung phu todn thdn ct3a doxorubicin trong qud trlnh theo ddi (ryng tdc, iJc chl tCy xifdng, vifim cd tim...).
Bdng 1: MOt sfi'ddc dilm ldm sdng vd can Idm sdng cOa nhdm BN nghifin ctfu
Die dilm Tudi trung binh
Nam/niJ
Yeu ttf nguy cd
Tridu chflng ldm sdng
Dp bidt hda te' bdo u gan
Stf u gan
Vi tri u gan
Viem gan B Viem gan C Nghien rfldu
Khdc Cd Khfing
Cao Vfla Tha'p Ikhtf'i 2-3 khd'i Thiiy phii Thiiy trdi Cd 2 thiiy Kich thfldc khtfi u trung blnh (mm)
AFP trung binh (lU/ml)
Stfliidng/Tyl?
54,5 ±11.7 29/1 24
0 1 5 23 7 9 15 6 25 5 26 3 1
80%
0%
3,3%
16,7%
76,7%
23,3%
30%
50%
20%
83,3%
16,7%
86,7%
10%
3,3%
55,8 ± 24,0 258,1+481,0
TAP CHf KHOA HOC TlfeU HdA V i t T NAM 2 0 1 2 - T A P Vll. S d s
Bdng 2: Thay ddi kich thfldc khfi'i u tai cic thdi dilm theo ddi Kich thfldc u gan
Kich thfldc u trung Hnh (mm)
Trfldc didu trj (1) 55,8 ± 24.0
1 thing (2) 48.5 ± 25.6 P2-l^ 0,122
3 thing (3) 47,8 ± 27,5 P3-l=0,011
6 thing (4) 42,9 ± 29,5s P4-l= 0,021,
Bing 3: Ty Id ddp flng khtfi u sau dilu trj tai cdc thdi dilm theo ddi D a p flng khd'i u theo RECIST cai tid'n
D i p flng hodn todn (CR) D i p flng 1 phin (PR)
Bdnh dn dinh (SD) Bdnh tie'n trien (PD)
1 thing (n/%) 7/30 19/30 3/30 1/30
23,3 63,3 10 3,3
3 t h a n g ( n / ' / f ) 6/30 14/30
8/30 2/30
20 46,7 26,7 6.7
6 thing (n/%) 4/18 7/18 5/18 2/18
22.2 38,9 27,8 ., 11.1
Ham Ifldng AFP (lU/ml) AFPTB
P
BSng 4: Biln ddi hdm Iflpng AFP flfldc vd sau dieu tri Trfldc d i l u
trj(1) 258.U481.0
T u i n d ^ u s a u d i l u trj (2) 64.5 ± 85.8 P2-l= 0.016
1 thing (2) 78.2+ 155.8 P3-1=0.026
3 thing (3) 84.3+ 159,3 P3-1=0,024
1
6 thing (4) 120.2±304,2 P4-l=0,310
Bdng 5: Hpi chtfng sau tic mach Trieu chflng lam sang
Dau vdng gan Sot Mdt moi
Ndn
So Iflc/ng/Ty Id 28/93,3%
24/85,7 16/53,3 3/10
Sd' ngay bi trung binh 3,5 + 1,6 2,6 ± 2,3 2,7 ± 2,3 0.7 ± 0.3 Bdng 6: Thay dli transaminase vd chtfc ndng gan sau dilu tri Xet nghidm dinh g i i
GOT (U/1) GPT (U/1) Bilirubin todn phin (^imol/l)
Albumin (g/1) Ty Id prothrombin (%)
Trfldc can thi$p 59,1 ± 5 . 5 53.8 ± 5,4 14,8 ± 0 , 8 38,5 ± 1 , 9 91,0 ± 2 , 0
Sau can thi$p 180,3 ± 3 4 , 0 141,1+32,7 20,8 ± 2,4 35, 9 ± 1 , 0 91,9 ± 2,7
P 1
0,001 0,006 i 0,015 4 0,084 j
0,79 1
TAP CHf KHOA HQC TifiU H O A V I 6 T NAM 2012 - T A P VII -1
U gan tri^dc di^u trj Sau 1 thang 3 thang 6 thang Anh 1: Hoai tt3: kho'i u hodn todn sau can thifip vd tai cdc thdi dilm Iheo doi (ddp tfng khd'i u hodn todn vd
thu nho kich thifdc tai cdc Ihdi dilm theo doi-BN Vo Van D. 76T)
U gan trtfdc dilu tri Sau dilu tri 1 thang
Anh 2: Hoai ttf u gan gin hodn todn sau 1 thdng (ddp tfng 1 phan), cdn phin ton thiTdng tdng sinh mach rat nho (mui ten). Kich thiTdc kho'i u gidm hdn so vdi tnrdc dilu Qi nhuYig sir thay doi chira dang ke (BN Ng. Van T. 63T)
U gan P kem nang gan Sau 1 thang Sau 3 thang
Anh 3: U gan P ha phdn thuy VIII (kem nang gan) hoai tit hodn todn sau I thdng dieu tri, tdi phdt tai chd sau 3 thdng, nguIn nuoi Id tuin hodn bdng he ttf ddng mach hodnh dtfdi phdi, dirdc dieu tri hda
tie mach DC-Beads lin 2 (BN Ddu Mmh Kh. 67T)
IV. Ban lu$n
UBTG Id mgt trong nhu'ng loai ung thtf cd tifin ItTdng r^Tt xKu. CU cd khoang 20-30% so trtfdng hdp dtfdc chi dinh cdc phtfdng phdp dilu tri trifit cdn (phlu thudt, cac phtfdng phdp tifiu hiiy khdi
u qua da) tai thdi d i l m chan dodn. Ddi vdi cdc trtfdng hdp khfing cdn chi dmh dilu tri trifit cdn, thi phtTdng phdp hda tic mach la phtfdng phdp dilu tri tam thdi cd bdn, vdi hifiu qud lam sdng da dtfdc chtfng minh Id kiem sodt dtfdc stf tifi'n trien
TAP CHf KHOA HOC TlfiU H d A VI^T NAM 2012 - T ^ P Vll- s d 2 ^ f i
cda khtfi cilng vdi kdo ddi thdi gian stfng thdm cho b$nh nhdn [1,2]. Hi$u qui ky thu?t \i tfldng khi dat dfldc ndng dtf hda cha't ttfi da, Iiu ddi trong khd'i u vd ndng dtf thufl'c ttfi thilu S tuin hodn ngoai vi nhim giim thilu cdc dtfc tinh do hda chd't chtfng ung thfl giy ra. Hda tic mach vdi vi hilt vi ciu tii hda chit Id phfldng phdp dilu trj cii tiln, sil dyng cic hat vi ciu vfla Id tic nh9n tic mach, vira Id chd't mang thud'c vd giii phdng thud'c mtft cdch ttt Itt nhim duy trt ndng dtf hda chi't cao, dn dinh trpng khtfi u, ddng thdi giim ndng dtf thutfc khuylch tin ra tuin hodn ngoai vi. DC Bead''"
(Bicempatibles UK, Surrey. UK) Id mtft dang h?t vi nang ciu dfldc thid't k l ddc hidu chp ky thuit hda tic mach, cd thi dflcjc chuyin tii cilng vdi hda cha't chd'ng ung thfl nhfl Dpxprubicin. Diy Id mOt dang vit lidu mIm hinh ciu, ciu tao bdi dfldng da phdn cd gin cic nhdm sulfpnat (S03-) dfldc pplymer hda. ICich thfldc cdc hat ttt 100 din 900Hm, bio quin dfldi dang dung dich phosphate vd khi trpn vdi dung dich hda chit thi cic tic nhan hda cha't dfldc gin ktft vdo cic hat. Sau ktii dfla hat DC Bead vdo mdi trfldng khd'i u, cic hat niy se gidi phdng ttt ttt hda chS't. Sfl gin ktft vd phdng thich hda cha't dflpc thflc hidn thep cd che trao ddi ion. Cic nghidn cflu tren dtfng vat cho thiy hoai til khtf'i u dat cao nhit vdo ngdy thfl 7 den ngdy thfl 14 sau can thi^p. Ndng dd hda cha't trong khtfi u tai thdi dilm 72 gid sau can thitfp cao gd'p 4 lin so vdi hda tic mach truyen thd'ng trpng khi ndng do hda cha't d tuin hodn ngoai vi thip hdn cd ^ nghTa[5]. Cic nghien cflu ldm sdng trin cdc miu benh phim u gan dfldc cit bd md trfldc dd dfltjJc dilu tri bing hda tic mach vdi hat DC-Beads cho thd'y hda chit chtfng ung thfl vin dfldc giii phdng ttt hat vi ciu hdng thdng sau can thidp[9].
Mdc dtt ket qui dat dfldc trpng cdc thil nghiem ldm sdng dilu tti UBTG (cd dtfi chflng vd khfing dtf'i chflng) cho thiy hieu qui kilm spdt khtfi u tfi't hdn cdng it tdc dung phu hdn khi s^ dung hda tic mach vdi hat vi ciu SP vdi hda tic mach truyin thtfng. tuy nhien Iiidu qui vl thdi gian stf'ng thdm liy ddi cda BN cung dang cin dfldc tilp tuc khing dinh. Mdt khdc ktft qui vl t^ le hoai tfl hodn todn khtfi u dat dfldc Id khdc nhau trpng cic bio cip. Mpt sfi' vin
dl cdn chfla dfltjc hodn tpdn khing djnh nhfl lilu hda chit ttfi flu chp mtft lin can thi#p, s i dyng lilu Ifldng vd kich c8 h?t DC-Beads, mflc dtf tic mach...; bdi vi vi$c ip dyng cy thi Id khic nbaud cic trung tim can thitfp [4]. Trong nghiSn cflu ndy, chdng tdi sil dyng lilu dpxprubicin 75mg dfltjc tii vdi 2ml hat DC-Beads nhim dim bio lilu lii hda chit ttfi da theo khuyin cio (37.5mg/lml hat). 1 hode 2 trong 3 Ipai kich cd hat khdc nhau dfldc sil dyng vdi loai nhd bdm trfldc theo sau Id loai kich cd hat ldn hdn.
Sy thay dtfi kich thfldc u gan sau dilu tri dinh gii trdn hinh inh cit ngang trfldc diy dfldc xem Id mtft chi tidu quan trpng dl ddnh gid hidu qui dilu trj. Tdng kich thfldc u phin dnh btfnh titfn triln trpng khi giim kich thfldc u dflijc chp Id ddp flng vdi dilu trj. Trpng cic nghidn cflu trong vd ngodi nfldc vl hda tic m^ch truyin thtfng dilu tri UBTG thiy hitfu qui giim kich thfldc u dat dflpc tren 50% stf trfldng hpp. Kel qui nghiSn cflu ciia chdng tdi d bing 2 ciing cho thiy tai cdc thdi dilm 1 thing, 3 thing vd 6 thing sau can thitfp kich thfldc u trung blnh d nhdm nghitfn cflu giim din vd nhd hdn so vdi trfldc dilu tri. Tuy nhiln sfl thu nhi kich thfldc khd'i u chi thiy rd tai cdc thdi dilm mutfn hdn (3 thdng, 6 thdng) trong khi tai thdi dilm 1 thdng diu tidn theo ddi stf thay ddi Id chtfa cd j nghia. Thflc ttf Id. trpng khoing thdi gian sdm sau dilu tri. giim stf Ifldng ttf bdo u stf'ng sdt khtfng hpdn todn dfldc phin dnh thdng qua giim kich thfldc khfi'i u. Sau dilu tri bing hda tic mach hode bing cdc phfldng phip can thitfp qua da, ngfldi ta quan tdm den vttng hoai til niiilu hdn Id giim kich thfldc khtfi u [8], Dtfi vdi dilu tri hda tic m?ch thdng thfldng, dinh gii viing hoai ti ddi khi gip khd khdn do si; ling dpng ciia lipiodol sau can thitfp. Tuy nhiSn, dtfi vdi hda tic mach sil dung hat DC-Beads, do khfing cd lipiodol liBgd dpng nSn vitfc ddnh gid ndy chinh xdc hdn. Do v^y, chdng ttfi sil dyng titfu chuin ddnh gid ddp flng khd'i u cii titfn (mpdified RECIST) cila Hiep htfi Gan MJt My de xuSft ndm 2008 dl ddnh gid ddp flng trpng nghiSn ctfu niy.
Trong UBTG, mflc dtf ddp tfng khtfi u cd ^ ngHa trpng vitfc titfn itfdng vl thdi gian stfng them Iiu
TAP CHf KHOA HOC Ti&U H d A Vt^T NAM 2012 - TAP Vll - s d 29
ddi. Kfi't qud nghifin ctfti ctia chtfng tfii ttf bdng 3 cho did'y: t^ 1$ ddp (tag khdi u tai cdc thdi dilm 1 thdng sau dilu tri Id 86,6% (ddp tfng hodn todn 23,3% vd ddp tfng 1 phin 63,3%), tai thdi dilm 3 thdng Id 66,7% (ddp tfng hodn todn 20% vd 1 phin 46,7%), tai thdi dilm 6 thdng Id 61,1% (ddp tfng hodn todn 22,2% vd 1 phin 38,9%). T^ 1§ kilm sodt b$nh tai cdc thdi dilm theo doi iln Itfdt Id: 96,7%; 96,7%
vd 88,9%. Cdc kfi't qud dat dtfdc ndy cao hdn so vdi cdc kdt qud v l ddp tfng khdi u khi dp dyng hda tic mach ddn thuin dilu tri UBTG 6 trong cdc bdo cdo trtfdc ddy. Kfi't qud nghifin ctfu ctfa chtfng tdi cung phtf hdp vdi cdc kfi't qud bdo cdo ctfa cdc tdc gid ntfdc ngodi, vdi ty le ddp tfng khfi'i u tai thdi dilm 1 thdng sau dieu tri dat dtfdc ttf 60-85%. Bdo cdo diu tifin ve dp dung hda tic mach stf dung hat vi clu tdi hda chit trong dilu tri UBTG trfin n l n gan xd cua Varela vd cOng stf d chdu Au cho thd'y ty le ddp tfng khdi u Id 75% trong khi t^ lfi sdng them 1 ndm vd 2 ndm rd'l cao (92,5%; 88,9%) [11]. Trfin nhdm bfinh nhan chdu A trong nghifin ctfu cua Song MJ vd CS (Hdn Qufi'c), tf lfi ddp tfng kho'i u tai thdi diem 1 thdng d nhdm bfinh nhan dieu tri b^ng DC-Beads TACE Id 85%, cao hdn cd J ngMa so vdi nhdm bfinh nhdn dtfdc d i l u tri bllng hda t i c mach vdi lipiodol (30%), (p =0,001)[10]. Thtf nghifim ldm sdng nglu nhifin da trung tdm PRECISION V ct chau Au, so sdnh hi$u qud ctf a hda t i c mach DC- Beads vdi hda t i c mach truyin thd^ng, thd'y r i n g t^ lfi ddp tfng, ddp tfng hodn todn vd ty le kilm sodt khdi u deu cao hdn d nhdm dtf^c dilu tri bSng hda tic mach vi clu, ddc biet do'i vdi cdc bfinh nhdn cd bfinh tie'n trien (xd gan Child B, EC0G=1, da 6... stf khdc bi^t cd ^ nghia vdi p < 0,05)[7]. Nhieu nghien ctfu ddn trung tdm khdc cung cho kfi't qud htfa hen vdi hda t i c mach stf dung hat vi clu tdi hda chit, mdc dtf kdt qud Idu ddi v l thdi gian sdng thfim cung dang cin dtfdc tie'p tuc ddnh gid.
AFP Id diu In huyet thanh rit cd gid tri trong ddnh gid ddp flng dilu tri vd theo doi tdi phdt. Bie'n ddi hdm Itfdng AFP cd lifin quan vdi stf thay ddi kich thtfdc vd mtfc dO hoai ttf khdi u. Trong nghifin cfln ndy, chflng tfii thd'y hdm Itfdng AFP trung binh 6 nhdm nghifin cflU gidm cd ^ nghla ngay sau can thifip so vdi trtfdc d i l u tn, vd gitt ttfdng ddi dn dinh
tai cdc thdi dilm theo ddi. Kfi't qud ndy phtf hdp vdi cdc bdo cdo c^a cdc tdc gid d ntfdc ngodi, cung nhtf phtf hdp vdi t^ 1§ ho^i ttf khfi'i u sau can thi^p.
Ddnh gid v l mtfc dO an todn vd khd ndng dung n9p ctfa ky diudt, trong 35 iln can thi$p chflng tfii gdp 1 d^dng hdp bj dp xe hda khdi u gdy trdn dich mdng phdi phdi phdn thig (khdi u n^m d ha phdn thiiy 8, dinh gan). Tuy nhifin trtfdng hdp ndy dirdc dilu trj n0i Wioa In djnh. Bifi'n chtfng dp xe hda khdi u gdp vdi t^ 1| khodng 0,2 - 0,5% trong cdc bdo cdo v l hda tic m^ch truyin thd'ng. Chflng tfii khfing gdp Uirdng hdp ndo bi vifim tfli mdt cd'p, xud't huyet tifiu hda, suy gan cd'p sau can thi^p. Khdng gdp trtfdng hdp ndo ttf vong lifin quan de'n ky thudt. Cd 1 trtfdng hdp ttf vong tai thdi dilm 4 thdng theo doi sau can thi$p diu tifin do khfi'i u tifi'n trien (trtfdng hdp ndy cd kich thtfdc khdi u ban diu Id 108mm dtfdng kinh).
Hfii chtfng sau tic mach gdp d 93,3% sfi' trtfdng hdp vdi 2 tri^u chtfng chinh Id dau ha stfdn phdi vd sfi't. Tuy nhifin phin ldn so' trtfdng hdp dau mtfc do nhe vd vtfa sau can thifip vdi thdi gian trung binh Id 3,5 ± 1,6 ngdy. Sdt d phin ldn sd trtfdng hdp cfing chi dao dgng 37- 38,5°C vd kdo ddi trung blnh 2,6 ± 2,3 ngdy. Nguyen nhdn cua hgi chtfng ndy Id do tinh tf-ang hoai ttf khfi'i u gdy ra. Theo cdc bdo cdo trong vd ngodi ntfdc, hdi chtfng sau tic mach gdp d 90-100% so' trtfdng hdp sau can thiep ke cd dd'i vdi hda tic mach thfing thtfdng cung nhtf hda t i c mach vi clu, mang tinh chd't tam thdi chi difin bidn trong vdng 3-5 ngdy. Malagari K vd c0ng stf tdng kfi't 237 ca UBTG dtfdc dieu tri hda tic mach vdi hat DC-Beads, hfii chtfng sau tic mach gdp phin ldn (86,5%) d dfi I, II [6].
Tdn thtfdng gan Id van de cin liTu ^ trong dilu tri hda tic mach cho UBTG. Tdng transaminase vd bilirubin tam thdi Id bieu hien thtfdng gdp trong vdng tuin lfi diu sau can thiep. Kfi't qud d bdng 6 cho thd'y hdm Itfdng SGOT vd SGPT tang gd'p khodng 3 iln so vdi trtfdc dilu tri vd hdm Itfdng biluTubin huyfi't thanh tdng gd'p 1,5 lin. Stf bifi'n d l i tJ 1^ prothrombin vd hdm Itfdng albumin khong cd ^ nghla thdng ke. Cdc bdo cdo d ntfdc ngodi cho tha'y hda tic mach vdi hat vi clu tdi hda chd't cd dfi dung nap tfi't, khfing gay suy gidm chtfc ndng gan. Trong nghifin ctfu PREQSION V, doc tinh gan thip hdn cd
TAP CHf KHOA HOC T l 6 u H 6 A VlgT NAM 2012 - TAP VII- SO1
S nghla d nhdm b$nh nhdn dtfdc dilu tri bing hda tic mach vi clu khi so sdnh vdi nhdm b|nh nhdn dtfdc dilu trj bing hda tic mach truyin thdng[7].
Chflng tfii khfing gdp trtfdng hdp ndo bilu hi$n tdc dyng phu todn thdn cfla Doxorubicin.
Cdc nghifin ctfu trfin d0ng vdt vd nghifin ctfu ldm sdng dd chtfng minh trong hda t i c mach vdi hat vi clu. ndng dO hda chS't d tuin hodn ngoai vi rfi't thd'p. Ddc tinh dtfdc ddng hgc ndy ldm han ch^
dtfdc ddc tinh tinh todn thdn ciia hda chd't chdng ung thtf gdy ra. Kfi't qud nghifin ctfu PRECISION V cung cho thd'y ddc tfnh todn th9n ctfa Doxorubicin thd'p hdn cd y nghTa (p = 0,0001) d nhdm BN dtfdc d i l u tri bing hda t i c mach vi clu so vdi nhdm dilu tri hda tic mach vdi lipiodol [7). Nhilu nghifin ctfu khdc cfing khing dinh tinh an todn vd khS ndng dung nap ctfa phtfdng phtfdng phdp hda tic m^ch vdihai viclu[6].
Mdc dtf cd mdu trong nghifin ctfu ndy cdn nhd, thdi gian theo ddi ngin, nhtlhg nhiiTng kfi't qud btfdc dau ve hi?u qud dieu tri vd dg an todn ky thudt dd cho thd'y phtfdng phdp hda tic mach stf dung hat DC-Beads Id mgt phtfdng phdp cd triln vgng tdt, nfin dufdc tifi'p ttjc nghifin ciJu ddnh gid diy dtf hdn vd cd the trien khai vd dp dung rpng rai tai cdc Bfinh vifin ldn trong cd ntfdc trong dilu tri UBTG.
V. Kfi't ludn
Qua nghifin cflli 30 b$nh nhdn UBTG dtfdc dieu tri bing phtfdng phdp hda tic mach stf dung hat DC-Beads, chiing tfii rflt ra mgt sfi' kfi't ludn sau:
- Hda tic mach vdi hat vi clu Id phtfdng phdp dieu tri cd hieu qud cao v l ty 10 ddp tfng khfi'i u cfing nhtf ddp tfng huye't thanh: ty 10 ddp tfng khfi'i u tai cdc thdi d i l m 1 thdng, 3 thdng, 6 thdng iln Itfdt Id: 86,6%; 66,7% vd 61,1%. Hdm Itfdng AFP gidm cd ^ nghia sau can thifip.
- Phtfdng phdp ndy cd dd an todn vd dung nap tfi't ddi vdi cdc trtfdng hdp ung thtf bieu mfi tfi' bdo gan tren n l n gan xd: 93,3% cd hgi chtfng sau t i c mach nhtfng phin ldn chu yfi'u mtfc dg nh?, khdng cd trtfdng hdp ndo b i l u hien d0c tinh todn thdn do doxorubicin, 1 trtfdng hdp bie'n chtfng dp xe hda khdi u vd khfing cd trtfdng hdp ndo ttf vong Hfin quan dfi'n ky thuat.
Tdi lifu tham khiio
1. NguySn Tiln Thinh, Mai Hing BSng. Le Van TnTdn vd CS (2005), Kit qud 4 nam dilu trj ung thir bilu m i^ bho gan kfch thiTdc Idn bdng phUdng phfip gSy ti mgch hoii diu, Dftc san Ung thiT hpc. quj III, tran 151-159.
2 Pham Minh Thfing (2004), Ddnh gifi kit qufi dilu t ung ihir bilu mfl l l bdo gan bdng mit hofi chit dfln mach gan trgn 134 bfnh nhfin d B0nh Vi0n Bac Mai, Tap chl Nghifin ctfu Y hpc. 27(1). ir.99-104.
.1. GLOBOCAN 2008. cancer fad shed: Liver car cer incidence and mortality worldwide in 200f Online publish.
4. Joachim Kettenbach. E. Alfred Stadler, et al (2008
"Drug- loaded Microspheres for the Treaunent c Liver Cancer: Review of Current Results", Cardie vase Intervent Radiol; 31; 468-476.
5. Katerina Malagari (2(X)7), Drug-eluting beads: a nei opportunity in the Ueatment of hepatocellular caic noma. C212. Volume V. Issue 3.2007.
6. Katerina Malagari, Pomoni M.. ec al. (2011). "Safet profile of sequential iranscatheler chemoembolizi tion with DC BeadTM, results of 237 hepalocelluii carcinoma (HCC) padents". Cardlovasc Intervei Radiol; 34(3): 774-785.
7. Lammer J. Malagari K, VogI T. et al (2010). PRE CISION V invesUgators. Prospective Randomize study of Doxorubicin- eluling bead embolization i the Ureatment of hepatocellular carcinoma: results c the PRECISION V Study, Cardiovasc Intervent Ri did; 33:41-52.
8. Ricardo Lencioni. Josep M. Llovet (2008), "Modifie RECIST (mRECIST) Assessment for Hepatocellulf Carcinoma", Semin Liver Dis;30:52-60.
9. Julien Namur, Steven J. Citron, et al. (2011), Embd zation of hepatoceUular carcinoma with drug-elutin beads: Doxorubicin tissue concentration and distributic in patient liver explants, J Hepatol; 55(6): 1332-1338 10. Song MJ, Park CH, Kim JD. et al. (2011), Dnig-elu
mg bead loaded with doxorubicin versus convei tional Lipiodol-based transarterial chemoemboliz;
lion in the treatment of hepatocellular carcinoma:
case- control study of Asian padents, J Gastroenter Hepatol; 23(6)1521-527.
11. Varela M. Real MI, Burrel M. et ai (2007), Ched embolization of hepatocellular carcinoma with d^
eluting beads: effecacy and doxorubicin pharmao kinetics, J Hepatol; 46(3): 474-481.