Phm thI anh

Nghin cu iu tr phu thut ung th i trng ti pht sau m ti bnh vin Vit c giai on 2005 2011
Ngi hng dn:
PGS.TS Nguyn thanh long PGS.TS trn hiu hc

t vn

Ung th i trng (UTT) l 1 bnh thng gp trong ung th ng tiu ho.

Php: t l mc 31/100.000, t vong 18,5/100.000. Hng cng 2008: mc mi 4000, t vong 1680.

Ti Vit Nam UTT l mt trong 3 loi ung th ng hng u thuc h tiu ho.
T l mc ti Vit nam: 7,5/100.000.

UTT ch yu l ung th biu m tuyn (Adernocacinome), chim khong 95%.

t vn

UTT c coi l ti pht khi pht hin nhng thng tn mi cc BN c iu tr PT ct i trng theo nguyn tc. UTTTP thng c pht hin nh do theo di nh k sau m. Phu thut vn l phng php iu tr ch yu i vi UTTTP.

t vn

mc tiu nghin cu:

1.

M t cc c im lm sng v cn lm sng ca ung th i trng ti pht. nh gi kt qu iu tr ung th i trng ti pht bng phu thut

2.

tng quan GiI phu

Hnh th ngoi:

i trng sp xp nh mt khung hnh ch u ngc v c phn chia thnh 2 phn: TP v TT.

Hnh th ngoi

tng quan

GiI phu

Cu to: thnh i trng c 4 lp:

Lp nim mc.

Lp di nim mc.
Lp c. Lp thanh mc.

tng quan

giI phu

M ca i trng:

i trng c cp mu t ng mch MTTT v ng mch MTTD.

ng mch

tng quan

giI phu
TM ca i trng:

Cc tnh mch ca i trng bt ngun t li mao mch di nim mc v gan qua TM ca.

tnh mch

tng quan

giI phu

Bch huyt: chia lm 4 chng:

Chui hch trong thnh i trng. Chui hch cnh i trng nm dc cc cung mch vin. Chui hch trung gian nm dc theo ng i cc mch mu i trng. Chui hch trung tm nm nguyn u cc mch mu ca i trng.

tng quan

sinh l i trng
Chc nng ch yu ca i trng l hp thu nc, Na+ v 1 s cht khong. Cc t bo tuyn ca i trng tit ra cht nhy bo v nim mc i trng. Vi khun i trng tham gia vo nhiu qu trnh sinh hc, di tc dng ca vi khun 1 s cht c to thnh nh: Vitamin K, Vitamin B12,

tng quan

giI phu bnh l

Hnh nh i th: thng thng c 3 loi:

Ung th th lot. Ung th th si. Ung th th thm nhim cng.

Hnh nh vi th:

Ung th biu m tuyn chim khong 95%. Cc loi ung th khc : ung th c trn, ung th t chc bch huyt, carcinoid,...

tng quan

chn on
Da vo lm sng v cn lm sng: Lm sng: c tnh cht gi (au bng, st cn, ri lon tiu ho, i mu, s thy u bng, hch bn, hch thng n,... ).

Cn lm sng: c vai tr quyt nh (ni

soi i trng ng mm, siu m, chp khung i trng, chp CT, MRI, PET,...).

tng quan

iu tr phu thut

Phu thut k hoch:

PT trit . PT khng trit : ct phn T c u v a 2 u ra ngoi lm HMNT, m thng hi trng. lm HMNT vnh vin trn u, ni tt (by-pass).
PT cp cu v 1 s tnh trng c bit:

Tc rut do u. VFM do thng i trng. Di cn gan n c. abces quanh khi u.

tng quan

iu tr b sung
Ho tr:

5 FU + Levamisol. 5 FU + Leucovorin. 5 FU + folinat acid. FOLFOX 4, FOLFOX 6, FOLFIRI,

Min dch tr liu: s dng ASLEM.

X tr: p dng trong 1 s t trng hp.

i tng v phng php nghin cu i tng nghin cu

Tiu chun chn bnh nhn:

BN c iu tr PT ct T theo nguyn tc do K, GPB chn on xc nh K. BN c chn on UTTTP c iu tr PT ti BV Vit c, GPB chn on xc nh K. BN c BA ghi chp y thng tin cho NC.
Tiu chun loi tr:

BN khng c m ti BV Vit c. BN c HSBA ghi chp khng y . BN khng c kt qu GPB. BN ln PT trc khng c ct T trit .

i tng v phng php nghin cu

phng php nghin cu

Thit k NC: M t hi cu (t 04/05 - 06/11). C mu: c mu thun tin. Thu thp thng tin: t cc h s bnh n

tiu chun NC, lp danh sch BN, ghi chp, phn loi, nh gi kt qu iu tr sau m theo khm nh k, y t c s, gi th hoc T.

X l s liu: thng k s dng cc thut

ton thng k trong y hc, s liu c x l bng phn mm STASTA, SPSS 16.0, Word,

i tng v phng php nghin cu

phng php nghin cu

Cc ch tiu NC phc v mc tiu 1:

NC c im chung. NC c im lm sng. NC c im cn lm sng. NC chn on trc m. NC tn thng trong m.

Cc ch tiu NC phc v mc tiu 2:

NC c im phu thut. NC kt qu iu tr sau phu thut.

kt qu v bn lun c im chung

c im v tui:

Biu tui

40BN>40tui chim 87,0%. 25BN>50 tui chim 54,4%. Tui trung bnh 54,5 tui (nh nht 26, ln nht 90).
Ng.T.Sn: 54,1. Obrand: 62. Sugarbaker: 63.

kt qu v bn lun

c im chung
c im v gii:

29 nam chim 63,1%. 17 n chim 36,9%. T l nam/n l 1,71.

c im v a d:

54,3% bnh nhn sng khu vc nng thn, 45,7% bnh nhn khu vc thnh th.

Biu gii

kt qu v bn lun

tin s iu tr u nguyn pht

V tr u nguyn pht:

25 BN phu thut u nguyn pht TF chim 54,3%. 18 BN TT chim 39,2%. 3 BN TN chim 6,5%.
Nguyn Tin Sn: TP 50%, TT 45,5%, TN 4,5%. V tr u nguyn pht

kt qu v bn lun

tin s iu tr u nguyn pht

Pppt u nguyn pht

(n) 25

T l % 54,3

Ct na tf

Ct na tt
Ct on tn Ct on t sigma

12
3 6

26,1
6,5 13,1

Phu thut phi hp

Tng s

0
46

0
100,0

46/46 BN u c ct i trng theo nguyn tc.

kt qu v bn lun

tin s iu tr u nguyn pht

Thi gian ti pht trung bnh: l 34,3 thng

(ti pht nhanh nht l sau 2,8 thng, lu nht l sau 193,7 thng).
Camilleri: l 25 thng, Ng.T.Sn: l 30,94 thng.

T l ti pht: cao nht l sau 6-24 thng (50%),

67,4% ti pht xy ra trong 3 nm u sau m, t l ti pht sau 3 nm l 32,6%.

Silvana C: l 16 24 thng. John P. Welch: nghin cu thy 2/3 ti pht trong 2 nm u.

kt qu v bn lun

tin s iu tr u nguyn pht

Thi gian ti pht TB (thng)

Giai on Dukes v TMN

(n)

T l%
0,0 43,5 39,1 0,0 17,4

X SD
49,1 18,5 17,0 12,9 -

Ngn nht
2,8 4,7 -

Di nht
193,7 47,8 69,8 193,7

A (T1, N0, M0) B (T2-T3, N0, M0) C (Tx, N1, M0) D (Tx, Nx, M1) K. c thng tin Tng s

0 20 18 0 8

36,4 6,5 27,3 Nguyn Tin Sn, Nguyn Quang Thi: khng c G A v D. 46 100,0 34,3 27,3 2,8

kt qu v bn lun

tin s iu tr u nguyn pht

Thi gian ti pht nhm c bin chng l 38,3 thng, nhm khng bin chng l 33,9 thng. Thi gian ti pht nhm m cp cu l 30,5 thng, nhm m k hoch l 34,7 thng.
Phm Vn Trung: 82,5% trit cn v 21,3% ni ngay th u.

Thi gian ti pht nhm PT ni soi l 10,0 thng, nhm PT m l 36,0 thng.

kt qu v bn lun

tin s iu tr u nguyn pht

Xm Ln c quan ln cn

Thi gian ti pht TB (thng)

%
X SD Ngn nht Di nht

C xm ln K xm ln

17 44,7 17,6 3,2

2,8

193,7
<0,0 5

21 55,3

47,0 10,5

4,7

47,8

Nguyn Tin Sn: 32,2 thng v 12,8 thng. Arnette, Backwell: coi y l yu t nguy c dn n TP sm.

kt qu v bn lun

tin s iu tr u nguyn pht

iu tr b sung Ho tr Ph. hp ha x tr Khng iu tr K. c thng tin

28,3th).

Thi gian ti pht TB (thng)

n
27 1 11 7

%
X SD 58.7 2.17 23.9 15.2 39,5 48.7 40.2 28,0 31.1 23,1 24.2

p Ngn nht 6.4 40.2 6.6 2.8 Di nht 146.7 40.2 193.7 84.9
>0,0 5

iu tr b sung gip ko di TG ti pht (Ng. T. Sn: 30,6th v T l ti khm sau m 65,2% (Cochrane: 42%, Ng.T.Sn: 25,8%).

kt qu v bn lun

lm sng

12BN ti khm pht hin ti pht (26,1%), 33BN c triu chng i khm (71,7%), 1BN c bin chng i khm ( 2,2%). 91,3% BN c au bng, 63,0% c st cn, 17,4% c a mu, 23,9% s thy u bng.
Nguyn Xun Hng: au bng 100%, st cn 61,2% v 55,6% a mu. Phm Hong H: l 85,7%, 54,0% v 38,0%.

kt qu v bn lun

Cn lm sng
Kt qu nhm mu: Nhm O
Biu nhm mu

chim 45,7%, A 26,1%, B 23,9% v AB 4,3% (ph hp vi phn b dch t hc ca ngi VN).
Trn Vn B: O 42,9%, A 28,6%, B 22,5%, AB 5,9%.

Cc ch s sinh ho: hu ht

trong gii hn sinh l.

kt qu v bn lun

Cn lm sng

nh lng CEA:

29 BN c mc CEA>10ng/ml (76,3%). 8 BN >100ng/ml (21.1%).

Sugarbaker: nh lng CEA sau m 1 thng/ln trong nm u sau m v 3 thng/ln 2 nm tip theo thy 70% cc trng hp ti pht c CEA tng dn theo thi gian. Connell: l 69% v Boey: l 65%. Ng.D.Thanh, Ng.Q.Thai: cho rng ch s CEA>10ng/ml rt c gi tr trong theo di v chn on sm ti pht ca UTT .

kt qu v bn lun

Cn lm sng
Siu m 40BN

C HA tn thng
33BN (82,5%)

Bnh thng
7BN (17,5%)

U i trng
9BN

U gan
11BN

Gan phi
8BN (72,7%)

C 2 gan
1BN ( 9,1%)

Gan tri
2BN (18,2%)

Tn thng khc
14BN

c im ca HA tn thng ch yu l gim m.

Steven D. Bines: NC 13 BN c ti 69,2 % di cn gan phi.

kt qu v bn lun

Cn lm sng
Chp ct 42BN

C HA tn thng
38BN (90,5%)

Bnh thng
4BN (9,5%)

U i trng
18BN

U gan
11BN

Gan phi
8BN (72,7%)

C 2 gan
1BN ( 9,1%)

Gan tri
2BN (18,2%)

Tn thng khc
14BN

c im HA ca chp CT ch yu l gim t trng. Tn thng di cn gan ph hp vi kt qu siu m.

kt qu v bn lun

Cn lm sng

Ni soi 29BN

C HA tn thng
23BN (79,3%)

Bnh thng
6BN (20,7%)

Ti ming ni
15BN (65,2%)

Di ming ni
6BN (26,1%)

Trn ming ni
2BN (8,7%)

Bilan trc m cha tt.

Silvana C: TP trn khung T thng xuyn c chn on nh theo di sau m bng PP ni soi.

kt qu v bn lun

giI phu bnh l

46/46 BN (100%) u c kt qu GPB l Adenocarcinome.

Nguyn Phc V Anh: 97,3%. Nguyn Tin Sn: 98,4%.

kt qu v bn lun

tn thng trong m

Ti i trng
18BN (39,1%)

Jonathan C: 30-40% ti pht ti T.

i trng + di cn gan
3BN (6,5%)
Tn thng trong m

i trng +di cn khc

11BN (24%)

Di cn gan n c
8BN (17,4%)

Di cn khc
6BN (13%)

60,9% TP ti T km di cn v TP di cn (Adloff l 86%, Ph.V. Trung l

73%).

kt qu v bn lun

phng php phu thut

PPPT

PT cp cu
1BN (2,2%)

PT k hoch
45BN (97,8%)

Trit
34BN (73,9%)

Khng trit
9BN (19,6%)

Thm d
3BN (6,5%)

Perter S: PT trit tng TG sng. John P. Welch: 10-15% BN ti pht c PT.

kt qu v bn lun

phu thut tI pht di cn

Pppt

Di cn gan
11BN

Khung T
32BN

V tr khc
17BN

Ct gan
2 (18,2%)

L.nhn DC Ct ni ngay
9 (81,8%) 26 (81,2%)

Ni tt
3 (9,4%)

Ct K.hch Ct u SFM
17 BN 7 BN

HMNT
3 (9,4%)
Trnh Hng Sn, Steven D. Bines: a s cc trng hp di cn gan phi.

Ct u TB
11 BN

Ct R.Non
5 BN

PT khc
8 BN

kt qu v bn lun

kt qu sm sau phu thut

Bin chng trong v sau m: 1 BN chy

mu SM (2.2%), 3 BN nhim trng vt m (6.5%).

T l bin chng: nhm PT trit 2,9% (1/34),

nhm PT khng trit v thm d l 25% (3/12).

Thi gian PT trung bnh: nhm PT trit

l 174 pht, nhm PT khng trit 115 pht.

Thi gian nm vin trung bnh:

l 15,2 ngy (PT trit 15,5, K trit 14,3).

kt qu v bn lun

kt qu xa sau phu thut

Tg sng TB sau m:

l 11,5 thng.

0.00

l 13,6 thng so vi 6,05 thng, khc bit c ngha thng k (p< 0,05).

0.25

0.50

Tg sng TB sau m ca nhm PT trit v khng trit :

0.75

1.00

Bieu do Kaplan-Meier danh gia thoi gian song sau phau thuat

20 Khong triet can

40

60 thoi gian song (thang) Triet can

kt qu v bn lun

kt qu xa sau phu thut

TG sng TB gia 2 nhm tui < 60 tui v >= 60 tui: l

12.5 thng so vi 9.4 thng, c s khc bit nhng khng c ngha thng k (p> 0,05).

0.00

0.25

0.50

0.75

1.00

Bieu do Kaplan-Meier uoc luong thoi gian song sau phau thuat

20 Nhom tuoi < 60

40

60 thoi gian song (thang)

Nhom tuoi >=60

kt qu v bn lun

kt qu xa sau phu thut

Nhm phu thut

n
X

Thi gian sng TB (thng) Ngn nht 2,0 Di nht 15

<

PT DC gan n c

6,3

PT TP trn khung t

18

13,6

1,5

62

0, 05

PT TP trn khung t + DC v 14 TPDC

11,8

1,5

46

kt qu v bn lun

kt qu xa sau phu thut

T l bnh nhn sng sau m Kt thc NC 10 BN cn sng (21,7%), 6 BN mt tin

(13,1%).

Kt lun c im ls v cls ca UTTTP

Tui TB 54,5 tui, t l nam 63,1%, n 36,9%. TG ti pht TB l 34,3 thng, 67,4% ti pht trong 3 nm u, 32,6% ti pht sau 3 nm. 65,2% TK nh k, 26,1% TK pht hin ti pht. Triu chng: au bng 91,3%, st cn 63,0%, s thy u bng 23,9%, a mu 17,4%. 76,3% c CEA >10ng/ml, 21,1% >100ng/ml. Ni soi: 65,2% TT ti ming ni, 26,1% di ming ni, 8,7% trn ming ni. 100% di cn gan c pht hin qua S v CT.

Kt lun

kt qu iu tr UTTTP bng phu thut

6,5% nhim trng vt m, 2,2% chy mu sau m. T l t vong l 0%. TG nm vin TB 15,2 ngy, TG sng TB l 11,5 thng. TG sng nhm PT trit l 13,1th, K. trit l 6,05th. TG sng NT < 60 l 12,5th, NT >= 60 l 9,04th. TG sng nhm PT di cn gan n c l 6,3th nhm PT ti pht trn khung T l 13,6th. T l BN sng thm SM trn mt nm, hai nm v sau ba nm ln lt l 25%, 15% v 7,5%.

Xin trn trng cm n !