Hóa xạ trước mổ kết hợp phẫu thuật trong điều trị ung thư trực tràng giai đoạn ii iii bệnh viện ung bướu

ỦY BAN NHÂN DÂN TPHCM SỞ KHOA HỌC VÀ CÔNG NGHỆ SỞ Y TẾ TPHCM BỆNH VIỆN UNG BƢỚU CHƢƠNG TRÌNH KHOA HỌC VÀ CƠNG NGHỆ CẤP THÀNH PHỐ BÁO CÁO TỔNG HỢP KẾT QUẢ NHIỆM VỤ NGHIÊN CỨU KHOA HỌC VÀ CƠNG NGHỆ “HĨA XẠ TRƢỚC MỔ KẾT HỢP PHẪU THUẬT TRONG ĐIỀU TRỊ UNG THƢ TRỰC TRÀNG GIAI ĐOẠN II – III” Cơ quan chủ trì nhiệm vụ: BỆNH VIỆN UNG BƢỚU TPHCM Chủ nhiệm nhiệm vụ: PGS-TS BÙI CHÍ VIẾT Thành phố Hồ Chí Minh – 2018 LỜI CAM ĐOAN Tơi cam đoan cơng trình nghiên cứu riêng Các số liệu kết luận án hoàn toàn trung thực chƣa đƣợc công công trình khác Tác giả Vƣơng Nhất Phƣơng MỤC LỤC Trang TR NG PHỤ LỜI C M O N MỤC LỤC NH MỤC C C CHỮ VI T TẮT ẢNG I CHI U THUẬT NGỮ VI T – ANH NH MỤC C C ẢNG NH MỤC C C IỂU NH MỤC C C H NH ẶT VẤN Ề MỤC TIÊU NGHIÊN CỨU Chƣơng 1: TỔNG QU N TÀI LI U 1.1 GIẢI PHẪU HỌC[4] 1.1.1 Giới hạn trực tràng 1.1.2 Liên quan giải phẫu ống hậu môn 1.1.3 Liên quan giải phẫu học trực tràng 10 1.1.4 ộng mạch trực tràng ống hậu môn 13 1.1.5 ẫn lƣu tĩnh mạch bạch mạch trực tràng ống hậu môn[4], [80] 14 1.1.6 Phân phối thần kinh trực tràng ống hậu môn 15 1.2 UNG THƢ TRỰC TRÀNG 17 1.2.1 ịch tễ học 17 1.2.2 Chẩn đoán đánh giá 18 1.2.3 Xếp giai đoạn[100] 25 1.2.4 Giải phẫu bệnh 26 1.2.5 iều trị 27 Chƣơng 2: 2.1 I TƢỢNG VÀ PHƢƠNG PH P NGHIÊN CỨU 44 I TƢỢNG NGHIÊN CỨU 44 2.2 PHƢƠNG PH P NGHIÊN CỨU 44 2.3 QUI TRÌNH HĨA-XẠ TRỊ NG THỜI 49 2.3.1 Chuẩn bị tâm lý bệnh nhân trƣớc điều trị 49 2.3.2 Qui trình xạ trị 49 2.3.3 Hóa trị lúc với xạ trị 51 2.3.4 ánh giá lại tình trạng bƣớu sau bốn đến sáu tuần t nh từ lúc kết thúc xạ trị 52 2.4 QUI TRÌNH PHẪU THUẬT 53 2.4.1Phẫu thuật cắt trực tràng b ng nội soi ổ bụng 53 2.4.2.Phẫu thuật cắt trực tràng b ng mổ hở 64 2.4.3 Sau phẫu thuật 66 2.5 THU THẬP S LI U 69 2.6 TH NG KÊ VÀ XỬ LÝ DỮ LI U 69 Chƣơng 3: K T QUẢ 70 3.1 ẶC IỂM NHÓM NGHIÊN CỨU 70 3.1.1 Tuổi 70 3.1.2 Giới t nh 70 3.1.3 Vị tr bƣớu 71 3.1.4 ộ di động bƣớu 71 3.1.5 Mức độ xâm lấn theo chu vi lòng ruột 72 3.1.6 Giai đoạn bệnh 73 3.1.7 ịnh lƣợng CE 74 3.1.8 ịnh lƣợng C 19-9 74 3.2 HÓA - XẠ TRỊ TRƢỚC MỔ 75 3.2.1 Hậu môn nhân tạo trƣớc hóa - xạ trị 75 3.2.2 Hóa chất dùng hóa - xạ trị trƣớc mổ 75 3.2.3 áp ứng lâm sàng sau hóa - xạ trị 76 3.2.4 áp ứng mặt bệnh học sau hóa - xạ trị 76 3.2.5 Giai đoạn bệnh sau hóa - xạ trị phẫu thuật ypTNM 77 3.3 PHẪU THUẬT 78 3.3.1 Các loại phẫu thuật đƣợc thực 78 3.3.2 Các loại phẫu thuật đƣợc thực bƣớu cách bờ hậu môn từ 5cm trở xuống 79 3.3.3 Hậu môn nhân tạo hồi tràng bảo vệ miệng nối 80 3.3.4 Các phƣơng pháp mổ 80 3.3.5 iện cắt sau phẫu thuật 81 3.3.6 Lƣợng hạch thu hoạch đƣợc sau phẫu thuật 81 3.3.7 Thời gian phẫu thuật 82 3.3.8 Lƣợng máu 82 3.3.9 Các tạng bị xâm lấn đƣợc phẫu thuật kèm theo 83 3.3.10 Các biến chứng thƣờng gặp 83 3.4 K T QUẢ S NG CÒN VÀ TỶ L TÁI PHÁT TẠI CHỖ 83 Chƣơng 4: ÀN LUẬN 86 4.1 ẶC IỂM CỦA NHÓM NGHIÊN CỨU 86 4.2 HÓA - XẠ TRỊ TRƢỚC MỔ 88 4.2.1 Hóa chất dùng hóa - xạ trị trƣớc mổ 88 4.2.2 ánh giá đáp ứng điều trị sau hóa - xạ trị 90 4.3.PHẪU THUẬT 96 4.3.1 Phẫu thuật tận gốc 96 4.3.2 Phẫu thuật bảo tồn thắt 100 4.3.3 Hóa - xạ trị trƣớc mổ khơng gây gia tăng mức độ khó khăn, tai biến, biến chứng cho phẫu thuật 103 4.4 TÁI PHÁT TẠI CHỖ, S NG CỊN KHƠNG B NH, VÀ S NG CỊN TỒN BỘ 105 4.4.1 Tái phát chỗ 105 4.4.2 Tỷ lệ sống cịn tồn khơng bệnh OS FS 107 K T LUẬN 109 Ề XUẤT 110 DANH MỤC CÁC CƠNG TRÌNH NGHIÊN CỨU CĨ LIÊN QUAN TÀI LIỆU THAM KHẢO PHỤ LỤC i DANH MỤC CÁC CHỮ VIẾT TẮT TIẾNG ANH APR Abdominal Perineal Resection ASCO America Society of Clinical Oncology CA Carcinoma Antigen cCR clinical Complete Responde CEA Carcinoembryonic Antigen CDH Curved Detachable Head CRM Circumferential Resection Margins CT Computerised Tomography DRE Digital Rectal Examination ECG Electrocardiogram ELD Extended Lateral lymph node Dissection EUS Endoscopic Ultrasound FAP Familial Adenomatous Polyposis FU Fluorouracil G Grade GITSG Gastrointestinal Tumor Study Group HNPCC Hereditory NonPolyposis Colorectal Cancer IBD Imflammatory Bowel Disease IMRT Intensity Modulated Radiation Therapy MRI Magnetic Resonance Imaging ii NCCTG North Central Cancer Treatment Group NSABP National Surgical Adjuvant Breast and Bowel Project NCI National Cancer Institute pCR pathology Complete Responde PET Positron – Emission Tomography SPSS Statistical Package for the Social Sciences TME Total Mesorectal Excision TNM Tumor – lymph node – Metastasis TRG Tumor Regression Grade TRUS Transrectal UltraSound VMAT Volumetric Modulated Arc Therapy TIẾNG VIỆT BN ệnh Nhân HMNT Hậu Môn Nhân Tạo NC Nghiên Cứu PT Phẫu thuật iii BẢNG ĐỐI CHIẾU THUẬT NGỮ VIỆT - ANH Abdominal Perineal Resection Carcinoma Antigen Clinical Complete Responde Carcinoembryonic Antigen Cắt trực tràng qua ngã bụng tầng sinh mơn Kháng ngun sinh ung áp ứng hồn tồn lâm sàng Kháng ngun phơi biểu mơ Curved Detachable Head ầu kết nối dạng cong Circumferential Resection Margins iện cắt vịng Computerised Tomography Cắt lớp điện tốn Digital Rectal Examination Khám trực tràng b ng ngón tay Electral Cardiography Extended Lateral lymph node Dissection Endoscopic Ultrasound iện tim Nạo hạch bên mở rộng Siêu âm qua ngã nội soi Familial Adenomatous Polyposis ƣớu ống tuyến gia đình Grade ộ mô học Hereditory NonPolyposis Ung thƣ đại trực tràng không bƣớu Colorectal Cancer ống tuyến, di truyền Imflammatory Bowel Disease Intensity Modulated Radiation Therapy Magnetic Resonance Imaging Pathology Complete Responde PET: Positron – Emission Tomography Total Mesorectal Excision ệnh viêm ruột Xạ trị tƣơng th ch mô Hình ảnh cộng hƣởng từ áp ứng hồn tồn mặt bệnh học Chụp cắt lớp b ng hạt điện t ch dƣơng Cắt toàn mạc treo trực tràng iv Tumor – lymph node – Metastasis Bƣớu – hạch – di xa Tumor Regression Grade Mức độ thoái triển bƣớu Transrectal UltraSound Volumetric Arc Therapy Siêu âm qua ngã trực tràng Xạ trị góc phù hợp thể t ch DANH MỤC CÁC CƠNG TRÌNH LIÊN QUAN 1/ Vƣơng Nhất Phƣơng, ùi Ch Viết (2015), Hóa xạ tiền phẫu kết hợp phẫu thuật điều trị ung thƣ trực tràng khơng thể phẫu thuật đƣợc, Tạp chí ung thƣ học Việt nam, số 4, trang 241-250 2/ Vƣơng Nhất Phƣơng, Cung Thị Tuyết Anh, Bùi Chí Viết, Lê Huỳnh Trang (2017), Kết bƣớc đầu hóa xạ tiền phẫu kết hợp phẫu thuật điều trị ung thƣ trực tràng giai đoạn II – III,Tạp chí Y học Việt Nam, Tập 459, trang 445 – 450 3/ Vƣơng Nhất Phƣơng, Cung Thị Tuyết Anh, Bùi Chí Viết, Lê Huỳnh Trang (2017), Initial findings: Neo-adjuvant Chemoradiotherapy combined with Surgery in Treatment of Stage II – III Rectal Cancer, Journal of Oncology Vietnam, English Edition, page 45 - 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