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1 T L , C IM LM SNG V SIU M BU GIP NHN NGI TRN 40 TUI

Thanh Bnh **, Nguyn Th T Nga*, Nguyn nh Yn* , Nguyn Hi Thu** ** Trng i Hc Y Khoa Hu, * Trung Tm Bu c Tnh Qung Bnh Prevalence, clinical and ultrasonographic characteristics of thyroid nodules in subjects over 40 years old Objective : evaluated Prevalence, clinical and ultrasonographic characteristics of thyroid nodules in subjects over 40 years old Subjects & Method : 470 subjects over 40 years old with normal iodine intake , were examened by clinical and thyroidechgraphy ( prober 7,5 Mhz ) 3. Results : Approximately 10,4% of adults over 40 years old have thyroid nodule, the prevalence of thyroid nodule increased parallel with age . 4,9% of aged 40-49, 9,0% of 50-59, 12,9% of 60-69 and 13,7% off aged over 70. The prevalence of thyroid nodule in female was higher than that male with ratio 2,5 . the solid thyroid nodule was 56,2%, mono nodule was 85,7% and nodule with dimension under 2 cm was 80,7%. thyroid nodule with dimension over 2 cm could be detected by clinical examen, but only 15% subjects with thyroid nodule under 1 cm by this method Conclusions . Prevalence of thyroid nodule increases parallel with age, thyroid nodule with small dimension ( under 1 cm ) could be only visible on ultrasonography. Tm tt 1. Mc ch : Kho st t l, c im lm sng v siu m bu gip nhn i tng trn 40 tui 2. i tng v Phng php : 470 ngi trn 40 tui sng vng khng thiu it c khm lm sng v siu m tuyn gip 3. Kt qu : T l bu gip nhn ngi trn 40 tui l 10,4%. T l bu gip nhn tng dn theo tui: 4,9% tui 40-49, 9,0% la tui 50-59, 12,9% la tui 60-69 v 13,7% la tui trn 70. T l bu gip nhn ca n gii cao gp 2,5 ln nam gii. a s bu gip nhn thuc loi bu nhn c (56,2%), n nhn (85,7%) v ng knh di 2cm (80,7%). Kh nng pht hin trn lm sng nhn gip c ng knh trn 2cm tng ng nh siu m nhng di 1cm ch pht hin 15% trng hp. Kt lun : Bu gip nhn tng dn theo tui , phn ln kch thc nh ch pht hin qua siu m tuyn gip.

I. T VN Th tch v trng lng ca tuyn gip tng dn t khi sinh ra cho n lc trng thnh v c lin quan vi tui, gii tnh, chiu cao, cn nng, din tch da... Sau tuyn gip c khuynh hng nh li dn ngi gi. Song song vi s teo nh sinh l ca tuyn gip l s thay i cu trc nhu m gip, iu ng ch nht trong s bin i ny l s gia tng t l bu gip nhn ngi gi. y l mi nguy c e da ung th gip v tng nng gip ngi trn 40 tui b bu gip nhn lu ngy m nhiu quc gia trn th gii nh Thy in, Zim-ba-bu, n ... tng gp phi. Bu gip nhn n gin pht hin khi c kch thc ln , Tuy nhin nhng th tim n pht hin bu gip nhn i hi can thip ca chn on hnh nh trong s siu m l phng tin pht hin nhn gip hin c x dng ph bin trn lm sng. Siu m tuyn gip l mt trong nhng k thut thm d hnh nh (cng vi x hnh, X quang, CT scan,

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MRI...) khch quan v chnh xc hn. y l xt nghim an ton, khng xm nhp, t hoc hu nh v hi, kinh t, c ng, d thc hin v cho kt qu nhanh vi chnh xc cao (c bit trong vic pht hin bu gip nhn). Vit Nam hin vn cha c nhiu nghin cu bng siu m v cu trc tuyn gip ngi trn 40 tui Mc tiu : Xc nh v kho st t l bu gip nhn ngi trn 40 tui bng khm lm sng v siu m hai bnh din (2D). II. I TNG V PHNG PHP NGHIN CU 1. I TNG NGHIN CU 1.1. i tng chn - Ngi kho mnh 40 tui. - C hoc khng c bu gip nhn. 1.2. a im nghin cu : - Cc i tng c chn vo nghin cu ca chng ti l nhng ngi c tr ti th x ng Hi - Qung Bnh. 1.3. Thi gian nghin cu : T thng 7/2003 n thng 7/2004. 2. PHNG PHP NGHIN CU 2.1. Thit k v chn mu y l nghin cu m t ct ngang. 2.2. Cc bc tin hnh Bc 1: Khm tuyn gip nh gi kch thc v mt tuyn gip theo tiu chun ca WHO (1993): Bc 2: Siu m tuyn gip - S dng my siu m Aloka SSD-500 (Nht Bn) vi u d Linear 7.5MHz. - Phng php: Siu m kiu B, . - T th bnh nhn: Nm nga trn ging, k c bng gi mm dy 10cm. - S dng mt ctngang & Mt ct dc: + Phi hp thm cc mt ct khc kho st cu trc ca ton b nhu m tuyn gip. - nh gi cu trc tuyn gip: Bnh thng hoc Bu nhn: Th bu c phn loi theo tiu chun OHIO-1997 (M): Nhn c (Solide): Nhn lng (Liquide): Nhn hn hp (Mixte): Bc 3: Hon chnh phiu Protocol. 3. Cc ch s thu thp 3.1. Tm mi lin quan - Bu gip nhn vi tui, gii. 3.2. S khc nhau v kt qu gia khm lm sng v siu m tuyn gip 4. X l s liu : chng trnh SPSS, EPI INFO 6.04 v EXCEL 2000. : III. KT QU & BN LUN 1. Phn b cc i tng theo tui v gii : 470 i tng kt qu nh sau : Bng 3.1: Phn b nhm tui v gii ca cc i tng nghin cu Nhm tui Nam N Chung T l % 40 - 49 44 59 103 21,9 50 - 59 49 62 111 23,6 60 - 69 65 67 132 28,1 47 77 124 26,4 70 Tng cng 205 265 470 100,0 Khng c s khc bit nam v n cc nhm tui (p > 0,05).

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2. Cu trc tuyn gip vi bu gip nhn i tng nghin cu 1. T l bu gip nhn theo tui v gii
2 0 1 8 1 6 1 4 1 2 1 0 8 6 4 2 0
1 .4 6 1 .9 2 9 .2 6 .8 4 .1 2 .3 1 .6 0 1 .6 5

T l%

Na m N

4 -4 0 9

5 -5 0 9

6 -6 0 9

7 0

N t h mu i

Biu 3.1. T l bu gip nhn cc nhm tui ca nam v n T l bu gip nhn nhm tui trn 60 tui l 13,3% (34/256) cao hn so vi nhm tui 40-59 l 7,0% (15/214) c ngha thng k (p < 0,05). 3. S lin quan bu gip nhn vi tui v gii A. Brander v cng s (Phn Lan) siu m 253 ngi 19-50 tui (123 nam v 130 n), nhn thy tn sut thng tn tng dn theo tui, n nhiu hn nam . M, i vi ngi ln, t l bu gip nhn thng gp khong 4%, trn 60 tui t l khong 5%, trong n nhiu gp 4 ln nam gii . iu tra vng Whickham (Anh) cho thy t l bu nhn khong 1% nam, 5% n v tng dn ln 45 tui, ln ti 9% n gii la tui 75 . Theo Vander iu tra 5000 dn th c 4% l bu gip nhn, t l bnh nhn n/nam l 13/1 . Theo G. Manciet th 15% ngi trn 60 tui khng c bt thng v hnh thi tuyn gip, nhng sau 90 tui gn nh 100% c bu gip nhn, trong n nhiu hn nam . T l bu gip nhn : Trong nghin cu ca chng ti 470 ngi trn 40 tui pht hin c 49 ngi b bu gip nhn, chim t l chung 10,4%. Yu t tui : T l bu gip nhn tng dn theo tui: 4,9% la tui 40-49, 9,0% la tui 50-59, 12,9% la tui 60-69 v 13,7% la tui trn 70. T l bu gip nhn nhm tui trn 60 (13,3%) cao hn so vi nhm tui di 60 (7,0%) c ngha thng k (p < 0,05). Yu t gii : im lu th hai l t l bu gip nhn ca n cao hn ca nam (p < 0,05), t l n / nam l 2,5/1. Nhn thy kt qu nghin cu ca chng ti ph hp vi nhiu kt qu ca cc tc gi nghin cu trc y l t l bu gip nhn tng dn theo tui tc v t l bu gip nhn ca n cao hn ca nam. 4. c im nhn gip trn siu m : 4.1. Theo cu trc :
7 0 Nh t i m u 6 -6 0 9 5 -5 0 9 4 -4 0 9 0 % 4 .0 5 6 .0 0 6 .6 6 6 .0 0 5% 0 Tl % 1 .0 5 1 .0 0 1 .7 6 2 .0 0 4 .0 0 3 .0 0 c 1 .7 6 2 .0 0 10 0% L g n Hnh p

Biu 3.6. Phn b cc loi nhn gip cc nhm tui a s nhn gip gp ngi trn 40 tui thuc loi nhn c (56,2%), k tip l nhn hn hp (29,8%), v t nht l nhn lng (14,0%). Trong tng nhm tui cng c s phn b tng t. T l mc bu nhn hn hp ngi trn 60 tui cao hn so vi ngi di 60 tui (14/40 so vi 3/17, p < 0,05). Cng trong nghin cu 250 bnh nhn trn, T Vn Bnh ghi nhn tn thng dng c l ch yu vi 60%, dng lng 32,4% v dng hn hp l 7,6% [4]. 4.2. Theo th

Th n nh n 14.3 Th nh a n

85.7

Biu 3.8. Phn b th bu gip nhn A. Brander v cng s (Phn Lan) siu m 253 ngi (19-50 tui) c chn ngu nhin thy 69 ngi (27,3%) c hnh nh echo bt thng, gm 39 (57%) n nhn, 15 (22%) a nhn, 15 (22%) bu lan to . T Vn Bnh khi nghin cu 250 bnh nhn trn 16 tui b bu gip nhn thy tn thng n nhn chim 61,8%, a nhn 38,2% . Phm Vn Choang v cng s (1993-1995) siu m 4526 ca nhiu la tui thy c 703 ca n nhn, 163 ca a nhn . Trong nghin cu ny, khi siu m 470 ngi trn 40 tui thy c 42 (85,7%) trng hp n nhn, 7 (14,3%) trng hp a nhn. T l mc bu n nhn cao hn a nhn tt c cc nhm tui. Nh vy, bu gip th n nhn chim a s so vi th a nhn v khng khc nhau cc la tui trn 40 cng nh di 40 tui cc nghin cu ca cc tc gi trn. 4.3. Theo kch thc

12.3

7.0

35.1

k <1 k [1 - 2) k [2 - 3) k=3

45.6

Biu 3.7. Phn b nhn gip theo kch thc

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Nhn c ng knh di 2cm chim t l cao (80,7%), nhn t 2cm tr ln c t l thp (19,3%). Nhm tui trn 60 c t l mc bu nhn ng knh di 2cm cao hn so vi nhn ng knh trn 2cm. nhm tui 40-49 khng thy c nhn trn 2cm. Theo T Vn Bnh khi nghin cu 250 bnh nhn bu gip nhn thy kch thc nhn hay gp l loi c ng knh 1-3cm [4]. nghin cu ny ghi nhn: Nhn gip c ng knh di 2cm chim a s (80,7%), nhn t 2cm tr ln chim t l thp (19,3%) nhng ngi trn 40 tui v c bit l nhm ngi trn 60 tui. nhm tui 40-49 cng khng thy c nhn to trn 2cm. 5. Lm sng v siu m gip trong pht hin bu gip nhn. 5.1.So snh s ph hp gia khm lm sng v siu m gip Bng 3.2. S ph hp gia khm lm sng v siu m tuyn gip Siu m Tng cng C nhn Khng Lm C nhn 27 1 28 sng Khng 22 420 442 Tng cng 49 421 470 H s Kappa = 0,677 (p < 0,001; 95%CI = 0,548-0,806). 5.2. Khc nhau v vic pht hin bu gip nhn Deandrea M v cng s ngi (2002) khi so snh kt qu khm trn 420 bnh nhn bu c gia s nn v siu m tuyn gip nhn thy: 140 bnh nhn khng s thy nhn gip th siu m pht hin 106 bu n nhn v 34 bu a nhn. 182 bnh nhn s thy mt nhn gip th siu m xc nh l 138 bu n nhn, 42 bu a nhn v 2 bu lan to. Cn 98 bnh nhn s thy bu a nhn th qua siu m cng cho kt qu tng t [53]. Sadol nhn thy s chnh lch gia hai phng php lun l 10 ln, nu trn lm sng t l bu gip nhn t 3-5% th siu m l 50% Welker M.J, Orlov D (Ohio - M) thy t l bu gip nhn qua khm lm sng l 47% nhng siu m c ti 19-67% . Mackenzie E.J, Mortimer R.H (Australia) thy t l bu gip nhn pht hin trn lm sng khong 5% v trn siu m khong 25% Bruneton J.N, Tramalloni J, Bleuse A, Maestro C, Marcy P.Y, Chapellier C (Php) thy rng, trn lm sng t l bu gip nhn l 5% cn qua siu m (tn s 13 MHz) l 34% trng hp ngi ln Nguyn Th Thng, Trn nh Ngn (1998-2002) khi nghin cu trn 117 bnh nhn b bu gip nhn tui 17- 69 bng siu m thy t l ph hp gia khm lm sng vi khm siu m trong vic xc nh s bu l kh cao ( h s Kappa = 0,67 vi p = 0,0013) [36]. Kt qu iu tra ca chng ti trn 470 ngi cho thy, t l bu gip nhn pht hin qua lm sng l 5,7%, trong khi bng siu m l 10,4%, gn gp i so vi lm sng. S trng lp gia hai phng php khm l mc kh (h s Kappa = 0,677, p < 0,001). Nhn thy kt qu nghin cu ca chng ti v cc tc gi trong nc l ph hp nhau, cn so vi cc tc gi nc ngoi th c khc nhau kh nhiu, iu ny c l lin quan khng nhng v kinh nghim ca ngi khm m cn lin quan ti cu to gii phu vng c, c im ca nhn (s bn lun phn tip sau) v phng tin my mc mi quc gia. 5.3. S khc bit ca lm sng so vi siu m trong vic pht hin cc nhn gip Bng 3.12: S khc nhau gia lm sng v siu m trong pht hin nhn gip theo kch thc Siu m Pht hin lm sng Kch thc nhn S lng C Khng TL pht hin < 1 cm 20 3 17 15,0 % 1- 1,99 cm 26 15 11 57,7 %

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2- 2,99 cm 7 7 0 100 % 3 cm 4 4 0 100 % Bng 3.13: S khc nhau gia lm sng v siu m trong pht hin bu gip nhn theo cu trc Cu trc nhn Pht hin lm sng (trn siu m) C Khng T l pht hin Nhn c (n = 14 18 43,8 % 32) Nhn lng (n = 8) 4 4 50,0 % Hn hp (n = 17) 11 6 64,7 % 5.4. Khc nhau trong vic pht hin cc c im ca bu gip nhn Bng siu m tuyn gip, chng ti pht hin c nhng trng hp bu gip nhn c ng knh t 5 mm tr ln v c th xc nh c kh chnh xc cu trc ca chng. So vi siu m, th lm sng (bng nhn v s nn tuyn gip) ch gii hn mc : - Theo kch thc: Nhng nhn c kch thc trn 2cm th kh nng pht hin trn lm sng l hon ton (100%) nh siu m. Kch thc nhn cng nh th kh nng pht hin cng thp (ch pht hin c khong 15% trng hp khi bu nhn nh di 1cm). Cn Papini E v cc cng s (Italy) gp 494 bnh nhn bu nhn gip c kch thc 8-15mm l khng s thy v phi nh n siu m thng v mu [75]. - Theo cu trc: Nhn hn hp c kh nng pht hin qua s nn kh cao (64,7%) so vi siu m v d dng hn so nhn lng hay nhn c. Cn theo Nguyn Th Thng, Trn nh Ngn th t l ph hp gia khm lm sng vi khm siu m trong vic xc nh cu trc nhn l rt cao (Kappa = 0,96; p = 0,0001), c bit l bu nhn c v lng [36]. Nh vy, mt s c im ca nhn gip c nh hng n kh nng pht hin chng trn lm sng, trong khi siu m hu nh t b nh hng. Tm li, s khc bit trn ni ln u im ni bt ca siu m trong chn on bu gip nhn, c quy cho l tiu chun vng, bi siu m khng nhng pht hin d dng ra nhn gip m cn bit c kch thc v phn loi tn thng mt cch kh chnh xc. KT LUN Qua khm v siu m tuyn gip ca 470 ngi trn 40 tui sng vng khng thiu it chng ti i n mt s kt lun sau: T l bu gip nhn ngi trn 40 tui l 10,4%, t l ny tng dn theo tui: 4,9% tui 40-49, 9,0% la tui 50-59, 12,9% la tui 60-69 v 13,7% la tui trn 70. T l bu gip nhn ca n gii cao gp 2,5 ln nam gii. a s bu gip nhn thuc loi bu nhn c (56,2%), n nhn (85,7%) v ng knh di 2cm (80,7%). Kh nng pht hin trn lm sng nhn gip c ng knh trn 2cm tng ng nh siu m nhng di 1cm ch pht hin 15% trng hp. Nhn hn hp th s pht hin d hn so vi nhn c v nhn lng. Cn siu m gip i tng trn 40 tui pht hin sm bu gip nhn nht l n gii.

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TI LIU THAM KHO 1. L Ngc Bnh (1992), Nhn v ung th gip, Tp ch cc ri lon thiu ht i-t, (7), B Y t, tr. 48-50. 2. T Vn Bnh (2000), c im bu gip nhn nh gi bng siu m, K yu ton vn Cng trnh nghin cu khoa hc Ni tit v Chuyn ho, Nxb Y hc, tr. 10-17. 3. Nguyn Th Thng, Trn nh Ngn (2003), nh ga vai tr ca siu m v chc ht t bo bng kim nh trong chn on bu nhn tuyn gip, Tp ch Y hc Thc hnh, (12), Nxb Y hc, tr. 38-39. 4. Nguyn Hi Thy (2000), Chn on v iu tr bnh tuyn gip, Nxb Y hc. H Ni. 5. Alexander E.K, Hurwitz S, Heering J.P, Benson C.B, Frates M.C, Doubilet P.M, Cibas E.S, Larsen P.R, Marqusee E (2003), Natural history of benign solid and cystic thyroid nodules, Ann Intern Med, 138(4), pp. 315-8. 6. Deandrea M, Mormile A, Veglio M, Motta M, Pellerito R, Gallone G, Grassi A, Torchio B, Bradac R, Garberoglio R, Fonzo D (2002), "Fine-needle aspiration biopsy of the thyroid: comparison between thyroid palpation and ultrasonography", Endocr Pract, 8(4), pp. 282-6. 7. Gallo M, Pesenti M, Valcavi R (2002), "Ultrasound thyroid nodule measurements: the "gold standard" and its limitations in clinical decision making", Endocr Pract, 9(3), pp. 194-9. 8. Gluckman Jack L (1994), A Practical Approach to Thyroid Tumors, The Neck: Diagnosis and Surgery, Mosby, pp. 223-240. 9.Wemeau Jean - Louis (1994), "Goitre diffus et nodule thyrodien: Orientation diagnostique, La revue du praticien, Tome 44(No 19), pp. 2653-2656.9.

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