' •«- 4~.S'i
;N ciru KHOA HOCKET QUA DIEU TRj UNG THU TE BAO DAY BANG PHAU THUAT MOHS
Pham Cao Kiem",Iran Hau Khang'", Nguyen Hong Som*; Vu Thii Ha*", Nguyen Quang Minh*, Nguyen HuTu Sau*"
T6MTAT
Muc tieu: Danh gia hieu qu5 phSu thuat Mohs trong dieu trj ung thiTte bao day dau mat co.
D o i tUtfng va phiTcmg p h a p nghien cihi: Nghien ciiru m o th dt ngang. 88 benh nhan bj u n g t h u te bao day duoc dieu trj bang p h l u thuat Mohs. Phau thuat idp Mohs day 2 m m , chia ldp Mohs t h a n h cac mSnh n h 6 thfch hop, kiem tra tren kinh hien vl de xem con hay het ung thU. Neu con ung t h a thl t i e p tuc phau t h u a t cho d e n het.
Ket q u i i T y 1$ khdi ung t h u t ^ bao day la 100%.
Ket luan: Phau t h u a t Mohs rat co hieu qua t r o n g dieu t n ung thU te bao day 6 dau mat co.
TiJf Ichoa: Phau thuat Mohs, ung thiJ te bao day, ung t h u da.
I. DAT V A N D E
Co nhieu p h a o n g phap dieu trj ung t h u t e bao day (basal cell carcinoma: BCC) nhU phau thu$t t h o n g t h u d n g , xa trj, d o t dien, ap l a n h . . . n h u n g phau t h u a t Mohs (Mohs micrographic surgery) cho hieu qua dieu trj cao nhat.
Phau t h u a t Mohs la m o t ky thu$t loai b6 hoan toan te bao ung t h u bSng each lay b d t o chUc ung t h u t h e o dien cat hinh l o n g chcio, sau do kiem tra bang kinh hien vi 100% dien c3t 6 be mat day de t i m ra vj t r i con u n g thU. Vung con ung t h u duoc t^i phau t h u a t v^ lap lai quy trinh nay d e n khi dat d u o c m p t mat p h i n g khong con ung t h u . Dieu nay c h o p h e p bSo ve t o i da t o chufc lanh va loai b 6 'Binh viin Da lieu Trung uang
**86 mdn Da lieu, TrUdng Ogi hoc YHd Ngi Phdn bien khoa hgc: GS.TS. Trdn Hgu Khang
ung t h u d mUc cao nhat.
De dam b i o viec dieu t n BBC d mUc t o t nhat va de g o p phan nghien cUu phau thuat Mohs d Viet Nam chung toi nghien cu'u de tai nay vdi muc tieu: "Ddnh gid hieu qua phau thugt Mohs trong dieu tri ung tht/ tebao day d ddu mat co".
11. D O I T l / p N G VA PHUONG P H A P N G H I E N C I J U 1. D o i tUtfng nghien cuTu: g o m 88 benh nhan duoc chan doan lam sang - m d b§nh hoc I I BCC, duoc phau thuat Mohs tai Benh vien Da li^u Trung u o n g tU 2 0 1 2 - 2 0 1 3 .
2. PhUtfng phap nghien cClu: nghien cUu m d t l cat ngang, tien cUu.
3. Ccic bade tien hanh
Gay te tai cho, phau thuat lam giam p h ^ n Idn
s 6 l 9 ( T h ^ n 9 06/2015} D A L l E U H p C l 1 1
- • - •
khdi BCC, cat ldp Mohs day 2mm, chia ldp Mohs thanh nhieu minh nhd thfch hpp, danh dau vi tri tren bd Idp Mohs, ve so do Mohs. Tat c l cic manh nhd dUpc llm dong lanh va kiem tra bang kinh hien vi 6i tim ra vi trf cdn ung thU. Vi trf cdn ung thU dUpc t l i phau thuat den khi khong cdn u thi chuyen tao hinh khuyet da.
Cac so lieu dupc ghi trong ho so va xO ly b^ng chuong trinh SPSS 16.0.
III.K^TQUA 1. Thdi gian theo doi
Thdi gian theo ddi d l i nhit II35 thing, sdm nhit I113 thing, trung binh la X ± SD = 22,8 ± 6,1 thang.
2. Vi tri thucmg ton va so ldp Mohs
Bdng 1. Vj trithUc/ng ton va so ldp Mohs
Vitri
Mui Ma Mat
Lien vung ( m l , mat, mui...) Tran
Moi tren Tai Ben NgUc e l m Cung may Thai d u o n g
Nhieu vj tri, nhieu thuong ton
Tong s6/(Ty le %)
So ldp Mohs 1
18 17 12 6 5 3 3
70/
(79,5%) II i 2
2 3
3
1
15/
(17,0%) III 0
1
1
2 / (2,3%)
IV 0
1
1 / (1,1%)
V 0
0
l o n g 50
(%)
22 (25%) 19/(21,6%) 12/(13,6%) 9/(10,2%) 8/(9,1%) 5/(5,7%) 6/(6,8%) 1/(1,1%) 1/(1,1%) 1/(1,1%) 1/(1,1%) 2/(2,3%) 1/(1,1%)
88/(100%)
Nhgn xet: 97,7% ung thu nam d vung hd. 79,5% phau thuat mot ldp Mohs.
12 I D A L i i u HOC S6 19 (ThSng 05/2015)
i-i-4-^
3. Kich thifdc thifdng ton va so idp Mohs
Bdng 2. Kich thtt&c tbiicfng ton vd so ldp Mohs
Kich tliirdc
< 2 c m 2 - 5 cm
> 5 c m
Tong
So ldp Mohs 1
37 24 9 7 0 / (79,5%)
II 7 8 0 15/
(17,0%) III 0 1 1 2/
(2,3%) IV
1 0 0 1/
(1,1%) V 0 0 0 0
Tong so
45(51,1%) 33 (37,5%) 10%(11,4)
88
Nhdn xet: 100% thuong ton <5 cm. p> 0,05 do do so Idp Mohs khdng phu thudc vao k
4. The ung thif va so Idp Mohs
Bdng 3. The ung thuva s6l&p Mohs
The
T h e u The t u y e n T h e x o The n o n g Tong
Ldp Mohs 1
61 5 3 1 70
II 10 4 1
15
ill 2
2
IV 1
1
V 0
0
S o l u o n g
(%)
74(84,1) 9(10,2) 4 (4,5) 1 0 , 1 )
88 Whdnxef:Chuyeu lathe u chiem 84,1%.
IV. BAN LUAN Vitri thifcmg tdn
Theo Robert S Bader va cpng su (2011) thi 70,0% BCC phan bo d dau, 25,0% phan bd d than ngiidi, 5,0% phan bo d dUOng vat, am hd va quanh hau mdn. Hau het BCC gap d mat, trong do vj tri hay gap nhat la mui, dac biet II canh mui va dau mui [6]. Theo Graham Colver (2002) thi BCC dUpc gpi II nguy co cao khi thuong ton Idn, d vung chU H, bd khd xac dinh, de t l i p h l t [ l ] .
Nghien cu'u cua chung tdi cd 97,7% thuong tdn nam d vung hd. Nghien cUu cua chung tdi phu hpp vdi cac nghien cUu tren vi phan Idn BCC nam dvung hdcua mat. Day la vung vung can tdi da ve tham my. Viec I p dung phau thuat Mohs d vung nay la can thiet vi nd khdng nhUng giup loai bd BCC d mUc cao nhat ma nd con bao ve tdi da td chijfc llnh xung quanh. Viec bao ve tdi da to chUc llnh xung quanh giup cho khuyet to chUc nhd, khuyet td chUc nhd thi de tao hinh hon khuyet to chUc Idn. Do do ket qua tham my cung cao hon.
So 19 (Thang 06/2015) DA LI^U HOC I 13
NGHIEN CLAJ KHOA HOC
Nghidn cCru cua chiing tdi cd 63,6% thuang ton nim 6 vung chU H. Theo Graham Colver thi day la vung m l ung thU de tai phit sau dieu trj VI d nhUng vung nay cd nhieu bo mach than kinh va ung thU cd xu hUdng I n sau d giai doan sdm.
Maureen Mooney (2005) [4] chi ra ring moi vung cd mpt ty I& t l i phat BCC khac nhau (43,0% d gdc mat ngoii, 33,0% d bd tren mi mat va Idng may, 24,0% d tai, 0,5% d than minh, co va tCf chi). Ro rang viec chi djnh phau thuit Mohs de dieu tn BCC II cln thiet de giim nguy cotai phit khi nd d vung chOH.
Nghien cUu cua cic tac gii khic cung nhU nghien cOfu cOa chung tdi cho thay BCC chu yeu nam d vung hd cua mat, dac biet la BCC n^m 6 vung chCt H cd nguy co t l i phat cao v l vung can toi da ve tao hinh tham my, do dd viec ap dung phau thuat Mohs la can thiet de khdng nhCfng han che den mUc thap nhat BCC tai phat ma cdn giup cho tao hinh tham my dat ket qui cao nhat.
Kich thudc thifdng ton
Khi kfch thudc thuong ton cang ting thl ty le t l i phit sau dieu trj BCC clng cao. Vf du khi kich thudc BCC nhd hon 0,6cm thi ty le tai phat sau phau thuat thdng thudng la 3,2%, khi kfch thudc BCC 6 - 9mm thi ty le t l i phit sau phau thuat thdng thudng la 5,2% - 8,0%, v l BCC Idn hon 9mm thi ty le tai phat la 9,0% [3]. Maureen Mooney (2005) [4] cho ring, BCC d tren mat cd dudng kfnh 0,6 - 1cm thi phau thuit Mohs cho hi$u q u i dieu trj cao nhit. Kfch thUdc thuong ton trong nghien cufu cua chung tdi trung binh X ± SD = 2,8 ± 1,6cm. Cd 79,5% BCC cd kfch thudc nhd hon 5cm, trong dd cd 48,9% BCC cd dudng kfnh Idn hon 2cm. Khi kfch thudc BCC cang Idn thi phau thuat thdng thudng cang phli phau thuat rpng, clng phau thuat rdng thi khuyet cang Idn,
khuyet cang Idn thi cang khd tao hinh. Mat khic phlu thuat rpng nhUng t)f le t l i phit van cao vi khdng biet chinh xac vj tri cdn ung thU. Viy phau thult Mohs da gill quyet dUpc c l hai van de la bio v§ tdi da t6 chUc lanh v l loai trU BCC d miJc cao nhat bat k^ BCC d kich thUdc nao.
The BCC
Khi dieu tn BCC bing phau thuat thong thudng thi the cue v l the ndng chi can cat b6 thuong tdn each bd nhin thay ve mat lam sang khoing Smm d l dilu tn khdi 90% BCC [4]. BCC the cue ldn hon 2cm dudng kinh v l the xothi Maureen Mooney (2005) [4] khuyen rang nen cat bd thuong ton cich bd tU 9-10mm. Theo Walter F. Lever va cpng sU (1990) [8] thi the cue la hay gap nhat trong BCC. Theo Mark R. Wick [3] thi the cue xap xt 70,0%
eic trudng hpp. Trong nghien cUu cua chung toi thi the cue chiem 84.1 %.The cue eua chung tdi eao hon cCia Mark R. Wick. Ve lam sang chung tdi co mdt sd trUdng hpp thude the tang sac td, nhung ve md benh hpc thi the tang sac to cung ed hinh Inh nhuthe U, nhung cd nhieu te bio nhigm sac to d giUa cac te bio u, va chan doan dUpc trong giii phau benh bang nhudm 5100. ChCing tdi khdng nhudm 5100 nen xep the tang sac td vao the cue.
Diy eung la ly do llm cho t)/ le the cue eua chiing tdi cao hon Mark R. Wick. The xo ehiem 7,0%, the hdn hpp chi cd 1,1%. Ky thuat Mohs de thue hien d the cue vi de phit hien te bao ung thU, khd thuc hien d the xd vi te bio thanh dli dli gidng to chile xo. Tuy the xo khd thuc hien hon the cue nhUng phlu thuat Mohs vln cho ket qui tdt hon phau thuat thdng thudng vi biet ehinh xae vj tri cdn ung thude loai bdtiep.
Ldp Mohs
Theo Paul O Larson va edng sU [5] thi diem mau chdt de thinh edng trong phau thuat Mohs
14 I D A L I ^ U H O C S6 19 (Thang 06/2015)
4 4-^Jfcl|eHiiN
la kha nang dat dupc mdt Idp Mohs khdng ehi mdng, mem mai ma cdn khdng bj thung, rich hole khuyet bd.
Theo Howard K. Steinman [2] thl dp diy Idp Mohs tii 1 - Smm. Dp day nay phu thupe vao loai ung thu, vj tri, va phlu thuat vien. Phau thuat Mohs dupe thuc hien lan lUpt theo tUng Idp (tuy thupc vao tinh trang cdn hay het ung thu), nhUng khong phai Idp nao cung clt bd toan bp Idp diy thuong ton ma chi ed Idp dau tien la eat bd toan bd dudi be mat diy thuong ton, cac Idp sau ehi phau thuat d vj tri cdn ung thU. Moi ldp lai dupc phln chia thanh cac minh ed kieh thudc thich hpp de cat lanh, nhupm va soi tren kfnh hien vi vdi muc tieu tim ra vi trf edn BCC, vj tri cdn BCC niy lai dupc tai tiep tue theo quy trinh tren cho den khi khdng cdn BCC. Trong nghien c i ^ ciia chiing tdi cac thuong t6n dupe phau thuat mot Idp CO 70 benh nhan chiem 79,5%, phau thuat den Idp thU hai ed 18 benh nhan chiem 20,5%.
Phau thuat tren 2 Idp Mohs cd 3,4%. Vdi Idp Mohs day tii 2 mm trong nghien cii'u niy thi khi eat bd thuong ton cich bd 2mm (dp day cua Idp Mohs) mdi dieu tri khdi 79,5% benh nhan. Vay nhd phau thuat Mohs ma 79,5% benh nhan trong nghien cufu eua ehiing tdi chi can phau thuat each bd 2mm ma van dim bio loai bd ung thu d mUe cao nhat. Khi phau thuat eleh bd 2mm thi dudng kinh khuyet da rdng ra 4mm. Cung vdi thuong ton dd ma loai bd bing phau thuat thdng thudng eleh bd tren Smm thi dudng kinh khuyet da tang tren 10mm. Rd rang khuyet Idn khd tao hinh hon khuyet nhd.
So ldp Mohs d cac vj tri: Mdt Idp gap d hau het cle vj tri, nhung tren hai Idp gap d vung mdi, mui va ma. Mui cd 22 benh nhan thi cd tdi 4 {18,1 %) benh nhin phli phau thuat tren mot Idp
Mohs. Mdi ed S benh nhan thi ed 2 (40,0%) benh nhin can tren 2 Idp Mohs. Mdi, mui nSm trong vung nguy co tai phat cao sau phlu thult. Dieu niy cho thay viee I p dung phau thuat Mohs de dilu tn BCC d viJng nguy cd cao tren mat II rat can thiet.
S6 Idp Mohs v^ cac the BCC: Trong nghien CLfu niy thl cle the deu phli phau thuat tren mdt Idp Mohs. The u cd 74 benh nhan thi cd 13 (14,8%) benh nhin phau thult tren 1 Idp Mohs.
Thl xo cd 4 blnh nhan thi ed 1 benh nhin phli phau thult tren 1 Idp Mohs. Sd lupng b§nh nhin cac the xo, the tuyen trong nghien cufu cua chung tdi cdn qua it, do do ehiing tdi se tiep tue nghien cUu de lam sing td hon van de nay trong phau thult Mohs.
Ket qui phau thuat Mohs
Theo Paul O. Larson [5] ty le khdi la 99,0% ddi vdi ung thu te bao day tien phit va 94,4% ddi vdi ung thu te bao diy tai phit. Ty le khdi eua chiing tdi la 100% doi vdi ung thu te bio diy tien phit.
Hruza [7] qua nghien cUu phau thuat Mohs cho 2414 benh nhan ung thu da da ket luan ring: (y do giii thfch cho t l i phit ung thu da gom: yeu td ky thult, die diem u, dac diem benh nhan. Hon 75,0% ung thutai phat la do loi ky thuat, bao gom:
dpc tieu bin sai chiem hon 25,0%, ky thult labo sai chiem 40,0%, that bai trong viec lay hoan toan phan cdn lai cua u chiem 10,0%.
V.K^TLUAN
Phlu thuat Mohs II ky thult don giin, cd hieu q u i cao trong dilu trj ung thu te bao diy d dau mat co.Tuy nhien de dat hieu q u i cao trong dieu trj thi can phli t i l n hlnh ti mi d tat c l cic giai doan.
S6 19 (Th^ng 06/2015) DA LI§U HOC I 15
TAI LI£UTHAMKHAO
1. Graham colver. Skin cancer A practical guide to management, Martin Dunitz Ltd, 2002:
25-43,93-152,174-180.
2. How/ard K. Steinman, Mohs surgical techniques, Mohs surgery, Mosby 1999,49-66.
3. Mark R. Wick, "Malignant tumors of the epidermis". Pathology of the skin, Applton and Lange, 1990:568-579.
4. Maureen Mooney, "Mohs Micrographic surgery", eMedicine February 7,2005.
5. Paul O. Larson, Stephen N. Snow/, Freederic E. Mohs, Mohs micrographic surgery, Principles and Techniques of Cutaneous Surgery, McGraw- Hill 1996, 561-576.
6. Robert S Bader, Basal Cell Carcinoma, Updated: Nov 15,2011
7. Vincent A. Muscarella, Mohs cure rates, Mohs surgery, Mosby 1999:277-279.
8. Walter F. Leveret aI,"Basal cell epithelioma' Histopathology oftheskinJ.B.Lippncott Company, 1990:622-639.
SUMMARY
TREATMENT OF BASAL CELL CARCINOMA WITH MOHS MICROGRAPHIC SURGERY Objective: The objective of this study is to evaluate the effect of micrographic Mohs surgery for basal cell carcinoma.
Method: this is a descriptive, cross-sectional study. 88 basal cell carcinoma patients were performed with Mohs micrographic surgery from 2012 - 2013. We operated Mohs layer (2mm thichness) and then divided it into many small pieces. All pieces were frosted and examined under microscope in order to ascertain wether basal cell carcinoma remains or not? Positive areas were reexeised and the process repeated until a tumour- free plane is reached.
Result: 100% of patients have their basal cell carcinoma removed completely.
Conclusion: Mohs micrographic sugery was very good to remove basal cell carcinoma.
Key words: Mohs surgery, basal cell carcinoma, skin cancer.
16 I DA LI^U HOC s6 ig (Th^ng O6/2015)
