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NGHIN CU C IM LM SNG.

CN LM SNG V KT QU IU TR U BUNG TRNG TR EM


Nguyn Thanh Lim, Nguyn Th Hon, Nguyn Th Kim Nhung Bnh Vin Nhi Trung ng Summary: Ovarian tumor is usually encountered in adults, rarely in children. According to Vecchia, the prevalence of the disease is 1/1,000,000 females below 15 years. To treat an ovarian tumor when it is still small can reduce acute surgical complication and to preserve the ovary for children. The purpose of ovarian tumor treatment is to ensure patients endocrine state and fertility. In Vietnam this problem does not have enough attention, as the result we carried out this study Clinical characteristics, laboratory and treatment result of ovarian tumour in children. The study would help pediatricians to early detect and treat the disease. In studying 51 patients of ovarian tumours, aged from 7 months to 15 years, in a period 19972002 in National Hospital of Pediatrics, we found the following valuable, clinical characteristics of ovarian tumors in children. The disease could be seen in different ages, but patients aged more than 5 years accounted for 78.4%. Abdominal pain was found in 54.9%. In examination 72.5% of patients had a tumour, 100% of patients with a twisted ovarian tumour had abdominal pain, nausea. An ovarian tumour caused rarely precocious puberty (in 3.9%). Abdominal ultrasound discovered an ovarian tumour in 65.2%. Alpha-fetoprotein was high only in a malignant, ovarian tumour. On cytology, a germ cell type was composed of 96.1% of the group. A malignant germ cell type constituted 15.7% of patients having a germ cell type. A benign tumour of the ovaries constituted 82.4 and a malignant tumour was 17.6%. After operation, 3 patients (5.9%) died at home and the rest of the patients (95%) had abdominal ultrasound and alpha-fetoprotein which were within normal ranges. I.t vn Bung trng l mt b phn quan trng ca ngi ph n. Ngoi chc nng sinh sn, bung trng cn l ni sn xut nhiu ni tit t cng l ni pht sinh ra nhiu khi u. Khi u bung trng (UBT) thng gp ngi ln nhng him gp tr em gi theo La Vecchia gp 1/1.000.000 tr em gi di 15 tui [13]. Biu hin lm sng rt a dng nh khi u bng, au bng, nn, dy th sm v cc tnh trng cp tnh bng, tuy nhin nhiu trng hp lm sng im lng, c pht hin tnh c trong khi thm khm lm sng hoc l trong cc chn on hnh nh [7,10]. Khi UBT tr em gi khc vi khi UBT ngi ph n trng thnh mt s kha cnh nh dch t hc, bnh hc, iu tr, tin lng [2,10], do vy vic chn on v cc bin php iu tr phi c thay i vi nhm tui nhi khoa. Tui bnh nhn tng lin quan n tng khi UBT v gim bt nguy c c tnh [9], [15] nhng cng c mt s tc gi thy nguy c c tnh tng theo tui: 6%, 21% v 73% ln lt tng ng vi cc nhm tui di 5 tui; 5 - 9 tui; v 10 - 14 tui [8]. Cc dng tn thng ca UBT ngi ln u c th gp tr em, tuy nhin tr em trn 70% khi UBT c ngun gc t t bo mm [12]. Vic pht hin v iu tr sm UBT khi khi u cn nh c ngha quan trng v khng nhng lm gim cc bin chng phi can thip ngoi khoa cp cu m cn c kh nng bo tn bung trng c bit quan trng i vi tr em. Gia cc tc gi c nhiu kin khc nhau v vic iu tr khi UBT tr em v cu to phc tp v t chc hc nhng tu chung li cc phng php iu tr u nhm mc ch ko di tui th, m bo cn bng ni tit trong i sng sau ny v duy tr chc nng sinh sn cho bnh nhn. Trn th gii c nhiu cng trnh nghin cu khi UBT tr em, nhng Vit Nam vn ny cha c quan tm nhiu, do vy chng ti tin hnh nghim cu vi 2 mc tiu: 1. Nhn xt v c im lm sng, cn lm sng khi UBT tr em.

2. Nhn xt v kt qu iu tr khi UBT. Hy vng vi kt qu thu c ca nghin cu s gip ch cho cc bc s lm sng nhi khoa c th pht hin v chn on bnh sm , t c hng iu tr v duy tr chc nng sinh sn cho bnh nhn b khi UBT. II. i tng v phng php nghin cu 1. i tng nghin cu: 51 bnh nhn c chn on xc nh v iu tr phu thut UBT t 01/01/1997 n 30/09/2002 ti khoa ngoi, khoa ni tit chuyn ho - di truyn, khoa ung bu Bnh Vin nhi Trung ng. Tiu chun la chn: + Tr gi nh hn hoc bng 15 tui. + Tiu chun chn on: UBT c xc nh bng phu thut. Phi c lm gii phu bnh l. Phn loi GPB da vo bng phn loi ca t chc y t th gii, chng ti s dng kt qu GPB do cc bc s chuyn khoa GPB - BV Nhi TW cung cp. Tiu chun loi tr: Tt c nhng bnh nhn khng c kt qu GPB u khng c a vo mu nghin cu. 2. Phng php nghin cu: Nghin cu m t Nghin cu tin cu 16 bnh nhn b UBT t 01/06/2001 n 30/09/2002 Nghin cu hi cu 35 bnh nhn b UBT t ngy 01/01/1997 n 30/05/2001 3. Phng php thu nhn thng tin: -c im chung: tui, tin s gia nh, tin s bnh tt, chn on v iu tr ca tuyn trc, chn on ca BV Nhi, l do vo vin. - Lm sng: + Bnh s: triu chng xut hin u tin, thi gian t khi xut hin triu chng cho n khi vo vin, tnh trng ca bng, dy th sm, st, gy st nhanh. + Thm khm lm sng: ton thn, khm bng, khm tit niu. Khm ni tit: b phn sinh dc v nh gi giai on lm sng theo phn loi ca Tanner. - Cn lm sng: + Siu m bng: lm ti phng siu m khoa Chn on hnh nh BV Nhi TW. + Xquang tim phi: tm di cn khi UBT. + Xt nghim mu: FT, FSH, LH, estradiol. + Xt nghim gii phu bnh: Theo bng phn loi khi UBT ca WHO. - Chn on: Chn on trc v sau m. - Nghin cu trong m: V tr, kch thc khi u, dch bng. Phn loi lm sng: da vo bng phn loi ca hi ngh ton th lin on quc t sn ph khoa FIGO: International Federation of gynecology and obsstetrics. - Kt qu gii phu bnh - Nhn xt kt qu iu tr sau phu thut: S pht trin th cht sau m (cn nng, chiu cao), tnh trng n ung, tnh trng bng, kt qu siu m bng, kt qu FB. 4. Phng php x l s liu: c s l trn my vi tnh theo chng trnh EPI-INFO 6.0. II. kt qu nghin cu Tin s gia nh: 1/ 51 bnh nhi c b ngoi v m b m khi UBT (1,9%). Tin s bn thn: Tt c bnh nhn u khng c biu hin c khi u nguyn pht ti c quan khc. Tin s kinh nguyt: 2 bnh nhn (3,9%) c kinh nguyt sm (1 bnh nhn 3 tui, 1 bnh nhn 5 tui). Chn on ca khoa - phng bnh nhn vo iu tr u tin ti BV Nhi TW. Bng 1: Chn on bnh nhn UBT ti phng khm

Khoa vo u tin Ni Ngoi S BN % Chn on nhi nhi U nang bung trng 10 6 16 31.4 Xon UBT 0 2 2 3.9 Xon u 1 2 3 5.9 U bng 8 8 16 31.4 Vim rut tha 0 2 2 3.9 Tc rut do b thc n 0 1 1 1.9 Tc rut dnh sau m 1 0 1 1.9 Dy th sm 2 0 2 3.9 C chng cha r nguyn nhn 3 0 3 5.9 au bng cha r nguyn nhn 4 1 5 9.9 Cng 29 22 51 100 Nhn xt: Bnh cnh lm sng ca khi UBT rt a dng. C 18/51 bnh nhn UBT c chn on ng ngay ti khoa iu tr u tin (35,3%). 23 bnh nhn (51,1%) c cc chn on cn c xc nh can thip ngoi khoa. Bng 2. Tui bnh nhn lin quan ti bnh S BN n % Tui < 1 tui 2 4 1 - 5 tui 9 17.6 5 - 10 tui 17 33.4 0 - 15 tui 23 45 Cng 51 100% Tui mc bnh trung bnh l 7.9 + 4.1 tui, nh tui nht l 7 thng, ln tui nht l 15 tui. T l mc UBT gia tng theo tui 40/51 bnh nhn (78,4%) trn 5 tui Bng 3. S phn b tui bnh nhn mc khi UBT c tnh Dng tn thng c tnh < 1 tui 1-5 5-10 10-15 U qui cha trng thnh 2 U t bo mm hn hp c tnh 2 U dy mm sinh dc hn hp 1 U ti non hong 1 3 8/9 bnh nhn trn 5 tui mc UBT c tnh v t l c tnh tng theo tui. Bng 4. Triu chng lm sng: Triu chng (n = 51) S BN % Bng to nhanh 11 21.6 Bng to C chng xut hin nhanh 3 5.9 Bng to dn 26 51 D di tng cn 11 21.6 au bng m 17 33.3 S nn bng pht hin u 36 70.6 U bng U vng tiu khung 30 58.8 Kinh nguyt 2 3.9 Dy th sm V B2 1 1.9 Mi ln, mi b pht trin 1 1.9 Thiu mu 1 1.9 Khng c triu chng 3 5.9 40 bnh nhn (78,5%) c triu chng bng to, 6/11 bnh nhn c bng to nhanh c kt qu gii phu bnh c tnh, 3 trng hp c chng mc ln khng s thy u.

au bng d di t ngt tng cn gp 11 bnh nhn (21,6%) trong 9/11 trng hp l c xon u, 3/17 bnh nhn (17,6%) au bng m c bn xon u. U bng l triu chng gp nhiu nht (n = 37; 72,5%) trong 1 bnh nhn c pht hin u bng thm trc trng kt hp vi s nn bng. Bng 5. Biu hin lm sng ca xon u Triu chng (n = 12) S BN % au bng t ngt, d di, tng cn 9 75 m 3 25 S thy u 9 75 Nn 5 41.7 St 3 25 Phn ng thnh bng 3 25 n khi u rt au 9 75 100% bnh nhn xon u c biu hin au bng v 75% l au bng d di tng cn.

Bng 6. Kt qu siu m
Kt lun siu m S BN % U nang bung trng 12 26.1 U qui bung trng 13 28.3 UBT di cn 2 4.4 UBT xon 1 2.2 U qui bung trng gy gin niu qun - b 2 4.4 thn 6 13 Nghi UBT 5 10.8 U qui bng 3 6.5 U mc treo 2 4.4 Cng 46 100% 36 bnh nhn (78.3%) c khi u hng ti ngun gc bung trng, trong 30 bnh nhn (65.2%) khng nh chc chn l UBT; 10 bnh nhn (21,8%) c chn on SA khng ph hp. Xt nghim FP: C 24 bnh nhn c lm xt nghim FP. - 18/24 bnh nhn lnh tnh v 2 bnh nhn c tnh (u qui cha trng thnh c mc FP gii hn bnh thng (10.028+2.1ng/ml); - 4 bnh nhn c tnh (3 u ti non hong v mt khi u t bo mm c tnh hn hp) u c mc FP rt cao so vi bnh thng (1.109+907.5ng/ml) o Xt nghim nh gi dy th sm + C 2 bnh nhn dy th sm u c lm xt nghim FSH: 1.64mol/ml- 2.8mol/ml v LH: 6.43mol/ml- 9mpl/ml: Kt qu trong gii hn bnh thng. + Bnh nhn 3 tui c lm xt nghim estradiol 44 pmol/ l (tng nh) v phiu m o hnh nh ca ph n trng thnh * Kt qu trong m xc nh: 56.9% (29/51) khi u c v tr bn phi v 39,2% (20/51) khi u c v tr bn tri, nhng khng c s khc bit (p > 0.05). Bng 7. Kt qu gii phu bnh Dng tn thng gii phu bnh S BN % U dng t bo mm lnh tnh - U qui trng thnh 34 66.7 - U nang b bung trng 7 13.7

U dng t bo mm c tnh - U ti non hong 4 7.8 - U qui cha trng thnh c tnh 2 3.9 - U t bo mm c tnh hn hp 2 3.9 U dy m sinh dc - U t bo ht trng thnh 1 2 - U dy mm sinh dc hn hp 1 2 Cng 51 100 Nhn xt: 42 bnh nhn (82.4%) l c kt qu lnh tnh, c tnh 9 BN (17.6%). 49 bnh nhn (96.1%) c khi u ngun tc t bo mm trong 15.7% l khi u t bo mm c tnh. 2 bnh nhn (3.9%) c khi u ngun gc dy m sinh dc, c 2 bnh nhn c dy th sm, trong 1 bnh nhn u dy mm sinh dc hn hp (3 tui). 1 bnh nhn 7 thng (u qui chy mu), chn on trc m cp cu l vim rut tha, sau m l xon nang. 5. Kt qu sau phu thut * Kt qu gn sau phu thut: Trong 51 bnh nhn c phu thut khi UBT, khng c bnh nhn no t vong ti vin. 42 bnh nhn khi v ra vin (82.4%), 6 bnh nhn bnh (11.8%) v 3 bnh nhn (5.8%) c tin lng xu. - Thi gian nm vin sau phu thut: S ngy nm vin trung bnh ca phng php ni soi ct u 4 + 1,3 ngy ngn hn so vi phu thut m ct u 5,6 + 2,2 ngy l c ngha thng k (vi 2 = 19.84; p<0.001). - Bin chng sm sau m: Khng c cc bin chng ngay sau m nh nhim trng vt m, tnh trng bng ngoi khoa sau m v khng phi m li ln 2 cng nh khng c bnh nhn no t vong ti vin. - iu tr ni khoa sau m: C 1 bnh nhn u ti non hong giai on Ic iu tr ho cht ti vin K. * Kt qu xa sau m: Thi gian kim tra sau m ngn nht l 1 thng, lu nht l 60 thng. Thi gian iu tr sau m trung bnh l 27.8 thng. 51 bnh nhn dc mi kim tra ti vin nhi. Mt tin tc 16 bnh nhn (31.4%). Kim tra trc tip 24 trng hp (47.1%). nh gi qua phiu kim tra 8 trng hp (15.6%).3 trng hp t vong sau khi ra vin. Thng bo bng th chim 5.9%. Kt qu nh sau: - 32 bnh nhn c kim tra chiu cao, cn nng trong 24 bnh nhn c kim tra trc tip, 8 trng hp c nh gi qua phiu. Cn nng thp gp 4 bnh nhn (12,5%), cn nng gim t (15 - 20%) trng lng c th; chiu cao ca cc tr bnh thng khng tr no c chiu cao thp c ghi nhn. - 32 bnh nhn (100%) khng c cc ri lon c nng nh n km, au bng, chng bng, ri lon i tiu tin, kinh nguyt bt thng sau khi m khi UBT. - nh gi v siu m: 22/24 bnh nhn (91.6%) c kim tra siu m c kt qu bnh thng, 2 bnh nhn c kt qu siu m bt thng l 2 bnh nhn khng c m ct UBT bn i din m ch c chc ht khi u (1 trng hp u qui trng thnh v 1 trng hp u ti non hong). - Kt qu xt nghim FP: 23/24 bnh nhn c kim tra FP c kt qu bnh thng; 1 bnh nhn u ti non hong giai on Ic sau phu thut 2 thng, cha c iu tr l c mc FP bt thng ( Fp = 210ng/ml). - Thi gian sng thm sau m: Bng8. Thi gian sng sau m Thi gian sng st (nm) Kt qu gii phu bnh Ghi ch S 1 2 3 4 5 BN

U dng bo mm lnh tnh U qui trng thnh U nang bi bung trng U dng t bo mm c tnh U ti non hong U qui cha trng thnh c tnh U t bo mm c tnh hn hp U dy m sinh dc U t bo ht trng thnh U dy mm sinh dc hn hp

34 7 4 2 2

10

3 2

7 mt tin tc 5 mt tin thc 2 mt tin thc 1 mt tin thc 2 BN t vong sau ra vin 3 thng v 8 thng mt tin thc T vong 2,5 nm sau ra vin

1 1

1 1

T vong sau ra vin: c 3 bnh nhn t vong ti nh u khng c khm li trc khi t vong v khng c iu tr ho cht. Cc bnh nhn u khng t vong v mt bnh phi hp no khc km theo. Hai bnh nhn u t bo mm c tnh hn hp t vong sau 3 thng v 8 thng sau khi ra vin v 1 bnh nhn u dy mm sinh dc hn hp giai on Ia t vong sau ra vin 2,5 nm.

IV.Bn lun
1. c im lm sng Tin s bnh tt: tt c cc bnh nhn u c UBT nguyn pht v l t pht bnh ln u tin. Khng trng hp no l UBT ti pht c ghi nhn. Tin s kinh nguyt: 2 trng hp c kinh nguyt sm (3 tui v 5 tui), l du hiu gia nh a tr n khm, m trc bnh nhn khng c biu hin bt thng ca bnh, chng t UBT gy dy th sm 2 trng hp ny. 2. Tui bnh nhn lin quan ti bnh Tui mc bnh trung bnh l 7.9 + 4.1 tui. Theo mt s tc gi khc tui mc bnh trung bnh l 10 tui [11] v 14 tui [4], c l do tui ca i tng trong cc nghin cu cao hn (di 16 tui v18 tui). La tui mc UBT c tnh theo nghin cu ca chng ti (bng 3) ch yu l bnh nhn trn 5 tui (8/9 bnh nhn ; 88.9%) v nhm bnh c tnh (8.6 + 3.9; n = 10) ca khi UBT. T l mc UBT gia tng theo tui 40/51 bnh nhn (78.4%) tr mc UBT trn 5 tui. iu ny cng ph hp vi nghin cu ca Groeber WR v Norris HJ cng cs[15] v nhiu nghin cu gn y cng ch ra rng nguy c c tnh tng theo tui nh nghin cu ca La Vecchia v cs, thy t l UBT c tnh l 6%; 21% v 73% tng ng vi cc nhm tui (di 5 tui; 5 - 9 tui; 10 - 14 tui) [13]. 3. Triu chng lm sng N.V.Ti(198) E.Frend(1999) Daren L(2001) N.T.L (2002) [3] (n=31) [8](n=34) [7] (n=102) (n=51) au Cp 16 26,4 56 21,6 khng c thng tin bng m 23,5 4 33,3 khng c thng tin khng c thng tin Bng to Nhanh 48 15,6 khng c thng tin khng c thng tin C 6 5,9 chng U bng hoc vng chu 27 6 22 72,5 khng c thng tin Nn 2,9 21,5 9,8

Dy th sm 0 18 2 3,9 au bng l triu chng thng gp, c th biu hin ca tnh trng xon, v nang hoc do khi u chn p gy au. au bng cp gp vi t l 21,6%, kt qu ny ph hp vi y vn v mt s tc gi khc (p<0,001). Nhng trng hp au bng cp d di tng cn nu khm thy u trn lm sng hoc siu m pht hin u th cho php ngh nhiu n kh nng tr b xon u. Bng to l du hiu c nng khin gia nh bnh nhn lu v a tr i khm bnh. Bng to chim ti 78,5%, 3 bnh nhn c c chng nhng lm sng khng pht hin c u v c 3 bnh nhn ny u c gii phu bnh kt lun l c khi UBT c tnh (2 trng hp l u t bo mm c tnh hn hp giai on IV, 1 trng hp l u ti non hong giai on Ic). Theo Ng Vn Ti: 2 bnh nhn (6%) c nc c chng c chc tho lm xt nghim v tm thy t bo ung th trong dch c chng. Nc c chng l do phc mc b cc ung th lan trn kch thch tit dch ti cc ph tng. Bnh nhn UBT c dch c chng cn phi c lm xt nghim tm t bo ung th tin lng bnh. Trong nghin cu ca chng ti c 11 bnh nhn bng to nhanh trong 6/11 bnh nhn (54,5%) l khi u c tnh. Nh vy du hiu u bng & bng to nhanh (k c c chng) gi n s tin trin ca khi u c tnh. Xon u: au bng v nn l 2 du hiu c nng thng gp ca xon khi UBT, do cc m ri thn kinh tng, do tng p lc ln cc tng xung quanh v do tng nhu ng rut khi b kch thch. Trong nghin cu ca chng ti, xon UBT chim 23,5% (12 bnh nhn) v 100% bnh nhn xon u c au bng trong 9 bnh nhn au bng d di tng cn. Trong 7 trng hp pht hin thy khi u, c 3 trng hp l xon UBT. Khi thm khm l nhng khi u di ng c th y c ln pha trn rn, n pha di h chu phi hoc tri bnh nhn au nghi l cung u, n khi u rt au. Nghin cu ca chng ti ph hp vi nhiu tc gi khc [3, 7, 10]. La tui b xon UBT l 8,2 3,8. Thng gp xon UBT bn phi hn bn tri (8/4). Khi UBT ch tit hormon gy dy th sm (xut hin kinh nguyt, v pht trin, lng mu, c th pht trin..) nhng tr gi tui cn rt nh, gi ti khi UBT c ngun gc m m sinh dc. Khi u sn xut ra hormon c th gp bt k la tui no.Trong nghin cu ca chng ti c 2 bnh nhn (3,9%) c biu hin dy th sm (1 tr xut hin kinh nguyt lc 3 tui, 1 tr xut hin kinh nguyt lc 5 tui), c cc biu hin nh m t bng 4 v khng c biu hin nam ho. Mt tr kinh nguyt ko di 20 ngy v mc nhiu gy thiu mu nng (Hb lc vo: 4,1g/l). Qua siu m c 2 bnh nhn c pht hin c khi UBT, hormon hng sinh dc mc bnh thng. 1 bnh nhn 3 tui c xt nghim Estradiol tng hn bnh thng, c tim nng ung th cao, iu ny ph hp vi gii phu bnh l khi u mm sinh dc hn hp. 1 bnh nhn l khi u t bo ht, c 2 thnh phn ny u giu thnh phn ht ch tit Estrogen bt thng lm cho tr dy th sm, rong kinh gy thiu mu nng, ph hp vi biu hin lm sng. Kt qu nghin cu ca chng ti ph hp vi kt qu ca mt s tc gi khc bng trn. Trong s 37 bnh nhn c s thy khi u bng c 30 trng hp khi u nm vng tiu khung v vy hng ti UBT. 4. Cn lm sng Siu m chn on Trong kt qu nghin cu ca chng ti xc nh c v tr UBT chim 64,5%, c 17 trng hp (35,5%) khng xc nh c v tr u th c 7 trng hp vn hng ti UBT nhng khng xc nh c v tr ( 1 trng hp chn on UBT, 6 trng hp nghi UBT). Nhng trng hp chn on khng ph hp l do v tr bt thng ca u di gan, di ti mt, i trng phi hoc mn sn phi, c l l do u c kch thc ln khng xc nh c cung u hoc v tr xut pht v thy cu trc u nh dch trong, hoc cu trc ging

nh ca ng tiu ho do vy thng c chn on u mc treo rut hoc nang nc trong bng. Nhng khi u c cc v tr nh h chu sau, sau bng quang, cu trc c hoc hn hp nhng thnh phn ch yu c ch lo sng nghi do t chc xng thng c chn on Teratom h v. Theo cc tc gi khc th nhng trng hp ny rt kh phn bit vi 1 u c c ngun gc khc trong khung chu. Xt nghim FP Trong kt qu nghin cu ca chng ti c 24 bnh nhn c lm xt nghim, mc FP trong gii hn bnh thung nhm c kt lun gii phu bnh lnh tnh (n=18) v c tnh (u qui trng thnh, n=2). 4/6 bnh nhn c tnh cn li c mc FP cao (1109,9 907,5 ng/ml, nh nht l 129,4 ng/ml v cao nht l 2310 ng/ml) l ti non hong hoc kt hp vi u ti non hong, iu ny ph hp vi y vn. tr em khi u dng t bo mm l ch yu, trong khi u c tnh ca t bo mm ng hng u l u lon pht t bo mm v ti non hong do vy tt c nhng bnh nhn c khi UBT cn c lm xt nghim FP tin lng, i chiu lm sng, siu m, gii phu bnh v theo di tin trin ca bnh [1,2]. Xt nghim nh gi dy th sm Trong nghin cu ca chng ti c 2 bnh nhn c biu hin dy th sm trn lm sng th c 2 u c FSH, LH trong gii hn bnh thng iu ny chng t l dy th sm ngoi bin. Ch c bnh nhn 3 tui c nh lng Estradiol thy tng nh, gi n kh nng ung th v c gii phu bnh ph hp lm sng (u dy mm sinh dc hn hp). Nh vy nh lng FSH v LH gip chn on nguyn nhn gy dy th, nh lng estradiol giip tin lng mc lnh tnh v c tnh ca bnh. Gii phu bnh Theo nghin cu ca chng ti t l khi u lnh tnh l 82,4%, t l c tnh l 17,6%. So snh vi kt qu nghin cu ca cc tc gi khc c th hin bng sau cho thy kt qu nghin cu ca chng ti ph hp vi kt qu nghin cu ca cc tc gi khc. T l Lnh tnh c tnh Tc gi N.V.Ti (1982) (n=31) [3] 30 70 B.M.Tun (1998) (n=40) [5] 77,5 22,5 E. Freud (1999) (n=51) 76,5 23,5 N.T.Lim (2002) (n=51) 82,5 17,6 Trong nghin cu hng ti gp khi u c ngun gc t bo mm l ch yu (94,1%) ph hp vi kt qu nghin cu ca Menczer J (72% l UBT c ngun gc t bo mm). 2 bnh nhn c khi u dy m sinh dc, 2 loi u ny u giu thnh phn ht nn gy ch tit estrogen bt thng ph hp vi lm sng c dy th sm, tr em nhng khi u ny c tin lng tt bi v trn 90% biu hin bnh giai on i v t l sng thm ln ti 95% i vi bnh nhn giai on Ia v 80% vi giai on Ic[27]. i vi khi u dy mm dinh dc hn hp, c tnh cao. Trong nghin cu ca chng ti c 1 bnh nhn giai on Ia khng iu tr ho cht sau phu thut t vong sau 2,5 nm sau khi ra vin v tin trin ca bnh v 1 bnh nhn mt tin tc. i vi khi u t bo mm c tnh th dng gp nhiu nht l u ti non hong (4/8). Tu thuc s bit ho ca cc m mm bt thng m to ra cc dng u t bo mm c tnh khc nhau, nhng tr em hay gp nht l u lon pht t bo mm v u ti non hong. Nhng khi u ny c kt qu iu tr kh quan nu giai on sm ca bnh [23,52]. 5. Kt qu iu tr sau m Kt qu sm sau phu thut

Khng c bnh nhn no c cc bin chng ngay sau m, khng c bnh nhn no phi m li ln 2 v 42 bnh nhn (84%) khi v ra vin, 6 bnh nhn (11,8%) bnh v 3 bnh nhn (5,8%) c tin lng xu. Kt qu theo di sau ra vin Kim tra c 43 bnh nhn vi thi gian sau n trung bnh l 27,8 thng , ngn nht l 1 thng, lu nht l 69 thng. Kim tra trc tip 24 bnh nhn, nh gi qua phiu iu tra 8 bnh nhn. Kt qu cho thy khng c bnh nhn no gim chiu cao, cn nng do nh hng tin trin ca bnh, khng c cc du hiu c nng bt thng, khng bnh nhn no c bt thng kinh nguyt. C 32 bnh nhn (trong c trng hp c tnh) u c phu thut ct b khi u v gi li t cung v vi trng 1 bn, do vy cha c bin i v chc nng ni tit. Kt qu siu m 91,6% c kt qu siu m bnh thng trong c 1 u qui cha trng thnh; 1 u ti non hong iu tr, 2 trung hp siu m bt thng l do khng c phu thut ct b khi UBT bn i din m ch c chc ht khi UBT 2 bn, d l u c kch thc nh (2,5 cm v 3 cm). Kt qu FP 21 bnh nhn c khi u lnh tnh v 1 trng hp u qui cha trng thnh c xt nghim kim tra li mc FP, kt qu cho thy mc FP gii hn bnh thng, ph hp vi kt qu khm lm sng, siu m v ph hp vi y vn. 2 bnh nhn u ti non hong c kim tra mc FP th c 1 bnh nhn c mc FP gii hn bnh thng (bnh nhn ny uc iu tr ho cht Vin K v ngng iu tr 1,5 nm nay), 1 bnh nhn c mc FP bt thng l do khng iu tr ho cht. Trong qu trnh theo di, chng ti thy rng nhng khi u lnh tnh v u qui cha trng thnh (giai on Ia) ch cn phu thut ct b u. i vi u ti non hong (giai on I) kt qu kh quan sau phu thut c dng ho liu php, ph hp vi kt qu nghin cu ca cc tc gi khc[6,14]. i vi khi u t bo mm c tnh hn hp giai on IV trong nghin cu ca chng ti khng iu tr ho cht, bnh nhn t vong sm sau phu thut. Tuy nhin v khng loi b c nhiu t chc di cn nn nu c iu tr ho cht tin lng bnh nhn cng d dt v giai on cui ca bnh. Trong 9 bnh nhn c khi u c tnh th c 3 bnh nhn t vong, 7/9 bnh nhn cn phi iu tr ho cht sau m th ch c 1 bnh nhn c iu tr ho cht. iu tr ho cht l quan trng sau phu thut khi u c tnh, vic khng tip tc iu tr ho cht sau m khng nhng gy nh hng xu nhng bnh nhn c tnh giai on cui m cn tc ng khng tt cho bnh nhn c tnh giai on u ca bnh .

V.Kt lun 1. Cc triu chng lm sng c gi tr chn on UBT tr em. Bnh c th xy ra cc la tui, ch yu trn 5 tui (78,4%). au bng l triu chng thng gp (54,9%), khm thy khi u bng chim

72,5%, v tr h chu phi hoc tri (63,9%) c ranh gii r v di ng 100% UBT xon c au bng v bun nn. Dy th sm trong UBT tr em him gp, chim 3,9%. 2. Cn lm sng: Siu m:90,2% bnh nhn lm siu m v pht hin c u bng, trong 65,2% kt lun l UBT. FP: tng cao trong UBT c tinh.

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t bo mm c tnh. Khi u lnh tnh ca bung trng l 82,4% v c tnh l 17,6%. Bnh nhn c tnh giai on I (77,8%), giai on IV (22.2%). Kt qu sau phu thut Bnh nhn c kim tra thi gian ngn nht l 1 thng, lu nht 60 thng, trung bnh l 27,8 thng: 100% pht trin chiu cao bnh thng, 12,5 % cn nng gim (t 1520% trng lng c th). Khng c du hiu c nng hoc gy kinh nguyt bt thng. Siu m bng v xt nghim FP: 95% c kt qu xt nghim bnh thng. T vong ti nh : 5,9% bnh nhn (3/51) v din bin xu ca bnh.

T bo hc: 96,1% UBT c ngun gc t bo mm, trong 15,7% l khi u

Ti liu tham kho


1. Nguyn B c (2000), U t bo mm bung trng, Ho cht iu tr ung th, Nh xut bn Y hc, H Ni, tr 127-129. 2. Trn Th Phng Mai. (1999), Khi u bung trng, Bi ging sn ph khoa, Nh xut bn Y hc, tr 259-306. 3. Ng Vn Ti. (1982), Khi u bung trng tr em v con gi tui dy th trong 5 nm (1978-1982) ti Vin Bo v b m v tr s sinh, Lun vn tt nghip BSCK cp i, kho VII, H ni. 4. Vi Huyn Trc (1998), Bnh ca b phn sinh dc, Gai phu bnh hc, Nh xut bn y hc tr 390-429. 5. Bi Mnh Tun-L Phc Pht-Ng Vn Tn.(1998), Cc u bung trng tr em, Tp ch y hc Vit nam s 8, tr 12-15. 6. Baranzelli MC et al. (2000), Non-Semiomatous ovarian germ cell tumors in children, Eur J Cancer, 36(3),p 376-383. 7. Darell L et al. (2001), Surgery for ovarian masses in infants, children, and aldolescents: 102 consecutive patient treated in a 15 year period, J of pediatr sur, Vol 36, No5(May), p 693-699. 8. Gribbon M, Ein SH, Mancer K. (1992), Pediatric malignant ovanrian tumour: a 43 year review, , p 480. 9. Groeber WR. (1963), Ovarian tumors during infancy and childhood, Am J Obstet Gynecol, 86, p 1021. 10. Hasse GM et al. (1998), Ovarian tumours, J Pediatr Surg, Vol 1. 5th Edition, p513-540. 11. Kinnern S et al. (1993), Ovarian neoplasma in children, Arch-Surg, Pediatric sugery, chicago, Mosby-year book. 12. Konzlowski KJ. (1999), Ovarian masses. Aldoles Med, 10(2),p 337-350. 13. La Vecchia C, Morris HB, Draper JG. (1983), Malignant ovarian tumours in childhood in Britan 1962-1978, Br J Cancer, 48, p 363. 14. Linasmita V et al. (1999), Recent management of malignant ovarian germ cell tumours: A study of 34 cases, J Obstet Gynecol Res, 25(5), p 315-320. Norris HJ, Jensen RD. (1972), Relative Frequency of ovarian neoplasmas in children and aldolescents, Cancer 30, p713.

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