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NHN XT V C IM LM SNG, CN LM SNGV IU TR PHU THUT CA 249 TRNG HP

UNG TH TUYN GIP TI BNH VIN NI TIT TRUNG NGTrn Ngc Lng, Mai Vn Sm, Nguyn Tin Lng.

Bnh vin Ni tit Trung ng.

Summary : The aim of this study was to

review the clinical, paraclinical signs andoutcome of patients undergone surgicaltreatement for thyroid cancer at Hospital of

Endocrinology from January 2002 to June2004.A retrospectve analysis was

performed in 249 patients including 28males and 221 females.Most age from 20 to49 years old(71,9%), with primary surgeryin 94,3%, immovable nodules in 6,0%, the

pain sign in 3,6%,compressive sign in18,6%,no patient with hoarseness of voice.

There was only one of hypothyroidisme.The echography: single nodules in 57,7%,multiple nodules in 42,3%,solid nodules in62,8%, complex nodules in 36,4%. The fineneedle aspiration: thyroid cancer or

suspicious for malignance in 63,5%. Thehistologic diagnosis composed of papillarycarcinoma in 71,0%,follicular carcinomain 23,0%, medullary in 2,7%,anaplastic in3,6% and lymphoma in 0,8%. Totalthyroidectomy and total thyroidectomyassociated with cervical nodes dissectionwere the most common procedure in about67,8%. There were 71% of the tumuorlimited to the thyroid gland,9,3% muscleinvasion and 16,1% tracheal invasion.Morbidity included hemorrage in0,4%,respiratory insufficiency in 5 cases(2%) with tracheotomy in 0,8% (2 cases),transient hypocalcaemia in 7,7%, transienthoarseness of voice in 11,4%, permanent

hypocalcaemia in 0,4%.

Mortality in 2 patients (0,4%) due to

respiratory insufficiency and circulatoryfaillure.The author found that the clinical

presentation of thyroid cancer is notusually acute, the paraclinical signs are not

specific. The fine needle aspiration playsan important role to do the diagnosis. Toavoid the severe morbiditys andcomlplications,it is necessary to do earlythe diagnsois and the surgical treatement.

T m tt

Cc tc gi nghin cu lm sng,cn lm sng v phu thut ca 249 bnhnhn ung th tuyn gip (UTTG) c

phu thut ti Khoa ngoi - Bnh vin Nitit Trung ng t thng 1 nm 2002 nthng 6 nm 2004. T l nam/n l28/221=1/7, vi tui ch yu t 20 n49 tui: 179 bnh nhn (71,9%), thi gian

pht hin bnh


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trong khi m dng tnh 67,7% s bnhnhn. M bnh hc c 176BN (71,0%) thnh, 57BN (23,0%) th nang, 5 BN(2,0%)th tu, khng bit ho 9BN (3,6%) vlymphoma l 2BN (0,8%). Phu thut ct

ton b tuyn gip v ct ton b km novt hch l ch yu 168BN (67,8%).Trong khi m thy 176 (71%) bu cnnm trong tuyn, 23BN (9,3%) u xm lnc, 40 BN (16,1%) u xm ln vo kh qunhay bao kh qun, c 2 trng hp u lanrng khp c.

Sau m c 1 bnh nhn (0,4%) phim li ngay do chy mu, 5 BN suy h hpcp trong c 2 BN phi m kh qun cp

cu, nut sc tm thi 5 BN (2,0%), nikhn tm thi 28 BN (11,4%), h canxi tmthi 19 BN (7,7%), h canxi vnh vin 1 BN(0,4%). T vong 2 BN sau m bu

IV, khi m u xm ln ht vng c, cht

do suy h hp cp v suy tim cp.Cc tc gi thy rng UTTG lm sngthng biu hin m , khng rm r, cc

xt nghim cn lm sng thng khng cgi tr c hiu, chc t bo trc khi mrt quan trng hng ti chn on,vic chn on v phu thut sm rt quantrng trnh cc bin chng v di chng

sau khi m.

1. T VN

Ung th tuyn gip (UTTG) chim 1% cc loi ung th ni chung. Ti Vit Nam, H Ni ung th tuyn gip chim 2% tng s ung th trong nam gii 0,8%, ngii 3,6% (1). Ung th tuyn gip l loi t triu chng, triu chng khng rm r, chyu l pht trin ti ch (12). Chnh v th nhiu bnh nhn thng n giai onmun. Vic iu tr UTTG l phu thut cng vi cc phng php h tr khc nhdng hormon tuyn gip c ch, x tr bng I131. C nhiu loi tn thng gii phu

bnh l khc nhau ca UTTG, t loi rt c tnh nh ung th th khng bit ho nloi coi nh lnh tnh ca bit ho th nh. Cc phng php phu thut c p dngkhc nhau v thi gian sng thm sau m cng khc nhau tu theo mi loi tn thngny.

ti ny nhm xem xt cc c im lm sng v cn lm sng ca UTTG ;ng thi nh gi cc tn thng gii phu bnh ca loi ung th ny v cc kt qusm ca phu thut.2. I TNG V PHNG PHP NGHIN CU.2.1. i tng nghin cu.

Bao gm tt c cc bnh nhn c chn on v c m do UTTG tiKhoa ngoi Bnh vin Ni tit Trung ng t 7 thng1 nm 2002 n 30 thng 6nm2004.2.2. Phng php nghin cu.

Phng php nghin cu hi cu, tp hp h s ca tt c nhng bnh nhn c m v c kt qu cui cng l UTTG v phn tch cc thng s sau.2.2.1. Cc du hiu lm sng trc m.

- Xc nh tui, gii.- Thi gian pht hin bnh.- Cc hnh thc iu tr trc y.- Biu hin lm sng vi cc du hiu chn p nh kh th, kh nut, au- Thm khm lm sng vi v tr, ln ca bu, mt , di ng v hch

c.2.2.2. Cc du hiu cn lm sng trc m.

- Hormon: Nng cc hormon FT4, TSH trong mu.


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- Siu m tuyn gip: Xc nh v tr, s lng v tnh cht ca bu vi dngc, lng hay hn hp.

- X hnh: Vi cc hnh thi nhn lnh, nhn m v nhn nng.- Chc t bo bng kim nh: Thc hin khoa t bo nhm xem xt s bnh

nhn c chn on l ung th v khng c chn on l ung th trc m.2.2.3. nh gi trong khi m.

- nh gi ca phu thut vin v tnh trng ca u cn nm trong nhu m hay ra ngoi, tnh trng thm nhim vo cc c quan xung quanh, hch di cn.

- p t bo: ngay sau khi ct, u c b i p vo lam knh nhum soi ti khoachn on t bo t cho phng hng x tr tip theo.

- Cc phu thut thc hin: ct bn phn,ct mt thu, ct ton b tuyngip, ct ton b km theo no vt hch, ct mt phn tuyn gip trong nhng trnghp di cn rng khng th ct trit c2.2.4. Din bin sau m.

- Tnh trng chy mu sau m: phi can thip li hay khng- Suy h hp sau m: ch cn th oxy n thun hay phi m kh qun.- H canxi mu, ni khn.- Cc bin chng khc.

2.2.5. Kt qu gii phu bnh l:Bnh phm sau m c ngm vo dung dch formon v lm m bnh hc ti

khoa chn on t bo.2.3. X l s liu:

Cc s liu c phn tch bng phn mm EPI INFO 6.0

3. KT QU.B ng 1. S phn b theo la tui

La tui S bnh nhn T l %< 20 tui 17 6,8

20-29 tui 63 25,330- 39 tui 62 24,940- 49 tui 54 21,750- 59 tui 31 12,460 - 69 tui 16 6,4

> 70 tui 6 2,4

Bng 2.S phn b v giiGii S bnh nhn (249) T l %

Nam 28 11,2N 221 88,8

Bng 3.Thi gian pht hin bnhThi gian pht hin S bnh nhn (n=241) T l %

< 6 thng 61 25,36 thng 1 nm 57 23.7

2 5 nm 58 24,16 10 nm 16 6,6


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>10 nm 49 20,3

Bng 4. c iu tr trcLoi iu tr trc S bnh nhn (n=245) T l %

Cha iu tr g 160 65,3Ung thuc n thun 74 30,2Ung thuc+chc ht 6 2,4

p l 5 2,0B ng 5. m c

S ln m S bnh nhn (n=247) T l %M ln u 233 94,3M ln 2 11 4,5M ln 3 3 1,2

B ng 6. ln ca bu

ln ca bu S bnh nhn (n=247) T l %Bu Ia 19 7,7Bu Ib 126 51,0Bu II 69 27,9Bu III 25 10,1Bu IV 8 3,2

Bng 7.V tr ca buS bnh nhn (n=248) T l %

Thu bn phi 99 39,9Thu bn tri 81 31,7

C 2 bn 59 23,8Thu eo 9 3,6

Bng 8.Tnh cht ca buMt di ng

Mm Chc Cng Di ng bt Khng dS bnh nhn

(n=248)1 225 22 233 15

T l % 0,4 90,7 8,8 94,0 6,0

Bng 9.Du hiu chn p, au (n=247)Chn p au

S bnh nhn 46 9T l % 18,6 3,6

Bng 10.Tnh trng hch, ging niHch khm thy (n=248) Ging ni (n=248)

Khng thy Khm thy Bnh thng Thay iS bnh nhn 228 20 248 0


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T l % 91,9 8,1 100 0

Bng 11.Nng hormonNh nht Ln nht Trung bnh

FT4 (pmol/l) 4,0 26,1 14,7TSH (mU/l) 1 9,8 1,91

Bng 12.c im siu m

Tnh cht nhn (n=247) Slng nhn (n=246)c Lng Hn hp n nhn a nhn

S bnhnhn

155 2 90 142 104

T l % 62,8 0,8 36,4 57,7 42,3

Bng 13.X hnhS bnh nhn(n=6) T l%

Nhn lnh 6 100Nhn m 0 0

Nhn nng 0 0B ng 14. Chc t bo (n=249)

T l % Loi t bo S bnh nhn33,3 Bu nhn 832,0 U tuyn 5

63,5 Ung th hay nghi ng 1580,8 Khng xc nh c 20,4 Vim gip mn 1

B ng 15. nh gi trong khi m (n=248)S bnh nhn T l %

U cn trong tuyn 176 71,0U xm ln ht vng c 2 3,6

U xm ln ra c 23 9,3U xm ln vo kh qun 40 16,1

Bng 16.p t bo trong khi m (n=217)Loi t bo S bnh nhn T l %Bu nhn 69 31,8Carcinoma 147 67,7

Khng xc nh 1 0,5B ng 17. Kt qu m bnh hc (n=249)

S bnh nhn T l %Ung th th nh 176 71,0Ung th th nang 57 23,0

Ung th th tu 5 2,0Th khng bit ho 9 3,6


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Loi khc 2 0,8

Bng 18.Tnh trng hch (n = 248)S bnh nhn T l %

Thy trong khi m 90 36,3Di cn vi th 37 14,9

B ng 19. Cc phu thut thc hin (n = 249)S bnh nhn T l %

Ct 1 thu 65 26,2Ct thu + eo 6 2,4Ct ton b 85 34,3

Ct ton b + No hch 83 33,5Ct 1 phn u 3 1,2

Ct gn ton b 2 0,8

Ct eo 1 0,4Ct thu + ly nhn thu 4 1,6B ng 20. Cc tai bin v bin chng

Cc tai bin v bin chng S bnh nhn T l%Chy mu m li 1 0,4

Suy h hp(n=248)

Khng m kh qun 3 1,2M kh qun 2 0,8

Nut sc tm thi (n=248) 5 2,0Ni khn

(n=246)

Tm thi 28 11,4

Vnh vin 0 0H canxi mu

(n=246)Tm thi 19 7,7Vnh vin 1 0,4

T vong (n=249) 2 0,8

4. BN LUN4.1. c im lm sng

Bnh gp ch yu ph n, vi t l Nam/N = 28/221 =1/7 v la tui t 20n 39 tui(50,2%)

Thi gian b bnh < 1 nm chim a s 118 bnh nhn (49,0%), ch yu chac iu tr g (65,3%) v c 233 (94,3%) bnh nhn l m ln u. ln ca bu

ph bin mc I(theo phn loi ca WHO) 145 bnh nhn(58,7%). Bnh vinNi tit Trung ng l n v cui cng chuyn khm v iu tr bu c, Khoa ngoili c ngay bnh vin, chnh v vy a s bnh nhn s c m lun khng phichuyn vin hoc iu tr ni khoa lng vng trc khi n c c s iu tr ngoikhi bu c ch nh m.

V tr ca nhn thy tng ng nhau gia bn phi, bn tri v c hai bnvi t l ln lt l 39,9%, 32,7%, 23,8%. Trn Minh c m 131 bnh nhn giacc bn ln lt l: 42, 23 v 66 bnh nhn (2).Nh vy s lng bu c hai bnca chng ti t hn ca Trn Minh c.


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- Khi thm khm bu chc 225 bnh nhn chim 90,7% vi di ng bnhthng 233 bnh nhn(94,0%). Nut vng, kh nut, kh th ch gp 18,6% cctrng hp, thm khm thy hch vng c l 20 bnh nhn, c 9 bnh nhn auvng c nhng khng c bnh nhn no thay i ging ni. iu ny cho thy bnhnhn b UTTG rt d b b qua khi thm khm bu n thun bng lm sng.4.2. c im cn lm sng

- Ch c 1 bnh nhn trong tnh trng suy gip cn tt c bnh nhn u bnhgip vi nng trong mu trung bnh ca FT4 l 14,71 v ca TSH l 1,91

- Khng c s khc bit nhau gia n nhn v a nhn trn hnh nh siu m.n nhn l 142 bnh nhn, a nhn l 104 chim ln lt 57,7 % v 42,3% trongtng s bnh nhn.Trong nhn c chim ch yu 155 bnh nhn (62,8%) vnhn th hn hp l 89 bnh nhn (36,0%). Hch c ch pht hin c 15 bnhnhn (6,1%) khi lm siu m. Nh vy vi kt qu trn cho thy rt kh phn bitnhn lnh tnh v nhn ung th trn hnh nh siu m.

- Chc t bo bng kim nh chn on ung th hay nghi ng c ung th gp 158 bnh nhn (63,5%) trong khi bu nhn lnh tnh l 83 bnh nhn (33,3%).c im ny cng gn vi thng bo ca Trn Minh c thng bo(2) vi chn ondng tnh l 83,2% 131 trng hp m ung th gip.V vi cc tc gi khc chnon dng tnh t 69% n 93% (6,12). Nhng p t bo trong khi m chn ondng tnh l ung th ln n 67,7%. Tuy khng c k thut ct lnh chn ontc th nhng p t bo cng gip cc phu thut vin a ra c phng php

phu thut ngay trong m. Tt nhin khi quyt nh th cng cn phi da vo cc tnthng i th quan st c trong khi phu thut.4.3. Kt qu phu thut4.3.1. Tnh trng quan st c trong khi m.

- C 176 bnh nhn (71,0%) u cn nm trong bao tuyn trong t chc theo TrnMinh c ch c 29,8% s ca l cha dnh vo m ln cn (2). S bnh nhn cachng ti dnh vo bao kh qun li nhiu hn l 40 bnh nhn (16,1%) ca Trn Minhc l 5,3 %, s xm ln vo khi c vng c li tng ng nhau 9,3 % v 9,2%(2). Cc kinh nghim ca Mayo Clinic cho thy rng khi mt ung th th nh ra khi

bao tuyn gip xm ln vo cc cu trc bn cnh th v tr b xm ln s nh hngn vic sng thm. S xm ln vo kh qun v thc qun th nh hng c nghan vic sng thm trong khi th s xm ln vo c, thanh qun, dy qut ngc thnh hng c lp khng c ngha ti vic sng thm (7).

- Trong khi m thy c 90 bnh nhn (36,3%) c hch dc c c n chm vh thng n, Trn Minh c gp 45,2% s bnh nhn (2). Trong s 90 bnh nhnny ch c 37 bnh nhn (41,1%) c hch di cn khi lm m bnh hc.Theo cc tc gith t l di cn hch c t 30% n 50% (12) i vi nhng bnh nhn trong khi mthy c hch th chng ti tin hnh ct ton b c no vt hch khoang trung tm hayc khoang bn v khoang trung tm.4.3.2. Th m bnh hc.

Ung th biu m th nh chim nhiu nht 176 bnh nhn (71,0%), th nang 57 bnh nhn (23%), th tu 5 (2,0%), th khng bit ho 9(3,6%) v loi lymphomal 2 (0,8%). So snh vi cc tc gi khc thy nh sau:

Tc gi Th nhS Bn-% Th nangS Bn-% Th tuS Bn-% Th vyS Bn-% Lymphoma Khngbit ho


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T.M.c(n=131)

82(62,6%) 26(19,8%) 7(5,3%) 3(2,3%) 0 13(9,9)

R.SIM(n=149)

120(80,5%)

22(14,8%) 4(2,7%) 0(0) 0 3(2,0%)

T.N.Lng

(n=249)176(71,0%) 57(23%) 5(2,0%) 0(0%) 2(0,8%) 9(3,6%)

Trong cc th caUTTG th th nh v th nang l loi lnh tnh nht. TheoMayo Clinic, qua 2 278 bnh nhn c m UTTG v theo di t 1940 n 1990 th tl sng thm l (7):

M bnh hcS Bn - %(n = 2 278)

Tui trungbnh (nm)

Thi gian sng thm(%)

10 nm 20 nmTh nh 1851 (81%) 44,4 95,5 94,7

Th nang TB khng a axit 153(7%) 51,0 80,5 71,1Th nang TB a axit 93(4%) 58,4 84,4 78,7Th tu 181(8%) 41,4 82,9 79,7

Cn vi mt s tc gi khc th t l sng thm 10 nm i vi ung th th nhv th nang t 85 95% (6,11,12).

Phu thut ch yu l ct ton b tuyn gip 85 bnh nhn (34,3%), ct ton b+ no vt hch 83 bnh nhn (33,5%). Trong nhng trng hp khi m kim tra khngthy c hch th chng ti khng t vn no vt hch mt cch h thng, v nuno vt hch th s lm tng t l tn thng tuyn cn gip v dy thn kinh qutngc, tr nhng trng hp ung th th tu hay ung th th khng bit ho chn

on c trc khi m ; iu ny cng nh nhn xt ca cc tc gi khc(4,12).Trong nhng trng hp m u thm nhim nhiu vo kh qun khng th ct bhon ton c th chng ti ct gn nh hon ton ch li phn rt mng trn bmt ca kh qun nhm trnh cc bin chng nh phng php m Judith CzajaMcCaffrey lm (shave excision) (9). Ct 1 thu n thun thc hin 65 bnh nhn(26,2%). l nhng trng hp trc khi m hoc p t bo chn on l bu nhnlnh tnh hoc l khi ung th rt b (


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y l bin chng him gp hin nay do k thut cm mu tt, nht l dao in cmmu c s dng mt cch thng quy.

- C 5 bnh nhn c suy h hp sau m trong 2 trng hp (0,8%) phi mkh qun cp cu tm thi, canul m kh qun c rt sau 5 ngy. Trong 131 bnhnhn Trn Minh c c 7 bnh nhn phi m kh qun (2). Theo ng Ngc Hngsau m cc loi bnh tuyn gip th bin chng suy h hp hay gp nht l ung thtuyn gip vi t l l 33,3% (3). Ngoi nguyn nhn do tng tit m ri n cn dolit dy thanh m 2 bn. Hin tng ny xy ra ngay sau khi rt ng ni kh qun. C 2dy thanh m u nm pha cnh gia gy ra tc ng th bn phn. Bnh nhn thrt ging i v kh th d di (4).Tt c cc trng hp suy h hp m khng m khqun th u c iu tr bng th oxy, nm u cao, dng cc thuc chng vimgim ph n. Tnh trng bnh nhn s c ci thin dn.

- Nut sc tm thi (2%) v ni khn tm thi (11,4%) xy ra khi c tn thngtm thi ca dy thn kinh thanh qun trong qu trnh bc tch ly u. Theo R.Sim phn thanh qun ni ti l nguyn nhn hay gp nht ca khn ging sau m tuyn gip(10). T l tn thng dy thanh qun qut ngc khi nhn thy r v tch ra l 0-2%(4). H canxi mu tm thi gp 19 bnh nhn (7,7%). Chng ti nhn thy nu trongkhi m m thy nhiu tuyn cn gip phi bc tch ra th sau m s c nhiu nguy c

b h canxi mu.V trong qu trnh bc tch vic ng chm vo tuyn, vo mch mus lm ph n t s lm gim vic cung cp mu cho tuyn (4).Cc bin chng nys tng ln cng vi vic no vt hch(12). Trong 249 bnh nhn m c 1 trng hph canxi mu vnh vin (0,4%).T l ny theo cc thng bo chim t 1 n 4%(4,8,12).

- C 2 bnh nhn (0,8%) t vong, c 2 trng hp u trn 70 tui, bu to IV ; khi m bu xm ln vo cc c quan vng c. phu thut ct gnton b tuyn gip li phn thm nhim vo kh qun nhng sau m b suy h hpv suy tim cp. Gia nh xin v v bnh nhn t vong ti nh. y l 2 bnh nhntrong s nhng bnh nhn u ca 249 bnh nhn m. T i vi nhng bnhnhn gi yu, u to xm ln rng c du hiu chn p th chng ti ch ly b mt

phn t chc hoi t gim bt chn p ch khng t vn ct ton b. Qua 161trng hp cht do ung th tuyn gip Yutaka Kitamura thy rng cht do suy h hpl 43%, do suy tim 15%, chy mu 15%, tc ng th 13% (11)

5. KT LUN

- Ung th tuyn gip hay gp n hn nam gii. Cc du hiu lm sng thngkhng rm r v rt d b b qua giai on sm ca bnh.

- Chc ht t bo bng kim nh l phng php cn lm sng c gi tr nht hng ti chn on ung th tuyn gip trc khi m.

- Phu thut ct ton b tuyn gip hay ct ton b c no vt hch vn lphng php ch o ca phu thut ung th tuyn gip.

- Ung th bit ho th nh v th nang l ch yu chim 94% cc trng hp.- Cc bin chng v di chng sau m i vi tuyn cn gip v dy thn kinh

thanh qun qua 249 trng hp m u t l thp.


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TI LIU THAM KHO

1. Nguyn B c: Ung th tuyn gip trng. Hng dn thc hnh chn oniu tr ung th. NXB Y hc, Hani, 1999, tr 135-149.

2.

Trn Minh c, ng Ngc Hng, L Th Trung: Lm sng v iu tr ngoakhoa bnh nhn ung th tuyn gip ti bnh vin 103. Thng tin y dc s 8 / 2003,tr 29-33.

3. ng Ngc Hng, Ng Vn Hong Linh, Nguyn Ngc Trung, ng Thanh:Mt s nhn xt v bin chng suy h hp sau m cc bnh tuyn gip. Thng tin ydc s 1/2002,tr 24-28.

4. Adam D Rubin: Complication of thyroid surgery.http://www.emedicine.com/ent/topic649.htm

5. Ashok R.Shaha: Thyroid cancer: Extent of Thyroidectomy. Cancer control.2000 ; 7 ;3: 240 - 245.

6. Corrias and All: Accuracy of fine needle aspiration biopsy of thyroid nodulesin detecting malignancy in childhood:comparison with conventionalclinical,laboratory,and imaging approaches.The Journal of Clinical Endocrinology&Metabolism 2001 ;86 ;10:4644-4648.

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