I CHIU LM SNG, T BO HC V GII PHU BNH TRN BNH NHN BU GIP NHN

Lm Vn Hong1 - Nguyn Thy Khu2 TM TT MC TIU: nh gi gi tr tin on c tnh ca cc triu chng lm sng, siu m v chc ht kim nh (FNA) tuyn gip trn bnh nhn c bu gip nhn. PHNG PHP: Nghin cu hi cu 95 trng hp bnh nhn bu gip nhn c phu thut, ghi nhn nhng du hiu lm sng, cn lm sng, chn on t bo hc bng chc ht kim nh v gii phu bnh sau m. Kt qu gii phu bnh c dng lm tiu chun vng nh gi cc triu chng khc. KT QU: C 75 bnh nhn n v 20 bnh nhn nam. Tui trung bnh 43.9 (14.6). 25 bnh nhn (26.3%) c bu c tnh, trong 19 ung th gip dng nh, 3 ung th gip dng nang, 1 ung th t bo ty, 2 ung th t bo Hurthle. 70 bnh nhn (73.7%) c bu lnh tnh, trong 66 nhn lnh tnh v 4 vim gip. Triu chng khn ging ch gp trong 4 trng hp bu c tnh. C 25 trng hp c tnh u c tnh cht siu m km hoc hn hp, trong khi nhm lnh tnh c 49 (70%) trng hp. T bo hc FNA chn on c tnh trong 18 trng hp, nghi ng 11 trng hp. Kt qu gii phu bnh sau m ca 11 trng hp ny gm 3 ung th v 8 phnh gip. Gi tr chn on ca FNA: nhy 84%, chuyn 87,6%, t l dng tnh gi 12,8%, t l m tnh gi 1,64%, gi tr chn on dng 70%.

RELATIONSHIP BETWEEN CLINICAL FINDINGS, CYTOLOGICAL AND HISTOLOGICAL RESULTS IN PATIENTS WITH THYROID NODULE
Lm Vn Hong1 - Nguyn Thy Khu2 ABSTRACT OBJECTIVE: To assess the malignancy predicting of clinical signs, ultrasound findings and FNA cytology of thyroid nodule. METHOD: Retrospective cohort study enrolled 95 patients with thyroid nodule undergone surgery. Clinical signs, ultrasound findings, cytological diagnosis by FNA and post operated pathological results were recorded. Pathological result was the gold standard to compare with the others RESULTS: There were 75 women and 20 men. Mean age was 43.9 years (SD=14.6). 25 cases (26.3%) were thyroid carcinoma, of which 19 cases were papillary carcinoma, 3 cases were follicular carcinoma, 1 case was medullary carcinoma and 2 cases were Hurthles cell carcinoma. Of the remaining cases, 66 were benign thyroid nodule and 4 were Hashimotos thyroiditis. Hoarseness was presented in only 4 cases with carcinoma. Echogenicity were poor or mixed in all 25 malignant cases and in 49 benign cases (70%). FNA results were malignant in 18 cases and suspected in 11 cases. In
1 2

Khoa Ni tit Bnh vin Ch Ry B mn Ni tit i hc Y Dc TP H Ch Minh

KT LUN: Triu chng khn ging t gp, tuy nhin l du hiu rt c gi tr tin on c tnh. Hu ht cc trng hp c tnh u c c im siu m km hoc hn hp. Phng CONCLUSION: php t bo hc bng FNA c gi Hoarseness was an uncommon symptom but it tr chn on c tnh cao. strongly suggested thyroid cancer. Most of the malignant nodules had poor or mixed echogenicity. FNA was a fairly good diagnostic test of thyroid cancer. the latter group, post-op pathological result was 3 carcinoma and 8 benign goiters. FNA had a sensitivity of 84%, specificity of 87.6%, false positive of 12.8%, false negative of 1.6% and positive predictive value of 70%.

1 . T VN : Bnh bu gip nhn l bnh thng gp trong nhm bnh ni tit. Ghi nhn ring M mi nm khong 275 000 bnh nhn bu gip nhn mi c pht hin. T l bnh nhn c bu gip nhn l ung th c thay i theo nhiu nghin cu ca cc tc gi khc nhau. chim 4- 5%, trong t l ung th gip dng nh chim ln hn 80% trng hp. xc nh chc chn tnh cht ca bu gip nhn cng nh mt s bnh l khc, tiu chun vng vn l chn on m hc, v ch c thc hin sau khi bnh nhn phu thut bu gip, do thun li hn, vic tm hiu bn cht ca bu nhn gip qua s dng phng php sinh thit bng kim chc ht t bo tuyn gip (FNA) c nhiu chuyn gia gii phu bnh, cng nh cc nh lm sng ni tit thc hin trong nhiu thp k qua, Vit Nam c nhiu cng trnh nghin cu ti H Ni v TP H Ch Minh nh Nguyn So Trung, Ha Th Ngc H[1][2], vv cc tc gi ny ghi nhn hi cu i chiu kt qu t bo hc v m hc cho thy nhy, chuyn ca xt nghim ny cng kh cao v ph hp nh nhiu cng trnh bo co trn th gii. Tuy nhin nhng nghin cu ny mi ch mi xt yu t m hc v t bo hc ca bu gip nhn ch khng cp n kha cnh lm sng. Do vi mc ch tm hiu mi lin quan gia nhng yu t lm sng v cn lm sng trn bnh nhn bu gip nhn, v qua chng ta c th tm thy cc yu t c gi tr tin on trong chn on ung th gip trn bnh nhn c bu gip nhn. chng ti thc hin nghin cu ny. 2. I TNG & PHNG PHP NGHIN CU 2.1. Dn s nghin cu: 95 Bnh nhn c bu gip nhn c khm v phu thut ti khoa ngoi tng qut Bnh vin Ch Ry t thng 6 nm 2003 n thng 6 nm 2004. 2.2 Tiu chun chn bnh Tt c bnh nhn bu gip nhn, n nhn, a nhn c phu thut c lm y xt nghim hormon tuyn gip, siu m, chn on t bo hc, m hc tuyn gip v phu thut tuyn gip.

2.3. Tiu chun loi tr Tt c nhng trng hp khng y s liu. PHNG PHP NGHIN CU Thit k nghin cu Nghin cu hi cu m t. 3. X L THNG K Nhp v x l s liu theo phn mm Epi info 2003. nh gi nhng yu t bin c lp v ph thuc. nh gi cc yu t tng quan, kim nh bng cc php kim phi tham s. nh gi nhy, chuyn gi tr tin on ca cc xt nghim. KT QU & NHN XT. Hi cu trn 95 bnh nhn c phu thut ti bnh vin Ch Ry T thng 6 nm 2003 n thng 6 nm 2004 tiu chun nghin cu.
95 benh nhan

25 ung th giap 26.3%

70 lanh tnh 73.7%

19 ung th dang nhu

66 trng hp phnh giap

3 ung th dang nang 4 trng hp viem giap

1 ung th dang tuy

2 u te bao Hurthle

1. c im chung ca nhm nghin cu: 1.1 Tui: Bng 1 : Phn b tn sut tui v kt qu chn on m hc. Tui Phnh gip n=(66) < 20 n=3 20-40 n=35 2 (3%) 26 (39.4%) dng nh 1(5.2%) 5(26.3%) 13(68.5%) Ung th gip (n=25) dng nang 0 1(33.3%) 2(66.7%) dng ty 0 0 1(100%) Hurthle 0 1(50%) 1(50%) Vim gip (n=4) 0 2(50%) 2(50%)

> 40 38 (57.6%) n=57

70 60 50
pha tra n m

68

40 30 20 10 0
<20tuo i 20-40 tuo i > 40tuo i

28 4

Biu 1 : Phn b nhm tui trong bnh nhn ung th gip. Trong 95 trng hp bnh nhn c phu thut tuyn gip, tui trung bnh 43 tui 14.6. Trong bnh nhn ung th gip, t l bnh nhn c tui ln hn 40 chim 68%. - Khng thy mi tng quan c ngha thng k gia tui v ung th gip vi ( R = 0,1, P = 0,458 < 0.05 ). Kt qu ca chng ti khng ph hp so vi mt s tc gi, cc tc gi thy rng c mi tng quan gia yu t tui vi ung th tuyn gip, khi tui cng nh hay cng ln, th nguy c ung th cng cao. Theo nghin cu ca Hamburger [6] ghi nhn nguy c ung th gip trn bnh nhn bu gip nhn tr em cao hn nhiu so vi ngi ln, tr em 14 40% trong khi ngi ln ch chim 5%. Tc gi Walsh RM a ra nhng yu t nguy c c tnh thng nhm tui ln hn 20, v nh hn 40. 1.2 Phi * Kt qu t l 2 nhm ung th v khng ung th phn b theo phi Nam: 20 trng hp (21%), trong 7 trng hp l ung th gip N : 75 trng hp (79%) trong 18 trng hp ghi nhn ung th Bng 2: Phn b tn xut gii tnh theo chn on m hc Phi Phnh gip (n=66) Ung th gip (n=25) dng nh 5(26.3%) 14(73.7%) dng nang 1(33.3%) 2(66.7%) dng ty 0 (0%) 1(100%) Hurthle 1(50%) 1(50%) Vim gip (n=4)

Nam N

13(19.7%) 53(80.3%)

0 (0%) 4(100%)

T l bnh nhn nam so vi n l 3/1.(21% / 79%). Ring trong nhm bnh nhn ung th gip t l: Nam 7/25 trng hp (t l 28%), n 18/25 (t l 72%), so snh t l n/ nam ghi nhn n 72/ 28 gp khong 2.5 ln. Xt v tng quan gia yu t gii tnh vi kt qu l ung th gip, chng ti ghi nhn s tng quan khng c ngha thng k vi R= 0.1, P= 0.3. So vi 4

tc gi Kuma H [8], ghi nhn trn 1005 bnh nhn nam v n. Bnh nhn nam b bu nhn gip c kh nng c tnh cao hn so vi n . 2. Ghi nhn theo du hiu lm sng Bng 2.1: Du hiu lm sng phn b theo kt qu 2 nhm bnh nhn Ung th gip (n=25) au (+) Nut vng (+) Khn ging (+) 6/25 (24%) 17/25 (68%) 4/25 (16%) Khng ung th gip (n=70) 9/70 (12.8%) 45/70 (64.2%) 0

Bng 2.2 : nh gi cc yu t tng quan v lm sng v kt qu . au H s tng quan P 0.4 0.19 Khn ging R : 0.3 0.00004 Nut vng R 0.00 0.77

* au & nut vng l 2 triu chng ch quan xut hin trong c 2 nhm bnh nhn * Triu chng khn ging: Chng ti ghi nhn yu t khn ging c tng quan vi ung th gip, h s tng quan R = 0.34, vi php kim Fisher P = 0.0004 c ngha thng k, d cho mi tng quan thun ny l mt mi tng quan yu vi R< 0.7, nhng y cng l triu chng quan trng gi s xm ln ca ung th gip 3. Kt qu siu m: Bng3.1 : S lng nhn trn siu m phn b theo 2 nhm bnh nhn Ung th gip (n=25) n nhn a nhn Tnh cht siu m Bnh thng (n=7) Dy (n=14) Km ( n=49) Hn hp (n=25) 22/25 (88%) 3 ( 12%) Ung th gip (n=25) 0 (0%) 0 (0%) 22 (44.9%) 3 (12%) Ung th gip (n=25) 5 Khng ung th gip (n=70) 50/70 (71.4%) 20/70 (18.6%) Khng ung th gip (n=70) 7 (100%) 14 (100%) 27 (51.1%) 22 (88%) Khng ung th gip (n=70)

Bng 3.2 : Tnh cht siu m phn b theo 2 nhm bnh nhn

Bng 3.3. Du hiu vi ha v hch pht hin trn siu m theo 2 nhm bnh nhn.

Vi ha (+) (n=19) Hch (+) (n=6)

6/25 (24%) 6/25 (24%) Ung th gip

13/70 (17.3%) 0 ( 0%) Khng ung th gip 28.2 17.03 33.22 14.4 2 nhm 1 (1.15) 72 (75.8%) 22 ( 23.5%) Echo km R: 0.4 P 0.007

Bng 3.4: Th tch v trung bnh ng knh nhn qua siu m theo 2 nhm bnh nhn. Th tich trung bnh ng knh nhn trung bnh 30.14 20.34 32.92 13.27

Bng 3.5: ng knh nhn theo kt qu 2 nhm bnh nhn ung th v khng ung th Ung th gip <10 mm 10-39 mm > 40 mm 0 17 (17.8%) 8 (8.4%) Vi ha H s tng quan P value c im siu m * S lng nhn Trong nhm ung th gip, t l bu gip n nhn chim kh cao 88%, a nhn 12%, ph hp v mt l thuyt cng nh trong nghin cu ca tc gi Kumar.H [8] v cc tc gi khc, t l c tnh thng gp bu n nhn hn l bu gip a nhn v lan ta. * Th tch trung bnh tuyn gip nghin cu ca chng ti khng ghi nhn s khc bit v th tch gia cc nhm kt qu P = 0.3065. * ng knh tuyn gip: T l bnh nhn c bu gip kch thc ln hn 40mm chim 23.5% trong nhm nghin cu, ring trong nhm ung th chim 8/25 trng hp (32%). Kch thc bu gip nhn khng c s khc bit trong tt c cc nhm kt qu. kch thc ln 40 mm khng tng quan vi ung th gip, iu ny khc bit v mt l thuyt cho rng kch thc ln hn 40mm l yu t tin on c tnh, cng nh Theo tc gi Gideon Bahar ghi nhn kch thc ca bu gip l yu t c lp tng quan vi chn on c tnh [5], * Tnh cht siu m ca nhn gip: chng ti ch ghi nhn tnh cht gim m c ngha thng k vi P = 0.007, h s tng quan R= 0,4, h s tng quan ny l tng quan thun. y l du hiu kh quan trng vn tin lng bnh nhn b ung th gip. So snh vi tc gi Corias v cng s ghi nhn trn 85 bnh nhn t l Echo km xut hin trong c 2 nhm lnh tnh v c tnh, t l c tnh chim 57%, lnh tnh chim 26%. Do c s gii hn ca tnh cht ny tin on tnh cht lnh v c tnh ca bu nhn, v theo bo co ca Corias v cng s l tnh cht tng m khng loi tr c c tnh [4]. * Vi ha trong nhn c ghi nhn 19/95 (20%) trong cc nhm chn on, du hiu ny chng ti cng thy trong c 2 nhm ung th gip v khng ung th gip. Tuy nhin ring 6 R= 0.00 0.5651 Khng ung th gip 1 55 (58%) 14 (15.%) Kich thc R = 0.14 0.1285

Bng 3.6: nh gi cc yu tng quan v siu m v kt qu

trong nhm ung th gip chim 6/25 (24%) v ch xut hin trong nhm ung th gip dng nh. Nghin cu ca tc gi Khoo Ml [7] trn 361 bnh nhn phu thut tuyn gip t l bu nhn c du hiu vi ha 49/361 ( 13.6%), kt qu 29/49 bnh nhn l ung th gip vi kt lun du hiu vi ha trong bu gip nhn l du hin tin lng nguy c c tnh kh cao. *Hch: trong nghin cu ca chng ti ch ghi nhn trong nhm bnh nhn ung th gip vi t l 6/25 ( 24%). Xut hin trong c 2 nhm bnh nhn ung th gip dng nh, v dng nangTnh cht hch tng quan thun vi h s tng quan R=0.43, P= 0.00001, cho d tnh tng quan ny vn l tng quan yu, nhng c gi tr trong chn on ung th gip. So snh vi tc gi Nam-Goong v cng s nghin cu trn nhm bnh nhn ung th gip ti i hc Ulsan Hn quc. Trong 36 bnh nhn ung th gip thy t l s bnh nhn c km theo hch 18/36 (50%) bnh nhn. T l ny kh cao so vi nghin cu ca chng ti, nhng tt c nhng iu ny cnh bo cho chng ta nn khm xt cc nhm hch cn thn khi bnh nhn c nhiu yu t nghi ng ung th gip, v hn na khi pht hin c xut hin hch l du hiu gp phn tng kh nng nghi ng ung th gip trn bnh nhn. 4. i chiu t bo hc v m hc. Kt qu t bo hc (95BN) Khng chn on Nghi ng Phnh gip K gip dng nh K gip dng nang K gip t bo ty Km bit ha Hurthle cell Vim gip 6 ly mu li 11 61 18 1 0 1 1 2 66 19 3 1 0 2 4 Kt qu m hc(95BN)

Biu 4.1: i chiu kt qu t bo hc v m hc

63 BN T bo hc lnh tnh

21 BN T bo hc c tnh

61

70 BN lnh tnh Chn on m 8 11 BN nghi ng Chn on t bo 3

25 BN c tnh Chn on m

20

Bng 4.2 : Phn phi tn sut 2x2 chn on FNA v kt qu m hc Ung th gip Kt qu (+) Kt qu (-) Tng s 21 4 25 Khng ung th gip 9 61 70 Tng s 30 65 95

nhy ca xt nghim = dng tht / dng tht + m gi = 84% chuyn = m tht / m tht + dng gi = 87.2% Gi tr tin on dng = dng tht / dng tht + dng gi = 70% Gi tr tin on m = m tht / m tht + m gi = 93.8% T l dng tnh gi: 12.8% T l m tnh gi: 1.6% - 6 trng hp tht bi do mu tiu bn khng y , iu ny cng thng ghi nhn nh trong mt vi nghin cu ca cc tc gi khc. Theo Hossein Gharib [8] nghin cu cng cng s hn 18.000 mu bnh phm kt qu 25% khng chn on v 10% vi chn on nghi ng. -11/95 bnh nhn (11.5%) trng hp nghi ng phn ln c chn on l tn thng dng nang, nhm bnh nhn ny sau phu thut 8/95 (8%) trng hp l phnh gip, 3/95 ( 3.1%) trng hp l ung th gip, trong 1 trng hp l ung th dng nh, 1 ung th dng nang, v 1 trng hp l ung th t bo Hurthle. Trong nhng trng hp nghi ng chng ta rt kh phn bit gia cc dng tn thng dng nang. V phng din gii phu bnh c 4 th sau: phnh gip tuyn ( adenomatous hyperplasia). U tn sinh dng nang lnh tnh (follicular adenoma), Ung th tuyn gip dng nang ( follicular carcinoma), ung th dng nh bin th nang (follicular variant of papillary thyroid carcinoma).Vi nhng trng hp kh chn on ny, rt d lm ln, thng theo kinh nghim ca nhiu chuyn gia gii phu bnh chng ta nn lm li sinh thit v nn phu thut tuyn gip. trong qu trnh phu thut c th thc hin phng php sinh thit lnh, t

 c kt qu nhanh v chnh xc gip cho phu thut vin quyt nh phng php m thch hp cho bnh nhn. * Kt qu m tnh gi: trong nghin cu ca chng ti c 2 trng hp (1.6%). Chn on ban u l bu nhn lnh tnh, sau phu thut chn on l ung th gip dng nh, iu ny c th do mt s yu t sau: - Ly mu c th khng ng v tr ca khi ung th. - Trn tiu bn mu c th nhiu hng cu. - K thut pht tiu bn cha chun, lm cho tiu bn qu dy t bo, do khi c kt qu c th sai lm trong chn on. Theo Hamburger [6] ngh mu tiu bn tiu chun phi tht s ng.Trong l nghin cu ca tc gi c 21% ly khng ng bnh phm, nhiu trng hp vim gip Hashimoto d chn on lm vi bu lympho tuyn gip, ung th gip dng nang d lm ln vi bu gip dng nang. U t bo Hurthle lnh tnh phn bit vi ung th t bo Huthle. Trong trng hp nh vy cn s kt hp ca lm sng v nhiu yu khc. V Hamburger cng cho rng t l m tnh gi chp nhn c n 10%. Trong nhng trng hp nghi ng chng ta nn sinh thit li t bo t 6 thng n mt nm. Nghin cu ca Hamburger theo di 198 bnh nhn c kt qu t bo l lnh tnh, sau 3% l ung th gip trong lm xt nghim ln sau. Do hn ch nhng kt qu m tnh gi Hamburger ngh bng phng php loi tr, chn on bu lnh tnh khi c bng chng y l c t nht 2 tiu bn 2 ln chc khc nhau, mi tiu bn c y 6 chui t bo lnh tnh [6]. * Kt qu dng tnh gi theo nghin cu ca chng ti chim 12.6%, t l ny chng ti tnh bao gm c nhm bnh nhn nghi ng phi phu thut. do t l ca chng ti cao hn nhiu so vi mt s tc gi trong nc. Mt trng hp c bit bnh nhn c chn on t bo hc l ung th dng km bit ha, sau phu thut chn on kt qu m hc l vim gip Hashimoto, y l trng hp kh phn bit cng nh nhiu tc gi ghi nhn vim gip Hashimoto thng ph bin gy chn on sai v t bo hc do hnh nh t bo d lm ln, Cng nh trong chn on bu gip dng nang v t bo Huthle d lm ln vi ung th dng nh . Hamburger ghi nhn t l dng tnh gi ny 2-3%, nu c kinh nghim. S ln thc hin cng nhiu s cng gim t l ny. * Theo thng k ca cc tc gi t l pht hin ung th khi sinh thit t bo trn bnh nhn bu gip nhn thay i t 8-12%. Hamburger 8%, Gharid H 28/170 trng hp ( 9%) cng nh cc tc gi trong nc, kt qu ca chng ti 22.2% cao hn so vi kt qu ca cc tc gi khc, iu ny cng c th l trong nhm nghin cu ny bnh nhn phu thut thng khng mang tnh ngu nhin m c tnh nh hng nh nghi ng c tnh mi phu thut, nh kch thc ln, khn ging, hch v.v.. do lm cho t l kt qu ny tng cao.

KT LUN
Qua nghin cu ny chng ti rt ra mt s kt lun sau: 1.T l bnh nhn ung th gip trong nhm phu thut chim 26.3%, trong ung th gip dng nh chim phn ln 76%. 2. Cc du hiu lm sng v cn lm sng c gi tr trong chn on ung th tuyn gip: * Khn ging v hch * Siu m echo km .

3. Tui v gii: khng tng quan vi ung th gip 4. Xt nghim chc ht t bo tuyn gip bng kim nh : nhy: 84%. chuyn: 87.2%. Gi tr tin on dng: 70%. Gi tr tin on m: 93.8%. T l dng tnh gi : 12.8% T l m tnh gi : 1.6%.

TI LIU THAM KHO 1 Ha Th Ngc H, L Vn Quang (2002), Gi tr xt nghim t bo hc qua chc ht kim nh trong chn on sm cc bu nhn gip, Hi ngh khoa hc Hi i Tho ng & Ni Tit ton quc ln II, Nh xut bn y hc, trang 83-390 Nguyn So Trung (2001), "Phng php chc ht kim nh chn on t bo hc " Y hoc tp H Ch Minh,chuyn gii phu bnh, tp 5, s 1, trang 14-19, s 2 trang 74-80 Trn Vn Thip.& cng s (2003) nh gi v x tr ht gip . Y hoc Tp HCM, chuyn gii phu bnh, tp 7(4), trang 110-117 Corias.A, Eunaudi. S, Chiorboli.E (2003), Accuracy of fine needle aspiration biopsy of thyroid nodule in detecting malignancy in childhood: comparison with conventional clinical, laboratory, and imaging approaches. The journal of clinical Endocrinology & Metabolism, 86 (10): 4644- 4648 Gideon Bahar, MD, Diana Braslasky, MD,( 2003). The cytological and clinical value of the thyroid " Follicular lesion", American Journal of otolaryngology; Vol 24; (4): 217-220 Hamburger MD .(2000) Diagnosis of thyroid nodules by fine needle Biopsy: use ang abuse. Journal of clinical endocrinology and Metabolism. Vol 79. (2) : 335-339 Khoo ML. Asa SL, Witterick IJ . (Jul-2002) Thyroid calcification and its association with thyroid carcinoma Head Neck, 24(7) 651-5 KumaH, DaykinJ, Holder R, Warkinson JC, Sheppand MC, Franklyn JA (1999). Gender clinical findings, and serum thyrotropin measurement in the prediction of thyroid neoplasia in 1005 patients presenting with thyroid enlargement and investigated by fine needle aspiration cytology. PMID: 10595459 Pubmed Hussein Gharib, MD., FACE.(2003) Fine needle biopsy of the thyroid gland. Thyroid fuction Tests, 8: 400-412

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