ng dng mt s k thut y hc ht nhn

trong chn on bnh ung th

Hin nay, chuyn ngnh Y hc ht nhn c nhng ng gp to ln cho vic

chn on bnh ni chung v c bit cho chuyn ngnh ung th. Nhiu k
thut chn on v iu tr bng ng v phng x v ang c p dng rt
c hiu qu cc bnh vin trn th gii. Mt trong nhng ng dng c bit
quan trng l k thut chp hnh pht hin ung th bng mySPECT, SPECT-CT,
PET v PET-CT.
K thut chp hnh bng my PET vi kh nng ghi hnh mc phn t v mc t bo
gip chng ta c kh nng: Chn on sm ung th; Phn loi giai on ung th;
Kim tra v nh gi ti pht ung th; nh gi hiu qu ca cc phng php iu tr...
S phi hp hnh nh qua vic chp hnh bng my PET- CT lm tng nhy v
c hiu ca k thut ny cho vic chn on nh c c ng thi c hnh nh cu trc
gii phu ca CT v hnh nh chc nng chuyn ho ca PET.
1. Mt vi nt v ng dng cc ng v phng x trong lm sng.
Chuyn ngnh Y hc ht nhn (Nuclear Medicine) l mt chuyn ngnh tng i mi
ca y hc. Trong nhng nm qua n c nhng bc tin b vt bc v t c
nhiu thnh tu mi trong chn on v iu tr bnh ni chung v c bit trong bnh
ung th.
1.1. Chn on bnh bng ng v phng x (VPX):
Cch y hn 60 nm, cc ng v phng x (VPX) c s dng cho mc ch
chn on v iu tr.
Nguyn tc chung ca chn on bnh bng ng v phng x nh sau:
nh gi hot ng chc nng ca mt c quan, ph tng no ta cn a vo
mt loi VPX hoc mt hp cht c gn VPX thch hp, chng s tp trung c hiu ti
c quan cn kho st. Theo di qu trnh chuyn ho, ng i ca VPX ny ta c th
nh gi tnh trng chc nng ca c quan, ph tng cn nghin cu qua vic o hot
phng x cc c quan ny nh cc ng m t ngoi c th tng ng vi c quan
cn kho st. V d ngi ta cho bnh nhn ung 131I ri sau nhng khong thi gian
nht nh o hot phng x vng c bnh nhn, t c th nh gi c tnh
trng chc nng ca tuyn gip ...
ghi hnh (x hnh) cc c quan ngi ta phi a cc VPX vo c th ngi bnh.
X hnh (Scintigraphy) l phng php ghi hnh nh s phn b ca cc cht phng x
bn trong cc ph tng bng cch o hot phng x ca chng t bn ngoi c th.

X hnh khng ch l phng php chn on hnh nh n thun v hnh thi m n

cn gip ta hiu v nh gi c chc nng ca c quan, ph tng v mt s bin i
bnh l khc.
ghi hnh cc c quan, ngoi my scanner (ghi hnh tnh) ngi ta cn dng my
Gamma Camera, SPECT, PET, PET/CT hoc SPECT/CT.
Bng k thut ghi hnh y hc ht nhn, ngi ta c th ghi hnh tng c quan hoc
ghi hnh ton c th (Whole body scan), kt qu x hnh s cung cp cho chng ta cc
thng tin v hnh nh chc nng nhiu hn hnh nh v cu trc gii phu.
1.2. iu tr bnh bng ng v phng x:
iu tr ngi ta phi a cc ng v phng x hay dc cht phng x (DCPX)
vo trong c th ngi bnh. Ngi ta gi y l phng php iu tr chiu trong hay
cn gi l iu tr bng ngun h.
Nguyn l chung ca phng php iu tr chiu trong c da trn nh
Henvesy: C th sng khng c kh nng phn bit cc ng v ca cng mt nguyn t.
iu c ngha l khi a vo c th sng cc ng v ca cng mt nguyn t th
chng cng tham gia vo cc phn ng sinh hc v cng chu chung mt s phn chuyn
ho. V vy, khi bit mt nguyn t ho hc hoc mt cht no tham gia vo qu trnh
chuyn ho mt t chc hoc mt c quan no ca c th, c th dng VPX ca
nguyn t ho hc hoc cht a vo c th. Cc VPX (hay cn gi l thuc
phng x) ny s tp trung c hiu ti t chc bnh (t chc ung th, t chc cng
chc nng) v pht huy tc dng iu tr
iu tr l dng nng lng cc tia bc x lm thay i chc nng hay hu dit
mt t chc bnh l nht nh. Liu iu tr phi ln gp hng trm, hng ngn, hng
vn ln so vi liu chn on.
Trong nhiu trng hp, so vi cc phng php iu tr khc th iu tr bng cc
ng v phng x l phng php iu tr hu hiu, nhanh gn, n gin, kinh t Chng
hn c th dng I-131 iu tr rt hiu qu bnh nhn ung th tuyn gip th bit
ho: sau khi phu thut ct b khi u v tuyn gip, bnh nhn c ung I-131,
theo dng tun hon I-131 s truy tm v ng li nhng ni c t bo ung th tuyn
gip hoc cc t chc gip di cn vo bt k v tr no cu c th (vo phi, xng,
no). Nng lng bc x beta (b) ca I-131 s tiu dit rt hiu qu cc t bo ung th
gip. Sau bnh nhn s c bi ph hormon gip tr v bnh gip. Rt nhiu bnh
nhn khi v c th sinh v tr v cuc sng lao ng, sinh hot bnh thng
Ngoi ra, ngi ta cng cn dng I-131 iu tr nhiu bnh khc nh cng gip
trng, Basedow hoc s dng cc ng v phng x hng xng nh: Phospho-32 (P32), Stronti 89 (89Sr); Samarium 153 (153Sm); Rhenium 188 (188Re) iu tr
chng au do ung th di cn vo xng. Cc ng v phng x ny khi vo c th s theo
dng tun hon v n cc t chc xng b ung th v pht huy hiu qu iu tr nh
vo nng lng bc x beta (b) ca chng. Hiu qu iu tr gim au sau 1 ln tim l
t 3-12 thng, tu theo ng v phng x s dng
2. Ghi hnh khi u bng my SPECT, PET
2.1 Nguyn l chung ca ghi hnh ct lp vi tnh bng bc x n photon
(SPECT: Single Photon Emission Computed Tomography) v ghi hnh ct lp
bng bc x positron (PET: positron Emission Tomography)
Nm 1951 ln
Scintigraphe). Sau
c nhng tin b
(detector) rng v

u tin B. Cassen ch to ra my ghi hnh c hc (Rectilinear

khi my Gamma Camera ra i th cng vic ghi hnh phng x
vt bc v cho ta nhng hnh nh vi trng nhn ca u d
do theo di c cc bin i ng hc nhanh chng tim, thn,

no, gan... S tin b vt bc ca tin hc to ra k thut chp ct lp bng tia X qua

my vi tnh (CT - Scanner). Vn dng nguyn l , nm 1975, ngi ta to ra c
k thut chp ct lp bng cc bc x photon pht ra t cc VPX: K thut chp hnh
SPECT (Single Photon Emission Computerized Tomography). Vi nhng u im n sc
ca chm photon thu c qua hin tng hu ht (khi cc photon gp electron) trong
thit b chp ct lp bng chm positron (PET - Positron Emission Tomography), k thut
PET cho nhng hnh nh rt sc nt vi mt liu phng x t hn trong k thut SPECT.
S ra i ca my PET to ra mt bc t ph mi trong vic pht hin sm, chnh
xc cc khi u ung th, cng nh trong nh gi v chn on cc bnh tm thn, thn
kinh v tim mch...
* Nguyn l ca ghi hnh bng my gamma camera, SPECT:
K thut SPECT pht trin trn c s CT- Scanner. Nhng trong SPECT khng c chm
tia X na m l cc photon gamma ca cc VPX c a vo c th bnh nhn di
dng cc DCPX nh du i tng cn ghi hnh. Trong SPECT cc tn hiu cng c
ghi nhn nh trong u d ca Planar Gamma Camera v u d cc k thut YHHN
thng thng khc, nhng trong SPECT u d c quay xon vi gc nhn t
180360 (1/2 hay ton vng trn c th), c chia theo tng bc ng vi tng gc
nh (thng thng khong 3). Tuy mt chm photon c pht ra kh ln, nhng
u d ch ghi nhn c tng photon ring bit nn c gi l chp ct lp n photon.
Tia X hoc photon trc khi n c u d b cc m tng ca c th nm trn ng
i hp th. Do vy nng lng ca chng b suy gim tuyn tnh. Cho my qut trn c
th hoc bnh nhn quay th gc quay v gc nhn ca chm tia quyt nh hng, mt
chm tia n u d v gi tr hp th ca n. Ta hnh dung gi s chia lt ct thnh
nhiu n v vt cht vi kch thc nht nh. Khi chm tia photon qut qua lp vt cht
(ngang hoc dc) th n s ln lt xuyn qua cc n v vt cht. Tn hiu pht ra t
mi n v vt cht s khc nhau do c suy gim tuyn tnh khc nhau, tu thuc vo
gc quay, ln ca gc nhn trong mt phng qut v khong cch ca n ti u d.
My tnh (PC) vi cc phn mm thch hp c kh nng hiu chnh h s suy gim v
loi b c cc bc x t cc mt phng khc gi l lc nn (filtered back projection). Nh
th ngha l PC loi b cc tn hiu to ra t cc lp vt cht trc, sau (hoc trn, di)
i vi mt phng lt ct. Cc tn hiu gi l xung nhiu. V vy s thu nhn c
hng lot cc tn hiu ca tng n v th tch mt lp vt cht nht nh (ta hnh dung
nh mt lt ct). Do vy, cc tn hiu ch c ghi nhn theo tng thi im mt. S
lng gc nhn cn chn ti to nh mt cch trung thc tu thuc vo phn
gii ca u d. Cc tn hiu c a vo h thng thu nhn d liu (Data
Acquisition System: DAT) m ho v truyn vo PC. Khi chuyn ng qut kt thc,
b nh ghi nhn c mt s rt ln nhng s o tng ng vi nhng gc khc nhau
trong mt phng tng ng. Cc tn hiu thu c l c s ti to hnh nh. Vic ti
to nh da vo cc thut ton phc tp m PC c kh nng gii quyt nhanh chng.
l cc thut ton v ma trn (matrix). Cc s liu ghi o c t cc lp ct to ra ma
trn ny. Thng thng trong CT - Scanner ngi ta dng cc ma trn: (64x64),
(128x128), (252 x 252) hoc ln hn na, cn trong SPECT thng dng ma trn 64x64
l v nng lng cc photon gamma cao hn.
Di y m t s mt my SPECT 2 u (dual head). Hin nay ngi ta ch to
c cc my SPECT 1u (detector), 2 u, 3 u. Cc my SPECT 2 v 3 u s cho
kt qu ghi hnh nhanh hn, c bit khi cn kho st cc qu trnh ng hc xy ra
nhanh trong c th. Ngoi ra cc my SPECT va c th to ra cc lt ct (slide) hnh
nh nh CT, MRI, n cn cho hnh nh quet (Scan) ton thn, c im ny l c biet
c gi tr trong pht hin khi u v di cn ung th.

Nguyn l ca ghi hnh bng my PET:

Mt Positron pht ra t ht nhn nguyn t tn ti rt ngn, ch i c mt qung
ng cc ngn ri kt hp vi mt in t t do tch in m trong m v vo mt
trng thi kch thch gi l positronium. Positronium tn ti rt ngn v gn nh ngay lp
tc chuyn ho thnh 2 photon c nng lng 511 keV pht ra theo 2 chiu ngc nhau
trn cng mt trc vi im xut pht. Ngi ta gi l hin tng hu ht
(annihilation). Nu t 2 detector i din ngun pht positron v dng mch trng
phng (coincidence) th c th ghi nhn 2 photon g ng thi (hnh 3). Do vy cc
u m nhp nhy c th xc nh v tr pht ra positron (cng tc l ca cc photon
). V tr phi nm trn ng ni lin 2 detector ghi nhn chng. Ngi ta gi
l ng trng phng (coincidence line). Trong cng mt thi im my c th ghi nhn
c hng triu d liu nh vy, to nn hnh nh phn b hot phng x trong
khng gian ca i tng nh du phng x trc (thu thp d liu v ti to
hnh nh) theo nguyn l nh trong SPECT. S ti to cc hnh nh ny c hon thnh
bi vic chn mt mt phng nht nh ( su quan tm trong m, tng). V vy c
gi l chp ct lp bng Positron (Positron Emission Tomography: PET). Nguyn l v k
thut ging nh trong SPECT nhng cc photon ca cc VPX trong SPECT khng n
nng m tri di theo ph nng lung ca n, cn trong PET l cc photon pht ra t
hin tng hu ht ca positron v electron, n nng (511 keV).

im c bit i vi vic ghi hnh bng my PET l phi s dng cc VPX pht
positron. Tuy nhin cc VPX ny c thi gian bn r ngn nn bn cnh my PET phi
c Cyclotron sn xut VPX. iu gy thm kh khn cho vic ph cp PET c v
k thut v ti chnh. V vy hin nay s lng PET trn th gii khng nhiu nh SPECT.

Cng ging nh cc my SPECT, my PET cng va c th to ra cc lt ct (slide)

hnh nh nh CT, MRI, va co th cho hnh nh quet (Scan) ton thn, c im ny l
c bit quan trng trong pht hin khi u v s ti pht v di cn ung th.

My PET (bn tri) v Cyclotron (bn phi) sn xut cc VPX c i sng ngn
Gn y ngi ta nghin cu to ra h thng kt hp PET vi CT - Scanner hoc
SPECT/CT tc l ghp 2 loi u d trn mt my v dng chung h thng ghi nhn lu
gi s liu, cc k thut ca PC. H thng ny cho ta hnh nh nh ghp chng hnh ca
CT v x hnh ln nhau nn c th xc nh chnh xc v tr gii phu (do hnh CT l ch
yu) cc tn thng chc nng (do x hnh l ch yu). H thng ny mang li nhiu
mu sc phong ph cho k thut ghi hnh phng x ni ring v ghi hnh y hc ni
chung.

2.2. Ghi hnh khi u bng my SPECT, PET

Phng php ghi hnh (x hnh) c vai tr quan trng trong vic pht hin cc khi u,
c bit cc khi u c tnh, cng nh theo di ung th ti pht v nh gi hiu qu ca
cc phng php iu tr.

Nguyn tc chung ca ghi hnh y hc ht nhn l: ghi hnh (x hnh) cc c quan

ngi ta phi a cc VPX hay dc cht phng x (DCPX) vo c th ngi bnh. Cc
VPX hay cc DCPX ghi hnh phi c la chn sao cho khi vo c th n ch tp
trung vo c quan cn ghi hnh, t hoc khng tp trung phng x cc t chc hay c
quan khc v phi c lu gi mt thi gian di. S phn b trong khng gian
ca DCPX ny s c ghi thnh hnh nh. Hnh nh thu c c tnh c hiu ca c
quan cn nghin cu. Hnh nh ny c gi l x hnh , hnh ghi nhp nhy
(Scintigram, Scanogram, Scan). y l im khc bit rt quan trng trong ghi hnh
bng k thut y hc ht nhn so vi cc k thut ghi hnh khng a cc phng x vo
c th ngi bnh nh CT, MRI Thc cht x hnh (Scintigraphy) l phng php ghi
hnh nh s phn b mt cch c hiu ca cc cht phng x bn trong cc ph tng
bng cch o hot phng x ca chng t bn ngoi c th.
X hnh khng ch l phng php chn on hnh nh n thun v hnh thi m n
cn gip ta hiu v nh gi c chc nng ca c quan, ph tng v mt s bin i
bnh l khc ca chnh c quan .
pht hin khi u, hin c nhiu phng php khc nhau:
Cc phng php chp hnh thng quy (quy c) nh: XQ, siu m, CT, MRI...
Cc phng php ghi hnh bng y hc ht nhn nh: Scanner, Gamma camera,
SPECT, PET, PET/CT... Mi loi phng php u c nhng u nhc im ring. Trong
lm sng, ngi thy thuc cn bit s dng hoc phi hp cc phng php chn on
hnh nh c nhng thng tin chnh xc gip ch cho qu trnh chn on theo di
v nh gi hiu qu ca cc phng php iu tr.
Hin nay c th xp cc phng php ghi hnh khi u theo 3 nhm chnh nh sau:
Ghi hnh khi u vi my gamma camera v SPECT, loi ny gm 2 loi x hnh:
+ X hnh (ln hnh) bng tng phn m tnh (-)
+ X hnh (ln hnh) bng tng phn dng tnh (+)
Ghi hnh khi u c hiu (ghi hnh min dch phng x: Radioimmuoscintigraphy:
RIS).
Ghi hnh khi u theo nguyn tc chuyn ho (bng k thut PET).
2.2.1. Ghi hnh khi u vi my gamma camera v SPECT
* Ghi hnh khi u theo nguyn tc tng phn m tnh
Trn hnh ghi (scintigram), ni tng ng vi khi u, ta thy c mt vng khuyt hoc
gim hot tnh phng x so vi t chc xung quanh. Ngha l cht phng x ch tp trung
ch yu trong
t chc lnh v do ti khi u t hot tnh phng x hn. Nguyn nhn l do c s
thay i v mt chuyn ho, phn b mch, tn thng hoi t ca t bo ung th nn
lm cho t chc ung th gim (hoc mt hn) kh nng bt, gi cc cht phng x. V
d; ung th tuyn gip, ung th gan, ung th phi
Tuy nhin, c nhiu nguyn nhn c th to ra mt vng "lnh" hot tnh phng x,
do vy nu ch da vo hnh nh trn scintigram th khng c php ghi chn on xc
nh l c ung th hay khng.

Cc my x hnh gamma camera, SPECT thng c dng ghi ghi hnh cho loi
ny.
* Ghi hnh khi u theo nguyn tc tng phn dng tnh (Positive contrast)
Phng php ghi hnh ny ngy cng c ng dng rng ri hn. ni tng ng vi
khi u c vng tp trung hot tnh phng x cao hn t chc xung quanh. V d: ghi hnh
khi u no, xng, v..
Tuy nhin, cn lu rng c nhiu nguyn nhn c th to ra mt vng "nng" hot
tnh phng x ti vng tn thng, do vy nu ch da vo hnh nh trn scintigram
th ch ni c l c tn thng, nhng kh xc nh l khi u lnh tnh hay c tnh.
Nhng so vi phng php ghi hnh theo nguyn tc ghi hnh m tnh th phng php
ghi hnh theo nguyn tc tng phn dng tnh c nhy v c hiu cao hn trong
mt s loi khi u.
Cc my x hnh gamma camera, SPECT thng c dng ghi ghi hnh theo
nguyn tc ny.

2.2.2. Ghi hnh khi u c

Radioimmuoscintigraphy: RIS).

hiu

(ghi

hnh

min

dch

phng

x:

Trong nhng nm va qua, ngnh y hc ht nhn c nhng bc pht trin mi

trong cc k thut ghi hnh va c th ghi hnh c hiu c cc t chc c quan ,
li va nh gi c chc nng ca chng thng qua vic s dng k thut gn cc
receptor v tng tc gia khng nguyn - khng th.
K thut s dng khng th nh du phng x ghi hnh v nh gi cc c im
ca bn cht qu trnh bnh l c gi l k thut ghi hnh min dch phng x (RIS:
Radioimmuscintigraphy).
V nguyn tc, RIS c th p dng cho bt k loi bnh l no: lnh tnh, nh pht
hin nhi mu c tim vi antimyosin nh du phng x, hay c tnh... pht hin khi
u (lnh v c tnh) hin ngi ta c th s dng cc k thut: X quang thng thng, CT,
MRI, Siu m... Nhng phng php ny ch gip ta xc nh c c tn thng hay
khng, v tr khi u... Nhng khng xc nh c bn cht, loi tn thng ca khi u.

Vic s dng RIS va cho php xc nh c khi u (v tr, hnh dng, kch thc) v xc
nh chnh xc bn cht ca khi u. chnh l u im v u vit ca RIS.
* Nguyn l ca RIS nh sau:
Mi khi u c mt loi t bo ung th, nhng t bo ny to ra nhng khng nguyn
c hiu (thng nm b mt t bo). Mi loi ung th li c mt loi khng nguyn
c hiu. Khng nguyn ny s kt hp vi khng th c hiu vi n.
Nu dng cc khng th c hiu (khng th n dng: monoclonal anbibody)
c nh du bng mt ng v thch hp pht tia gamma (g) th khng th ny s kt
hp vi khng nguyn tng ng ca t chc ung th v to thnh phc hp: Khng
nguyn - khng th nh du phng x. Nh vy, lc ny khi u s tr thnh mt ngun
pht tia phng x (tia gamma) v kt qu ta s c mt hnh ghi dng tnh, l hnh
nh ca khi u ung th c hiu. tm v pht hin khi u ung th no , ngi ta
thng s dng mt s ng v phng x cho RIS nh 123I, 111In, 99mTc, 131I... bit
chnh xc bn cht, v tr ca khi u ta ch vic tim cc khng th c hiu vi loi ung
th cn pht hin m ta bit trc. Nu ln hnh c ta c th khng nh l hnh
ghi c hiu ca khi u ta cn tm. Chng hn pht hin ung th bung trng ngi ta
dng khng th n dng OC 125 nh du 111In (111In-OC125)...
* ng dng ca RIS trong lm sng
RIS khng c vai tr nh mt test sng lc (Screening test) cho nhng ngi kho
mnh pht hin ung th. RIS l mt k thut phc tp v i hi phi tim protein l,
cht phng x v khng th vo c th ngi bnh.
RIS c mt vai tr quan trng trong vic nh gi cc bnh nhn vi cc kt qu
nghin cu ban u. V d vi mt nang (cyst) hoc mt khi u vng h chu, ngi ta
c th s dng RIS pht hin v chng minh n c phi l mt ung th bung trng
hay khng... .
RIS l mt nghim php b sung lm tng kh nng pht hin cc du n ung th
(tumor marker) trong huyt thanh. Tuy nhin, mt khng nguyn l tng pht hin
c trong huyt thanh l phi c gii phng (tit ra) d dng t cc khi u nh CEA,
AFP, nhng hu ht cc marker li khng tng trong huyt thanh cho tn ti lc khi u b
hoi t. Trong khi i vi RIS th khng nguyn c nh ti khi u nn s cho cc kt
qu c hiu cao. Chng hn trong ung th trc trng, RIS c th gip chng ta pht
hin tt cc khi u nguyn pht hay th pht ngay c khi CEA trong huyt thanh mc
bnh thng. Tuy nhin cc khi u c khng nguyn trong mu tun hon cao v t khi
u th kh c hnh nh c hiu nu ta s dng RIS.
RIS c vai tr quan trng trong nh gi giai on s b ban u loi ung th bit.
Tuy nhin, i vi cc khng nguyn tit ra t khi u nh CEA th s tp trung ca chng
cc hch lympho a phng bnh thng s ln hn cc hch lympho c lin quan n
ung th trc trng.
RIS c vai tr quan trng trong vic nh gi li cc bnh nhn sau khi iu tr cc
ung th nguyn pht bng phu thut, ng v phng x, ho hc hoc kt hp ca cc
phng php iu tr ny. RIS khng c li ch lm sng trong vic pht hin cc hnh
nh di cn ln qu r rng khi c pht hin bng siu m hay CT. Nhng n c
bit c gi tr trong lm sng, nh cn chng minh rng mt khi (mass) xut hin trong
h chu l mt khi x sau phu thut hay l mt khi u ung th ti xut hin sau
iu tr, mt hch lympho to ra ch khng phi l khi di cn mi xut hin...
RIS c th gip chng ta chng minh cc di cn c t trc c khng nh trong
di cn da, mng bng, s ti xut hin ca ung th bung trng trong h chu, nhng
ni ny th CT, siu m t c tin cy, c bit l cc phng php ny khng khng

nh c s ti xut hin ca ung th i trc trng v di cn tu xng t ung th

v...
2.2.3. Ghi hnh khi u bng my PET (ghi hnh khi u theo nguyn tc chuyn
ho).
PET (Positrron Emision Tomography) c vai tr c bit quan trng trong pht hin
khi u ung th cng nh theo di nh gi kt qu ca cc phng php iu tr. Nu
nh CT, MRT cung cp hnh nh gii phu r nt th PET va cho chng ta hnh nh gii
phu va cho hnh nh chc nng chuyn ho ca khi u (ghi hnh mc t bo). Do
vy, nhn chung ghi hnh khi u bng PET c nhy v c hiu cao hn nhiu so vi
cc phng php chn on hnh nh khc, c bit l kh nng pht hin cc khi u
giai on rt sm khi m cc phng php chn on khc cha pht hin thy.
a. Nguyn l c bn ca ghi hnh khi u bng PET
Nguyn tc c bn ca ghi hnh khi u bng PET l cn phi c c ch tp trung mt
cch c hiu dc cht phng x (DCPX) la chn. DCPX c la chn da trn c
s nhng khc bit v sinh l hc hoc chuyn ho gia khi u v t chc bnh thng.
S khc bit v sinh l hc l kh r rt trong hnh nh ca chng, bao gm s khc
bit v phenotyp (kiu hnh) khng nguyn b mt khi u so vi t chc bnh thng.
Mt s nhng bin i thng thng v sinh l c trong cc khi u
ghi hnh bng PET, l: trong a s cc trng hp, khi u thng
nhanh so vi t chc bnh thng. iu ny c ngha l vic s dng
(percursor) ca DNA (nh thymidine) trong khi u thng tng hn nhiu
bnh thng.

c s dng
pht trin rt
cc tin thn
so vi t chc

Thng thng, khi u thng c tc tng hp protein cao hn so vi t chc lnh,

do vic vn chuyn v kt hp nhiu typ amin acid trong t chc ung th s tng ln
so vi t chc bnh thng, nn trong thc t 11C- methionine v 11C - tyrosine thng
c s dng ghi hnh cc khi u ung th bng PET.
Mt im c bit na l cc khi u thng c hin tng tng phn hu glucose k kh
v a kh hn so vi cc t chc bnh thng. iu ny c ngha l rt nhiu khi u c
nhu cu s dng glucose cao hn t chc bnh thng.
Bng di y tng hp mt s thay i trong khi u v cc DCPX tng ng dng
nh du cho ghi hnh PET.
Thay i sinh l hc trong khi u DCPX (Tracer)
Tng s dng glucose

18F - FDG , 11C - glucose

Tng vn chuyn amino acid/

11C - methionine,11C- ACHC,

tng hp protin

11C- Tyrosine

Tng tng hp DNA

11C
thymidine,
fluorodeoxyuridine

Gim oxy vo khi u

18F - fluoromisonidazole

Tng biu l receptor estrogen

18F - b - estradiol

Tng dng mu ti khi u

15O - H2O; 62Cu- PTSM

Tng khng nguyn

18F gn khng th n dng khng

khi u

Tng lu gi (duy tr) cc thuc ho 5-18F

Fluorouracil;

11C-

11C

cht dng cho iu tr

daunoubicin

Hin nay c nhiu DCPX dng cho ghi hnh PET, nhng cht c s dng rng ri l
18F - FDG: 2 - (18F) fluoro - 2 deoxy - D - glucose

C ch chuyn ho ca FDG trong t bo ung th

(T bo ung th c nm trong ranh gii ca hnh ch nht hnh v trn)
FDG i vo t bo ung th qua ng mu, ri c vn chuyn vo trong t bo
(K1), thng thng bi cht vn chuyn glucose GLUT1. Sau FDG c phosphoryl
ho bi hexokinase trong t bo thnh FDG - 6 phosphat. T l (K4) ca s bin i
FDG - 6P thnh FDG l rt thp.
b. Mt s c im ca ghi hnh khi u ung th bng PET
V nguyn tc th cc hot ng chuyn ho trong cc t chc ung th thng xut
hin trc nhng thay i v cu trc. Vic pht hin nhng thay i v ho sinh, chuyn
ho... trc nhng thay i v gii phu l c th thc hin c.
Nh vy, nu ta s dng cc cht bng trn v nh du chng bng cc ng v
phng x pht positron, chng s theo dng mu v tp trung ch yu ti cc t chc c
t bo ung th v tham gia vo cc qu trnh chuyn ho, tng hp, bin i trong tng

t bo ung th. Ti nhng ni c tp trung cc DCPX k trn, s c mt s chnh lch r

nt hot tnh phng x cao hn t chc lnh xung quanh (hnh nh dng tnh). Kt qu
l chng ta c mt hnh nh cc t chc ung th c hiu giai on rt sm, thm ch
ngay c khi cc t bo ung th ang giai on ri lon chuyn ho, chng ta c th
thy c hnh nh ca chng. iu ny khc bit so vi chp hnh bng CT, MRI l t
chc ung th phi b ph hu mt mc ln th cc thit b ny mi pht hin
c v mt ngi mi nhn thy c.
Kt qu ca qu trnh ghi hnh bng PET l c th pht hin cc t bo ung th giai
on sm v hnh nh thu c mang m hnh nh hnh nh chc nng hn l hnh nh
cu trc gii phu ca t chc ung th.
PET cn gip nh gi sm, chnh xc cc p ng iu tr ung th. Nhng thay i
ny din ra sm hn v trc rt nhiu nhng thay i trong cu trc gii phu. Ngoi ra
do ghi hnh vi PET theo nguyn tc chuyn ho nn rt c ch trong vic phn bit mt
s t chc ung th vi mt chc so x, hoi t... cng nh gip pht hin cc ung th
ti pht sm hn rt nhiu so vi nhng thay i v gii phu v th tch khi u c
pht hin bng cc phng php ghi hnh thng thng (X quang, CT, MRI...)
V mt k thut PET c th ghi li v ti to nh theo 3 chiu khng gian. dy
mt lp ct khong 3 - 4mm v c th ct theo 3 chiu (nm ngang, chiu ng trc sau v phi - tri). PET c th ghi hnh ton thn (quet ton thn) hoc tng c th.
Tm li ghi hnh bng my PET c th gip chng ta:
- Chn on sm ung th
- Phn loi giai on ung th
- Kim tra v nh gi ti pht ung th.
- nh gi hiu qu ca cc phng php iu tr
c. Mt s kha cnh k thut
Mt trung tm PET cn c:
- Cyclotron sn xut ti ch cc ng vphng x c i sng ngn
- Labo ho dc phng x nh du cc hp cht phng x
- i ng k thut (bc s, ngi iu khin cyclotron, k s vt l, dc s ho
phng x, k thut vin...)
Trong cc cyclotron, nh vic bn ph vo cc bia (target) c hiu s to ra cc ht
nhn phng x pht positron nh 18F, 11C, 15O...
Do cc dc cht phng x c nh du vi cc positron c i sng vt l rt ngn
nn vic phn phi, vn chuyn ti ni s dng phi rt nhanh. V vy cyclotron cn phi
t rt gn my PET, hoc 1 cyclotron phi t sao gn 2 3 my PET.
d. Mt s ch nh chnh ghi hnh PET trong ung th
Hu ht cc loi ung th u c th ghi hnh bng my PET
- Pht hin v phn loi giai on trc phu thut cho ung th phi, ung th i trc
trng

- nh gi ung th sc t (melanoma) sau giai on II.

- Nghin cu v pht hin cc hch v u phi dng c.
- Pht hin v phn loi trc m ung th u, c
- Pht hin v phn loi ung th v ti pht
- Chn on phn bit gia so v ung th ti pht hoc gia m hoi t v ung th
ti pht.
- Pht hin v phn loi u no
- Pht hin ung th ti pht v di cn
- nh gi p ng ca khi u vi cc phng php iu tr
- Ghi hnh (in vivo) tc dng ca thuc...
S minh ho ghi hnh khi u bng my PET-CT

PGS. TS. Mai Trng Khoa - Ph Trng B mn Y hc ht nhn - i hc Y H Ni

Trng Khoa Y hc ht nhn v Ung bu-BV Bch Mai