1 B GIO DC O TO TRNG I HC Y H NI B Y T NGUYN THNH NAM ĐáNH GIá KếT QUả SớM PHẫU THUậT CắT BáN PHầN UNG THƯ BàNG QUANG XÂM LấN TạI BệNH VIệN UNG BƯớU Hà NộI Chuyờn ngnh : Ung th Mó s : 60720149 LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS TRN NG KHOA H NI 2016 LI CM N Tụi xin trõn trng cm n Ban giỏm hiu, Phũng qun lý o to Sau i hc, B mụn Ung th - Trng i hc Y H Ni, Ban giỏm c Bnh vin Ung Bu H Ni, Phũng k hoch tng hp cựng cỏc khoa phũng bnh vin Ung Bu H Ni ó to iu kin thun li cho tụi quỏ trỡnh hc tp, nghiờn cu v hon thnh lun ny Vi tt c lũng kớnh trng, tụi xin by t lũng bit n sõu sc ti PGS.TS Trn ng Khoa, ngi thy trc tip hng dn lun vn, ó tn tỡnh ch bo, giỳp v ng viờn tụi sut quỏ trỡnh nghiờn cu v hon thnh lun tt nghip Tụi cng xin chõn thnh cm n cỏc Thy cụ b mụn Ung th Trng i hc Y H Ni ó to mi iu kin thun li v truyn t kin thc cho tụi quỏ trỡnh hc Tụi vụ cựng bit n B, m v gia ỡnh ó luụn ng h, ng viờn tụi hc tp, phn u v trng thnh cuc sng v s nghip H Ni, ngy 18 thỏng 11 nm 2016 Nguyn Thnh Nam LI CAM OAN Tụi l Nguyn Thnh Nam, hc viờn lp cao hc 23, chuyờn ngnh Ung th, Trng i hc Y H Ni, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca PGS.TS Trn ng Khoa Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim v nhng cam kt ny H Ni, ngy 18 thỏng 11 nm 2016 Nguyn Thnh Nam CH VIT TT BN : Bnh nhõn BQ : Bng quang CT : Chp ct lp M : Di cn xa N : Hch vựng T : U nguyờn phỏt UTBQ : Ung th bng quang MC LC DANH MC BNG DANH MC BIU DANH MC HèNH T VN Ung th bng quang l bnh ung th thng gp nht cỏc bnh ung th ca h tit niu Trờn th gii, nm 2008 cú khong hn 450.000 ca ung th bng quang mi mc, ng hng th tng s cỏc bnh ung th thng gp c gii vi t l 8% v s bnh nhõn t vong vo khong 130.000 trng hp [1] M nm 2008 cú khong 53.000 bnh nhõn ung th bng quang mi mc, t l mi mc ny tng hn 20% vũng 20 nm tr li õy Ung th bng quang gp mi la tui, nh cao l nhúm tui t 60 ti 70 v t l nam/n l 2,5/1 [2], [3] Vit Nam theo ghi nhn ung th H Ni (2000 - 2001), t l mc ung th bng quang l 2,2/100.000 dõn, ng sau cỏc bnh ung th phi, d dy, gan, vỳ v vũm mi hng Bnh hay gp nam gii hn n gii, ng v trớ th cỏc bnh ung th nam gii v th n gii [4], [5] Triu chng lõm sng ung th bng quang nghốo nn, bnh nhõn thng vo vin vỡ ỏi mỏu Vic chn oỏn ch yu da vo ni soi bng quang, sinh thit u v cỏc phng tin chn oỏn hỡnh nh Ni soi bng quang cú giỏ tr xỏc nh v trớ, hỡnh dỏng, kớch thc u, qua ni soi sinh thit u chn oỏn mụ bnh hc Tuy nhiờn xỏc nh mc xõm ln ca u ti thnh bng quang hoc t chc xung quanh v tỡnh trng hch vựng thỡ CT v MRI cú vai trũ quan trng vi chớnh xỏc cao [6], [7] V mụ bnh hc, loi ung th t bo chuyn tip l loi hay gp nht chim t l khong 90%, ung th biu mụ vy, ung th biu mụ tuyn ớt gp Trong ung th bng quang, 75% l ung th bng quang nụng, phng phỏp iu tr ch yu l ct u qua ni soi kt hp vi bm húa cht ti ch 10 hoc BCG, phng phỏp ny c ỏp dng ph bin trờn th gii v Vit Nam ó lm gim tỏi phỏt u [8], [9] Ung th bng quang xõm ln c chim 20 - 25%, phng phỏp iu tr ca giai on ny l ct bng quang bỏn phn hoc ct bng quang ton b, vột hch chu bt hai bờn Ti Vit Nam, ó cú nhiu nghiờn cu v ung th bng quang núi chung v phu thut ung th bng quang núi riờng ti cỏc bnh vin chuyờn khoa ung bu v cỏc trung tõm ngoi khoa ln c nc Ti bnh vin Ung Bu H Ni phu thut ung th bng quang ó c trin khai nhiu nm nhng cha cú nghiờn cu no ỏnh giỏ Do ú, chỳng tụi thc hin ti: ỏnh giỏ kt qu sm phu thut ct bỏn phn ung th bng quang xõm ln ti bnh vin Ung Bu H Ni vi hai mc tiờu sau: Mụ t c im lõm sng, cn lõm sng ung th bng quang xõm ln c phu thut ct bỏn phn ti bnh vin Ung Bu H Ni ỏnh giỏ kt qu sm phu thut ct bỏn phn ung th bng quang xõm ln ti bnh vin Ung Bu H Ni t nm 01/2011 n 08/2016 44 F Koga, K Kihara (2012) "Selective bladder preservation with curative intent for muscle-invasive bladder cancer: a contemporary review" Int J Urol, 19 (5), 388-401 45 Nguyn Diu Hng (2008) Nhn xột c im lõm sng, cn lõm sng v kt qu iu tr ung th bng quang nụng ti bnh vin K, Bnh vin K, i hc Y H Ni, 46 MD Nader Fahmy, Armen Aprikian, MD, Mohammed Al-Otaibi, MD et al (2005) "Impact of treatment delay in patients with bladder cancer managed with partial cystectomy in Quebec: a population-based study" J Urol 47 Phm Vn Yn (2008) Nghiờn cu c im lõm sng, cn lõm sng, mụ bnh hc ca ung th bng quang giai on mun v kt qu sm ca phu thut ct bng quang ton b ti bnh vin Vit c, Bnh vin Vit c, i hc Y H Ni, 48 Pashos C.L., Laskin B.L (2002) "Bladder cancer" Cancer practice, 10 (6), 311 49 F Koga, K Kihara, S Yoshida, et al (2012) "Selective bladder-sparing protocol consisting of induction low-dose chemoradiotherapy plus partial cystectomy with pelvic lymph node dissection against muscle-invasive bladder cancer: oncological outcomes of the initial 46 patients" BJU Int, 109 (6), 860-6 50 S Aluwini, P H van Rooij, W J Kirkels, et al (2014) "Bladder function preservation with brachytherapy, external beam radiation therapy, and limited surgery in bladder cancer patients: Long-term results [corrected]" Int J Radiat Oncol Biol Phys, 88 (3), 611-7 51 H M Bruins, R Wopat, A P Mitra, et al (2013) "Long-term outcomes of salvage radical cystectomy for recurrent urothelial carcinoma of the bladder following partial cystectomy" BJU Int, 111 (3 Pt B), E37-42 52 W M Bazzi, R P Kopp, T F Donahue, et al (2014) "Partial Cystectomy after Neoadjuvant Chemotherapy: Memorial Sloan Kettering Cancer Center Contemporary Experience" Int Sch Res Notices, 2014, 702653 53 Trng Thnh (2004) "Kt qu iu tr phu thut ung th bng quang ti Bnh vin Vit c nm (2000-2002)" Y hc thc hnh, 491, 466-469 54 Bryan R T Wallace D M, Dunn J A et al (2002) "Delay and survival in bladder cancer" BJU International, 89, 868 55 Matsuda Tomohiro, Exbrayat C (2003) "Determinants of quality of life of bladder cancer survivors five years after treatment in France" International journal of Urology, 10 (8), 423 56 Nieder Alan M., Simon M.A., Soloway M.S., et al (2006) "Radical cystectomy after bacillus Calmette- Guerin for high- risk Ta, T1, and carcinoma insitu: Defining the risk of initial bladder preservation" Urology, 67 (4), 737- 741 57 Treiber U May F., Hartung R Et al () (2003) "Significance of random bladder biopsies in superficial bladder cancer" European urology, 44 ( 1), 47-50 58 Guzzo TJ Canter D, Resnick MJ, et al ( 2009) "A thorough pelvic lymph node dissection in presence of positive margins associated with better clinical outcomes in radical cystectomy patients" Urology, 74, 161 59 M Townsend Jr, B Mark Evers (2010) Atlas of general surgical techniques, Saunders, 60 I Faiena, V Dombrovskiy, C Koprowski, et al (2014) "Performance of partial cystectomy in the United States from 2001 to 2010: trends and comparative outcomes" Can J Urol, 21 (6), 7520-7 61 J Knoedler, I Frank (2015) "Organ-sparing surgery in urology: partial cystectomy" Curr Opin Urol, 25 (2), 111-5 62 I H Shao, Y H Chang, K J Yu, et al (2016) "Outcomes and prognostic factors of simple partial cystectomy for localized bladder urothelial cell carcinoma" Kaohsiung J Med Sci, 32 (4), 191-5 63 D A Barocas, J Alvarez, T Koyama, et al (2014) "Racial variation in the quality of surgical care for bladder cancer" Cancer, 120 (7), 101825 64 M Kates, M A Gorin, C M Deibert, et al (2014) "In-hospital death and hospital-acquired complications among patients undergoing partial cystectomy for bladder cancer in the United States" Urol Oncol, 32 (1), 53 e9-14 65 M D Lyons, A B Smith (2016) "Surgical bladder-preserving techniques in the management of muscle-invasive bladder cancer" Urol Oncol, 34 (6), 262-70 66 o Tin Lc (2013) "Bc u ỏnh giỏ kt qu mt s phng phỏp chuyn lu dũng tiu v to hỡnh bng quang sau ct bng quang ton b trit cn" Tp ung th hc, 67 E K Cha, T F Donahue, B H Bochner (2015) "Radical transurethral resection alone, robotic or partial cystectomy, or extended lymphadenectomy: can we select patients with muscle invasion for less or more surgery?" Urol Clin North Am, 42 (2), 189-99, viii 68 B Ma, H Li, C Zhang, et al (2013) "Lymphovascular invasion, ureteral reimplantation and prior history of urothelial carcinoma are associated with poor prognosis after partial cystectomy for muscle-invasive bladder cancer with negative pelvic lymph nodes" Eur J Surg Oncol, 39 (10), 1150-6 69 H Miyamoto (2016) "Clinical benefits of frozen section assessment during urological surgery: Does it contribute to improving surgical margin status and patient outcomes as previously thought?" Int J Urol, 70 M C Biagioli, D C Fernandez, P E Spiess, et al (2013) "Primary bladder preservation treatment for urothelial bladder cancer" Cancer Control, 20 (3), 188-99 HèNH NH MINH HA Hỡnh nh siờu õm : u ỏy bng quang Hỡnh nh siờu õm : U thnh P bng quang Hỡnh nh ni soi: U bng quang Hỡnh nh ni soi : u bng quang Hỡnh nh CT : K bng quang Hỡnh nh : Ung th t bo chuyn tip Hỡnh nh : Ung th t bo chuyn tip BNH N NGHIấN CU K BNG QUANG GIAI ON II S h s bnh ỏn: Hi cu Tin cu I Hnh chớnh: - H v tờn: - Tui: Gii tớnh: Nam N - Ngh nghip: - a ch: - in thoi bỏo tin: - Ngy vo vin: - Ngy vin: - Tỡnh trng vin: II Ni dung: Lý vo vin: T n do: - ỏi mỏu au h v ỏi - S thy u ỏi but, ỏi dt - Tỡnh c phỏt hin u kim tra, hay khỏm bnh Thi gian n vin tớnh t triu chng phỏt: < thỏng - thỏng > thỏng - nm > nm (> ghi s nm c th) Tin s bnh: - Tin s gia ỡnh cú mc bnh KBQ quan h gia ỡnh - Tin s bn thõn: ỏi mỏu tỏi din - Bnh phi hp: Tim mch Huyt ỏp Phi Tiờu hoỏ Chn oỏn trc m: a Chn oỏn lõm sng: ỏi mỏu Bớ ỏi ỏi but, ỏi rt Triu chng khỏc C th gy, suy kit Cõn nng Mch Huyt ỏp - Khỏm ton thõn: b Chn oỏn cn lõm sng: - Xột nghim mỏu: - S lng HC (T/l) < 2Tr (ghi c th) 2,1-3 Tr 3,1- Tr 4,1- Tr - S lng BC (G/l) - Huyt sc t (g/l) - Hematocrit (l/l) M MC Nhúm mỏu Tc mỏu lng 1h mm Tc mỏu lng 2h mm Urộ mỏu: Bỡnh thng < 8,3 mmol/l Cao Crộatinin: Bỡnh thng < 115 àmol/l Cao - Xột nghim nc tiu: HC BC T bo K c Chn oỏn hỡnh nh: - Ni soi: v trớ u Hỡnh thỏi u Kớch thc u - Siờu õm: Hỡnh nh u: U cc Loột sựi Hỡnh nh khỏc Kớch thc u: < 2cm 2-3 cm > 3cm > 5cm V trớ u: nh BQ thnh trc thnh sau Thnh bờn Mc xõm ln Hỡnh nh NQ, thn gión cú khụng - Ct lp vi tớnh, MRI: Cú hỡnh nh u ti BQ Mc xõm ln Tènh trng hch vựng Gii phu bnh trc m TBCT tuyn vy kộm bit húa mụ hc trc m I III Phng phỏp phu thut: Vụ cm:NKQ phng phỏp khỏc: (nờu c th) 2.ng rch: ng trng gia di rn kộo di lờn trờn rn ng ngang trờn mu Phng phỏp phu thut: Thi gian phu thut < 30p 30 - 60p > 60p Bin chng m Thng trc trng Tn thng rut non Tn thng mch mỏu ln Tn thng khỏc iu tr hu phu: - Thi gian rỳt ng dn lu: - Thi gian iu tr khỏng sinh: + loi khỏng sinh my ngy + loi khỏng sinh my ngy - Hi sc hu phu truyn mỏu - Ngy nm vin 3-5 Bin chng sm Chy mỏu Nhim khun Viờm phỳc mc Bin chng mun: Tc rut Thoỏt v Gión thn I Gión thn II Gión thn III > Ngy c th: Tc niu qun Nhim khun tit niu Suy thn iu tr phi hp: Hoỏ cht Tia x Kt qu GPBL - Phõn loi u: - U t bo chuyn tip - U t bo tuyn - U t bo gai - U t bo khụng bit hoỏ - Phõn loi xõm ln (giai on u): pT2a pT2b pT3a pN0 G3 G4 pN1 - Phõn loi bit hoỏ: G1 G2 Thi gian tỏi phỏt, tin trin nm H Ni ngy thỏng nm 2016 Ngi thu thp thụng tin Nguyn Thnh Nam DANH SCH BNH NHN ST T S BNH N GII TNH TU I A CH 3600/12 Nguyn Vn V Nam 53 Thanh Húa 1998/13 Phm Th L N 62 H Ni 3219/11 Bựi Mnh Tr Nam 53 H Ni 10738/11 Phm Vn H Nam 62 Nam nh 4534/11 Nguyn Vn Ph Nam 56 H Ni 2842/12 Nguyn Hng V N 56 Phỳ Th 9801/13 o Vn T Nam 55 Thỏi Bỡnh 4466/14 Trn Th Ng N 56 H Nam 10009/14 Hong Vn Nam 42 Ngh An 10 9376/13 Nguyn Hu D Nam 55 Thỏi Bỡnh 11 9573/13 inh Vn Th Nam 69 H Ni 12 7300/12 T Vn Nam 67 Hng Yờn 13 8901/13 Nguyn Bỏ L Nam 80 H Ni 14 8562/13 Nguyn Chớ M Nam 53 H Ni 15 6447/12 Mai Thi D N 78 H Ni 16 6145/12 V Xuõn M Nam 63 H Ni 17 5890/12 Nguyờn c H Nam 57 H Ni 18 7828/12 V Vn L Nam 41 H Ni 19 7534/13 o Quang Nam 68 H Ni 20 13609/14 Nguyờn Th H N 66 H Ni 21 4330/14 Nguyn Vn V Nam 53 Ninh Bỡnh 22 10575/15 Nguyn Th D Nam 69 H Ni 23 9089/15 Lờ Th Ngc L N 53 H Ni 24 6574/16 V Th L N 62 H Ni 25 1542/15 V Xuõn H Nam 68 H Ni H V TấN 26 6112/16 Nguyn c S Nam 66 H Ni 27 4664/14 V Vn Th Nam 56 Hi Dng 28 4434/14 Thỏi Minh H Nam 73 H Ni 29 5885/15 Th Th N 55 H Ni 30 13103/15 Linh Th H N 59 Kon Tum 31 2095/16 Nguyn Vn Kh Nam 55 H Ni 32 15877/15 Lờ Vn B Nam 64 Hng Yờn 33 709/16 Nguyn Ngc B N 62 H Ni 34 3585/14 Phm Bỏ L Nam 67 H Ni 35 6900/16 Hong Hu D Nam 53 H Ni Xỏc nhn ca phũng KHTH Xỏc nhn ca thy hng dn PGS.TS: TRN NG KHOA ... th bng quang núi chung v phu thut ung th bng quang núi riờng ti cỏc bnh vin chuyờn khoa ung bu v cỏc trung tõm ngoi khoa ln c nc Ti bnh vin Ung Bu H Ni phu thut ung th bng quang ó c trin khai... vi hoỏ cht gõy ung th bng quang phi cú bo h lao ng an ton Ung nhiu nc Ch n nhiu rau qu cú th phũng chng ung th bng quang 1.4 c im gii phu bnh ung th bng quang 1.4.1 i th Ung th biu mụ chuyn... thõm nhim vo nh ung th trc trng, ung th tin lit tuyn, ung th t cung, phn ph [18], [19] 1.4.2 Vi th Cỏc t bo ung th bng quang u xut phỏt t lp t bo biu mụ bỡnh thng ca bng quang gm: Ung th biu mụ