Nghiên cứu áp dụng thang điểm RECIST sửa đổi trong đánh giá đáp ứng điều trị ung thư biểu mô tế bào gan

1 B GIO DC V O TO B Y T TRNG I HC Y H NI H TH KIM CHUNG Nghiên cứu áp dụng thang điểm RECIST sửa đổi đánh giá đáp ứng điều trị ung th biểu mô tế bào gan Chuyờn ngnh: Ni khoa Mó s: 60720140 LUN VN THC S Y HC Ngi hng dn khoa hc: GS.TS o Vn Long H NI 2016 LI CM N hon thnh lun ny, tụi xin chõn thnh cm n: - ng y, Ban giỏm hiu, Phũng sau i hc, B mụn Ni Trng i Hc Y H Ni - Ban Giỏm c Bnh vin Bch Mai, Bnh vin i Hc Y H Ni - Cỏc Thy cụ, Bỏc s, iu dng khoa Tiờu húa - Bnh vin Bch Mai, khoa Chn oỏn hỡnh nh - Bnh vin Bch Mai v khoa Ni tng hp Bnh vin i Hc Y H Ni ó to iu kin thun li cho tụi quỏ trỡnh hc v nghiờn cu Tụi xin by t lũng kớnh trng v bit n sõu sc nht ti: GS.TS o Vn Long, ngi thy ó ging dy, trc tip hng dn, giỳp tụi sut quỏ trỡnh hc tp, nghiờn cu v hon thnh lun ny Tụi xin trõn trng cm n: PGS.TS Nguyn Th Võn Hng v cỏc Phú giỏo s, Tin s Hi ng khoa hc bo v cng v chm lun ó úng gúp nhiu ý kin quý bỏu cho tụi quỏ trỡnh hc v hon chnh lun tt nghip Tụi xin trõn trng cm n: ng y, Ban Giỏm c Bnh vin 354, v Tp th khoa A3 bnh vin 354 ó to iu kin cho tụi sut quỏ trỡnh hc Tụi xin chõn thnh cm n ti nhng Bnh nhõn ó tin tng i ng thy thuc chỳng tụi, h va l mc tiờu va l ng lc tụi phn u hc tp, nh cú h tụi cú c nhng bi hc quý giỏ ngh nghip Cui cựng, tụi xin by t lũng bit n ti B M, v tt c nhng ngi thõn gia ỡnh, cựng bn bố ng nghip ó luụn bờn ng viờn,giỳp tụi hc v cuc sng Xin trõn trng cm n! H Ni, ngy 18 thỏng 11 nm 2016 H Th Kim Chung LI CAM OAN Tụi l H Th Kim Chung, hc viờn cao hc khúa 23, Trng i hc Y H Ni, chuyờn ngnh Ni khoa, xin cam oan: õy l Lun bn thõn tụi trc tip thc hin di s hng dn ca GS.TS o Vn Long 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 nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 18 thỏng 11 nm 2016 Ngi vit cam oan H Th Kim Chung DANH MC CC CH VIT TT AFP Alpha Feto Protein ALTMC p lc tnh mch ca BCLC Barcelona Clinic Liver Cancer BN Bnh nhõn CHT Cng hng t CLVT Ct lp vi tớnh CR Complete response CS Cng s CT Computed Tomography MGR ng mch gan riờng T iu tr EASL Eropean Association for the Study of the Liver HBV Hepatitis B virus HCC Hepatocellular carcinoma HCV Hepatitis C virus mRECIST modified Response Evaluation Criteria In Solid Tumors MRI Magnetic Resonance Imaging PD Progressive disease PEI Percutanous Ethanol Injection PR Partial response RECICL Response Evaluation Criteria in Cancer of the Liver RECIST Response Evaluation Criteria In Solid Tumors RFA Radio Frequency Ablation SD Stable disease SIRT Selective internal radiation therapy TACE Transcatheter Arterial ChemoEmbolization TM Tnh mch TMC Tnh mch ca TVTT Trung v trc iu tr UTBMTBG Ung th biu mụ t bo gan MC LC DANH MC BNG DANH MC BIU DANH MC S T VN Theo WHO (2012), ung th gan ng hng th nam gii v hng th n gii, s lng bnh nhõn mi mc c tớnh nm l 782.000, s ca t vong l 746.000, ú i a s l ung th biu mụ t bo gan (HCC) Vit Nam, UTBMTBG l loi ung th ng hng th hai sau ung th phi [1] UTBMTBG din bin õm thm, thng phỏt hin mun, tiờn lng ca bnh rt ti C 100 bnh nhõn ch khong ngi sng c ti nm sau chn oỏn [2] Thi gian sng trung bỡnh l nm, nu khụng c iu tr thớch hp thi gian sng thng di thỏng [3], [4] Ct gan v ghộp gan c xem l hai phng phỏp iu tr trit v tt nht, nhiờn kh nng ỏp dng ch cho 20-30% bnh nhõn ti thi im chn oỏn [5] Hin nay, cỏc phng phỏp iu tr hy u qua da di hng dn hỡnh nh hc, tr liu húa du kt hp thuyờn tc mch qua ng catheter (TACE), iu tr ớch phõn t ó em li nhiu kt qu ỏng khớch l, v ó c thc hin mt s c s y t nc ta Trong ỏnh giỏ hiu qu iu tr ung th, ngoi thi gian sng thờm ton b thỡ s gim kớch thc u v thi gian ti bnh tin trin l nhng tiờu nũng ct T nm 1981, tiờu chun WHO i ln u tiờn cp n phng phỏp ỏnh giỏ s ỏp ng iu tr ca u da vo vic o kớch thc ca u trc v sau iu tr [6] Nhng nm 1990, Nhúm cụng tỏc quc t ó hp v chun húa Tiờu chun ỏnh giỏ s ỏp ng ca u c sau iu tr (RECIST, 2000), a cỏch lng giỏ n gin hn thang im WHO Tuy nhiờn, c thit k vi mc tiờu ban u ỏnh giỏ kt qu iu tr u bng húa cht gõy c t bo, thang im WHO v RECIST o hot tớnh khỏng u ch da trờn s gim kớch thc ca u m khụng tớnh n s thay i mch mỏu v hoi t iu ny dn ti nhng hn ch v kt lun ỏp ng iu tr ớch phõn t hoc iu tr ti ch ca thang im Nm 2000, Hi Gan mt Chõu u a tiờu chun EASL da trờn tiờu chun WHO khng nh vic ỏnh giỏ ỏp ng iu tr u cn da vo phn u sng cũn li (viable tumour) [7] Nm 2008, Hip hi gan mt Hoa Kỡ (AASLD) thng nht hng dn a Tiờu chun RECIST sa i (mRECIST) Nm 2012, tiờu chun ny ó c s ng thun ca Hi Gan mt Chõu u v li ớch vic ỏnh giỏ, tiờn lng kt qu iu tr Theo tiờu chun sa i, phng phỏp ỏnh giỏ ti u ỏp ng iu tr l lng giỏ vic gim kớch thc t chc ung th cũn li bng hỡnh nh hc cú tiờm thuc tng phn Vit Nam, iu tr UTBMTBG ó cú nhiu tin b, c bit l cỏc bin phỏp iu tr can thip ti ch nh t súng cao tn v nỳt mch húa cht ó c ng dng mt s bnh vin Cỏc nghiờn cu v ỏp dng thang im mRECIST ỏnh giỏ ỏp ng iu tr UTBMTBG cũn ớt Vỡ vy, chỳng tụi tin hnh nghiờn cu ti Nghiờn cu ỏp dng thang im RECIST sa i ỏnh giỏ ỏp ng iu tr ung th biu mụ t bo gan vi hai mc tiờu sau: p dng thang im RECIST sa i ỏnh giỏ ỏp ng iu tr ung th biu mụ t bo gan ỏnh giỏ c im lõm sng v cn lõm sng ca ung th biu mụ t bo gan trc v sau iu tr 10 CHNG TNG QUAN 1.1 Dch t bnh ung th biu mụ t bo gan 1.1.1 Trờn th gii UTBMTBGl mt bnh ỏc tớnh ph bin trờn th gii, l nguyờn nhõn gõy t vong ng th cỏc loi ung th Tn sut mc bnh khỏc theo tng khu vc a lý v chng tc, ú hn 80% s ngi bnh l ngi chõu v chõu Phi [1] nam gii, khu vc cú t l mc cao l ụng v ụng Nam (31,9 v 22,2/100.000) n gii, t l mc bnh thp hn nhiu, khu vc mc cao nht l ụng v Tõy Phi (10,2 v 8,1/100.000) [1] Hỡnh 1.1 c tớnh t l mc ung th gan trờn th gii (GLOBOCAN 2012)[1] 1.1.2 Vit Nam Nc ta nm khu vc cỏc quc gia cú t l mc bnh rt cao ca th gii Thng kờ ca Phm Hong Anh ti 22 c s y t ca H Ni nm 1991-1993, UTBMTBG ng th cỏc loi ung th, t l mc c tớnh nam l 15,9/100.000, n l 4,2/100.000, la tui mc nhiu nht 55-64 tui [8] Theo kt qu ca mt nghiờn cu dch t t 2001-2004 ti tnh thnh (H Ni, Hi Phũng, Thỏi Nguyờn, Tha Thiờn Hu v Cn Th), ung th gan chim 82 33 Morris Sherman (2011) Primary Malignant neoplasms of the Liver, Sherlocks Diseases of the liver and biliary system,12th edition, Wiley Blackwell, 681-703 34 Bruix J, Sherman M, AASLD (2011), Management of hepatocellular carcinoma: an update, Hepatology, 53(3),1020-1022 35 G L 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