Y HQC VigT NAM THANG 10 - s 6 OAC BlfT/ZOIS
NGHIEN ClJfU GIA TRj CUA SIEU AM VA CAT LQfP VI TINH TRONG CHAN DOAN UNG THlTTUY
Nguyin Xuan Khdi*, Tran Dinh Du&ng*, Nguyin Thanh Le*, Nguyen M^nh Hiing*, Nguyen Vdn Ba**
T6MTAT
Trong nghien cirtj hoi ciiXi nay, chung toi da tien hanh danh gia mu'c dp chan doan chinh xac CLia sieu am thanh bung (SAOB) va chup cSt Idp vi tinh (CLVT) so sanh vdi phau thuat tren benh nhan ung thu" tuy. 35 benh nhan du'dc chan doan xac dinh la ung thu* tuy. £}p nhay, dp dSc hieu va do chinh xac cua SAOB va CLVT lan lu'dt la 7 3 % ; 53%; 63% va 9 5 % ; 100%; 9 8 % . Tren cP sd ciJa nghien cirtJ nay, chung toi khuyen nghi SLr dung CLVT trong chan doan ung thu' tuy.
Td'khda: Sieu am, cat Idp vi ti'nh, dp nhay, ung thu" tuy
SUMfMARY
EVALUATE THE DIAGNOSTIC ACCURACY OF ULTRASOUND AND COMPUTED TOMOGRAPHY IN PANCREATIC CANCER
PATIENTS
This retrospective study was carried out to evaluate the diagnostic accuracy of ultrasound (US), computed tomography (CT) comparing with surgery in pancreatic cancer patients. Thirty-five patients had the final diagnosis of pancreatic cancer.
The sensitivitjes, spedfidty, accuracy of US, CT were 73%; 53%; 63% and 95%; 100%; 98%, respectively.
On the basis of this study, we recommend CT as a diagnostic test of pancreatic cancer.
tCey words: ultrasound, computed tomography, sensitivities pancreatic cancer.
I. OjjkT VAN O l
Tuy la tang nam sau trong khoang phuc
* 5enA vien 103; ** Hoc vi?n Quart y Phan bien fc/ioa hoc: GS.TS. Hoang VSn Lirong
mac, kh^ nang tiep can vk quan sat tyy bang cac phuong phap chkn doan hinh anh thong thuang nhu sieu am qua th^nh bung (SAOB) gay khd khan cho cac bdc sT Iam sang trong viec phat hien khoi u vung tuy. Ngay nay vdi sir phat trien cua khoa hpc ky thuat va nhOng tien bp trong chuyen nganh ch4n doan hinh anh thi chup cat Idp vi tinh (CLVT) ngay cang dupe ap dung pho bi6n va rpng rSi. Vdi cac may cat Idp xoan 6c, may ch\ip da day dau do da khac phuc dupe cac han ch8 cua SAOB, nang cao chat lupng chAn doan u viing tuy. Ngoai viec xac dinh vi tri, kich thudc khoi cua kh6i u thi chup CLVT co kha nang xac dinh muc dp lan rpng, di can, ton thuang hach, giup cho phau thuat vien lua chpn phuang phap dieu tri thich hap [6], [8], [9]. Do vay, chiing toi tien hanh nghien ciiu nay vdi muc tieu danh gia hieu qua chan doan u tuy cua CLVT so vdi SAOB cd doi chiing vdi ket qua phau thuat va hinh anh giai phau benh ly.
II. o 6 l T U Q N G V A PHUONG PHAP NGHIEN CCfU 2.1. BSI tu-pTig: G6m 35 benh nhan dupe chan doan cd khoi u viing tuy nam va dieu tri tai khoa Ngoai bung (BM2), Benh vien 103 tii thdng 12/2009 dan 05/2012.
2.2. Phu-oTig tien:
- May sieu am ALOKA SSD 3500 (Nhat Ban) sir dung dku do cong vdi tan so 3,5MHz-5MHz.
- May chup CLVT Brivo 325 (GE Hoa Ky), tai khoa ChSn doan hinh anh Benh vien 103.
CHUYEN Pg; HlHH THAI HQC VA caNO NGHfe T H 6 N G TIN
2.3. Ky thuat sir dyng
- SAOB: b?nh nhSn dirge sieu 4m sau khi da nliin an it nliat 6 giii, lian che dpng tdc n6i v4 nhai. Sieu am 6 tu the ngoi vi nSm ngijra. Khio sdt tvy qua mjt cit ngang viing thircjug vj Icet hqp vdi m§u gidi phau Id tTnh m^ch Idch.
- Chvp CLVT: ti^n hdnh cdc Idp cdt dau tien Ichong tiem TCQ tTnh m?ch vdi dp ddy 16p 10 mm lien ti^p. Cdc Idp cdt sau khi tiem TCQ tTnh mach vol dp ddy 3 - 5 mm lien tuc.
- Phlu thudt cdt kh6i td tyy khi chua c6 di cdn xa tai khoa phau thuat bung- b^nh vi$n
103.
- Lam tieu bdn giai phau b?nh ly tai khoa Gidi phau benh- benh vien 103.
2.4. Cac chi tieu danh gia - Vi tri u tuy tren sieu am, CLVT doi chieu vol phau thuat
- Dp nhay, dp ddc hieu, ti 1? am tinh gid,
duong tinh gia va dp chinh xdc ciia sieu Im doi chiSu vdi CLVT.
- Dp nh?y, dp ddc hipu, ti le am tinh gia, ducmg tinh gid vd dp chinh xac cua sieu am, CLVT ddi chifiu phau thuat
- Dp nhay, dp ddc hieu, ti le dm tinh gid, duong tinh gid va dp chinh xac xam ldn cua CLVT doi chieu phau thuat
- Dv kiSn phau thuat tren CLVT d6i chiSu vdi phau thuat that d benh nhan u tyy
2.5. Xir ly so lieu thong ke
+ So sdnh hai ti 1? hodc nhiju ti 1$ bang thudt toan Chi - square test.
+ Ddnh gid dp nhay (Se; sensivity), do ddc hifu (Sp: specificity), miic am tinh gia (FNR: false negative rate), mic duong tinh gid (FPR: false positive rate), gid Ui tien lupng ducmg tinh (PVP: predictive value positive) vd gid tri tien luong am tinh (PVN:
predictive value negative).
IM. KET QuA
Bang 3.1. Vj tri u tuy tren sieu am doi chieu vdi phau thudt
Vi t r i u
Khonq thay u Oau tuy Than tuy Ouol tuy OMC Bdnq Vater Than + duoi Tonq
Sieu a m ( n = 2 3 ) n
5 14 0 2 0 1 1 23
»/o 21,7 60,9 0,0 8,7 0,0 4,3 4,3 100
P h l u t h u a t ( n = 2 3 ) n
0 17 1 1 0 1 3 23
»/o 0,0 74,0
4,3 4,3 0,0 4,3 13,1 100
P
p < 0,05
* Nhdn xet: ti le thay vj tri u tren sieu am doi chieu vdi phau thuat d benh nhSn duoc phau thuat cd su khac biet cd y nghTa thong ke p < 0,05.
Bdng 3.2. Vi tri u tuy tren CLVT doi chJeu vdi phau thuat.
Vi t r i u
Khonq thay u Oau tuy
CLVT ( n = 2 3 ) n
1 16
»/o 4,3 69,6
Phau t h u a t ( n = 2 3 ) n
0 17
°/o
0,0 74,0
P
Y HQC VrgT NAM T H A N G 10 • s6 B A C BIET/2013
Than tuy Buoi tuv OMC Bona Vater Than + duo!
Tona
0 3 1 1 1 23
0,0 13,0 4,3 4,3 4,3 100
1 1 0 1 3 23
4,3 4,3 0,0 4,3 13,1 100
p > 0,05
* Nhdn x4t: Ti le phat hi?n vj tri u tren CLVT doi chieu vdi phau thuat d benh nhan dugc phlu thuat u tyy khong cd sy kh^c bi?t p > 0,05.
Bang 3.3. Do nh^y, do dSc hi?u, ti le am tinh gia, duang tinh gid va dp chinh xac cua sieu amd6i chieu vdi CLVT (n = 35).
^"~~~~---..,5!^i t i e u
Chan doan sieu am
Do nhay
78%
DddSc higu 54%
Ti le am tinh
gia 22%
Tile du'dng tinh
qia 46%
Do chinh
xac 66%
*Nhgn xet: sieu am cd dp nhay, dp dac hieu va dp chinh xac la: 78%; 54% va 66% vdi ti le am tinh gia va duang tinh gia ldn luot la: 22% va 46% so vdi CLVT trong chdn doan u tuy.
Bdng 3.4. Dp nhay, dp dac hieu, ti le am tinh gia, duong tinh gia va dp chinh xac cua sieu am doi chieu phau thuat (n = 23).
^"""•"^^^i tieu Phlu thuat ^ " ~ " ~ - - - , ^ ^ Chan doan sieu am
D o nhay
73%
D o dac hieu 53%
Ti le a m tinh
gia 27%
Ti le du'dng tinh
qia 47%
Do chinh
xac 63%
* Nhdn xet: sieu am cd dp nhay, dp dac hieu va dp chinh xac thap so vdi phau thuat va GPB ldn lucrt la: 73%; 53% va 63%.
Bdng 3.S. Dp nhay, dp dac hieu, ti le am tinh gia, ducmg tinh gia va dp chinh xac cua CLVT ddi chi6u ph§u thuat (n = 23).
^ h i tieu Phau thuat Chan doan CLVT
D o nhay D o dac hieu
Ti le a m tinh gia
Ti le du'dng tinh
gia Do chinh
xac
*Nh^n xet: CLVT cd do nhay, dp dac hi?u va dp chinh xac rk cao trong chan doan u tuy ifii chik vdi GPB sau phau thuat \kn luat la: 95%; 100% va 98%.
Bdng 3.6. Dp nhay, dp ddc hieu, ti le am tinh gia, duang tinh gia va dp chinh xac xam lan
^ ^ ^ ^ ^ Chi tieu PTvaGPB ^ ~ ~ ~ ~ - ^ . , ^
CLVT
at.
Oo nhay
28%
43%
Do dac hieu 100%
100%
Ti le am tinh gia
72%
57%
Tile du'dng tinh gia 0%
0%
06 chinh xac 64%
72%
153
CHUY^M D i ; HiNH THAI HQC VA C 6 N G N G H $ T H 6 N G TIN
* Nhfn xit: dp nh?y vd dp chinh xdc cua CLVT (ldn luot Id: 43%; 72%) cao hon so voi sieu am {ldn lugt la: 28%; 64%) doi chieu vdi k^t qud phau thudt.
Bdng 3.7, Du kien phau thudt tren CLVT doi chi6u voi phlu thuat thjt 6 beiih nhan u tuy.
Lo^i phlu thullt DPC No! mat ruot Ti le du" kien chinh xac
Tru'dc phlu thu#t (n = 23) n 8 15
%
34,8 65,2
Phlu thu$t (n = 23) n 6 17
»/o 26,1 73,9 21/23 (91,3%)
P
>0,05
* Nh^n xit: Ti 1? cdt khoi td tyy vd noi m$t rupt khi phau thu^t (lan \\iql la: 26,1% v^
73,9%); trong khi dd dy kien theo CLVT ldn lugrt Id 34,8% vd 65,2%; svr khac bift chua co y nghla th6ng ke (p > 0,05). Ti 1? dir kien dung cdt khoi td tyy 6/8 b?nh nhan (75%). Ti le dii kien phuong phdp phau thuat theo CLVT doi chieu vol thirc te phau thu^t cao (91,3%).
IV. BAN LUAN
4.1. Gid tri hinh anh sieu dm u tuy doi citiiu CLVT va phdu Ihudt, GPB d benh nhdn u tuy dirac phdu thuat
Trong nghien cihi cua chiing toi co 23 truang hpp dupe phau thudt thay u tuy thi sieu am khong phat hien u tuy chi§m ti 1?
21,7%; CLVT chi co 01 truang hpp khong phat hien u tuy dupe chdn dodn la soi OMC (4,3%), su khac biet giiia sieu am vd CLVT CO y nghia th6ng ke p < 0,05. D6i chidu vol kSt qud phau thuat vd GPB ti le sieu am khong phat hien u vd vi tri u tuy tren sieu am so vai phdu thuat co sir khac biet p < 0,05.
Mat khde ket qua cua nghien cuu cho thdy SAOB co c6 dp nhay, dp dac hieu vd dp chinh xdc la: 78%; 34% vd 56% vol ti le am tinh gid va ducmg tinh gid ldn luot Id: 22% va 66% so voi CLVT trong chdn dodn u tuy. Dp nhay, dp ddc hieu vd dp chinh xdc thap so voi phdu thuat va GPB ldn lupt Id: 73%; 33% vd 53%. Danh gia mirc dp xam ldn ciia siSu am CO dp nhay 28%; dp dac hieu 100%.
Maringhini A vd CS; Karlson BM vd CS thdy SAOB CO dp nhay tir 75-89% vd dp ddc hieu tir 90-99% trong chdn dodn u tuy. Tian YT
vd CS thay SAOB co dp nh^y xdc dinh sir xdm ldn ciia u tyy (mach mdu, hach vd phuc mac) chi co 18,7% [4], [7], [9].
4.2. Gii triciB CLVT toi chieu pbau tbaat Trong nghien cim ndy 01 tmcmg hpp (4,3%) CLVT chdn doan nhdm Id soi OMC.
Ti le vi tri u dau, than, duoi va hon hpp tren CLVT va k^t qud GPB sau phdu thuat khong CO sy khde biet (p > 0,05). CLVT co dp nhay, dp ddc hipu va dp chinh xdc rdt cao trong chan dodn u tyy d6i chiSu vcri phau thudt ISn lupt la: 95%; 100% vd 98%. Nguyen Duy Hue danh gid gia tri ciia CLVT trong chin doan u ddu tuy thay dp nhay, dp ddc hieu ldn lupt la: 96,8% va 90%. Hd Xudn Tung nghien ciru tren 52 truong hpp cdc kh6i choan cho o tuy thdy CLVT co dp nhay trong chan dodn u tuy la 98% [1], [2]. Fusari M va CS (2010) nghien ciru 40 benh nhdn dupe chan doan lam sang va SAOB co u tyy, thdy dp nhay, dp dac hieu, dp chinh xac cda CLVT d6i chiSu GPB sau phlu thuat ldn lupt la: 100%; 88% vd 98% [3].
4.3. GU tri cua CL VT du liiin phumg phdp phdu thufl u tiiy
Trong tdng s5 23 benh nhan dupe phlu thuat, du kiSn co thS tiSn hanh DPC dupe 8
Y HQC VigT NAM T H A N G 10 • SO PAC BIET/2013 benh nhan (34,8%), nhung thyrc te chi thuc
hien DPC 6 benh nh^n (26,1%), 02 b?nh nhan con l?i phai chuy§n sang tdi lap luu th6ng dudng din mat, tyy; ti 1? dy kiSn dung cat kh6i ta tuy theo CLVT la: 75%. Tuy nhiSn, ti le du kien chinh xac cua CLVT tnrdc phdu thuat rat cao 21/23 trudng hpp (91,3%). Lu (199nghien cuu 25 benh nh^n u tuy xam ISn mach mdu thay CLVT du kien phuong phap phdu thuat vdi gia tn tien dodn am phau thuat va gja tri tien doan duang khdng phlu thuat \kn luat la: 95% va 93%). [5].
V. KET LUAN
CLVT CO dp nhay, d6 dac hi?u va dp chinh xdc trong chan doan u tuy lan lugt la:
95%; 100% va 98%. CLVT cd dp nhay, dp dac hieu va dp chinh xac trong chan doan su xam \kn cua u tuy ldn lupt la: 4 3 % ; 100% va 72%. Tl le du kiSn chinh xac phuang phdp phdu thu^ theo CLVT cao (91,3%).
TAI UEU THAM KHAO
1. Nguyea Duy Hue, Nguyen Van Dinh (2004), "Nghien cuu gia tri cua chyp cat Idp vi tinh tFong chan doan cac khoi u vCing dau t ^ ' , Tapchl nghien cuuy hoc 27(1), fr.SS-SS.
2. Ha Xuan Tung (2004), "Nghien cuu dac diem htnh anh cat Idp vi tinh khoi choan cho cua tuy CO ddi chifiu lam sang-phlu thuat", luan van bdc si chuyen khoa 11, Hpc vien Quany, Ha Noi.
3. Fusari M,Maurea S, Imbriaco M, Mollica C,AvitabileG,Soscia F, Camera L, Salvatore M (2010), "Comparison between multislice CT and MR imaging in the diagnostic evaluation of patients witii pancreatic masses", Radiol Med n5(3):ASiM.
4. Karlson BM; Ekbom A; Lindgren PG;
Kallskog V; Rastad J (1999), "Abdominal
US for diagnosis of pancreatic tumor:
prospective cohort analysis", Radiology 213fl):\07-\\.
5. Lu ZC,Guo JM, Zhang YL,Tian PL, Zhang L,Yu JP,Bao XY (2006),
"Comparison of endoscopic ultrasonography with computer-assisted tomography in the determination of preoperative stage and resectability of pancreatic and ampullary cancers". Zhonghua Zhong Liu Za Zhi 28(6)A4\-4.
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7. Maringhini A; Ciambra M; Raimondo M;
Baccelliere P; Grasso R; Dardanoni G;
Lanzarone F; Cottone M; Sciarrino E;
Pagliaro L (1993), "Clinical presentation and ultrasonography in the diagnosis of pancreatic cancer". Pancreas 8(2): 146-50.
8. Michele Scialpi, Luisa Pierotti, Irene Piscioli, Luca Brunese and Antonio Rotondo (2012), "Detection of Small (< 20 mm) Pancreatic Adenocarcinoma: Histologic Grading and CT Enhancement Features", Radiology 262:31044-1045.
9. Tian YT,Wang CF, Wang GQ,Zhao XM, Ouyang H,Hao YZ, Chen Y, Zhang HM, Zhao P (2008), Prospective evaluation of the clinical significance of ultrasonography, helical computed tomography, magnetic resonance imaging and endoscopic ultrasonography in the assessment of vascular invasion and lymph node metastasis of pancreatic carcinoma", Zhonghua Zhong Liu Za Zhi 30(9):6S2-5.
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