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NGHIN CU
CHN ON V IU TR
BU M M NG TIU HA
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THNH PH H CH MINH NM 2016
B GIO DC V O TO
B Y T
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DIP BO TUN
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CHN ON V IU TR
BU M M NG TIU HA
Chuyn ngnh : Ung th
M s
: 62720149
LUN N TIN S Y HC
Ngi hng dn khoa hc:

PGS. TS. TRN VN PHI
THNH PH H CH MINH - NM 2016
LI CAM OAN
Ti cam oan y l cng trnh nghin cu ca ring ti. Cc s liu,

cc kt qu nu trong lun n ny l hon ton trung thc v cha tng c
ai cng b trong bt k cng trnh no khc.
Tc gi
Dip Bo Tun
MC LC
Trang
TRANG PH BA
LI CAM OAN
MC LC
DANH MC CC CH VIT TT
BNG I CHIU THUT NG VIT - ANH
DANH MC CC BNG
DANH MC CC HNH
DANH MC CC BIU , S
T VN ...........................................................................................................1
MC TIU NGHIN CU CA LUN N ........................................................3
Chng 1: TNG QUAN TI LIU ......................................................................4
1.1- Cu to ca thnh ng tiu ha v t bo k Cajal ...............................................4
1.2- Lch s nghin cu v bu m m ng tiu ha .........................................7
1.3- Chn on ............................................................................................................8
1.4- iu tr
............................................................................................................25
1.5- Tin lng v sng cn ......................................................................................40

Chng 2: I TNG V PHNG PHP NGHIN CU ........................43
2.1- i tng nghin cu .........................................................................................43
2.2- Phng php nghin cu ....................................................................................44
2.3- X l s liu ......................................................................................................55
2.4- o c trong nghin cu .................................................................................56
2.5- Thi gian v a im nghin cu .....................................................................56
2.6- Mt s vn lin quan n nghin cu ...........................................................57
Chng 3: KT QU NGHIN CU ..................................................................58
3.1- c im nhm bnh nhn tham gia nghin cu ..............................................59
3.2- Lm sng.............................................................................................................62
3.3- Triu chng cn lm sng ..................................................................................64
3.4- Chn on trc m ...........................................................................................67

3.5- iu tr .............................................................................................................67
3.6- Theo di v kt qu iu tr ...............................................................................83
3.7- Cc yu t tin lng ..........................................................................................91
Chng 4: BN LUN ....................................................................................... 102
4.1- c im nhm bnh nhn tham gia nghin cu ........................................... 102
4.2- Triu chng lm sng ...................................................................................... 105
4.3- Triu chng cn lm sng ................................................................................ 109
4.4- Chn on trc m ........................................................................................ 116
4.5- iu tr .......................................................................................................... 117
4.6- Theo di v kt qu iu tr ............................................................................. 131
4.7- Cc yu t tin lng ....................................................................................... 134
4.8 Hn ch ca lun n ...................................................................................... 137
KT LUN .......................................................................................................... 138
KIN NGH .......................................................................................................... 139
DANH MC CC CNG TRNH NGHIN CU LIN QUAN N LUN N
TI LIU THAM KHO ................................................................................... i-xvi
PH LC:
PH LC 1: Phiu thu thp d liu bu m m ng tiu ha
PH LC 2: Th thm hi bnh nhn
PH LC 3: Bn chp thun tham gia nghin cu
PH LUC 4: Giy chp thun ca Hi ng o dc trong nghin cu Y Sinh hc
PH LC 5: Xc nhn danh sch bnh nhn trong nghin cu
DANH MC CC CH VIT TT
1- Ting Vit :
Ch vit tt
Nguyn gc
BMTH
Bu m m ng tiu ha
BN
Bnh nhn
BV
Bnh vin
PT
Phu thut
PTNS
Phu thut ni soi
SCTB
Sng cn ton b
SCKBTT
Sng cn khng bnh tin trin
SCKBTP
Sng cn khng bnh ti pht
TP
Thnh ph
TPHCM
Thnh ph H Ch Minh
VBHQ
Vin Bnh hc qun i (Hoa K)
VYTQG
Vin Y t Quc gia (Hoa K)
2- Ting Anh
Vit tt
Nguyn gc
Ngha ting Vit
AFIP
Armed Forced Institute of
Vin Bnh hc Qun i (Hoa
Pathology
K)
American Joint Committee on
Hip hi Ung th Hoa K
AJCC
Cancer
ASCO
American Society of Clinical
Hi Ung th Lm sng Hoa K
Oncology
CML
Chronic myelogenous leukemia
Bch cu mn dng ty
CR
Complete response
p ng hon ton
CT
Computed Tomography
Chp ct lp vi tnh
DOG-1
Discovered on GIST-1
Th th DOG-1
ECOG
EGFR
The Eastern Cooperative
Nhm Ung Bu Hp Tc
Oncology Group
Phng ng
Epidermal Growth Factor
Th th yu t tng trng biu b
Receptor
EORTC
European Organization for
T chc Nghin cu v iu tr
Research and Treatment of Cancer Ung th Chu u

ESMO
FDA
European Society of Medical
Hip Hi Ung Th Ni Khoa
Oncology
Chu u
Food and Drugs Administration
C quan Qun l Thc Phm v

Dc Phm Hoa K
FDG
Fluorodeoxyglucose
Fluorodeoxyglucose
FNA
Fine Needle Aspiration
Chc ht bng kim nh
GANT
Gastrointestinal autonomic nerve
Bu t bo thn kinh t ng
tumors
ng tiu ha
GIST
GastroIntestinal Stromal Tumors
Bu m m ng tiu ha
GIPAP
The Glivec International Patient
Chng trnh Quc t h tr bnh
Assitance Program
nhn dng Glivec
HPF
High-Power Field
Quang trng ln
kD
KiloDalton
103 Dalton
MRI
Magnetic Resonance Imaging
Chp cng hng t
NC
Non-change
Bnh khng thay i
NCCN
National Comprehensive Cancer
Mng li quc gia (Hoa K)
Network
ton din v ung th
NIH
National Institute of Health
Vin Y t Quc Gia (Hoa K)
OS
Overall Survival
Sng cn ton b
PD
Progressive Disease
Bnh tin trin
PDGFRA Platelet-Derived Growth Factor
PET
Th th Yu t Tng trng c
Receptor alpha
ngun gc Tiu cu loi anpha
Positron Emission Tomography
Chp ct lp phng x psitron
PFS
Progression-Free Survival
PR
Part response
p ng mt phn
RFS
Relapse-Free Survival
SCF
Stem Cell Factor
Yu t t bo gc
TKI
Tyrosine Kinase Inhibitor
Thuc c ch Tyrosine Kinase
TME
Total Mesorectal Excision
Ct ton b mc treo trc trng
TNM
Tumor - Node Metastasis
Bu nguyn pht Hch vng

Di cn xa
UICC
Union for International Cancer
Hip hi Quc t Chng Ung th
Control
VPAP
WHO
Vietnamese Patient Assitance
Chng trnh H Tr Bnh nhn
Programme
Vit Nam
World Health Organization
T chc Y t Th gii
BNG I CHIU THUT NG VIT ANH

Cc thut ng dch t ting Anh, da vo:
- T in gii ngha bnh hc ca tc gi Trn Phng Hnh, 1997
- T in Y hc Anh Vit ca tc gi Bi Khnh Thun, 1993
- Ung th hc lm sng tp 1 v 2 ca tc gi Nguyn Chn Hng v cng s,
1986
Ting Vit
Ting Anh
Bu nguyn pht
Primary tumor
Bu kch thc ln
Bulky tumor
Carcinm tuyn
Adenocarcinoma
Cht nh du bu
Tumor marker
Di cn hch
Lymph node metastasis
Di cn xa
Distant metastasis
iu tr tn h tr
Neoadjuvant treatment
Giai on
Stage
Hch vng
Regional lymph node
Ha tr
Chemotherapy
Khng nguyn
Antigen
Phc iu tr
Treatment protocol
Phu thut ni soi
Endoscopic surgery
Phu tr
Surgery
Phn tch a bin
Multivariate analysis
Phn tch n bin
Univariate analysis
Sinh thit
Biopsy
Soi trc trng
Proctoscopy
Sng cn
Survival
Progression-free survival
Relapse-free survival
Sng cn ton b
Overall survival
T bo k Cajal
Interstitial cells of Cajal
Ti pht ti ch
Local recurrence
Th nghim lm sng
Clinical trial
Tin lng
Prognosis
Tin xa ti ch
Locally advance
X tr
Radiation therapy
Xp giai on
Staging
Xp giai on lm sng
Clinical staging
Xp hng
Classification
Yu t tin lng c lp
Independent prognostic factor
DANH MC CC BNG
trang
Bng 1.1: Xp giai on BMTH theo UICC ln th 7 (2010) ..........................17
Bng 1.2: Mt s chn on phn bit vi BMTH ...........................................21
Bng 1.3: Phn nhm nguy c ti pht BMTH theo VYTQG Hoa K .............22
Bng 1.4: Phn nhm nguy c BMTH theo VYTQG Hoa K b sung .............22
Bng 1.5: Phn nhm nguy c ti pht BMTH theo VQQG Ha K ............23
Bng 2.6: Thang im Karnofsky ............................................................................47
Bng 2.7: Thang im ECOG ..................................................................................48
Bng 2.8: Bng chuyn i gia thang im Karnofsky v ECOG ........................48
Bng 2.9: Phn loi c tnh huyt hc v tiu ha .................................................50
Bng 2.10: Phn loi cc bin s .............................................................................53
Bng 3.11: c im nhm bnh nhn tham gia nghin cu .................................59
Bng 3.12: Phn b t l nam/n theo v tr bu ..................................................60
Bng 3.13: Phn b tui theo v tr bu ................................................................60
Bng 3.14: Phn b l do nhp vin theo v tr bu ..............................................61
Bng 3.15: Phn b thi gian khi bnh theo v tr bu .......................................62
Bng 3.16: Phn b triu chng khi bnh theo v tr bu ...................................62
Bng 3.17: Giai on bnh khi chn on ..............................................................67
Bng 3.18: Cc phng php phu thut ................................................................68
Bng 3.19: Cc loi phu thut trit theo v tr bu .........................................69
Bng 3.20: Phn b kch thc bu sau m .........................................................71
Bng 3.21: Phn b kt qu ha m min dch theo v tr bu .............................74
Bng 3.22: Phn b s phn bo trn 50 QTL theo v tr bu ..............................75
Bng 3.23: Phn b kch thc bu v s phn bo/50 QTL ...............................75
Bng 3.24: Phn nhm nguy c ti pht i vi BMTH ...................................76
Bng 3.25: Phn nhm nguy c i vi BMTH d dy ................................76
Bng 3.26: Phn nhm nguy c i vi BMTH rut non .............................77
Bng 3.27: Phn nhm nguy c i vi BMTH i trng .............................77
Bng 3.28: Phn nhm nguy c i vi BMTH trc trng ............................77

Bng 3.29: Phn nhm nguy c i vi BMTH mc treo .............................78
Bng 3.30: iu tr BMTH ti pht sau phu thut trit ...............................78
Bng 3.31: iu tr Imatinib sau m ........................................................................79
Bng 3.32: p ng iu tr Imatinib ln u .........................................................80
Bng 3.33: p ng iu tr Imatinib .....................................................................81
Bng 3.34: T l p ng vi Imatinib theo v tr bu .........................................82
Bng 3.35: Cc tc dng ph ca Imatinib ..............................................................82
Bng 3.36: c tnh t l SCTB 5 nm ca BMTH theo v tr bu ................84
Bng 3.37: Thi gian SCTB trung bnh theo v tr bu .........................................85
Bng 3.38: T l SCTB 5 nm theo v tr bu i vi bnh nhn c phu thut
trit ......................................................................................................................86
Bng 3.39: T l SCKBTP 5 nm theo v tr bu i vi bnh nhn c phu
thut trit ..............................................................................................................88
Bng 3.40: T l SCTB 5 nm theo v tr bu i vi bnh nhn c phu thut
tm b .......................................................................................................................89
Bng 3.41: T l SCKBTT 5 nm theo v tr bu .................................................90
Bng 3.42: Thi gian SCKBTT theo v tr bu .....................................................91
Bng 3.43: Phn tch a bin cc bin s c lp ..................................................101
Bng 4.44: Cc nghin cu bo co v t l phu thut trit ......................117
Bng 4.45: Kch thu bu trung bnh trong cc nghin cu ............................122
Bng 4.46: Kt qu ha m min dch ca BMTH ..........................................124
Bng 4.47: Nguy c ti pht BMTH theo cc nghin cu .............................126
Bng 4.48: So snh v t l p ng vi Imatinib gia cc nghin cu ...............131
Bng 4.49: T l ti pht/di cn sau phu thut ...................................................132
DANH MC CC HNH
trang
Hnh 1.1: Cu trc thnh ng tiu ha ......................................................................4

Hnh 1.2: T bo k Cajal .........................................................................................5
Hnh 1.3: Cu trc ca th th c-KIT v th th PDGFRA ......................................6
Hnh 1.4: Phn b BMTH trn ng tiu ha .................................................10
Hnh 1.5: Hnh nh siu m BMTH rut non ................................................12
Hnh 1.6: Hnh nh siu m qua ni soi BMTH t trng ...............................13
Hnh 1.7: Chp ct lp vi tnh BMTH d dy ...............................................14
Hnh 1.8: i th BMTH rut non .................................................................18
Hnh 1.9: Vi th BMTH dng t bo hnh thoi .................................................19
Hnh 1.10: Vi th BMTH dng t bo biu m .................................................19
Hnh 1.11: Nhum ha m min dch .....................................................................20
Hnh 1.12: Ct thc qun kiu Ivor Lewis ..............................................................27
Hnh 1.13: Phu thut Merendino ...........................................................................27
Hnh 1.14: Phu thut ct BMTH d dy hnh ch V ....................................29
Hnh 1.15: Cng thc ha hc ca Imatinib mesylate .............................................33
Hnh 1.16: C ch hot ng ca Imatinib ..............................................................34
Hnh 3.17: CT Scan BMTH d dy.................................................................66
Hnh 4.18: Hnh nh siu m BMTH rut non .............................................109
Hnh 4.19: Hnh nh siu m qua ni d dy .........................................................110
Hnh 4.20: Ni soi d dy ......................................................................................111
Hnh 4.21: Vin nang ni soi ................................................................................112
Hnh 4.22: BMTH rut non (ni soi bng vin nang) ..................................112
Hnh 4.23: X quang d dy cn quang ...................................................................113
Hnh 4.24: Chp ct lp vi tnh BMTH rut non .........................................116
Hnh 4.25: Phu thut ct BMTH d dy ......................................................118
Hnh 4.26: Nhum ha m min dch cho thy biu l qu mc th th CD117..124
DANH MC CC BIU , S
trang
Biu 3.1: Phn b bnh nhn theo ch s ECOG ...............................................63
Biu 3.2: V tr BMTH d dy ...................................................................72
Biu 3.3: V tr BMTH rut non ................................................................72
Biu 3.4: V tr BMTH i trng ...............................................................73
Biu 3.5: V tr BMTH trc trng ..............................................................73
Biu 3.6: T l sng cn ton b ........................................................................83
Biu 3.7: T l SCTB i vi bnh nhn c phu thut trit ....................86
Biu 3.8: T l SCKBTP i vi bnh nhn c phu thut trit ................87
Biu 3.9: T l SCTB i vi bnh nhn c phu thut tm b .....................89
Biu 3.10: T l SCKBTT i vi bnh nhn c phu thut tm b .............90
Biu 3.11: nh hng ca gii tnh n t l sng cn ton b .........................92
Biu 3.12: nh hng ca tui n t l sng cn ton b ................................93
Biu 3.13: nh hng ca ch s ECOG n t l sng cn ton b ................94
Biu 3.14: nh hng ca kch thc bu n t l sng cn ton b ...........95
Biu 3.15: nh hng ca s phn bo/50 QTL n t l sng cn ton b ....96
Biu 3.16: nh hng ca v tr bu n t l sng cn ton b .....................97
Biu 3.17: nh hng ca nhm nguy c ti pht n t l sng cn ton b...98
Biu 3.18: nh hng ca mc phu thut n t l sng cn ton b ........99
Biu 3.19: nh hng ca nhm nguy c ti pht trong bnh nhn c phu
thut trit i vi t l sng cn khng bnh ti pht .......................................100
S 2.1: Quy trnh nghin cu bu m m ng tiu ha ti bnh vin Ung
Bu TP. H Ch Minh.............................................................................................46
S 3.2: S iu tr bu m m ng tiu ha ti bnh vin Ung Bu TP.
H Ch Minh .............................................................................................................58
T VN
Bu m m ng tiu ha (BMTH) l cc bu xut pht t trung m
ng tiu ha hoc him hn l t cc m mm trong bng [72].
Thut ng bu m m ng tiu ha (GastroIntestinal Stromal Tumor:
GIST) c Mazur v Clark s dng u tin nm 1983 [70]. Nhng phi n u
th k XXI, loi bu ny mi c nhn bit rng ri [72]. Nm 1998, hai tc gi
Kindblom v Hirota [80] xc nh t bin gen sinh ung c-KIT trong cc t bo
BMTH.
Nm 2002, cc cng trnh nghin cu chng minh hiu qu ca Imatinib,
mt thuc c ch tyrosine kinase chn lc u tin, trong iu tr BMTH v
thuc ny c C quan Qun l Thc phm v Dc phm Hoa K (FDA)
chp thun. Trc thi gian ny, BMTH thng c chn on l bu c
trn, sarcm c trn hoc bu nguyn bo c trn ca ng tiu ha. Tuy nhin
nhng pht trin v m bnh hc ngy nay chng t BMTH l mt loi bu
khc vi cc loi bu c trn [38], [70], [72].
BMTH xut ngun t t bo k Cajal. Cc t bo ny nm trong m ri
Auerbach (m ri c rut) ca ng tiu ho chu trch nhim iu khin nhu
ng rut [70], [72].
BMTH c th gp bt k v tr no ca ng tiu ho, trong khong
60% BMTH gp d dy, 25% gp rut non, 10% i trng v trc trng.
S t cn li nm ri rc trong cc v tr khc ca ng tiu ho nh ti mt, rut
tha, mc ni ln, hay mc treo rut. Trong khi , BMTH ch chim khong
2% bu d dy, 14% bu rut non v ch 0,1% bu i trng [38].
Trc y, phu thut l phng php iu tr ch yu cho BMTH, vi t
l sng cn ton b 5 nm thay i trong khong t 40% n 55% sau khi ct b
c hon ton khi bu [50], [137]. Ho tr v x tr t c vai tr trong iu tr
BMTH [48], [126]. Hin nay vi s pht trin ca liu php nhm trng ch, s
dng cc thuc iu tr nhm trng ch nh Imatinib cho thy c hiu qu tt i

vi BMTH xm nhp v ngay c cc trng hp c di cn [73], [91].
Vic chn on BMTH cn c thc hin ti cc c s y t c trang b
y cc k thut xt nghim gii phu bnh cng nh ha m min dch v c
cc bc s gii phu bnh nhiu kinh nghim. Ngoi ra, vic iu tr cng cn c i
ng bc s chuyn khoa ung bu c tay ngh cao v phu tr v ha tr, ng thi
cn c ngun thuc nhm trng ch. V th, ti Vit Nam, c rt t bnh vin hi
cc iu kin v chn on v iu tr BMTH.
T nm 2001, bnh vin Ung Bu TP H Ch Minh pht trin k thut
ho m min dch trong chn on mt s bnh ung th, trong c BMTH.
Ngoi ra, t nm 2005, bnh vin Ung Bu TP. H Ch Minh cn l mt trong s
t c s y t c la chn trin khai chng trnh ti tr thuc Imatinib cho bnh
nhn iu tr BMTH (chng trnh GIPAP, VPAP) nn nhiu bnh nhn c
c hi s dng thuc Imatinib. Do , bnh vin Ung Bu TP. H Ch Minh c
kh nng chn on v iu tr hiu qu bnh l him gp ny. V th, ngy cng
c nhiu bnh nhn BMTH c nhp vin hoc c cc bnh vin khc
chuyn n bnh vin Ung Bu TP. H Ch Minh.
Vi cc phng tin v li th k trn, kt qu chn on v iu tr bu
m m ng tiu ha ti bnh vin Ung Bu TP. H Ch Minh nh th no?
Nhng yu t no c ngha tin lng i vi bnh nhn BMTH ti bnh vin
Ung Bu TP. H Ch Minh? Chng ti chn nghin cu ti ny nhm mc ch
tr li cc cu hi trn nhm rt ra nhng kinh nghim thc tin gip ch cho cc
bc s khc trong thc hnh lm sng loi bnh him gp nhng c tin lng tt
hn cc loi ung th biu m ca ng tiu ha.
MC TIU NGHIN CU CA LUN N

1- Kho st cc yu t lin quan n chn on bu m m ng tiu ha
ti bnh vin Ung Bu TP. H Ch Minh.
2- nh gi cc yu t lin quan n iu tr bu m m ng tiu ha.
3- Xc nh cc yu t tin lng lin quan n sng cn.
Chng 1 TNG QUAN TI LIU

1.1- CU TO CA THNH NG TIU HA V T BO K CAJAL
1.1.1- Cu to ca thnh ng tiu ha
Thnh ng tiu ha c 5 lp, t ngoi vo trong bao gm [8]:
- Lp thanh mc: nm ngoi cng, thuc l tng ca phc mc.
- Lp di thanh mc: l mt t chc lin kt rt mng
- Lp c: T ngoi vo trong gm c lp c dc ngoi v lp c vng trong.
Ring d dy cn c lp c cho, y l mt lp khng hon ton, chy vng
quanh y v v i cho xung di v pha b cong ln.
- Tm di nim mc: l t chc lin kt rt lng lo nn d b x y.
- Lp nim mc: lt mt trong ca thnh ng tiu ha.
Thanh mc
C dc
C vng
Di nim mc
Nim mc
Hnh 1.1: Cu trc thnh ng tiu ha

Ngun: http://www.sciencephoto.com/media/309981/view
1.1.2- T bo k Cajal
T bo k Cajal l loi t bo c bit nm gia lp c dc v c vng ca
thnh ng tiu ha, c Santiago Ramn y Cajal [16] m t u tin vo th k
XIX. Mc d cc t bo k Cajal ch chim khong 5% cc t bo c nim ng
tiu ha nhng chng c vai tr quan trng trong vic iu ha chc nng c trn
v nhu ng ng tiu ha. CD117 l mt th th glycoprotein xuyn mng t bo,

c vai tr quan trng trong s pht trin v trng thnh ca t bo k Cajal.
Lp nim mc
Lp di nim
Lp c
T bo k Cajal
Hnh 1.2: T bo k Cajal

Ngun: Bassotti G. et al, 2007 [16]
Tng t nh cc loi t bo khc, t bo k Cajal cng b tn thng do

vim, do tui tc, Cc tc ng ny c th lm gim s lng t bo, ph v cu
trc v chc nng t bo, lm nh hng n nhu ng ng tiu ha. t bin
gen c-KIT c th lm t bo k Cajal tng sn, thm ch chuyn dng, pht trin
thnh bu m m ng tiu ha.
- Cht nh du t bo k Cajal
+ CD117:
Ch n khi khm ph ra th th c-KIT (CD117) th ngi ta mi nhn din
ra t bo k Cajal. CD117 l mt tyrosine kinase, c bn cht l mt th th
glycoprotein xuyn mng c phn t khi l 145 kD. y l thnh vin trong h cc
th th tyrosine kinase typ III. CD117 c lin quan n yu t tng trng c ngun
gc tiu cu. CD117 hot ng nh l th th ca yu t t bo gc, vi vai tr l
mt cu ni. Bnh thng, CD117 l mt n phn t mng t bo. Nh vo s

gn kt vi yu t t bo gc ca CD117, hin tng nh trng phn xy ra lm
CD117 t hot ha qua qu trnh phosphoryl ho t ng ca phn tyrosine cn li.
Hin tng ny kch hot ng dn truyn tn hiu ni bo, lm t bo tng
trng v pht trin. Mt s t bin gen c-KIT c th gy ra s chuyn dng t bo
v hot ha yu t t bo gc lm hot ha kinase v pht trin thnh ung th [45],
[72].
Hnh 1.3: Cu trc ca th th c-KIT v th th PDGFRA

Ngun: Joensuu H. et al, 2103 [72]
+ CD34:
Ngoi CD117, cht nh du t bo k Cajal t c hiu khc l CD34. CD34
l mt glycolprotein xuyn mng, c phn t khi l 34 kD. y cng l mt cht
nh du i vi t bo biu m, t bo to huyt v nguyn bo si [16].
+ CD44:
Mt cht nh du khc i vi t bo k Cajal l th th CD44. y cng l
mt th th glycoprotein xuyn mng, c cc bu v t bo gc trung m [16].
+ DOG-1:
DOG-1 l mt protein c chc nng cha r nhng c biu l cao trong
BMTH. Mt s nghin cu cho thy DOG-1 c t l dng tnh cao hn 13% so
vi CD117 trong BMTH. Do DOG-1 cho thy c nhy v c hiu hn
CD117 trong BMTH [86], [133].
Cc cht nh du khc i vi t bo k Cajal l th th Vimentin, Actin,
PDGFRA, [46].
1.2- LCH S NGHIN CU BU M M NG TIU HA
Lc u, theo quan im ca Stout v cng s nu ra nm 1940, bu m
m ng tiu ha c gi l bu t bo c trn. Quan im ny c chp
nhn rng ri nhng n thp nin 1970, nh c knh hin vi in t cc nh khoa
hc thy iu ny khng ng na [92].
Nm 1980, nh ha m min dch ngi ta thy bu khng phi c ngun
gc t t bo c trn m l t t bo k Cajal trong thnh ng tiu ha [92].
Nm 1983, c tc gi l Mazur v Clark; ri nm 1984, c Schaldenbrand v
Appleman ln u tin t tn l bu m m (stromal tumor). Tuy nhin
quan im ny cng b lu m [70], [72].
Nm 1989, BMTH c gi l bu thn kinh t ng ng tiu ha
(Gastrointestinal autonomic nerve tumors - GANT). Lc ny, trong y vn c rt
nhiu ln ln v BMTH.
Nm 1994, ngi ta thy cc bu thn kinh t ng ng tiu ha dng
tnh vi CD34. y l cht nh du u tin cho BMTH trong gia thp nin
1990. T cc nh khoa hc cho rng BMTH khi ngun t t bo k Cajal
tc t bo thn kinh ni ti trong thnh ng tiu ha (trong m ri thn kinh
Auerbach iu khin nhu ng rut) (hnh 1.2) c c 2 cu trc: c trn v thn
kinh. Cng thi gian ny cc nh khoa hc thy t bo k Cajal c iu khin bi
t bo gc qua trung gian th th CD117. Tuy nhin, vn cn m h v quan im

[72].
Mi n nm 1998, Hirota v cng s [80] mi khm ph ra hin tng t
bin ca gen c-KIT cng nh protein KIT trong BMTH. Khm ph ny m u
cho liu php nhm trng ch trong ung th vi thuc STI-571 (Imatinib mesylate)
trong vic iu tr BMTH.
Thng 3 nm 2002, C quan Qun l Thc phm v Dc phm Hoa K
chp thun cho dng Imatinib trn ngi iu tr bnh bch cu mn dng ty v
BMTH. Nm 2003, Heinrich v cng s ri nhm nghin cu ca Hirota tm ra
th th PDGFRA. Ngy 26/01/2006, Sunitinib l th h 2 ra i dng khi
Imatinib tht bi. Nm 2011, mt loi thuc nhm ch th h th ba ra i, l
Regorafenib. Ngy nay li c thm cc thuc mi na [3], [4], [31].
Ti Vit Nam, thut ng Gastrointestinal Stromal Tumor ng ra c
dch l Bu m m d dy-rut. Tuy nhin, do thi quen v c nhiu ngi
s dng nn ngy nay thut ng trn c dch l Bu m m ng tiu ha.
1.3- CHN ON
1.3.1- Dch t hc
1.3.1.1- Tn sut mc bnh
Tn sut mc bnh thc s ca BMTH hin nay cha c xc nh r
rng. c tnh tn sut mc bnh trn ton th gii l 1,1 -1,4/100.000 dn [112].
Theo s liu ghi nhn qun th ti Phn Lan, tn sut mc bnh hng nm ca
BMTH l khong 1-2 trng hp/100.000 dn [73]. Thy in, theo
Kindblom v cng s [80] th t l ny l 2 trng hp/100.000 dn. Theo ghi nhn
ca Jean M. Coindre [116], Php hng nm c khong 150 n 300 trng hp
mi c chn on, con s ny Anh [73] l t 500 n 1000 bnh nhn; tuy
nhin, s liu ny c th cha c nh gi y lm. Theo cc s liu ghi nhn
ti M c khong 150 trng hp BMTH mi c chn on hng nm [73],

[125].
Ngi ta cho rng tn sut mc bnh ny ny cha phn nh ng thc t v
hai l do:
(1) Hu nh tt c cc bu c kch thc nh thng b b st v khng
c a vo s liu ghi nhn ung th;
(2) Trc y, BMTH thng c chn on l bu c trn thc s
hoc n gin l mt loi sarcm c trn [73], [91].
1.3.1.2- Gii tnh
T l mc bnh nam gii khng khc bit nhiu hoc ch hi cao hn so
vi n gii [73], [135]. Nhng c mt s tc gi khc cho rng t l mc bnh
nam gii tri hn hn n gii, vi t l l 2:1 [89], [113].
BMTH trc trng c khuynh hng ni tri nam gii hn nhiu so
vi n gii, t l ln lt l 71% v 29% [92], [113].
1.3.1.3- Tui mc bnh
Cc nghin cu cho rng bu m m ng tiu ha phn ln xy ra
bnh nhn tui t 50 n 70 tui, trung bnh l 60 tui [73], [99]. Tuy nhin, bnh
c th gp bt k la tui no, t nh nhi cho n ngi gi, bnh t gp ngi
di 40 tui v rt him gp tr em [73]. Ty theo v tr sang thng, tui mc
bnh c th thay i.
* BMTH thc qun: c khuynh hng xy ra bnh nhn tui tr hn so vi
cc v tr khc trn ng tiu ha, trung bnh l 35 tui [125].
* BMTH d dy: tui trung bnh l 63 tui. Ch c 2,7% BMTH xy ra
trc 21 tui v 9,1% trc 40 tui [94].
* BMTH rut non: nhiu thng k cho thy tui hay gp ca BMTH rut
non thng tr hn cc v tr khc (tr thc qun), tui trung bnh l 55 tui [37].
10
* BMTH i trng: la tui thng gp l vo khong 60 tui [76].

* BMTH trc trng: thng xy ra bnh nhn la tui t 50 n 60 tui,
him khi gp bnh nhn di 40 tui [83].
1.3.2- V tr bu
BMTH ch chim t l t 0,1% n 3% ca tt c cc loi bu c tnh
ng tiu ha [44], [65]. Nhng BMTH li l loi bu hay gp nht trong cc
bu xut pht t trung m ng tiu ha v chim t l khong 80% [5], [50],
[53].
BMTH c th xut hin bt k v tr no trn ng tiu ha, nhng
thng gp nht l d dy vi t l t 60% n 70%; k n l rut non, chim t
20% n 30%. Cc on cn li ca ng tiu ha th him gp hn, thc qun ch
chim khong 3%; i - trc trng chim khong 10% [93], [125], [126]. BMTH
cng c th gp ngoi ng tiu ha, trong xoang bng nh mc ni, mc treo,
ti mt, ty, hoc sau phc mc nhng vi t l rt thp [40], [44], [114].
< 3%
60%
20 -30%
5%
5%
Hnh 1.4: Phn b BMTH trn ng tiu ha

Ngun: Foo WC et al, 2012 [54]
-
BMTH thc qun rt him, ch chim di 3%; cc bu trung m v

tr ny a s l loi bu c trn lnh tnh [93].
11
BMTH d dy chim t l cao nht (60%-70%), nhng ch chim 2,2%

trong tt c cc loi bu c tnh d dy [129].
BMTH rut non ng th hai sau d dy vi t l t 20% - 30%. N

chim 13,9% trong tt c cc loi bu c tnh rut non [129]. Nhiu cng
trnh nghin cu cho thy bu hay gp nht l hng trng; k n l hi
trng; v cui cng l t trng, ngi ta nhn thy bu on D2 t trng
thng gp hn cc on khc; ngoi ra cng c khong 1-2% BMTH
xut hin trong ti tha Meckel [116].
BMTH i trng tng i him gp, ch khong 5%. BMTH ch

chim 0,1% cc loi bu c tnh i trng [76], [129].
BMTH trc trng chim khong 5%. Bu c th gp bt k ni no

trong trc trng t ng lt cho n hu mn [83].
1.3.3- Triu chng lm sng

Khong 70% BMTH l c triu chng lm sng, 20% trng hp
BMTH khng c triu chng v c pht hin tnh c; 10% cn li ch c
chn on khi t thit [17], [112].
Triu chng lm sng ca BMTH biu hin ty thuc vo kch thc,
cch thc pht trin v v tr ca bu trn ng tiu ha.
BMTH thng khng c triu chng cho n khi t n mt kch thc
ln; lc , c th c cc triu chng nh xut huyt, au bng, kh tiu, s thy
bu trn lm sng, tc nghn, hoc c bin chng thng tng rng gy bnh l
bng cp hoc cc triu chng ca tnh trng mt mu cp hoc mn tnh
Bu kch thc nh thng khng c triu chng lm sng hoc triu
chng rt m h. a s cc trng hp ny c chn on mt cch tnh c trong
lc phu thut do mt bnh l c quan khc nh ti mt, ph khoa hoc c pht
hin trong lc ni soi ng tiu ho v mt l do khc hoc tnh c c pht hin
trn X quang. i khi, BMTH thc qun c pht hin trn phim X quang
12
ngc thng quy. Cc trng hp bu nh trc trng c th c pht hin

trong khi khm tm sot ung th tin lit tuyn nam gii hoc trong khi khm ph
khoa n gii [92].
1.3.4- Cn lm sng
1.3.4.1- Siu m
Siu m bng thy hnh nh mt khi bu ln trong thnh ng tiu ha
hay di thanh mc gi BMTH, c bit khi bu c nhiu thy, bn trong c
vng echo trng do tnh trng hoi t v ha nang nhiu ch [126]. Siu m cn
gip nh gi tnh trng di cn trong bng [12].
Hnh 1.5: Hnh nh siu m BMTH rut non

Ngun: http://radiopaedia.org/cases/gastrointestinal-stromal-tumour-1
Gn y, ngi ta ng dng siu m ni soi chn on phn bit

BMTH vi cc thc th khc nh bu c trn, sarcm c trn ca ng tiu
ha. Trn hnh nh siu m BMTH c mt echo km, c vin halo xung
quanh, mt phn m hi tng hn lp c nim v sarcm ca c trn. Ngoi ra
n cn c th biu hin di dng nang. Okai v cng s [125] cho rng khi c cu
trc phn m km i i vi hin tng canxi ha th ch thy trong BMTH.
Hnh nh nhiu thy cng gi kh nng BMTH c tnh. Davila v Faigel [119]
13
cho rng khi c hai trong ba triu chng: hnh nh dng nang, c im phn m
km, hnh nh bu nhiu thy bt thng, th lm gia tng nhy ca siu m ni
soi ln n 80%-100% trong vic pht hin bu c tnh [119], [125]. Kai Fu v
cng s [57] tin hnh chc ht t bo bng kim nh (FNA) di hng dn ca
siu m ni soi cho 10 trng hp, kt qu l c 8/10 trng hp cho chn on xc
nh l BMTH ph hp vi chn on gii phu bnh sau m [57].
Hnh 1.6: Hnh nh siu m qua ni soi BMTH t trng

Ngun: Fu K. et al, 2002 [57]
1.3.4.2- X quang ng tiu ha c cn quang
- D dy: C th thy c hnh nh bu nm bn trong, v tr ca bu trong d
dy cng c gi tr trong nh gi c tnh ca n.
- Rut non: kh xc nh c v tr bu.
- i trc trng: gip nh gi v tr, mt s c tnh ca bu [90].
1.3.4.3- Ni soi tiu ha
Ni soi c th pht hin c cc tn thng di nim mc ng tiu
ha trn v di. Nhng sinh thit qua ni soi chn on xc nh thng b hn
ch v bu nm su di nim mc; do vy, khng th ly lng m cn thit
cho chn on gii phu bnh chnh xc. Ch c 50% tn thng ny c chn
on xc nh m bnh hc trc phu thut [119], [126]. i vi rut non th ni
soi kh c th vi ti c.
14
1.3.4.4- Chp ct lp vi tnh

Chp ct lp vi tnh vng bng gip xc nh v tr gii phu v nh gi
mc lan rng ca bu nguyn pht, xc nh tnh trng xm ln cc cu trc
xung quanh, tnh trng di cn trong bng hoc di cn gan. Hnh nh trn ct lp vi
tnh thay i ty kch thc ca tn thng. Ghanem v cng s [119] nhn thy
BMTH kch thc nh th c ranh gii r rng, bu c khuynh hng pht
trin nh vo lng rut, mt ng nht c hai th, c v khng c tng tng
phn. Ngc li, khi bu c kch thc ln th ranh gii khng r rng, bu pht
trin hng ra ngoi thnh rut, v mt khng ng nht. Cc du hiu biu hin
tnh trng xm ln ca BMTH c tnh bao gm: hin tng canxi ha, lot, hoi
t, c nhiu nang bn trong bu, d, di cn, bng bng, v cc du hiu thm
nhim. Tuy nhin, hnh nh ct lp vi tnh khng th phn bit c tnh trng vim
dnh v tnh trng dnh vo cc c quan ln cn do bu n lan. Cng kh c th
pht hin c cc di cn phc mc c ng knh di 2 cm [119].
Hnh 1.7: Chp ct lp vi tnh BMTH d dy

vi hnh nh ha nang, hoi t
Ngun: Choi H et al, 2007 [29]
1.3.4.5- Chp cng hng t
Chp cng hng t c th gip xc nh cc c im, xp giai on v
nh gi s p ng iu tr ca BMTH. Cc hnh nh p ng ca bu vi
15
iu tr nhm trng ch bao gm: nhng thay i hyaline nhy, s ha si v hoi

t xut huyt. u im ca chp cng hng t l c th nh gi tnh trng tng
sinh mch mu trong chn on cng nh trong khi theo di p ng iu tr ca
BMTH [90].
1.3.4.6- Chp ct lp pht x psitron
Nm 2004, tc gi H. Choi nhn thy cc thng tin t hnh nh chp ct
lp vi tnh a lt v hnh nh ct lp pht x psitron b sung cho nhau trong
vic nh gi p ng iu tr [15], [90].
Ngy nay, chp ct lp pht x poositron l mt cng c chn on cn thit
nhm nh gi lm sng v theo di iu tr BMTH. Chp ct lp pht x
psitron c nhy cao trong vic pht hin sm p ng iu tr nhm trng ch
ca BMTH v c bit hu hiu trong vic theo di tnh trng di cn xa [12],
[90].
1.3.5- Di cn xa
V tr di cn thng gp nht ca BMTH l gan v phc mc, t khi n
phi v rt him cho di cn xng, hch bch huyt [40], [91].
Nh vy kiu cch di cn ca BMTH tng t sarcm ng tiu ha v
sarcm phn mm, vi u th l gieo rc theo ng mu, t lan trn theo ng
bch huyt.
1.3.6- Xp giai on
Hin ti cha c mt h thng xp giai on no c thng nht i vi
BMTH. H thng xp giai on TNM theo Hip hi Quc t chng Ung th
(UICC) ln th 7 (2010) [123] nh sau:
16
T: Bu nguyn pht
TX: Khng th nh gi c bu nguyn pht.
T0: Khng thy bu nguyn pht.
T1: Bu 2 cm.
T2: Bu > 2 cm v 5 cm
T3: Bu > 5 cm v 10 cm
T4: Bu > 10 cm
N: Hch vng
NX: khng nh gi c hch vng
N0: khng di cn hch vng
N1: di cn hch vng
Lu : BMTH him khi di cn hch vng, v vy trong trng hp khng nh
gi c hch vng trn lm sng v trn gii phu bnh th nn xp l N0
M: Di cn xa
M0: Khng c di cn xa.
M1: Di cn xa.
G: Grad m hc
Grad m hc trong BMTH ph thuc vo t l phn bo
T l phn bo thp: 5 phn bo/50 QTL
T l phn bo cao: > 5 phn bo/50 QTL
17
Bng 1.1: Xp giai on BMTH theo UICC ln th 7 (2010) [123]

Kch thc bu
Phn bo/50 QTL
(cm)
BMTH
BMTH
d dy
ngoi d dy
2 cm
IA
> 2-5 cm
IB
> 5-10 cm
IC
II
> 10 cm
II
IIIA
2 cm
>5
II
IIIA
> 2-5 cm
>5
II
IIIB
> 5-10 cm
>5
IIIA
IIIB
> 10 cm
>5
IIIB
IIIB
Lu : xp giai on cc bu trn y c gi tr khi N0 v M0. Tt c bu di

cn hch hoc di cn xa u c xp l giai on IV
1.3.7- Gii phu bnh

c rt nhiu gi thuyt v ngun gc ca BMTH nhng hin nay gi
thuyt c nhiu nh khoa hc chp nhn nht l BMTH xut ngun t t bo
k Cajal, l cc t bo sinh ra t l phi gia, nm trong thnh ng tiu ha, c chc
nng nh mt t bo lm ch nhp chu trch nhim iu khin nhu ng rut.
Mt trng hp c chn on xc nh l BMTH khi kt qu ha m min
dch cho thy dng tnh vi CD117. Tuy nhin, mt s tc gi vn xp cc trng
hp CD117 m tnh nhng c hnh nh m bnh hc ging BMTH v khng
cho thy bit ha r loi bu no cng thuc BMTH [54]. Bn cnh CD117
BMTH cn dng tnh vi CD34, SMA, S100 nhng vi t l thp hn.
1.3.7.1- Hnh nh i th
Hu ht cc trng hp BMTH u c v bao, n c, khi trn hoc
bu dc, hoc c nhiu thy [10], [94]. Mt ct c mu sc thay i ty bu, mu
18
nu-hng, hi vng, trng-xm, trng hi cam, c hnh nh nhiu ng vin do vt

mu ca xut huyt. Mt thay i c th chc trong cc bu nh, lnh tnh;
mm nh tht c hoc sn st trong cc bu c tnh. Cc bu ln c th c cu
trc hnh qu t hai u, mt nh vo trong lng rut, mt hng ra ngoi thanh
mc, v thng km nhng vng lot, xut huyt, hoi t trung tm, ha nim hay
thoi ha nang [10], [94], [114].
Hnh 1.8: i th BMTH rut non

Ngun: Joensuu H et al, 2013 [72]
1.3.7.2- Hnh nh vi th
Ch yu ca BMTH i trng v rut non l bao gm nhng t bo
hnh thoi, to b. Nhng t bo hnh thoi ny kch thc a dng, him phn bo v
c. Nhng dy si - mch mu c th hin din to thnh .
Hnh nh vi th BMTH cho thy c 70% trng hp l loi t bo hnh
thoi, 20% trng hp l loi t bo dng biu m v 10% l loi hn hp [54], [84].
19
Hnh 1.9: Vi th BMTH loi t bo hnh thoi

(Ngun: Foo WC, 2012 [54])
Hnh 1.10: Vi th BMTH loi t bo dng biu m

Ngun: Foo WC, 2012 [54]
Nhng cu trc dng biu m t gp nhng c th c t trng v c th bo

hiu mt din tin c tnh. i khi nhng bu ny c nn m m ch yu ha
nim v mt s rt him trng hp c hnh nh t bo nhn do tch t Glycogen
ch khng phi cht nhy. Mt s bu ca i trc trng c hnh thi ca mt
bu c trn thc qun kinh in hay mt bu c trn d dy giu t bo. Nhng
tn thng trc trng c th hin din nh mt polyp nh, do xut pht t lp c
nim [94].
20
1.3.8- Ha m min dch

Khong 75% - 80% BMTH c t bin gen c-kit, in hnh l v tr cn
mng, c exon 11 m ha. Khong 10% - 15% BMTH c t bin gen
PDGFRA, khong 5% - 15% khng c t bin c hai gen ny v c gi l
BMTH loi t nhin [38], [72]
Hnh 1.11: Nhum ha m min dch cho thy biu l qu mc ca CD117

Ngun: Foo WC, 2012 [54]
Ngoi CD117, khong 60 70% BMTH c biu hin CD34, 20 40% c
dng tnh min dch vi actin c trn. Mc d BMTH him khi biu hin
Desmin (<2%) hoc S100 (<5%), v s biu hin 2 loi protein ny cng khng lm
thay i kt cc khi s dng Imatinib mesylate.
Mt s nghin cu cho thy DOG-1 c t l dng tnh trong BMTH cao
hn CD117. DOG-1 cho thy c nhy v c hiu hn CD117 trong
BMTH [86], [133].
1.3.9- Chn on xc nh
CD117 c xem l du n cha kho mang tnh xc nh. Tuy nhin, CD117
li khng c hiu cho BMTH. CD117 cng c th biu hin trong t bo gc
hng cu, trong dng bo, t bo mm v t bo k Cajal. BMTH v t bo k
Cajal u c pht hin vi khng th khng CD34 v CD117, gi rng
BMTH bt ngun t cc t bo k Cajal. Khng phi tt c bu dng tnh vi
21
CD117 u l BMTH. CD117 cng gp trong nhiu loi bu nh sarcm nt

xoang, sarcm c vn, sarcm mch mu, sarcm Ewings, lymphm loi t bo
ln, glima, bu t bo mm, mlanm, bu si, sarcm t bo ht, Chn
on BMTH cn phi da thm vo hnh thi bu, chn on hnh nh v c
im lm sng [38], [72].
1.3.10- Chn on phn bit
V mt ha m min dch, BMTH cn phi phn bit vi bu c trn,
bu v bao thn kinh, v bu si. Cc bu c trn thng biu hin desmin v
actin c trn, hn na ho m min dch cc loi bu ny khng pht hin CD117.
Khong 10 35% bu c trn c biu hin CD34. Bu v bao thn kinh c ho
m min dch dng tnh vi S100 v m tnh vi CD117, nhng c th biu hin
CD34 khu tr. Bu si c th biu hin CD117, nhng khng biu hin CD34
[38].
Bng 1.2: Mt s chn on phn bit vi BMTH [92]
CD117
CD34
Nestin
SMA
Desmin
S100
GFAP
BMTH
+/-
/+
/(+)
/(+)
Bu c trn
/(+)
/(+)
+/()
bo
/(+)
khng
/(+)
Sarcm c trn
Bu
Schwan
Sarcm
bit ha
1.3.11- Cc yu t nguy c ti pht
c im m bnh hc thng c dng nht d on s xm ln ca
bu l kch thc bu v ch s phn bo. Cc tc gi ngh chia BMTH
thnh cc nhm nguy c ti pht rt thp, thp, trung bnh v cao da trn s nh
gi v kh nng ti pht v di cn xa [58].
22
Nghin cu ti Trung tm Ung th M.D. Anderson cho thy bu c kch

thc < 5 cm th c thi gian sng cn khng bnh trung bnh l 36 thng, di hn
nhm c bu 5 10 cm l 19 thng, v nhm >10 cm l 17 thng [38].
- nh gi nhm nguy c:
Theo xp loi ca Vin Y T Quc gia (VYTQG) Hoa K (nm 2002) [93],
da vo kch thc bu v s phn bo trn 50 quang trng ln (QTL),
BMTH c chia cc nhm nh sau:
Bng 1.3: Phn nhm nguy c ti pht BMTH theo VYTQG Ha K [93]
Nhm nguy c
Rt thp
Thp
Trung bnh
Kch thc bu
2 cm
2,1 5 cm
S phn bo/50 QTL

5
5
6 10
5 cm
5,1 10 cm
5
Cao
> 5 cm
>5
> 10 cm
Bt k s phn bo
Bt k kch thc
> 10
Nm 2008, VYTQG Hoa K ngh bng b sung phn nhm nguy c
nh sau [26], [68], [72]:
Bng 1.4: Phn nhm nguy c theo tiu chun b sung ca VYTQG Hoa K:
Rt thp
Thp
Trung bnh
Cao
Kch thc bu
(cm)
2
2,1 5
5
5,1 10
Bt k kch thc
> 10
Bt k kch thc
>5
5
5,1 10
S phn bo/50
QTL
V tr bu nguyn
pht
5
5
6 10
5
Bt k v tr
Bt k v tr
D dy
D dy
Bt k s phn bo
Bt k s phn bo
> 10
>5
6 10
5
V bu
Bt k v tr
Bt k v tr
Bt k v tr
Ngoi d dy
Ngoi d dy
23
H thng phn loi ca VYTQG Hoa K b sung c nhiu ng h t cc

nghin cu trn BMTH nguyn pht ti pht. Nilson (2005) [102] thu thp d
liu trn tt c cc trng hp BMTH Thu in t 1983 n nm 2000. Kt
qu thu c khng c trng hp no ti pht nhm nguy c rt thp, 2,4% ti
pht nhm nguy c thp, 1,9% nhm nguy c trung bnh v 62,5% ti pht
nhm nguy c cao. Mt nghin cu tng t cng c thc hin Iceland trong
giai on 1990 2003 [130], khng c trng hp no nguy c rt thp v nguy c
thp ti pht, 20% ti pht nhm nguy c trung bnh v 46% ti pht nhm nguy
c cao. Cc nghin cu ny khng nh vai tr ca bng phn loi VYTQG b sung.
Cc nghin cu khc khng trc tip nh gi hiu qu ca bng phn loi, nhng
cng khng nh yu t kch thc bu v t s phn bo l yu t d bo quan
trng cho ti pht hoc di cn [130].
Vin Bnh hc Qun i (VBHQ) Hoa K nh gi nhm nguy c da
trn 3 yu t: kch thc bu, s phn bo trn 50 QTL v v tr bu; v t
nguy c bnh tin trin theo cc yu t ny (Bng 1.5) [35].
Bng 1.5: Phn nhm nguy c ti pht BMTH theo VBHQ Hoa K [35]
S phn
Kch
bo/50
thc
QTL
bu
>5
Nguy c tin trin bnh

D dy
T trng
Hi/hng
i-trc
trng
trng
2 cm
Khng (0%)
Khng (0%)
Khng (0%)
Khng (0%)
> 2 5 cm
Rt thp (1,9%)
Thp (8,3%)
Thp (8,3%)
Thp (8,5%)
> 5 - 10 cm
Thp (3,6%)
Trung bnh (24%)
KDK*
KDK*
> 10 cm
Trung bnh (10%)
Cao (52%)
Cao (34%)
Cao (57%)
2 cm
Khng
KDK
KDK*
Cao (54%)
2 5 cm
Trung bnh (16%)
Cao (73%)
Cao (50%)
Cao (52%)
> 5 - 10 cm
Cao (55%)
Cao (85%)
KDK*
KDK*
> 10 cm
Cao (86%)
Cao (90%)
Cao (86%)
Cao (71%)
* KDK: khng d kin nh gi.
24
Gn y, Gold v cng s [87] ngh mt ton nh gi nguy c

bnh tin trin trong BMTH. Mi bu c cho im s trn mt thang im
da vo v tr bu (d dy, rut non, i trc trng, thc qun, ngoi ng tiu
ha), kch thc bu, v ch s phn bo ( 5 hay > 5 phn bo/50 QTL). Tng s
im s c lng t l sng cn khng bnh ti pht 2 nm v 5 nm.
Ch s Ki-67 cao, biu hin nhiu ca Bcl-2, p53, yu t tng trng ni
mch, p15, v protein c-Myc thng c lin h vi tin lng xu [18], [87]. t
bin gen c-KIT c vai tr tin lng nh th no vn cn ang tranh ci. Tuy nhin,
cc nghin cu cho thy t bin trn exon 9 thng khng p ng vi liu
imatinib thng thng v c tin lng xu [35].
1.3.12- Cc hi chng i km vi BMTH
- BMTH c tnh gia nh:
Bnh di truyn tnh trng tri trn nhim sc th thng. t bin xy ra
gen c-KIT trn v tr exon 8, 11, 13 v 18. Bnh thng xy ra trn tt c thnh vin
trong gia nh, u c CD117 (+). Bnh nhn b BMTH gia nh thng c tui
mc bnh tr hn, khong tui 18 [72], [92].
- Hi chng von Recklinghausen:
Von Recklinghausen tp I l bnh l c xut 1/3000 tr cc nc
phng Ty. Bin chng trn ng tiu ha ca n thng xy ra vo khong tui
trung nin ca bnh nhn. Kh nng gy bin chng trn ng tiu ha ca mt
bnh nhn von Recklinghausen tp I thay i t 12% n 60%.
Khi xy ra trn bnh nhn von Recklinghausen tp I th BMTH c
khuynh hng xut hin nhiu , c th c tnh hoc lnh tnh. Biu hin lm sng
bao gm cc triu chng m h vng bng, khm thy khi u, tc rut, hoc xut
huyt tiu ha [61].
25
- Tam chng Carney:

Nm 1977, Carney v cng s [108] m t mt hi chng gi l Tam chng
Carney vi biu hin gm sarcm c trn d dy (m ngy nay c xc nh l
BMTH), bu hch ph giao cm ngoi thng thn v u sn phi [94].
1.4- IU TR
1.4.1- Hng dn iu tr:
Theo Hng dn ca Mng Li Quc Gia Hoa K Ton din v Ung Th
(NCCN) nm 2015, cng nh ca Hip Hi Ung Th Ni Khoa Chu u (ESMO)
nm 2014 v y vn [52], [63], [101], c th tm tt vic iu tr BMTH nh sau:
- BMTH cn khu tr ti ch:
iu tr tiu chun i vi BMTH khu tr ti ch l phu thut ct bu
hon ton (R0), khng cn no hch vng. Khng nn phu thut ni soi ct cc
bu ln v c nhiu nguy c lm v bu gy ra tnh trng ti pht.
Ch nh iu tr nhm trng ch h tr sau m bao gm: bu c nguy c
cao, bu b v trong lc phu thut, phu thut ct bu cn st.
Nhng trng hp phu thut ct bu trit , thuc nhm nguy c thp
hoc rt thp khng cn iu tr h tr. i vi cc BMTH thuc nhm nguy c
trung bnh cn ang c bn ci v vic c nn s dng thuc nhm trng ch sau
m khng [52].
- BMTH di cn xa:
iu tr tiu chun BMTH di cn xa, BMTH tin trin ti ch khng
m c v BMTH di cn sau m ct bu nguyn pht l s dng Imatinib.
Liu khi u thng thng ca Imatinib l 400 mg mi ngy. Tuy nhin, cc
nghin cu cho thy rng nhng bnh nhn b t bin exon 9 c t l sng cn
khng bnh tin trin tt hn khi c iu tr vi liu 800 mg mi ngy [63].
26
1.4.2- Cc phng php iu tr

1.4.2.1- Phu tr
- C s ca iu tr phu thut BMTH:
Khng ging nh cc ung th biu m ng tiu ha, BMTH c nhng
im c bit nh hng n vic iu tr phu thut [56], [59], [135]:
- Trc ht bu thng cho di cn n gan v phc mc nhng him cho di
cn n hch ti vng.
- Th hai, cc BMTH c khuynh hng pht trin ra hng i din vi
lng rut, v pha bng.
- Th ba, d khi l bc c tnh r nhng cc BMTH c khuynh hng
chim ch nhng khng xm ln cc c quan xung quanh.
- Cui cng cc BMTH mm nn d b v vo bng trong qu trnh
phu thut, lm tng nguy c lan trn bng.
Mc ch ca phu tr l ct ton b khi bu vi b din ct an ton v
mt m hc, trnh lm v bu v khng cn no hch vng [69], [22], [73].
Cc phu thut nh no hch m rng v ct ton b mc treo trc trng
khng cn cn thit trong iu tr BMTH d dy v BMTH trc trng
tng ng. Tng t vic ct BMTH t trng c th c bo tn hn vi
phu thut ct t trng bo tn ty. Khuynh hng pht trin ra ngoi lng rut ca
BMTH lm tng c hi iu tr bng cc k thut ngoi khoa t xm ln nh
phu thut ni soi [107], [111].
- Phu tr BMTH thc qun:
i vi cc BMTH thc qun nh (< 2 cm), Blum v cng s [73]
khuyn nn ct hn ch vi iu kin l b din ct an ton. i vi cc bu ln
hn v nm gn ch ni thc qun-d dy, tt nht l nn ct thc qun kiu Ivor
Lewis (Hnh 1.12), nhng khng cn no hch.
27
D dy c a ln
thay cho thc qun
V tr d dy bnh thng
Hnh 1.12: Ct thc qun kiu Ivor Lewis

Ngun: http://www.cancer.ca/en/cancer-information/cancertype/esophageal/treatment/surgery/?region=on
i vi nhng bnh nhn c nguy c cao v c sang thng 1/3 di thc
qun th ct thc qun kiu Merendino (Hnh 1.13).
A: ng ct trong phu thut Merendino

B: cc ming ni tiu ha trong phu thut Merendino
Hnh 1.13: Phu thut Merendino
Ngun: http://www.medandlife.ro/medandlife266.html
28
- Phu tr BMTH d dy:

Nhng bnh nhn b d dy him khi b ti pht ti ch ti vng, do ch
cn ct d dy hn ch vi b din ct m tnh. Tuy nhin, cn cn thn trnh lm
v bu trong lc m, v iu ny s c tin lng tng ng vi vic ct bu
khng hon ton.
Mt s cng trnh nghin cu ngoi khoa gn y cho thy rng vic ct d
dy hnh ch V qua ni soi cho cc BMTH d dy l an ton v v mt ung
bu. Tuy nhin, nhng hng dn hin nay ca cc chuyn gia Chu u v M
ngh vic ct bu hnh ch V trong iu tr BMTH d dy ch nn dnh cho
nhng bu c ng knh < 2 cm v cn nm trong lp c d dy v s c t nguy
c b v bu v gieo rc phc mc [25].
+ Bu b cong nh v ch ni thc qun-d dy:
Nhiu phu thut vin Chu u thng tip cn khi bu ti v tr ny bng
cch phu thut m bng hoc chuyn sang phu thut m bng sau khi phu thut
ni soi thm st. Nu c th nn ct hn ch bng k thut va ct, va may v
ti to mt ti cha thc qun vi mc ch bo tn ch ni thc qun-d dy.
Tuy nhin, phu thut ny c th khng an ton i vi nhng bu ln,
khi nn ct phn trn d dy sau ti to li bng hng trng (phu thut
Merendino).
+ Bu b cong ln v y v:
Phn ln cc BMTH v tr ny c th iu tr bng phu thut ni soi
ct rng bu hnh ch V ty theo kch thc bu.
Mc d khng cn thit phi ct rng lm nhng phu thut phi t c b
din ct an ton. L tng l ng may nn theo hng dc vi trc ca d dy
trnh lm hp lng. Cc BMTH nm thnh sau d dy c th c ct theo
chiu ngang.
29
Hnh 1.14: Phu thut ct BMTH d dy hnh ch V

Ngun: Casali PG and Blay JY, 2010 [24]
+ Hang v:
Mt s t BMTH nm vng hang v hoc tin mn v c th c phu
thut ni soi an ton bng k thut va ct, va may. Tuy nhin, nu ng m
rng qu 3 cm v tr ny rt d c nguy c gy hp mn v. Nu khng th ct hn
ch th tt nht l ct bn phn di d dy bng phu thut m m hoc phu thut
ni soi hoc c bn tay tr gip, nht l i vi cc bu > 10 cm.
- Phu tr BMTH rut non:
+ Bu t trng:
Nhng phu thut thng thc hin l ct on t trng, ct hnh ch V v
phu thut Whipple [44], [138].
Tnh kh thi ca phu thut ct bu hnh ch V i vi cc BMTH t
trng ch yu da vo kch thc bu v khong cch t bu n bng Vater.
Cc bu ln on D2 t trng v lin quan n bng Vater nn c iu tr
bng cch ct khi t ty l tt nht nhng nhng bnh nhn thuc nhm nguy c
cao s c li hn khi c iu tr tn h tr bng Imatinib mesilate lm gim
30
kch thc bu [98]. Vic iu tr tn h tr c th gip phu thut hn ch hn,

bo tn c ty. Cc tc gi khuyn nn ni tn-tn sau khi ct on t trng hoc
ming ni t trng-hng trng kiu Y khi ch khim khuyt qu ln [80].
Tm li, vic ct bu hnh ch V nn c ch nh cho cc BMTH t
trng nh < 1 cm v nm xa bng Vater > 2 cm. Ct on t trng c ch nh cho
cc bu ln > 3 cm nm on D3/D4, sau ti lp lu thng ng tiu ha bng
cch ni t trng-hng trng bn bn i din vi bng Vater. Ct khi t ty vn l
cch tt nht iu tr BMTH quanh bng Vater v cc bu ln vng D1/D2
[44], [80], [139].
+ Bu hng trng v hi trng:
Nn ct on rut nu BMTH hng trng v hi trng m khng cn
no hch, y l phu thut d thc hin hu ht bnh nhn. i vi nhng bu
nm ngay ch ni hng-t trng cn phi thc hin k thut ct on rut non, may
kn 2 u rut ngay dy chng Treirtz v ni t-hng trng bn-bn i din bng
Vater [97].
Ct bu qua phu thut ni soi ch nn thc hin i vi nhng trng hp
bu nh hng trng hoc hi trng. i vi nhng bu BMTH ln (> 5 cm)
pht hin c qua CT scan v nm gn gc Treitz th nn m m [97].
- Phu tr BMTH i trng:
Ct on i trng khng cn no hch l chin lc iu tr i vi
BMTH i trng. Nhng BMTH i trng thng c khuynh hng y
lch cc cu trc nhng him khi xm nhim cc c quan xung quanh hoc xm ln
vo thnh bng. Bu thng c th c ct vi b din ct an ton [85].
- Phu tr BMTH trc trng:
Nhiu tc gi cho rng bnh nhn BMTH trc trng c nguy c phu
thut ct bu khng hon ton (30% trong nghin cu ca Trung tm Ung Th
Memorial Sloan-Kettering) v hu qu l t l ti pht ti ch, ti vng rt cao mc
31
d c phu thut rt rng nh phu thut ct trc trng qua ng bng tng
sinh mn (phu thut Miles) hoc phu thut on chu [27]. Trong lot nghin cu
ca Mayo Clinic, 9/14 bnh nhn b BMTH trc trng c ct rng ti ch
[59].
V BMTH trc trng khng di cn theo ng bch huyt nn phu
thut ct rng mc treo trc trng t c thc hin. Ngoi ra, nguy c tn thng
m ri thn kinh t ch v nguy c b mt chc nng sau ct trc trng phi c
quan tm, c bit l i vi nhng bnh nhn tr.
Ct bu qua ng hu mn l la chn thch hp cho cc BMTH nh
(< 3 cm). Phu thut ny thng b hn ch khi ct nhng bu ngoi trc trng.
Phu thut ct bu qua ng hu mn thng khng i vi cc bu ln (> 5
cm) pht trin ngoi trc trng v pha tin lit tuyn hoc pha xng cng. Ct sau
qua xng cng (phu thut KRASKE) vi vic ct bu trc trng hnh ch V l
mt la chn thch hp m khng cn phi m bng, trnh nguy c ri lon niu
dc do ct ton b mc treo trc trng. Tng t, i vi nhng bnh nhn n,
BMTH trc trng thnh trc trc trng thp th nn c ct rng bu qua
ng m o [118].
Tm li, 2 phu thut thng p dng vi carcinm tuyn trc trng l ct
ton b mc treo trc trng v ct bu qua ng hu mn thng khng thch
hp trong iu tr BMTH. Ha tr tn h tr bng Imatinib c th lm gim kch
thc bu BMTH ln, c bit l cc bu nm gn c vng hu mn. Vic
iu tr ny c th gip bo tn c vng.
- Phu tr BMTH di cn:
Khong 40% bnh nhn sau ct bu nguyn pht s b ti pht m ch yu
l b di cn n gan v phc mc [22], [100]. Trc khi c thuc Imatinib, thi gian
sng cn l 19 thng. T l sng cn 5 nm l 25%. Mt nghin cu bo co kt
qu trn 60 bnh nhn phu thut cc BMTH ti pht v di cn t nm 1982
1995, kt qu cho thy rt ng tht vng: thi gian sng cn trung bnh l 15
32
thng, iu ny cn cho thy ch nn phu thut iu tr cc triu chng m thi

[59].
T nm 2002, Imatinib mesylate tr thnh tiu chun iu tr BMTH
di cn, vi t l p ng rt n tng. Tuy nhin, hn ch chnh ca liu php ny l
hin tng bu khng thuc do s t bin gen c-KIT. V th, cn phi iu tr a
m thc; trong , phu thut s lm gim tng khi bu, ngn cc dng t bo
khng thuc [30], [40], [47].
1.4.2.2- Ho tr
Kh c th xc nh chnh xc t l p ng ca BMTH vi cc tc nhn
ho tr thng thng, nhng nhiu tc gi cho rng t l ny rt thp, di 5% [48],
[40]. Khi so snh s p ng vi Dacarbazine, Mitomycin C, Doxorubicin,
Cisplatin gia cc bnh nhn BMTH tin trin v cc bnh nhn sarcm c trn
tin trin ti Mayo Clinic, J. Edmondson v cng s [72] nhn thy ch c 4,8%
bnh nhn BMTH c p ng vi liu php ny. Kt qu ny tng t nghin
cu ti Vin Ung th Dana Farber [40]. Trong mt nghin cu khc s dng
Doxorubicin v Dacarbazine, M. Zalupski v cng s nhn thy ch c 3/43 bnh
nhn sarcm c trn tiu ha bao gm BMTH p ng vi iu tr [89].
Do cc kt qu khng mong i nh vy vi cc tc nhn ho tr thng
thng nn kh c th a ra mt phc ho tr chun no iu tr BMTH
[78]. Tuy nhin, c mt vi kt qu kh quan c bo co khi p dng cc k
thut khng thng quy nh truyn Mitoxantrone trong phc mc hoc ha liu
php gy nghn mch [89], [119].
1.4.2.3- X tr
Mc d x tr l m thc iu tr ch yu cho cc sarcm phn mm, nhng
vai tr ca n i vi BMTH th tng i nh. X tr rt hn ch i vi
BMTH rut non v y l mt c quan di ng v ngay c tn thng cc
cu trc c nh th li ch ca x tr cng rt thp. X tr cn lm tn thng n
cc cu trc xung quanh [72], [119]. Nhng x tr c th c mt vai tr trong cc
33
trng hp BMTH d dy hoc trc trng m din ct dng tnh trn vi th

[40]. Theo Dematteo v cng s th ch c khong 11% bnh nhn BMTH c
p dng x tr, nhng kt qu khng ng k [40].
Mt s tc gi ngh rng vi mt trng chiu rng bao ph ton b
bng v vi liu x va phi th x ngoi c th c xem nh mt liu php h tr
c ch i vi BMTH [105].
i vi cc trng hp BMTH cho di cn xa th x tr hu ch trong
vic lm gim bt triu chng au nhng di cn gan ln hoc nhng khi bu
nm vng chu hoc thnh bng [40].
1.4.2.4- Liu php nhm trng ch
Vo nm 2002, C quan Qun l Thc phm v Dc phm Hoa K (FDA)
chp nhn cho Imatinib, mt yu t c ch tyrosine kinase trong th th c-KIT,
iu tr BMTH ti pht, di cn hoc khng cn kh nng phu thut [31].
Imatinib Mesylate c cng thc ha hc l 4-[(4-methylpiperazin-1yl)methyl]-N-(4-methyl-3-{[4-(pyridin-3-yl)pyrimidin-2-yl]amino}phenyl)
Benzamide (Hnh 1.15).
Hnh 1.15: Cng thc ha hc ca Imatinib mesylate

Ngun: http://en.wikipedia.org/wiki/Imatinib
34
Imatinib Mesylate l iu tr nhm trng ch u tin c chp nhn cho

iu tr BMTH v tr thnh iu tr la chn cho trng hp BMTH tin
trin [78]. Imatinib l mt cht c ch th th tyrosine kinase.
Nm 1989, mt h cc cht gi l tyrphostins c tm thy l c hiu cho
th th yu t tng trng. Cc pht trin tip theo dn n vic tm thy hp cht
2-phenylaminopyrimidine c kh nng c ch mnh nht th th tyrosine kinase.
Chnh iu ny dn n s pht trin Imatinib. Imatinib c chng minh c ch
kinase ABL ni bo v protein BCR-ABL trong t bo bch cu dng tu mn,
nhng sau li c tm thy l c hot ng chng li th th KIT (loi t nhin
v t bin) v PDGFRA [44], [48].
Imatinib l cht i vn hon ton, cnh tranh v tr gn vi ATP (adenosine
triphosphate). iu ny s kho s chuyn phosphate t ATP n cc phn t
tyrosine di, s dn n gin on l trnh tn hiu dn n tng sinh t bo, bao
gm MAPK v Akt [44] (hnh 1.16).
Hnh 1.16: C ch hot ng ca Imatinib

Ngun: Quek R and George S, 2010 [108]
35
Tc gi Druker v cng s [46] ln u tin nhn thy protein BCR-ABL

l ch nhm tt nht cho Imatinib, v t bin BCR-ABL gp trong phn ln cc
trng hp bnh bch cu mn dng ty. H chng minh c rng Imatinib c
ch c hiu s tng sinh ca cc t bo dng tu. Nng ca cc protein bt
thng gim 95%, cng nh t c tnh trn mt xng. Kt qu th nghim
trong th nghim c p dng cho c th sng mt cch nhanh chng, vi hiu
qu ng ch ca Imatinib trn chut thun chng v sau l ngi bnh bch
cu mn dng ty [44]. V s thnh cng ca Imatinib trong iu tr bnh bch cu
mn dng ty dn n cc nghin cu nh gi hiu qu ca n i vi th th
tyrosine kinase ca c-KIT. Tnh trng phosphoryl ho c-KIT t ng, s hot ho
MAPK v hot ho Akt u b c ch trong dng t bo c biu hin c-KIT. Trong
dng t bo m c t bin c-KIT th hiu qu c ch cn c th hn so snh vi
nhm th th t nhin khng t bin [44].
Bnh nhn c BMTH u tin c iu tr vi Imatinib l mt ph n
50 tui, c CD117 dng tnh lin quan vi t bin exon 11 v c di cn. Tnh
trng bnh ca bnh nhn ny vn tip tc tin trin, mc d phu thut, ha tr
kt hp, thalidomide v interferon alpha. Bnh nhn c iu tr vi Imatinib 400
mg mi ngy, v nh gi p ng bng 18-FDG PET v CT-scan. Sau 1 thng,
bnh nhn c p ng hon ton, v sau 8 thng nhiu khi di cn gan bin mt
hoc gim kch thc [78].
- Dc ng hc ca Imatinib mesylate:
Cc nghin cu v dc ng hc ca Imatinib trn ngi tnh nguyn kho
mnh, bnh nhn bch cu mn dng tu, v bnh nhn BMTH u cho kt qu
thuc hp thu tt qua ng ung, v sinh kh dng l 98%, bt k dng thuc
(dng dch, thuc vin nang hay vin nn), hoc liu dng (100 mg, 400 mg) [103].
Mt khi c hp thu, thuc s gn kt vi protein huyt thanh (thng l
albumin v alpha 1- acid glycoprotein) v t nng nh sau 4 gi dng thuc (45 g/mL i vi liu 600 mg, v 2-3 g/mL i vi liu 400 mg). Imatinib mesylate
36
c th qua hng ro mu no v t nng 38 ng/mL trong dch no tu sau liu

400 600 mg mi ngy. Thuc s c tch ly khong 1,5 3 ln sau liu dng
mi ngy, v s tng nhanh trong 1 tun. Khong 13% thuc s thi tr qua nc
tiu, v phn ln cn li s chuyn ho qua gan bi cytochrome P450 ng enzyme
CYP3A4. Cht chuyn ho chnh ca Imatinib mesylate l N-desmethyl-imatinib
(CGP74588), v nng cht ny ch khong 17% so vi nng Imatinib lc cao
nht. Cht chuyn ho ny c chng mnh l c tc dng tng ng vi
Imatinib trong c th sng. Thi gian bn hu ca Imatinib l khong 25 gi, trong
khi thi gian bn hu ca cht chuyn ho l 89 gi [36], [46].
V Imatinib c chuyn ho qua gan bi CYP3A4, cc thuc cng chuyn
ho qua h thng ny c th lm thay i dc ng hc. V d, Ketoconazole l
mt loi thuc khng nm ph rng cho thy l lm tng mn cm ca bnh nhn
vi Imatinib khi dng chung. Bn cnh , Rifampicin lm tng nng Imatinib
mesylate trong mu. Ngc li, Imatinib li lm tng mn cm i vi Simvastatin,
mt cht c ch HMG-CoA reductase. Hn na, c rt nhiu cc thuc khc cho
bnh nhn ung th, nh alprazolam, caffeine, clindamycin, clonazepam, cortisol,
ethinyl estradiol, v verapamil c th c cc tc dng c hi khi dng chung vi
Imatinib mesylate. Acetaminophen cng thng chuyn ho qua CYP3A4, v bnh
nhn nn c khuyn trnh s dng thuc ny hng ngy hay vi lng ln. Cc
nghin cu gn y cho thy tc dng phi hp trong th nghim gia Imatinib
mesylate, cc thuc c ch tyrosine kinase khc v ho tr c t bo [36].
i vi bnh nhn c BMTH, thuc t nng cao hn 1,5 ln so vi
bnh nhn bnh bch cu mn dng ty cng vi liu 400 mg/ ngy. iu ny ph
thuc ch yu vo albumin, s lng bch cu v bilirubin. Cc ri lon chc nng
gan, thn, v di cn gan c th gy gim chuyn ho ca thuc. Cc yu t nh tui,
chng tc, gii v cn nng khng nh hng n dc ng hc ca thuc [105].
Imatinib mesylate l mt cht c ch dn truyn tn hiu phn t nh c tc
dng chuyn bit l hn ch s hnh thnh cc men tyrosine kinase Alb, Arg (gen
37
lin quan Abl), KIT, th th ca yu t tng trng t tiu cu (PDGFR) v cc

dng sinh ung th ca cc men ny, ng ch nht l Bcr-Abl [3], [4], [28].
Imatinib mesylate l i din in hnh cho mt nhm thuc chng ung th
mi, nhm thuc phn t nh vi tnh chn lc cao trn cc phn t chuyn bit gy
ra s hnh thnh v duy tr cc bnh l c tnh. Imatinib cnh tranh gn vo v tr
gn ca ATP trn protein KIT ngn chn qu trnh phosphoryl ha v v vy c ch
dng tn hiu [49], [119]. Liu t 300 mg/ngy tr ln th c p ng vi hu ht
bnh nhn. Khi so snh liu 400 mg/ngy v 800 mg/ngy, cc tc gi M cng
nh Chu u thy rng khng c s khc bit v thi gian sng cn cng nh t l
bnh tin trin. Tuy nhin, liu 800 mg/ngy th c nhiu tc dng ph hn [91].
Thi gian bn hy ca Imatinib tng i di (20 gi). Thuc chuyn ha trong gan
v c bi tit qua phn [91]. Tc dng ph thng gp ca Imatinib l ph nh
quanh hc mt hoc ph ngoi bin, bun nn, ni ban, co cng c, chut rt (c
bit tay, chn), tiu chy, gim bch cu, hoc thiu mu[66], [74].
Theo nhiu th nghim lm sng, t l p ng khch quan vi Imatinib ca
cc trng hp BMTH tin trin l 53% - 65%, t l bnh n nh l 19%-36%
[48], [125]. Theo mt cng trnh phi hp gia M v Phn Lan [119] khi nghin
cu 147 bnh nhn BMTH c di cn hoc khng cn kh nng phu thut,
c iu tr Imatinib vi liu ung hng ngy l 400 mg hoc 600 mg th t l p
ng mt phn l 54%, t l bnh nhn n nh c bnh l 28%, v c 14% trng
hp khng hon ton vi Imatinib. T l sng cn 1 nm l 88%. Kt qu ny cho
thy c mt s ci thin r rt hn bt c mt ha liu php no c s dng
trc y cho cc bnh nhn BMTH tin trin hoc di cn. Do vy Imatinib
c nhiu tc gi cho l c u th trong iu tr BMTH hn cc tc nhn ho
tr thng thng khc [36], [112], [122].
V t c kt qu nh vy nn nhiu tc gi ngh dng Imatinib ho
tr h tr v tn h tr cho BMTH v t l ti pht sau phu thut l kh cao
[29], [48].
38
S khng ca BMTH i vi Imatinib c ghi nhn, Dematteo v

cng s bo co c 5%-14% bnh nhn BMTH khng vi Imatinib trong hai
thng u iu tr, mt s bnh nhn khc th khng sau vi thng [40], [128].
- iu tr tn h tr:
Imatinib c hiu qu lm gim kch thc bu phu thut, tng kh nng
t din ct m tnh v khng km theo cc bin chng hay bnh l nng. Trc khi
thc hin iu tr tn h tr, cn chp ct lp vi tnh trc. Thi gian iu tr ph
hp trc m vn cha xc nh c. i vi bnh nhn p ng iu tr, Imatinib
c tip tc n khi t p ng ti a (nh ngha l khng ci thin thm gia 2
ln chp ct lp vi tnh). iu tr ny c th ko di 6 12 thng, nhng khng phi
lc no cng phi ch n lc t p ng ti a ri mi phu thut. Phu thut
c ngh khi bu gim kch thc ti im m phu thut hon ton c th
thc hin c khng km bin chng nghim trng. Imatinib cn phi c ngng
trc phu thut v khi ng li sm ngay khi bnh nhn c th dng thuc ng
ung, bt k din ct ra sao [106].
Liu khuyn co l 400 mg mi ngy, liu c th tng n 800 mg mi ngy
nu c t bin gen c-KIT ti exon 9. Trong trng hp khng c tin trin, c th
tip tc liu Imatinib nh vy v phu thut nn c xem xt. Nu bu tin trin
thm, nn thc hin phu thut ngay khi ngng Imatinib [104], [112].
- iu tr h tr:
Nm 2008, C quan Qun l Thc phm v Dc phm Hoa K chp
thun thuc vin Imatinib mesylate (Gleevec) c s dng thng quy trong iu
tr h tr cho bnh nhn ngi ln b BMTH, phu thut hon ton v i th
v c CD117 (+) vi thi gian s dng thuc l 12 thng [32].
Cohen v cng s [33] thc hin mt nghin cu ti chu u. y l
nghin cu thc nghim pha III, ngu nhin, a trung tm, so snh gia dng
Imatinib 12 thng v 36 thng trn 397 bnh nhn. Kt qu nghin cu cho thy t
l ti pht l tng t gia 2 nhm nhng nhm dng thuc 36 thng c li ch hn
39
v t l sng cn ton b (TSNC=0,45; p = 0,019). V th, hin nay C quan Qun

l Thc phm v Dc phm Hoa K chp thun thi gian iu tr h tr
Imatinib t nht l 36 thng sau phu thut i vi cc bnh nhn thuc nhm nguy
c cao [71], [120]. Tuy nhin, cn c thm cc cuc nghin cu c th cho thy
li ch ca vic iu tr hn 3 nm [33], [72], [88].
Ch nh iu tr h tr vi Imatinib bao gm nhng bnh nhn BMTH
thuc nhm nguy c ti pht cao [72], [81].
- Cc thuc c ch tyrosine kinase khc [124], [134]:
Ngoi Imatinib, cc thuc c ch tyrosine kinase khc ang c khuyn co
s dng trong iu tr BMTH l: Sunitinib, Nilotinib, Sorafenib.
Hin vn cn nhiu thuc c ch th th tyrosine kinase ang trong qu trnh
th nghim pha II hoc pha III: Masitinib, Dovitinib, Pasopanib, Dasatinib,
Ponatinib.
- nh gi p ng vi iu tr nhm trng ch
Trong cc th nghim lm sng vi BMTH giai on tin trin iu tr
vi Imatinib, thi gian trung bnh t p ng theo mc tiu l khong 13 tun
[11]. Tuy nhin, mt vi bnh nhn c ci thin ng k v triu chng v du hiu
thc th ch trong nhiu ngy, km theo bng chng v gim hot ng chuyn ho
trn PET-scan. iu th v l khng c trng hp no c ghi nhn c hi chng
ly gii bu. Cc thay i sau p ng vi Imatinib kh khc bit. Cc thay i
thng thng ca t bo c th gy ra nhng nhm ln l bnh tin trin. Do , cc
tiu chun nh gi p ng truyn thng cha c tho ng ton b. Trn nhng
bnh nhn ban u iu tr vi Imatinib, mu sinh thit thi im 1 2 thng sau
iu tr cho thy c gim t bo bu ng k cng nh c s thoi ho cc m thay
th bng m x v m so. Khng c phn ng hoi t hay vim no c ghi
nhn. Cc t bo bu khng bt mu vi Ki-67 (cht ch du tnh trng tng sinh t
bo) gi rng c th bu hot ng thp [18], [39].
40
Nhiu nghin cu s dng CT-scan v 18-FDG PET trong nh gi p ng

i vi Imatinib [51]. Mt nghin cu so snh CT, PET v m thc i PET/CT
theo di hiu qu ca Imatinib trn 20 bnh nhn. PET/CT ghi nhn 282 di cn,
CT ghi nhn 249 sang thng v PET n thun ghi nhn 135 tn thng. Trong
nh gi bnh ti thi im 3 thng v 6 thng sau iu tr, PET nh gi p ng
chnh xc 100%, so snh vi CT ch 57 60%. PET cng pht hin p ng sm
hn CT. Trong mt nghin cu tng t trn 28 bnh nhn, vic khng c hnh nh
tng hp thu FDG sau iu tr thch hp c lin quan ti tin lng tt hn nhng
ngi c hnh nh tng hp thu. CT pht hin nhiu tn thng hn, nhng khng
tt bng trong d on tin lng [35]. Cc nghin cu sau ny cho thy p ng
trn PET c lin quan ti sng cn khng bnh tin trin cao hn c ngha [14].
Tc gi H. Choi v cc cng s [28] ra mt tiu chun nh gi p
ng mi dnh cho BMTH. Cc tc gi ny nghin cu 172 sang thng trn
40 bnh nhn vi bnh giai on di cn. Nhng bnh nhn ny c nh gi trc
v sau iu tr 2 thng bng CT v FDG-PET. Nu kch thc bu gim trn 10%
hoc gim mt bu trn 15% trn CT th c c hiu 100% v nhy 97%
xc nh p ng trn PET-CT [5], [28].
Trong nh gi p ng vi Imatinib, bao gi cng c tnh trng khng thuc
xut hin. Trong lot nghin cu 92 bnh nhn iu tr vi Imatinib, c 39 trng
hp bnh tin trin, 21 trong s ny c tin trin theo kiu nt-bn trong-khi. Cc
tc gi cho rng kiu ny l biu hin ca mt dng t bo t bin khu tr c khng
vi thuc c ch th th c-KIT. iu ny rt quan trng, v cc tiu chun nh gi
p ng truyn thng c th khng ghi nhn cc du hiu ny ca ti pht [14].
1.5- TIN LNG V SNG CN
Cc yu t tin lng c gi tr nht l giai on bu, kch thc bu, loi
m hc, mc hoi t, tnh d dng ca nhn, mt t bo v hot ng phn
bo [58], [67].
41
1.5.1- Thi gian sng cn sau phu thut

Ty thuc vo cc yu t tin lng v cch m ct bu hon ton hay
khng m t l sng cn khc nhau.
Theo J.A. Crosby [37] th t l sng cn 5 nm l 42% khi ct b c hon
ton khi bu gim xung cn 8%-9% nu khng ly c hon ton. Theo y vn,
trung v thi gian sng cn sau m l 19 thng; trung v thi gian sng cn sau ct
bu ti pht v di cn l 15 thng [64], [94].
1.5.2- Thi gian sng cn sau iu tr a m thc
Nhiu tc gi cho rng d hu ca cc bnh nhn BMTH thuc nhm
nguy c thp hoc trung bnh th tng i tt. Ngc li, ti pht sau m hu nh
khng th trnh khi i vi cc trng hp BMTH thuc nhm nguy c cao
[62].
Theo tiu chun b sung phn nhm nguy c ti pht ca VYTQG Hoa K,
t l sng cn khng bnh ti pht 10 nm theo tng nhm nguy c thp, trung bnh
v cao ln lt l 89,7%, 86,9% v 36,2% [72].
Dematteo v cng s [40], ghi nhn trong 200 bnh nhn b BMTH th t
l sng cn ton b 5 nm sau thi im ct bu nguyn pht l 20% i vi khi
bu c kch thc ln hn 10 cm, trong khi cc bu c kch thc nh hn 5 cm
th t l ny l 60% [62]. Theo Evans [125] th thi gian sng cn ton b trung
bnh ca bu c m hc thp (ch s phn bo 1-5/50 QTL) l 98 thng, trong
khi bu c m hc cao (ch s phn bo > 10/50 QTL) th thi gian sng cn
ton b trung bnh l 25 thng. i vi cc bnh nhn ct b c hon ton khi
bu th m hc l yu t chnh tin lng t l sng cn ton b 5 nm, t l
ny l 18% i vi bu c m hc cao v 72% i vi bu c m hc thp.
Kt qu ny tng t bo co ca Dougherty v cng s [125], theo tc gi th nu
bu m hc thp v c ct b hon ton th c n 80% bnh nhn sng cn
khng bnh ti pht c 8 nm, trong khi vi bu m hc cao th thi gian
trung bnh sng cn khng bnh ti pht ch t 18 thng.
42
1.5.3- T l ti pht
- Bu m m ng tiu ha d dy:
Sung Joon Kwon v cng s [82] nhn thy c 7/17 (41%) bnh nhn
BMTH c tnh d dy ti pht t 15 n 41 thng sau phu thut. Trong mt
nghin cu khc ca M. Miettinen v cng s [94] th c khong 85% n 90%
bnh nhn BMTH d dy nhm nguy c cao s c d hu xu ti pht ti
ch, di cn, hoc cht- nu ch c cha bng mt phng php duy nht l phu
thut. Ni chung, t l ti pht sau m ca BMTH l khong 50% trng hp.
T l sng cn 5 nm v 10 nm cc bnh nhn BMTH d dy c phu
thut vi mc ch cha khi ln lt l 32%-78% v 19%-63% [50].
BMTH d dy thng gy ti pht ti ch gii hn trong thnh, do
vy cc trng hp ny thng c th phu thut li c [94].
Ngoi ra, t l ti pht ca BMTH cn thay i ty theo ln phu thut
u tin c ly c hon ton bu hay khng, J.A. Crosby v cng s [37] nhn
thy t l sng cn 5 nm ca nhm bnh nhn c phu thut ly trn bu gp 4
ln nhm khng ly c trn bu.
- Bu m m ng tiu ha rut non:
J.A. Crosby v cng s [37] ghi nhn c 43% trng hp ti pht ti ch,
trung bnh 25 thng v 59% trng hp di cn, trung bnh 21 thng, khi nghin cu
50 bnh nhn BMTH rut non. BMTH rut non c nguy c ti pht cao
gp bn ln so vi d dy [119].
- Bu m m ng tiu ha i-trc trng:
Nghin cu 37 trng hp BMTH i trng, M. Miettinen v cng s
[76] thy c 11 trng hp (30%) bnh nhn ti pht ti ch.
43
Chng 2: I TNG V PHNG PHP NGHIN CU

2.1. I TNG NGHIN CU:
- Dn s mc tiu:
Tt c cc bnh nhn bu m m ng tiu ha.
- Dn s nghin cu:
Cc bnh nhn bu m m ng tiu ha iu tr ti bnh vin Ung Bu
TP H Ch Minh.
- Dn s chn mu:
Cc bnh nhn bu m m ng tiu ha iu tr ti bnh vin Ung Bu
TP H Ch Minh trong thi gian t 01/01/2006 n 31/12/2010.
2.1.1. Tiu chun la chn
Cc bnh nhn c kt qu gii phu bnh l bu m m ng tiu ha v
c CD117 (+).
Tui 18.
Ch s tng trng KPS 70.
D tr tu v chc nng gan, thn y .
. Hb > 9 g/dL.
. AST hoc ALT < 2,5 ln so vi gii hn trn ca mc bnh thng.
. Creatinin huyt thanh < 1,5 ln so vi gii hn trn ca mc bnh thng
hoc thanh thi creatinin > 50 ml/pht.
ng tham gia nghin cu.
i vi cc bnh nhn c iu tr ban u ti cc bnh vin khc, chng
ti ch nhn vo nghin cu cc h s bnh n c tm tt bnh n, tng trnh
phu thut, gii phu bnh v ha m min dch sau m.
44
2.1.2. Tiu chun loi tr

+ Bnh nhn khng ng phu thut.
+ Bnh nhn khng phu thut c v bnh l i km nng: nh cao huyt
p khng kim sot c, cn au tht ngc khng n nh, nhi mu c tim, i
tho ng c ng huyt khng kim sot c.
2.2. PHNG PHP NGHIN CU
2.2.1. Thit k nghin cu
Nghin cu hi cu, m t lot ca.
2.2.2. C mu v phng php chn mu
- C mu:
V l bnh him gp, s ca thu thp mi nm t nn chng ti tin hnh thu
thp nghin cu lot ca trong vng 05 nm (01/01/2006 31/12/2010).
- Phng php chn mu:
Chn mu khng ngu nhin, thun tin lin tip trong thi gian nghin cu.
Vi cch chn bnh v thi gian k trn, chng ti thu thp c 109
bnh nhn bu m m ng tiu ha p ng tiu chun la chn.
2.2.3. Quy trnh nghin cu
- Lp phiu ghi nhn d liu.
- Chn bnh nhn theo tiu ch thu nhn.
- i vi bnh nhn mi tip nhn:
Gii thch bnh nhn v chn on, v phu tr v iu tr nhm trng ch.
Thc hin cc xt nghim chn on v iu tr: siu m bng, X quang
tiu ha c cn quang, CT Scan bng-chu, xt nghim huyt hc, sinh ha,
min dch, ..
45
Hi chn khoa, ln lch m.

Thc hin phu thut, chm sc hu phu.
iu tr nhm trng ch nu c ch nh.
Theo di cc tc dng ph v hiu qu iu tr.
Trc tip khm hoc ghi nhn qua h s bnh n v tnh trng sau iu tr.
- i vi bnh nhn c iu tr trc khi bt u nghin cu:
Ghi nhn qua h s bnh n v cc bin s nghin cu.
- Nhp cc d liu vo phn mm SPSS 16.0.
- Rt ra cc kt qu t phn mm SPSS 16.0
- Phn tch d liu, bn lun v so snh vi y vn.
- Rt ra kt lun v kin ngh.
2.2.4. Kt cc nghin cu
- Kt cc chnh:
+ Thi gian v t l sng cn ton b i vi bnh nhn BMTH.
- Kt cc ph:
+ Thi gian v t l sng cn khng bnh ti pht trong nhm bnh nhn
c phu thut trit .
+ Thi gian v t l sng cn khng bnh tin trin trong nhm bnh nhn
c phu thut tm b.
46
- Quy trnh nghin cu bu m m ng tiu ha ti BV Ung Bu TP H Ch

Minh nh sau (S 2.1):
Bnh nhn bu m m
ng tiu ha
Phu thut trit
Ti pht
ti ch
n nh
Phu thut tm b
Di cn xa gieo
rc phc mc
Imatinib* 400 mg/ngy
Phu thut ct
rng bu
p ng
Phu thut tm b
Khng p ng

p ng
THEO DI
Khng p ng
p ng
Khng p ng
* Thi gian iu tr: 12 thng.
Chm sc gim nh
hoc thuc nhm trng ch khc
S 2.1: Quy trnh iu tr bu m m ng tiu ha

ti bnh vin Ung Bu TP. H Ch Minh
47
2.2.5- Cc bin s nghin cu

- nh gi tnh trng hot ng c nng (ch s Karnofsky hoc ECOG):
d dng so snh vi cc tc gi khc, chng ti nh gi tnh trng hot
ng c th bnh nhn theo ch s ECOG (Bng 2.7).
Nhng trng hp bnh nhn c nh gi hot ng c th theo ch s
KPS, chng ti s chuyn i sang ch s ECOG (Bng 2.8).
+ Thang im KARNOFSKY [103]:
Bng 2.6- Thang im Karnofsky
Gi tr
100
90
80
70
60
50
40
Mc kh nng cc chc nng
nh ngha
Bnh thng, khng than phin, khng c bng

chng ca bnh
C kh nng hot
C th thc hin hot ng bnh thng, c rt ng v lm vic bnh
t du hiu hoc triu chng bnh l
thng, khng cn
Hot ng bnh thng vi s c gng, c mt chm sc c bit
s triu chng hoc du hiu bnh l
C kh nng chm sc bn thn, khng th thc
Khng c kh nng
hin hot ng thng ngy hoc lm cng vic lm vic, c th sng
ch ng
ti nh v chm sc
i khi i hi s tr gip, nhng c th thc cc hot ng c
hin hu ht cc nhu cu c nhn
nhn, c nhiu mc
cn tr gip khc
i hi tr gip ng k v chm sc y khoa
nhau
thng xuyn
Mt kh nng, i hi s chm sc hoc tr
gip c bit
10
Khng th chm sc
Mt kh nng nghim trng, ch nh nhp vin, bn thn, i hi s
nhng khng t vong trong tng lai gn
chm sc tng
Bnh rt nng, cn thit phi nhp vin, i hi ng bnh vin,
tr gip ch ng
bnh c th din tin
xu nhanh chng
Cn t, tin trnh t vong din ra nhanh chng
T vong
30
20
48
+ Thang im ECOG [103]

Bng 2.7- Thang im ECOG
im ECOG
nh ngha
Hot ng y , c th thc hin tt c cc hot ng chc

nng trc khi b bnh m khng c hn ch no
Hot ng sinh l b gii hn, i hi gng sc, i li c v c

th lm vic nh
C kh nng chm sc bn thn nhng khng th lm bt c vic

g. i li c hn 50% thi gian
C th thc hin chm sc bn thn gii hn, nm ti ging

hoc gh hn 50% thi gian
Hon ton mt chc nng, khng th thc hin bt c hoat ng

chm sc bn thn no, ton b thi gian b gii hn ti ging
hoc gh
T vong
+ Chuyn i gia thang im KPS v ECOG [103]

Bng 2.8- Bng chuyn i gia thang im KPS v ECOG
KPS
ECOG
100
90
80
70
60
50
40
1
2
3
30
20
10
0
49
- Thi gian khi bnh: tnh t lc c triu chng c nng n khi c chn on
lm sng l bu m m ng tiu ha, thi gian ny c tnh bng thng.
- Triu chng lm sng: c ghi nhn trc tip t vic hi bnh s v khm lm
sng hoc t cc ghi nhn trong h s bnh n.
- Triu chng hnh nh hc: c ghi nhn t kt qu hnh nh hc (siu m, X
quang, ni soi, CT scan, MRI) c thc hin ti BV Ung Bu TP. HCM hoc t
cc c s y t khc.
- Gii phu bnh v ha m min dch: c ghi nhn t kt qu gii phu bnh v
ha m min dch c thc hin ti BV Ung Bu TP. HCM hoc t cc c s y
t khc.
- Chn on: da vo phi hp ca cc triu chng lm sng, hnh nh hc, hnh
nh gii phu bnh v kt qu ha m min dch vi CD117 (+); trong quan
trng nht l kt qu gii phu bnh v kt qu CD117 (+).
- Giai on bnh [52], [123]:
+ Giai on khu tr: bu pht trin ti ch, ti vng (giai on I-III)
+ Giai on tin xa: bu di cn xa hay gieo rc phc mc (giai on
IV).
- Phn nhm nguy c ti pht: da vo tiu chun b sung ca VYTQG Hoa K
(Bng 1.4), chng ti phn ra 04 nhm nguy c ti pht: rt thp, thp, trung bnh
v cao.
- Cc loi phu thut
+ Phu thut trit (phu thut R0): ct rng bu vi b din ct 2 cm v kt
qu gii phu bnh ca din ct khng c t bo bu.
+ Phu thut tm b: bao gm cc loi phu thut sau:
* Phu thut R1: ct rng bu vi b din ct 2 cm v kt qu gii phu
bnh ca din ct c t bo bu.
50
* Phu thut R2: phu thut ct bu nhng cn li bu v mt i th.

* Phu thut khng ct bu, ch sinh thit bu c hay khng c thc hin
cc th thut bc cu hoc m thng ng tiu ha.
- Ch nh iu tr thuc nhm trng ch:
Nhng bnh nhn c ch nh iu tr h tr bng Imatinib mesylate bao
gm:
+ Phu thut tm b.
+ Nhng bnh nhn ti pht/di cn sau iu tr phu thut m khng cn m
li c.
- Thi gian iu tr thuc nhm trng ch: tnh t lc bt u iu tr thuc nhm
trng ch n khi ung n liu cui cng thuc nhm trng ch. Thi gian ny
c tnh bng thng.
- Phn loi cc c tnh huyt hc v tiu ha [128]
Bng 2.9- Phn loi c tnh huyt hc v tiu ha
c tnh
1
2
ng tiu ha
Bun nn/nn Mt cm
Gim n ng
gic thm n ming nhng
khng st cn,
mt nc hoc
suy dinh dng
ng k, truyn
dch < 24 gi
Tiu chy
< 4 ln/
ngy, lng
phn qua
hu mn
nhn to
tng nh
4 - 6 ln/ ngy,
lng phn qua
hu mn nhn
to tng nh,
truyn dch < 24
gi
Nng lng
n ng
ming hoc
dch truyn
khng ,
truyn dch,
nui n bng
ng > 24 gi
7 ln/ngy,
lng phn
qua hu mn
nhn to tng
nghim
trng, phi
nhp vin
truyn dch >
24 gi, nh
hng ADL
e do
tnh mng
T vong
e do
tnh mng
(ri lon
huyt
ng)
T vong
51
Huyt hc
Hemoglobin
(g/dl)
Bch cu
(103 /mm3)
Tiu cu
(103 /mm3)
Xut huyt
> 10,0
10,0 8,0
8,0 - 6,5
< 6,5
T vong
> 3,0
3,0 - 2,0
1,0 - 2,0
< 1,0
T vong
> 75
50 75
25 50
< 25
T vong
C triu
chng, nh
hng ADL,
cn can thip
iu tr bng
phu, x tr
hoc ni soi
e
do T vong
tnh mng
Nh, khng C triu chng,

triu chng
cn can thip
iu tr
- p ng iu tr:
nh gi p ng iu tr BMTH theo Hng dn RECIST phin bn 1.1
v cc nghin cu trn y vn [28]:
+ Phng tin nh gi: CT Scan vng sang thng ban u.
+ Thi gian nh gi p ng: t nht l 2 thng.
+ T l p ng:
p ng hon ton: bin mt tt c cc bu hoc khng pht hin bu
mi trn lm sng sau t nht 1 thng.
p ng mt phn: gim t nht 10% tng ng knh ln nht ca bu
hoc gim mt bu t nht l 15% trn CT Scan so vi hnh nh ban u v
khng xut hin cc sang thng mi.
Bnh tin trin: tng t nht 10% ng knh bu so vi lc bu c
ghi nhn nh nht k t khi bt u iu tr v khng gim mt bu 15% trn
CT Scan hoc xut hin thm mt hay nhiu sang thng mi.
Bnh n nh: khng tiu chun nh gi l bnh p ng mt phn
hoc bnh tin trin.
52
- Ti khm:
+ Phng tin ti khm: khm lm sng, siu m vng bng chu, chp X
quang lng ngc, ni soi tiu ha, CT scan vng bu v vng bng chu.
+ Thi hn ti khm sau khi iu tr (phu thut/nhm trng ch) n nh:
trong 2 nm u: 3 thng/ln; trong 3 nm sau: 6 thng/ln; nhng nm tip theo: 1
nm/ln.
- Ti pht v sng cn:
+ Bnh ti pht: bnh nhn c bng chng xut hin bu bng cc phng
tin chn on hnh nh, gii phu bnh v ha m min dch sau thi gian iu tr
trit t nht 6 thng.
+ Bnh tin trin: tng t nht 10% ng knh bu so vi lc bu c
ghi nhn nh nht k t khi bt u iu tr v khng gim mt bu 15% trn
CT Scan hoc xut hin thm mt hay nhiu sang thng mi.
+ Thi gian sng cn ton b: Tnh t thi im phu thut ln u (trit
hay tm b) n lc t vong do bt k nguyn nhn no hoc thi im bit tin cui
ca bnh nhn (ln ti khm cui cng, qua th thm hi, in thoi) hoc thi im kt
thc nghin cu. Thi gian ny tnh bng thng.
+ Thi gian sng cn khng bnh tin trin: tnh t thi im phu thut tm
b ln u n khi bnh tin trin hoc t vong do bt k nguyn nhn no hoc n
thi im chm dt nghin cu. Thi gian ny tnh bng thng.
+ Thi gian sng cn khng bnh ti pht: tnh t thi im phu thut trit
ln u n khi bnh ti pht v/hoc di cn hoc t vong do bt k nguyn nhn
no hoc n thi im chm dt nghin cu. Thi gian ny tnh bng thng.
+ T vong: bnh nhn t vong do bnh (suy kit do bnh, di cn, ) hay do
bt k nguyn nhn no. Thi gian ny tnh bng thng.
53
+ Mt du: nhng bnh nhn khng th lin lc c (ti khm, gi th, gi

in thoi) trong t nht 3 ln lin tip trong qu trnh theo di bnh. Thi gian mt
du c tnh t lc iu tr ln u (phu thut hoc nhm trng ch) cho n khi
bt u mt lin lc. Thi gian ny c tnh bng thng.
2.2.6- Phn loi cc bin s
Bng 2.10: Phn loi cc bin s
Tn bin s
Bin s nn
Phn loi
Gi tr
Bin danh . 40 tui

nh
. > 40 tui
Tui
Bin lin Tui
tc
Bin danh . Nam
Gii
nh
. N
Bin danh . 70
KPS
nh
. 80-90
. 100
Bin s c lp
. au bng
. Bu bng
L do nhp
Bin danh
. i mu
vin
nh
. Tiu mu
. Tnh c
.
Thi gian
Bin lin
khi bnh
tc
Triu chng
lm sng
V tr bu
Bin danh
nh
Bin danh
nh
Pht hin
bu/siu
m
Mt
bu/ siu
Bin danh
nh
. C bu
. Khng bu
. D dy
. Rut non
. i trng
. Trc trng
. Mc treo
. Thc qun
. C bu
. Khng c bu
Bin danh
nh
. Hn hp
. Km
Cch thu thp

Tnh bng hiu s gia nm
nhp vin nm sinh dng
lch
Ghi nhn t h s bnh n
Ghi nhn t h s bnh n
Ghi nhn t h s bnh n
Ghi nhn t h s bnh n: tnh

t lc pht hin bnh n lc
c chn on ra bnh.
Ghi nhn t h s bnh n
Ghi nhn t h s bnh n theo
tng trnh phu thut
Ghi nhn t h s bnh n kt

qu siu m
kt qu siu m
54
m
Di cn
gan/siu m
Pht hin
bu/ni soi
tiu ha
Dng i th
bu/ ni soi
tiu ha
Pht hin
bu/CT
scan
Mt
bu/ CT
scan
Di cn gan/
CT scan
Mc
phu thut
Bu v
trong khi
phu thut
Bu ti
pht sau m
iu tr
bu ti pht
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
Bin danh
nh
iu tr
nhm trng
ch
Liu iu tr
nhm trng
ch
Kch thc
bu
Bin danh
nh
S phn
bo/50 QTL
Bin nh
lng
Nguy c ti
pht
Bin danh
nh
Bin danh
nh
Bin nh
lng
. Dy
. C di cn gan
. Khng di cn gan
. C bu
. Khng c bu

kt qu siu m
qu ni soi tiu ha.
. Chi si
. Lot
. Nhim cng
. C bu
. Khng c bu

qu ni soi tiu ha.
. Hn hp
. Km
. Dy
. C di cn gan
. Khng di cn gan
. Phu tht trit
. Phu thut tm b
. C
. Khng

kt qu CT scan
. C ti pht
. Khng ti pht
. Phu thut
. Imatinib
. Ni khoa
. C
. Khng
Ghi nhn t h s bnh n
. 400 mg/ngy
. 600 mg/ngy
. 800 mg/ngy
. < 5 cm
. 5 10 cm
. > 10 cm
. < 5 phn bo
. 5 10 phn bo
. > 10 phn bo
. Thp
. Trung bnh
. Cao
Ghi nhn t h s bnh n

qu CT scan

kt qu CT scan
Ghi nhn t tng trnh phu
thut
Ghi nhn t tng trnh phu
thut
Ghi nhn t h s bnh n

Ghi nhn t h s bnh n
Ghi nhn t h s bnh n: ghi

nhn t tng trnh phu thut
Ghi nhn t kt qu gii phu
bnh
Phn loi da trn v tr bu,
bu v, kch thc bu v s
phn bo/50 QTL
55
p ng vi
Imatinib
Bin danh
nh
. p ng hon ton Ghi nhn t h s bnh n

. p ng mt phn
. Bnh khng i
. Bnh tin trin
Bin s ph thuc
Kt qu
Thi gian
sng cn
ton b
Bin thay
i theo
thi gian
Thng
Thi gian
sng cn
khng bnh
ti pht
Bin thay
i theo
thi gian
Thng
Thi gian
sng cn
khng bnh
tin trin
Bin thay
i theo
thi gian
Thng
Tnh t thi im phu thut

ln u (trit hay tm b)
n lc t vong do bt k
nguyn nhn no hoc thi
im bit tin cui ca bnh
nhn (ln ti khm cui cng,
qua th thm hi, in thoi)
hoc thi im kt thc nghin
cu
trit ln u n khi bnh ti
pht v/hoc di cn hoc t
vong do bt k nguyn nhn
no hoc n thi im chm
dt nghin cu.
tm b ln u n khi bnh
tin trin hoc t vong do bt k
nguyn nhn no hoc n thi
im chm dt nghin cu.
2.3. X L S LIU
S liu c ghi nhn vo phiu thu thp d liu.
Theo di bnh nhn da vo h s bnh n, bnh nhn ti khm ti Khoa
Ngai 2, khoa Ni 4 hoc khoa Khm Bnh thuc BV Ung Bu TP. HCM, kt hp
gi th hoc gi in thai n bnh nhn v gia nh tm hiu tnh trng bnh ca
bnh nhn.
Thi im kt thc theo di l ngy 31/12/2012 hoc vo thi im bnh
nhn t vong do bt k nguyn nhn no.
Nhp v x l s liu bng phn mm SPSS 16.0.
56
+ Cc bin s nh tnh c m tn xut hin din c hoc khng. Mi

tng quan gia cc bin s c kim nh bng php kim Chi bnh phng (2).
Cc bin s c xc nh c ngha thng k qua phn tch n bin s c a
vo phn tch a bin vi phng php hi quy Cox tm ra cc bin s c tng
quan c lp.
+ Cc bin s nh lng c tnh gi tr trung bnh v lch chun.
+ Cc bin s thay i theo thi gian (thi gian sng cn khng bnh tin
trin, thi gian sng cn ton b) c c tnh bng phng php Kaplan-Meier.
Mi tng quan gia cc bin s trn c kim nh bng php kim Log-rank.
Cc bin s c lin quan n kt qu s c a vo phn tch a bin vi phng
php hi quy Cox tm ra cc bin s c gi tr tin lng c lp.
Cc php kim c xem l c ngha thng k khi p < 0,05, vi tin cy
95%.
+ Hiu qu ca m thc phi hp phu tr v nhm trng ch c xc nh
vi cc kt cc l thi gian sng cn ton b, thi gian sng cn khng bnh tin
trin i vi bnh nhn c phu thut tm b v thi gian sng cn khng bnh
ti pht i vi bnh nhn c phu thut trit .
2.4- O C TRONG NGHIN CU
Vic chn on v iu tr bnh nhn hon ton theo ng quy nh ca bnh
vin v cc phc hin hnh, ng thi c bnh nhn ng thun.
cng nghin cu c Hi ng o c trong Nghin cu Y sinh hc
chp thun thng qua (s 170/HYD-H).
Trong sut qu trnh thc hin nghin cu, Nghin cu sinh lun m bo
tun th ng theo cng c chp thun.
2.5- THI GIAN V A IM NGHIN CU
- Thi gian nghin cu:
57
+ Mu thu thp: nhng bnh nhn nhp vin t 01/01/2006 31/12/2010

+ Thi gian thu thp thng tin t cc mu: t 01/10/2008 - 31/12/2012
- a im nghin cu: khoa Ngoi 2 v khoa Ni 4 ti Bnh vin Ung Bu TP.
H Ch Minh
2.6- MT S VN LIN QUAN N NGHIN CU
- Trc nm 2005, do ngun thuc nhm trng ch iu tr bu m m
ng tiu ha (Imatinib mesylate) khan him v rt t nn khng c bnh nhn
no c iu tr bng loi thuc ny
- T nm 2005, c s ti tr ca mt t chc phi chnh ph v c Bo
Him X Hi Vit Nam ng chi tr cho nhng bnh nhn bu m m ng
tiu ha ti pht hoc di cn xa khng cn m c nn BV Ung Bu TP.HCM
mi bt u s dng liu php nhm trng ch iu tr cho nhng bnh nhn
ny trong thi gian l 12 thng.
- Khng c bnh nhn no trong nghin cu ny c iu tr h tr bng
Imatinib sau phu thut trit .
oOo
58
Chng 3 KT QU NGHIN CU
Trong 5 nm, t 01/01/2006 31/12/2010, chng ti thu thp 109 trng
hp bu m m ng tiu ha c iu tr ti Bnh vin Ung Bu TP. H
Ch Minh tha cc tiu ch nhn bnh; qua , chng ti ghi nhn cc kt qu nh
sau:
- Kt qu iu tr bu m m ng tiu ha ti Bv Ung Bu TP. H Ch Minh
c trnh by tm tt trong s 3.2 nh sau:
BN BU M M NG TIU HA
n=109
PT TRIT
n=66
N NH
n=30
PT TM B
n=43
TI PHT 1
n=36
CT RNG
n= 10
IMATINIB
n=75
(+4 B T)
KHNG PT/PT
TM B (n=26)
TI PHT 2
n=10
THEO DI
HT*
n=10
MP*
n=34
*
n=12
TTR*
n=19
* Ch vit tt: HT: p ng hon ton; MP: p ng mt phn; : bnh n nh; TTR: bnh tin trin
S 3.2: S iu tr bu m m ng tiu ha
ti bnh vin Ung Bu TP. H Ch Minh
59
3.1- c im nhm bnh nhn tham gia nghin cu

Bng 3.11: c im nhm bnh nhn tham gia nghin cu
c im
Gii tnh
S trng hp
T l (%)
Nam
70
64,2
39
35,8
T l nam/n
Tui
1,8/1
Bin thin
19 75
Trung bnh
51,9 11,0
40
19
17,4
> 40
90
82,6
Thc qun
0,9
D dy
46
42,2
Rut non
40
36,7
i trng
8,3
Trc trng
6,4
Mc treo
5,5
V tr khi bu
* Nhn xt:
- T l mc bnh nam gii cao hn n gii vi t l nam/n l 1,8/1
- Tui mc bnh trung bnh l 51,9 11, vi 82,6% bnh nhn > 40 tui.
- Phn b v tr bu trn ng tiu ha: nhiu nht l d dy (42,2%), k n l
rut non (36,7%), i trng (8,3%), trc trng (6,4%), mc treo (5,5%) v thc qun
(0,9%).
3.1.1- Phn b theo gii tnh
Chng ti ghi nhn t l nam/n l 70/39 # 1,8/1. Phn b gii tnh theo v
tr bu c trnh by trong bng 3.12.
60
Bng 3.12: Phn b t l nam/n theo v tr bu

V tr bu
Nam
T l nam/n
Thc qun
D dy
27
19
1,42/1
Rut non
28
12
2,33/1
i trng
3,50/1
Trc trng
1,33/1
Mc treo
1/1
* Nhn xt: t l nam/n i vi BMTH rut non v BMTH i trng

cao hn so vi BMTH ni chung.
3.1.2- Phn b theo tui
Trong nghin cu ny, bnh nhn c khong tui thay i t 19 75; tui
trung bnh l 54 11 tui. Theo v tr bu, phn b tui c trnh by trong bng
3.13.
Bng 3.13: Phn b tui theo v tr bu
V tr bu
Khong tui
Tui trung bnh
Thc qun
47
47
D dy
19-74
54,5 11,8
Rut non
28-73
53,0 9,8
i trng
32-72
54,0 11,5
Trc trng
33-75
55,0 16,4
Mc treo
39-56
48,0 6,8
* Nhn xt: tui trung bnh theo cc v tr bu thay i t 47 55 tui.

3.1.3- L do nhp vin
Cc l do nhp vin c ghi nhn trong bng 3.14.
61
Bng 3.14: Phn b l do nhp vin theo v tr bu

V tr
S BN
bu
Bu
au
Mt
Mt
Nut
Ngu
bng
bng
mi
rn
nghn
nhin
Thc qun
D dy
46
15
21
10
Rut non
40
17
17
i trng
Trc trng
Mc treo
Tng s
109
36
53
13
* Nhn xt:
a s bnh nhn nhp vin v au m vng bng (53 bnh nhn, 48,6%) v
bu bng (36 bnh nhn, 33,0%); c 13 bnh nhn (11,9%) hon ton khng c
triu chng v ch c pht hin bnh ngu nhin qua khm siu m v l do khc.
3.1.4- iu tr trc
Trong nghin cu ca chng ti, c 40 bnh nhn (36,7%) c phu
thut. Sau hoc l bu ti pht hoc l mun c iu tr Imatinib h tr sau
m nn bnh nhn c chuyn n Bnh vin Ung Bu TP. HCM.
3.1.5- Thi gian khi bnh
Thi gian khi bnh ko di t 1 -13 thng, thi gian khi bnh trung bnh l
3,8 1,2 thng. Theo v tr bu, thi gian khi bnh c thay i (Bng 3.15)
62
Bng 3.15: Phn b thi gian khi bnh theo v tr bu:

V tr bu
Bin thin thi gian
Thi gian khi bnh
khi bnh (thng)
trung bnh (thng)
D dy
1 10
7,4 2,5
Rut non
14
2,0 0,9
i trng
1 12
3,0 2,4
Trc trng
18
3,0 2,3
Mc treo
36
3,5 1,3
Thc qun
* Nhn xt: BMTH d dy c thi gian khi bnh trung bnh di hn

BMTH ni chung (7,4 thng so vi 3,8 thng).
3.2- Lm sng
3.2.1- Triu chng khi bnh
Cc triu chng khi bnh bao gm au bng, bu bng, mt mi, c
trnh by trong bng 3.16.
Bng 3.16: Phn b triu chng khi bnh theo v tr bu:
V tr
Bu
au
Mt
Mt
Nut
Tiu
bu
bng
bng
mi
rn
nghn
mu
mu
Thc qun
D dy
29
Rut non
20
i trng
Trc trng
Mc treo
Tng s
14
63
63
* Nhn xt:
Triu chng khi bnh ca BMTH khng c hiu, 57,6% bnh nhn
khi bnh vi tnh trng au bng vng thng v hoc au quanh rn, 14 bnh
nhn t s thy bu vng bng (12,9%); c 2 bnh nhn b nut nghn v 1 bnh
c triu chng nn ra mu, s bnh nhn cn li c cc triu chng m h nh mt
mi, bun nn, n kh tiu, (20,3%) hoc khng c triu chng g (11,9%)
3.2.2- Ch s hot ng c th
Ti bnh vin Ung Bu TP. H Ch Minh, bnh nhn c nh gi hot
ng c th bng ch s Karnofsky (Bng 2.6). c th so snh vi cc cng trnh
nghin cu khc v ch s ny, chng ti i t ch s Karnofsky sang ch s
ECOG (Bng 2.8).
Tt c bnh nhn trong nghin cu ny c ch s ECOG t 1 n 2, trong
ECOG = 1 c 99 bnh nhn, chim 90,8%; ECOG = 2 c 10 bnh nhn, chim
9,2%.
9%
ECOG=1
ECOG=2
91%
Biu 3.1: Phn b bnh nhn theo ch s ECOG
3.2.3- Triu chng lm sng

Khm lm sng pht hin c 54 trng hp c bu vng bng, chim t
l 49,5%; trong c 32 trng hp bu km di ng (59,3%).
64
i vi BMTH d dy, khm lm sng s c bu trong 29 trng

hp (63,0%).
i vi BMTH rut non, c 16 trng hp (40,0%) bu s c trn
lm sng, bu thng di ng v khng au khi khm.
5 trng hp BMTH trc trng (71,4%) khm c bu qua ng hu
mn.
4 trng hp bu mc treo (66,7%) khm s c bu bng.
3.3- Triu chng cn lm sng
3.3.1- Siu m
Siu m trc m pht hin 86 bnh nhn c bu trong bng (78,9%).
Kch thc bu pht hin trn siu m thay i t 2,0 cm 30,5 cm; trung bnh l
10,0 5,7 cm. a s bu c mt hn hp (76,7%), mt s trng hp c tng
sinh mch mu (36,1%) Qua siu m, pht hin 7 trng hp (8,1%) bu xm ln
cc tng ln cn nh lch, gan, ty.
Siu m cng gip pht hin 21 trng hp di cn gan (19,3%); a s l di
cn gan nhiu , 2 thy (14 trng hp, 66,7%).
Chn on qua siu m kt lun chnh xc BMTH (c di cn gan, gieo
rc bng hoc khng) l 81 trng hp (74,3%). Cc chn on nhm thng gp
l; bu mc treo (12 trng hp); bu sau phc mc (5 trng hp); ung th trc
trng (2 trng hp), ung th rut non (6 trng hp), ung th bung trng (3
trng hp).
3.3.2- Ni soi tiu ha
C 31 trng hp c ni soi ng tiu ha trc m, bao gm ni soi d
dy (24 trng hp; 22,0%); ni soi khung i trng (3 trng hp; 2,8%); ni soi
trc trng (3 trng hp; 2,8%) v 1 trng hp soi thc qun (0,9%). Qua 31
trng hp ni soi tiu ha, ch pht hin 14 trng hp c bu (45,2%); cc v tr
65
bu c pht hin qua ni soi l: 1/3 di thc qun (1 trng hp); d dy (8

trng hp); i trng (2 trng hp) v trc trng (3 trng hp). Hnh nh i th
bu c th gp qua ni soi l lot (6 trng hp), chi si (4 trng hp ) hoc
thm nhim (4 trng hp).
+ BMTH d dy: c 17 trng hp c ni soi d dy (37,0%), ch c 5
trng hp pht hin lot trong d dy do bu xm ln nim mc v 4 trng
hp cho kt qu sinh thit l BMTH vi CD117 (+).
+ BMTH i trng: ch c 01 trng hp chn on c bng siu m v
chp ct lp vi tnh l bu i trng sigma v c ni soi khung i trng. Qua
ni soi, ghi nhn bu vo lng i trng, kt qu sinh thit ch thy m vim.
+ BMTH trc trng: tt c 7 trng hp BMTH trc trng u c soi
i trng sigma. Qua , pht hin 2 trng hp bu chi si vo lng trc trng
v tr cch b hu mn 4 v 6 cm, 5 trng hp cn li ch thy bu vo lng
trc trng, trong 4 trng hp bu cch b hu mn > 8 cm.
* Gii phu bnh v ha m min dch trc m:
Trong 14 trng hp pht hin bu qua ni soi ng tiu ha v c sinh
thit lm gii phu bnh l v nhum ha m min dch, ch c 7 trng hp c kt
qu l bu m m ng tiu ha vi s phn bo > 5/50 QTL l 4 trng hp; 3
trng hp cn li c s phn bo < 5/ 50 QTL. C 7 trng hp u dng tnh
CD117 khi nhum ha m min dch.
3.3.3- X Quang ng tiu ha c cn quang
C 34 trng hp c chp X quang ng tiu ha cn quang; trong 1
trng hp chp thc qun cn quang; 24 trng hp chp d dy cn quang; 9
trng hp chp i trng cn quang. Qua hnh nh X quang, cho thy 14 trng
hp khi bu cho hnh nh chon ch.
66
3.3.4- Chp ct lp vi tnh

80 trng hp c chp ct lp vi tnh c cn quang (73,4%), 60 trng
hp pht hin khi bu nguyn pht, trong c 52 trng hp chn on chnh
xc l bu m m ng tiu ha. Cc bu c vi kch thc thay i t 2,4
30 cm; trung bnh l 11,7 3,2 cm.
a s bu m m ng tiu ha trn hnh nh chp ct lp vi tnh c mt
hn hp, va nang va c (48 trng hp; 92,3%); 6 trng hp bu c mt
dy (10,0%) v 6 trng hp cn li c mt km (10,0%). C 5 trng hp
bu xm ln cc c quan ln cn nh gan, lch, ty, c honh,.. 18 trng hp
pht hin di cn gan trn chp ct lp vi tnh (34,6%).
Chp ct lp vi tnh gip chn on chnh xc 52 trng hp bu m m
ng tiu ha (86,7%). Chn on nhm thng gp l: bu mc treo, bu sau
phc mc, ung th trc trng,
Hnh 3.17: CT Scan BMTH d dy vi hnh nh ha nang, hoi t
- BMTH d dy: ch c 28 bnh nhn c chp ct lp vi tnh, c 25 trng

hp pht hin bu trn hnh nh chp ct lp vi tnh; trong ch c 18 trng
hp chn on BMTH d dy (64,3%). 7 trng hp khc chn on nhm l
ung th d dy (5 trng hp) hoc ung th gan tri (2 trng hp). Kch thc
bu thay i t 2 18 cm, kch thc trung bnh l 9,5 5,2 cm. Bu trn hnh
67
nh chp ct lp vi tnh thng c mt hn hp. Qua chp ct lp vi tnh pht

hin 5 trng hp bu xm ln cc tng (gan, lch, ) v 8 trng hp c di
cn gan.
- BMTH rut non: 32 bnh nhn (80%) c chp ct lp vi tnh ti bnh vin
Ung Bu TP.HCM; trong pht hin 29 trng hp chn on bu m m
ng tiu ha, 2 trng hp cn li pht hin gieo rc bng v 1 trng hp c
di cn gan.
3.4- Chn on trc m
C 40 bnh nhn (chim t l 36,7%) c m v c kt qu CD117 (+)
ti cc bnh vin khc. Cc trng hp cn li, trc m da vo cc yu t lm
sng, hnh nh hc v CD117(+), c 51/69 trng hp (73,9%) c chn on l
bu m m ng tiu ha.
18 trng hp cn li b chn on nhm trc m l bu mc treo, bu
bung trng, carcinm i trng, bu bng, ung th ty, ung th gan tri,
Tnh chung, ti thi im chn on, giai on bnh c ghi nhn nh sau:
Bng 3.17: Giai on bnh khi chn on
Giai on
S ca
T l (%)
Giai on khu tr ti ch
75
68,8
Di cn gan gieo rc phc mc
34
31,2
Tng s
109
100
* Nhn xt: ch c 68,8% bu cn giai on khu tr, c n 31,2% bu cho

di cn xa c hay khng c km theo gieo rc phc mc.
3.5- iu tr
3.5.1- Phu tr
3.5.1.1- Cc phng php phu thut:
68
Trong s 109 trng hp ghi nhn trong nghin cu ca chng ti, c 69

trng hp c iu tr ln u ti BV Ung bu TP. H Ch Minh. Trong 40
trng hp c m ti t cc bnh vin khc v chuyn n BV Ung Bu TP.
HCM iu tr tip, c 17 trng hp bnh nhn ti pht c ch nh phu thut li v
23 trng hp cn iu tr nhm trng ch h tr sau m hoc ti pht nhng
khng cn ch nh phu thut (di cn gan, gieo rc bng, )
Bng 3.18: Cc phng php phu thut
Mc phu thut
S ca
T l (%)
Phu thut trit
66
60,6
Phu thut tm b
43
39,4
Phu thut sinh thit ni tt tiu ha
36
33,0
Bu v trong lc m
2,8
Phu thut triu chng
3,6
Tng s
109
100
* Nhn xt:
Ngoi 36 trng hp ch phu thut tm b hoc m thm st, c 3 trng
hp bu b v trong lc m v 4 trng hp ct bu triu chng, cn li bu.
Nh vy, ch c 66 trng hp c phu thut trit (60,6%).
a s bnh nhn (60,6%) c phu thut trit vi b din ct an ton 2
cm. Cc trng hp ny c thc hin nhng bnh nhn c bu cn khu tr (75
trng hp). V th, t l thc hin phu thut trit nhng bnh nhn cn khu
tr l (66/75 bnh nhn) 88%. 9 bnh nhn cn li l do bu xm ln ti ch nhiu
vo cc c quan quan trng (mch mu, ty tng, ..) nn khng th m ct bu
c.
69
Bng 3.19: Cc phng php phu thut trit

Phu thut trit
S ca
S ca thc
nghin cu
hin phu
T l (%)
thut
D dy
46
28
60,9
Ct d dy ton phn + ct lch
Ct d dy bn phn + ct tng
Ct rng bu
19
Ct on rut non
40
27
67,5
i trng
33,3
Ct i trng
Ct trc
Trc trng
57,1
Ct trc
PT Miles
Mc treo: ct rng bu
66,7
Tng s
66
109
60,6%
Chng ti ghi nhn c 18 trng hp bu xm ln cc tng ln cn nh

gan, lch, ty, mch mu ln, c honh, bng quang, thnh bng, trong c 9
trng hp phi ct bu nguyn pht cng vi tng b xm ln.
- Bu m m ng tiu ha d dy: trong 46 trng hp BMTH d
dy c 15 trng hp c phu thut ti cc bnh vin khc (8 trng hp phu
thut trit , sau c 5 trng hp ti pht, gieo rc bng; 7 trng hp khc
ch c phu thut tm b). Trong 31 trng hp BMTH d dy c phu
thut ln u ti BV Ung Bu TP. H Ch Minh, c 2 trng hp ct d dy bn
phn, 1 trng hp ct d dy bn phn km theo ct lch v ui ty, 21 trng
hp ct rng d dy vi b din ct cch bu 2 cm v khu phc hi d dy theo
70
chiu dc nhm trnh hp lng d dy, c 4 trng hp b v bu khi ct rng do

bu b..
- Bu m m ng tiu ha rut non: 17 trong s 40 trng hp
BMTH rut non c iu tr phu thut ti cc bnh vin khc, trong c
14 trng hp c ct on rut non mang bu v 3 trng hp ch m thm st
sinh thit.
23 trng hp cn li c phu thut ln u ti BV Ung Bu TP. HCM,
trong 16 trng hp (69,6%) c ct on rut non mang bu, c 3 trng
hp b v bu trong lc m, 7 trng hp khc ch c m thm st v sinh thit
bu do bu ln, c gieo rc hoc di cn gan.
- Bu m m ng tiu ha i trng: ch c 3 trong s 9 trng hp
BMTH i trng c ct trit (2 trng hp ct i trng phi v 1 trng
hp ct trc) 6 trng hp cn li ch c phu thut tm b bng cch m hu
mn nhn to do bu ln, xm ln ti ch nhiu, cho di cn gan
- Bu m m ng tiu ha trc trng: trong 7 trng hp BMTH
trc trng, c 2 trng hp c ct trc do bu nm 1/3 trn trc trng, 2
trng hp c phu thut Miles v 3 trng hp cn li ch lm hu mn nhn
to do bu xm ln v di cn gan.
- Bu m m ng tiu ha mc treo: 4 trong s 6 trng hp BMTH
mc treo c ct rng bu km vi on rut non tng ng, vi b din ct #
2 cm; 2 trng hp cn li khng ct c bu do bu ln, xm ln mch mu
ln.
- Bu m m ng tiu ha thc qun: trng hp BMTH thc qun
duy nht trong nghin cu ny nm 1/3 di vi kch thc # 6,5 cm. Tuy nhin,
bu cho di cn gan vo lc chn on nn ch c m d dy ra da nui n
71
3.5.1.2- Bin chng trong m

Ch c 3 trng hp chy mu nhiu trong lc m (# 500 mL) (1
BMTH d dy, 1 BMTH rut non v 1 BMTH i trng phi).
3.5.1.3- Hnh nh gii phu bnh v ha m min dch sau m
- i th:
Kch thc bu nguyn pht ghi nhn trong ln m u thay i t 3 32
cm; trung bnh l 12,3 5,7 cm. Mt s tnh cht i th khc chng ti ch ghi
nhn i vi cc trng hp m ln u ti BV Ung Bu TP. H Ch Minh (69
trng hp). a s bu c hnh nh u nn (52 trng hp; 75,4%), tng sinh mch
mu (54 trng hp; 78,3%).
Bng 3.20: Phn b kch thc bu sau m
V tr bu
>2 5 cm
>5 10 cm
> 10 cm
Tng s
Thc qun
D dy
16
26
46
Rut non
17
18
40
i trng
Trc trng
Mc treo
Tng s
12
45
52
109
T l (%)
11,0
41,3
47,7
100
* Nhn xt: trong nghin cu ny, chng ti khng ghi nhn trng hp no c
kch thc 2 cm. a s bu c kch thc t > 10 cm (47,7%)
- Bu m m ng tiu ha d dy: kch thc bu ghi nhn trong lc m l
t 4 25 cm; trung bnh l 12,9 5,4 cm, tt c u c hnh nh u nn, tng sinh
mch mu.
72
Phn b v tr bu d dy nh sau (biu 3.2):
TM V
4%
4%
9%
PHNH V
17%
B CONG NH
B CONG LN
38%
THN V
28%
HANG V
Biu 3.2: V tr BMTH d dy

* Nhn xt: Nhng v tr thng gp ca BMTH d dy l b cong ln (38%),
b cong nh (28%); trong khi BMTH hang v ch chim 4% cc trng
hp.
- BMTH rut non: kch thc bu ghi nhn trong lc m 2,5 - 32 cm, trung
bnh l 13,0 4,6 cm, bu thng t tng sinh mch mu. Phn b v tr bu
rut non c trnh by trong biu 3.2.
4
T trng
19
Hng trng
Hi trng
17
Biu 3.3: V tr BMTH rut non
73
+ a s BMTH rut non thng gp hi trng (19 trng hp, chim

47,5%)v hng trng (17 trng hp, chim 42,5%); BMTH t trng ch
chim 10% BMTH rut non.
- Phn b v tr bu i trng nh sau:
i trng P
i trng ngang
i trng T
i trng sigma
1
Biu 3.4: V tr BMTH i trng

- BMTH i trng gn nh chia u cho cc v tr.
Phn b v tr bu trc trng nh sau:
1/3 trn
1/3 gia
1/3 di
Biu 3.5: V tr BMTH trc trng
74
a s BMTH trc trng nm 1/3 di trc trng (57,1%).

- Hnh nh vi th v ha m min dch:
Tt c 109 trng hp trong nghin cu ny u c kt qu vi th l bu
m m ng tiu ha vi CD117 (+).
Kt qu nhum ha m min dch u cho dng tnh vi CD117. Ngoi
phn ng dng tnh vi CD117, cc bu m m ng tiu ha cn cho phn
ng dng tnh vi mt s th th nh Vimentin, Desmin, Actin, S100,..
Bng 3.21: Phn b kt qu ha m min dch theo v tr BMTH
V tr bu
CD117
Vimentin
Desmin
Actin (+)
S100 (+)
CK (+)
(+)
(+)
(+)
Thc qun
D dy
46
25
13
18
Rut non
40
20
12
13
i trng
Trc trng
Mc treo
Tng s
109
65
13
32
38
T l (%)
100
59,6
11,9
29,3
34,9
3,7
* Nhn xt: ngoi dng tnh vi CD117, cc t bo BMTH cn cho kt qu

dng tnh vi Vimentin (59,6%), S100 (34,9%), Actin (29,3%) him hn l dng
tnh vi Desmin (11,9%) v CK (3,7%).
75
Bng 3.22: Phn b s phn bo trn 50 quang trng ln theo v tr bu

V tr bu
5 phn bo
Thc qun
D dy
16
25
46
Rut non
13
24
40
i trng
Trc trng
Mc treo
Tng s
34
12
63
109
T l (%)
31,2
11,0
57,8
100
6-10 phn bo > 10 phn bo
Tng s
* Nhn xt: t l s phn bo/50 QTL > 10 chim a s (57,8%), iu ny cng ph

bin i vi tng v tr bu trn ng tiu ha. Ch c 11% bu c ch s phn
bo t 6-10; 31,2% bu c ch s phn bo thp ( 5/50QTL)
3.5.1.4- nh gi nhm nguy c theo tiu chun b sung ca VYTQG Hoa K
Da vo kch thc bu v s phn bo/50 QTL, chng ti c bng phn b
bu theo 2 yu t ny nh sau (Bng 3.23):
Bng 3.23: Phn b kch thc bu v s phn bo/50 QTL
Kch thc
Tng s
>2 5 cm
> 5 10 cm
> 10 cm
S phn bo/50 QTL
(t l)
5 phn bo
21
34 (31,2%)
6 10 phn bo
12 (11,0%)
> 10 phn bo
24
39
63 (57,8%)
12 (11,0%)
45 (41,3%)
52 (47,7%)
109
Tng s (t l %)
76
Theo Tiu chun b sung ca Vin Y t Quc gia (VYTQG) Hoa K, nh

gi nhm nguy c ti pht da vo cc yu t: kch thc bu, s lng phn bo
trn 50 quang trng ln, v tr bu v tnh trng bu v trong lc m. Theo ,
trong nghin cu ny, chng ti nh gi nhm nguy c nh sau (Bng 3.24):
Bng 3.24: Phn nhm nguy c ti pht i vi bu m m ng tiu ha
Nhm nguy c
S trng hp
Nguy c rt thp
Nguy c thp
4,6
Nguy c trung bnh
25
22,9
Nguy c cao
79
72,5
Tng cng
109
100
T l (%)
* Nhn xt: t l nhm nguy c ti pht cao trong nghin cu ca chng ti chim
a s (72,5%). C 22,9% trng hp l nhm nguy c trung bnh, 4,6% l nguy c
thp v khng c trng hp no thuc nhm nguy c rt thp.
- Phn nhm nguy c ti pht i vi BMTH d dy:
Bng 3.25: Phn nhm nguy c ti pht i vi BMTH d dy
Nhm nguy c
S trng hp
T l (%)
Nguy c rt thp
Nguy c thp
4,3
Nguy c trung bnh
11
23,9
Nguy c cao
33
71,8
Tng cng
46
100
* Nhn xt: a s BMTH d dy u thuc nhm nguy c ti pht cao (73,9%)

- Phn nhm nguy c ti pht i vi BMTH rut non nh sau:
77
Bng 3.26: Phn nhm nguy c ti pht i vi BMTH rut non

Nhm nguy c
S trng hp
T l (%)
Nguy c rt thp
Nguy c thp
5,0
Nguy c trung bnh
22,5
Nguy c cao
29
72.5
Tng cng
40
100
* Nhn xt: a s BMTH rut non thuc nhm nguy c cao (70%); bu
nhm nguy c thp ch chim 5%.
- Bng 3.27 cho thy phn nhm nguy c ti pht i vi BMTH i trng:
Bng 3.27: Phn nhm nguy c ti pht i vi BMTH i trng
Nhm nguy c
S trng hp
T l (%)
Nguy c rt thp
Nguy c thp
Nguy c trung bnh
22,2
Nguy c cao
77,8
Tng cng
100
* Nhn xt: 77,8% cc trng hp BMTH i trng u thuc nhm nguy c

ti pht cao; ch c 22,2% bu thuc nhm nguy c trung bnh.
Phn nhm nguy c ti pht i vi BMTH trc trng nh sau:
Bng 3.28: Phn nhm nguy c ti pht i vi BMTH trc trng
Nhm nguy c
S trng hp
T l (%)
Nguy c rt thp
Nguy c thp
Nguy c trung bnh
14,3
Nguy c cao
85,7
Tng cng
100
78
* Nhn xt: tuy s liu ch c 7 trng hp, nhng a s cc BMTH trc trng
u c thuc nhm nguy c ti pht cao (85,7%).
- i vi BMTH mc treo, phn b nguy c ti pht nh sau:
Bng 3.29: Phn nhm nguy c i vi BMTH mc treo
Nhm nguy c
S trng hp
T l (%)
Nguy c rt thp
Nguy c thp
16,7
Nguy c trung bnh
33,3
Nguy c cao
50,0
Tng cng
100
* Nhn xt: 50% BMTH mc treo thuc nhm ti pht cao.

3.5.1.5- Tnh trng ti pht sau phu thut trit
Trong 66 trng hp c phu thut trit , c 36 trng hp ti pht
(54,5%); trong c 14 trng hp ch ti pht ti ch (21,2%), 4 trng hp c di
cn gan v ti pht ti ch (6,1%); 9 trng hp di cn gan (13,6%) v 9 trng hp
gieo rc bng (13,6%). Cc trng hp ti pht sau phu thut trit c iu
tr tip bng phu thut li hoc Imatinib (Bng 3.30).
Thi gian ti pht thay i t 4 26 thng; trung bnh l 12,6 6,1 thng.
Bng 3.30: iu tr BMTH ti pht sau phu thut trit
Cch iu tr BMTH ti pht
S trng hp
T l (%)
Phu thut
18
50
Ct rng bu
10
27,8
Khng ct c bu ti pht
22,2
Imatinib
18
50
79
3.5.2- iu tr nhm trng ch sau m

3.5.2.1- Ch nh iu tr nhm trng ch
Ti thi im nghin cu (2006 - 2010), ch nh iu tr bng cc thuc c
ch tyrosin kinase (Imatinib) i vi bu m m ng tiu ha ch dnh cho cc
trng hp: sau m cn bu, di cn xa, gieo rc bng v bu ti pht khng
cn m c.
Trong nghin cu ca chng ti c 79 trng hp c ch nh iu tr sau
m bng Imatinib. Tuy nhin, c 04 bnh nhn t chi iu tr (d c min
ph). V vy, c 75 bnh nhn (68,8%) c iu tr Imatinib, bao gm cc trng
hp sau:
Bng 3.31: Ch nh iu tr Imatinib sau m
iu tr nhm trng ch sau m
S ca
T l (%)
Sau phu thut cn st bu
12,0
Di cn gan gieo rc bng
25
33,4
Ti pht ti ch khng m c
41
54,6
Tng cng
75
100
* Nhn xt:
- Phn ln cc trng hp dng thuc nhm trng ch l cho ch nh bu ti
pht ti ch khng cn m c (54,6%); cc ch nh khc l di cn gan c hoc
khng c km theo gieo rc bng (33,4%).
- Ch c 12% cc trng hp iu tr nhm trng ch l nhm h tr sau m
khng ct ht bu hoc din ct cn bu.
80
3.5.2.2- p ng iu tr Imatinib
- p ng iu tr Imatinib ln u
a s bnh nhn c s dng Imatinib ln u vi liu l 400 mg/ngy. C
mt bnh nhn sau m ct mt phn bu c gii trnh t gen vi t bin ti exon
9 nn c iu tr khi u l 600 mg Imatinib/ngy.
Thi gian iu tr Imatinib thay i t 4 12 thng, thi gian iu tr trung bnh
vi Imatinib l 10,8 2,1 thng.
Da vo tiu chun nh gi p ng iu tr BMTH ca Choi [28] v
hng dn RESIST 1.1 [51], chng ti ghi nhn t l p ng vi iu tr Imatinib
ln u nh sau (Bng 3.32):
Bng 3.32: p ng iu tr Imatinib ln u
nh gi iu tr
S trng hp
T l (%)
p ng hon ton
10
13,3
p ng mt phn
22
29,3
Khng i
16
21,4
Bnh tin trin
27
36,0
Tng s
75
100
* Nhn xt:
- C 13,3% cc trng hp c p ng hon ton vi Imatinib. Cc trng hp ny
bao gm: 09 trng hp sau m cn st bu v 01 trng hp bu cho di cn gan
n c ti h phn thy VIII, c kch thc 3 cm, khng th ct bu di cn c.
- T l p ng mt phn vi sau iu tr Imatinib ln u l 29,3% cc trng hp
BMTH, trong c 12 trng hp bu ti pht khng m c v 10 trng
hp bu di cn gan c hay khng c km gieo rc phc mc.
81
- C 21,4% cc trng hp BMTH bnh n nh v 36% bu vn tin trin sau

iu tr Imatinib ln u.
3.5.2.3- Tnh trng bnh tin trin sau iu tr Imatinib
Trong nghin cu ny, chng ti c 75 bnh nhn c iu tr Imatinib vi
cc ch nh: sau m tm b, bnh di cn gan hoc gieo rc phc mc, ti pht ti
ch khng m c (Bng 3.31).
Trong thi gian iu tr nhm trng ch, mc d c 32 bnh nhn c p
ng (hon ton v mt phn) v 16 bnh nhn n nh sau iu tr vi Imatinib
(chim t l chung l 68,3%), nhng sau iu tr c 33 bnh nhn (44,0%) tip tc
tin trin. Thi gian tin trin thay i t 4 12 thng; trung bnh l 7,2 3,1 thng.
C 28 trong s 33 bnh nhn BMTH tin trin c iu tr tng liu
Imatinib ln lt l 600 mg/ngy; sau l 800 mg/ngy.
Sau khi thi gian chm dt nghin cu (31/12/2012), chng ti tng kt p
ng vi iu tr Imatinib nh sau (Bng 3.33):
Bng 3.33: p ng iu tr Imatinib
nh gi iu tr
S trng hp
T l (%)
p ng hon ton
10
13,3
p ng mt phn
34
45,4
Khng i
12
16,0
Bnh tin trin
19
25,3
Tng s
75
100
* Nhn xt: c 58,7% bnh nhn c p ng vi Imatinib, trong c 13,3% bnh

nhn p ng hon ton. C 25,3% bnh nhn vn tin trin bnh d c iu
tr bng thuc nhm trng ch. S bnh nhn khng thay i tnh trng khi iu tr
bng Imatinib chim t l 16%.
Theo tng v tr bu, t l p ng (ton phn v mt phn) vi Imatinib
c trnh by trong bng 3.34 nh sau:
82
Bng 3.34: T l p ng vi Imatinib theo v tr bu

V tr bu
S ca iu tr
S ca p ng ton b
T l (%)
D dy
35
24
68,6
Rut non
27
13
47,2
i trng
60
Trc trng
50
Mc treo
50
Tng s
75
44
58,7
* Nhn xt: T l p ng vi Imatinib ca BMTH theo v tr bu thay i t

47,2% ( rut non) n 68,6% ( d dy).
3.5.2.4- Cc tc dng ph ca Imatinib
Cc tc dng ph ca Imatinib thng nh v t gp, bao gm: ph mi mt,
thiu mu, gim bch cu, tiu chy, .... cc tc dng ph ny c trnh by trong
bng 3.35
Bng 3.35: Cc tc dng ph ca Imatinib
S trng hp
T l (%)
Ph mi mt
21
28,0
Thiu mu ( I-II)
15
20,0
Gim bch cu ( I-II)
14
18,7
Mt mi
14
18,7
Tiu chy
10
13,3
Bun nn
9,3
au c/xng
8,0
Ph chn
6,7
Vp b
5,3
Ni mn
5,3
Tc dng ph
83
* Nhn xt: tc dng ph thng gp nht ca Imatinib l ph m mt (28%), 20%

bnh nhn c triu chng thiu mu trong khi iu tr vi Imatinib vi mc t
nh n trung bnh. Cc tc dng khc c th gp l gim bch cu (18,7%), mt
mi (18,7%), tiu chy (13,3%), bun nn (9,3%), au mi c (8%), ph chn
(6,7%), vp b (5,3%) v ni mn (5,3%)
3.6- Theo di v kt qu iu tr
Tnh n thi im kt thc nghin cu, thi gian theo di thay i t 1 68
thng; thi gian theo di trung bnh l 35,0 16,3 thng. C 13 trng hp mt du
do khng lin lc c (11,9%); Trong 96 trng hp theo di c (88,1%) c 62
trng hp ti pht hoc tin trin (37 trng hp ti pht/tin trin cn sng
(34,0%) v 25 trng hp t vong do bnh (22,9%)), ch c 34 trng hp sng
khng bnh (31,2%).
3.6.1- Sng cn ton b i vi bnh nhn nghin cu
- c tnh t l sng cn ton b 5 nm l 69,0 5,5%.
T l SCTB
n = 109
Thi gian (thng)
Biu 3.6: T l sng cn ton b
84
- c tnh t l sng cn ton b 5 nm ca BMTH theo v tr bu:

Theo v tr bu, t l sng cn ton b 5 nm c biu din trong bng
3.36.
Bng 3.36: c tnh t l SCTB 5 nm ca BMTH theo v tr bu
V tr bu
T l SCTB 5 nm (%)
BMTH d dy
76,1 7,8
BMTH rut non
64,8 9,7
BMTH i trng
66,7 20,8
BMTH trc trng
66,7 19,2
BMTH mc treo
66,7 19,2
BMTH thc qun
* Nhn xt: t l sng cn 5 nm ca BMTH d dy (76,1%) cao hn so vi

dn s nghin cu (69,0%), cc v tr bu rut non, i-trc trng v mc treo c
t l sng cn ton b thp hn dn s nghin cu, s khc bit ny khng c
ngha thng k (p > 0,05). Trng hp BMTH duy nht thc qun khi pht
hin c di cn gan v ch sng c 1 thng sau khi chn on.
- Thi gian sng cn ton b trung bnh l 54,9 2,2 thng.
- Thi gian sng cn ton b trung bnh theo v tr bu:
Theo v tr bu, thi gian sng cn ton b trung bnh c thay i v c
trnh by trong bng 3.37:
85
Bng 3.37: Thi gian SCTB trung bnh theo v tr bu

V tr bu
Thi gian SCTB

trung bnh (thng)
BMTH d dy
57,7 3,2
BMTH rut non
50,1 3,4
BMTH i trng
47,7 5,0
BMTH trc trng
57,7 6,0
BMTH mc treo
34,7 5,9
BMTH thc qun
* Nhn xt: ngoi tr trng hp bu thc qun bnh nhn ch sng 1 thng sau
khi c chn on, thi gian sng cn trung bnh ca BMTH mc treo thp
hn so vi cc v tr khc (34,7% so vi 47,7%-57,7%).
3.6.2- Sng cn ton b v sng cn khng bnh ti pht i vi bnh nhn
c phu thut trit
Trong nghin cu ny, chng ti thc hin c 66 trng hp phu thut
trit . Bng phng php Kaplan Meier, chng ti c tnh sng cn ton b v
sng cn khng bnh ti pht trong nhm bnh nhn ny nh sau:
- T l sng cn ton b 5 nm i vi bnh nhn c phu thut trit c tnh
l 84,3 5,4 % (Biu 3.7). T l ny cao hn so vi dn s nghin cu (84,3%
so vi 69%).
86
T l SCTB
n = 66
Thi gian (thng)
Biu 3.7: T l SCTB i vi bnh nhn c phu thut trit
- T l sng cn ton b 5 nm theo v tr bu i vi bnh nhn c phu thut

trit c trnh by trong bng 3.38.
Bng 3.38: T l SCTB 5 nm theo v tr bu i vi bnh nhn c phu
thut trit :
V tr bu
T l SCTB 5 nm
(%)
BMTH d dy
86,5 7,8
BMTH rut non
92,0 5,5
BMTH i trng
66,7 27,2
BMTH trc trng
66,7 27,2
BMTH mc treo
75,0 21,7
0,68
87
* Nhn xt: t l sng cn ton b 5 nm theo v tr bu i vi cc trng hp

c m trit thay i t 66,7% ( i-trc trng) n 92% ( rut non).
- Thi gian sng cn ton b trung bnh i vi bnh nhn c phu thut trit
l 60,9 2,3 thng.
- T l sng cn khng bnh ti pht 5 nm i vi bnh nhn c phu thut trit
l 39,2 6,6 %.
T l SCKBTP
n = 66
Thi gian (thng)
Biu 3.8: T l SCKBTP i vi bnh nhn c phu thut trit
- T l SCKBTP 5 nm theo v tr bu ca nhm bnh nhn c m trit c

trnh by trong bng 3.39.
88
Bng 3.39: T l SCKBTP 5 nm theo v tr bu ca nhm bnh nhn c

m trit :
V tr bu
T l SCKBTP (%)
BMTH d dy
28,9 9,2
BMTH rut non
39,9 10,8
BMTH i trng
66,7 27,2
BMTH trc trng
50,0 25,0
BMTH mc treo
75,0 21,7
0,63
* Nhn xt: Trong nhm bnh nhn c phu thut trit , t l SCKBTP 5 nm
thay i theo v tr bu, t 28,9% ( d dy) n 75% (mc treo).
- Thi gian SCKBTP trung bnh i vi nhm bnh nhn c phu thut trit
l 30,7 2,9 thng.
3.6.3- Sng cn ton b v sng cn khng bnh tin trin i vi bnh nhn
c phu thut tm b:
Trong nghin cu ca chng ti, c 43 bnh nhn BMTH do giai on
tin xa nn ch c m tm b bng cc loi phu thut: ni tt ng tiu ha,
phu thut triu chng gim khi bu, m sinh thit bu hoc bu b v trong
qu trnh phu thut. Bng phng php Kaplan-Meier, chng ti c tnh sng cn
ton b v sng cn khng bnh tin trin cc trng hp ny nh sau:
- c tnh t l sng cn ton b 5 nm i vi bnh nhn c phu thut tm b
l 47,7 9,4% (Biu 3.9).
89
T l SCTB
n = 43
Thi gian (thng)
Biu 3.9: T l SCTB i vi bnh nhn c phu thut tm b
- c tnh t l SCTB 5 nm theo v tr bu i vi bnh nhn c phu thut

tm b (Bng 3.40):
Bng 3.40: T l SCTB 5 nm theo v tr bu i vi bnh nhn c phu
thut tm b:
V tr bu
T l SCKBTT 5 nm
(%)
BMTH d dy
57,6 15,3
BMTH rut non
30,5 14,2
BMTH i trng
66,7 7,2
BMTH trc trng
66,7 7,2
BMTH mc treo
50,0 35,4
BMTH thc qun
90
- c tnh thi gian SCTB trung bnh i vi bnh nhn c phu thut tm b l
46,6 3,8 thng
- c tnh t l sng cn khng bnh tin trin 5 nm i vi bnh nhn c phu
thut tm b l 18,4 6,4%.
T l SCKBTT
n = 43
Thi gian (thng)
Biu 3.10: T l SCKBTT i vi bnh nhn c m tm b

- c tnh t l sng cn khng bnh tin trin 5 nm theo v tr bu:
Bng 3.41: T l sng cn khng bnh tin trin 5 nm theo v tr bu
V tr bu
T l SCKBTT (%)
BMTH d dy
26,4 12,2
BMTH rut non
21,4 11,0
BMTH i trng
16,7 15,2
BMTH trc trng
BMTH mc treo
BMTH thc qun
91
* Nhn xt: i vi BMTH trc trng, mc treo v thc qun, khng c bnh
nhn no sng qu 5 nm.
- Thi gian sng cn khng bnh tin trin trung bnh i vi nhm bnh nhn c
phu thut tm b: 23,8 2,3 thng.
- Thi gian sng cn khng bnh tin trin trung bnh theo v tr bu:
Bng 3.42: Thi gian sng cn khng bnh tin trin theo v tr bu
V tr bu
Thi gian SCKBTT

trung bnh (thng)
BMTH d dy
27,0 4,2
BMTH rut non
23,1 3,9
BMTH i trng
19,8 1,7
BMTH trc trng
28,0 1
BMTH mc treo
9,0 7,0
BMTH thc qun
< 0,001
* Nhn xt: BMTH mc treo c t l ti pht cao, t l sng cn khng bnh tin
trin thp. Ni chung, BMTH thng ti pht sau iu tr. Tuy nhin, vi iu
tr ti thi im nghin cu, thi gian sng cn khng bnh tin trin trung bnh
cng kh di (30,8 thng).
3.7- Cc yu t tin lng
Bng phng php Kaplan-Meier v php kim Log-rank, chng ti so snh
cc yu t: gii tnh, tui, ch s hot ng c th ECOG, kch thc bu, s phn
bo trn 50 QTL, phn nhm nguy c ti pht v mc phu thut n t l sng
cn ton b.
92
3.7.1- nh hng ca gii tnh n sng cn ton b
T l SCTB
N (n = 39)
Nam (n = 70)
P = 0,313
Thi gian (thng)
Biu 3.11: nh hng ca gii tnh n t l sng cn ton b
- c tnh t l sng cn ton b 5 nm ca bnh nhn n v nam ln lt l 77,8

7,6% v 63,6 7,4%.
* Nhn xt:
- c tnh t l sng cn ton b 5 nm ca bnh nhn n cao hn bnh nhn nam
khong 14%, tuy nhin s khc bit ny khng c ngha thng k (p = 0,313).
93
3.7.2- nh hng ca yu t tui n t l sng cn ton b 5 nm
T l SCTB
Tui > 40 (n =90)
Tui 40 (n= 19)
P = 0,977
Thi gian (thng)
Biu 3.12: nh hng ca tui n t l sng cn ton b
- c tnh t l sng cn ton b 5 nm ca bnh nhn 40 tui v > 40 tui ln

lt l 59,7 17,1% v 70,1 5,8%.
* Nhn xt:
- c tnh t l sng cn ton b 5 nm ca bnh nhn 40 tui thp hn bnh
nhn > 40 tui # 10%, tuy nhin s khc bit ny khng c ngha thng k (p =
0,977).
94
3.7.3- nh hng ca ch s ECOG n t l sng cn ton b

T l SCTB
ECOG=1 (n= 99)

ECOG=2 (n =10)
P = 0,189
Thi gian (thng)
Biu 3.13: nh hng ca ch s ECOG n t l SCTB
- c tnh t l sng cn ton b 5 nm ca bnh nhn c ch s ECOG = 1 v

ECOG = 2 ln lt l 69,6 5,7% v 70,0 14,5%.
* Nhn xt:
- c tnh t l sng cn ton b 5 nm ca bnh nhn c ch s ECOG = 1 v bnh
nhn c ch s ECOG = 2 tng ng nhau (p = 0,189).
95
3.7.4- nh hng ca kch thc bu t l sng cn ton b

T l SCTB
5 cm (n= 12)
> 5-10 cm (n =45)
> 10 cm (n= 52)
P = 0,035
Thi gian (thng)
Biu 3.14: nh hng ca kch thc bu n t l SCTB
- c tnh t l sng cn ton b 5 nm ca bnh nhn c kch thc bu 5 cm,

>5 -10 cm v > 10 cm ln lt l 100%, 77,3 7,5% v 55,4 8,6%; s khc bit
ny c ngha thng k (p = 0,035).
96
3.7.5- nh hng ca ch s phn bo trn 50 QTL n t l sng cn ton b
T l SCTB
5 (n= 34)
6-10 (n =12)
> 10 (n= 63)
P = 0,914
Thi gian (thng)
Biu 3.15: nh hng ca s phn bo/50 QTL n t l SCTB
- c tnh t l sng cn ton b 5 nm ca bnh nhn c ch s phn bo trn 50

quang trng ln l 5, t 6 -10 v > 10 ln lt l 71,9 8,6%; 72,7 17,7% v
65,9 7,8%; nhng s khc bit ny khng c ngha thng k (p = 0,914).
97
3.7.6- nh hng ca v tr bu n t l sng cn ton b
T l SCTB
Bu d dy (n= 46)
Bu ngoi d dy (n= 63)
P = 0,278
Thi gian (thng)
Biu 3.16: nh hng ca v tr bu n t l SCTB
- c tnh t l sng cn ton b 5 nm ca bnh nhn c bu d dy v bu

v tr khc ln lt l 76,1 7,8% v 63,9 7,5%, s khc bit ny khng c
ngha thng k (p = 0,278).
98
3.7.7- nh hng ca nhm nguy c theo tiu chun b sung ca Vin Y t

Quc gia Hoa K n t l sng cn ton b
T l SCTB
Nguy c thp (n= 5)
Nguy c trung bnh (n= 25)
Nguy c cao (n= 79)
P = 0,305
Thi gian (thng)
Biu 3.17: nh hng ca nhm nguy c ti pht n t l SCTB
- c tnh t l sng cn ton b 5 nm ca bnh nhn thuc nhm nguy c ti pht

thp, trung bnh v cao ln lt l 100%, 76,3 9,7% v 63,1 7,1%; s khc bit
ny khng c ngha thng k (p = 0,305).
99
3.7.8- nh hng ca mc phu thut n t l sng cn ton b

T l SCTB
Phu thut trit (n=66)
Phu thut tm b (n=43)
P < 0,001
Thi gian (thng)
Biu 3.18: nh hng ca mc phu thut n t l SCTB
- c tnh t l sng cn ton b 5 nm ca bnh nhn c phu thut trit cao

hn bnh nhn ch c phu thut tm b (84,3 5,4% so vi 47,7 9,4%). S
khc bit ny c ngha thng k (p < 0,001).
100
3.7.9- nh hng ca nhm nguy c ti pht i vi t l SCKBTP trong s

bnh nhn c phu thut trit
T l SCKBTP
Nguy c thp v trung bnh (n=13)
Nguy c cao (n= 53)
P = 0,268
Thi gian (thng)
Biu 3.19: nh hng ca nhm nguy c ti pht trong bnh nhn c

phu thut trit i vi t l SCKBTP
Trong 66 bnh nhn c phu thut trit , c 13 bnh nhn thuc nhm
nguy c thp v trung bnh, 53 bnh nhn thuc nhm nguy c cao.
Bng phng php Kaplan-Meier v php kim Log-rank, chng ti c tnh
t l sng cn khng bnh ti pht 5 nm ca nhng bnh nhn thuc nhm nguy c
thp-trung bnh v cao ln lt l 58,6 14,4% v 34,0 7,5%. S khc bit ny
khng c ngha thng k (p = 0, 268).
101
3.7.10- Phn tch a bin cc yu t tin lng

Chng ti tin hnh phn tch a bin cc yu t c lp bng php Hi quy
Cox nhm tm ra bin s tin lng c lp i vi tnh trng sng cn ton b
(Bng 3.43). Cc yu t c kho st l: gii tnh (nam v n), tui ( 40 v > 40),
ch s ECOG (=1 v =2), cch m (trit v tm b), v tr (d dy v ngoi d
dy), s phn bo (5, 6-10 v >10/50QTL), kch thc bu ( 5 cm, >5-10 cm v
> 5 cm) v nhm nguy c ti pht (thp, trung bnh v cao).
Bng 3.43: Phn tch a bin cc bin s c lp
Bin s c lp
T s nguy c
ECOG
3,5
0,07
Kch thc bu
3,1
0,10
S phn bo/50QTL
0,8
0,38
V tr bu
0,7
0,41
Nhm nguy c
0,7
0,66
Gii tnh (n v nam)
1,2
0,68
Tui ( 40 v > 40)
0,6
0,37
Mc phu thut
0,3
0,02
N = 109
* Nhn xt: phn tch a bin cho thy ch c mc phu thut (trit hay tm
b) l c tin lng c lp i vi tnh trng sng cn ton b (p = 0,02). Cc bin
s: gii tnh (nam; n), tui ( 40; > 40), ch s ECOG (=1; =2), v tr (d dy;
ngoi d dy), s phn bo (5; 6-10; >10/50QTL), kch thc bu ( 5 cm; > 510 cm; > 5 cm) v nhm nguy c ti pht (thp; trung binh; cao), khng c tin
lng c lp i vi sng cn ton b (p > 0,05).
oOo
102
Chng 4 BN LUN
4.1- c im nhm bnh nhn tham gia nghin cu
4.1.1- Gii tnh
Tng hp t y vn cho thy t l bnh nhn nam gii v n gii tng t
nhau hoc nam gii ch hi tri hn so vi n gii [6], [44], [57], [76], [93].
D liu tng hp M t nm 1992 -2000 cng cho thy t l nam gii c
phn cao hn so vi n gii, ln lt l 54% v 46% [127].
Tc gi Hng Kin (bnh vin K) [7] cng ghi nhn BMTH nam
gii chim n 74,6%. Trong nghin cu ca chng ti, nhng bnh nhn
BMTH l nam gii chim n 64% (70/109 trng hp) so vi 36% n gii
(39/109 trng hp).
Theo Zivkovic V. v cng s, phn b t l nam/n theo v tr bu ln lt
l 4,3 (thc qun), 2,8 (trc trng), 1,9 (i trng), v 1,4-1,5 (rut non) [140].
T l ny khc vi ghi nhn trong nghin cu ca chng ti: 1,4 (d dy), 2,3
(rut non), 3,5 (i trng), 1,3 (trc trng). Tuy nhin s khc bit ny khng c
ngha thng k (p > 0,05).
4.1.2- Tui mc bnh
Nhiu nghin cu cho thy BMTH c th gp mi la tui k c tr
em. La tui thng gp BMTH l trung nin v ngi cao tui, him khi gp
la tui di 40, c bit him gp nhng bnh nhn tr hn 30 tui [97].
Theo d liu phn tch ti M [127], tui trung bnh lc chn on i vi
bnh l ny l 63. Trong lot nghin cu ca Tryggvason [130] v Goerres [62] vo
nm 2005, tui trung bnh lc chn on BMTH ln lt l 66 v 69. Mai Trng
Khoa v cng s ghi nhn tui mc bnh trung bnh l 53,2 [6]. Hng Kin [7]
ghi nhn tui trung bnh mc bnh BMTH l 57,5 tui. Trong nghin cu ca
103
chng ti, vi tui trung bnh l 51,9, a phn l bnh nhn u trn 40 tui (90
trng hp, chim 82,6%), thp hn s vi ghi nhn ca cc tc gi khc.
Chng ti ghi nhn tui mc bnh ca BMTH theo mt s v tr bu nh
sau: BMTH d dy l 54,5 11,8, BMTH rut non l 53,0 9,8,
BMTH i trng l 54,0 11,5 v BMTH trc trng l 55,0 16,4
(Bng 3.13). Trong mt nghin cu ln trn 1765 bnh nhn BMTH d dy
ca tc gi M. Meittinen v cng s [94], tui trung bnh lc chn on l 63.
Mt nghin cu ln khc cng ca tc gi M. Meittinen trn 906 bnh nhn
BMTH hng trng v hi trng, tui trung bnh l 59 tui [97]. Tng kt 2 lot
nghin cu , tui mc bnh trung bnh cao hn ghi nhn ca chng ti; ch c
2,7% bnh nhn BMTH d dy v 0,6% bnh nhn BMTH rut non c
tui tr hn 21. Trong nghin cu 70 bnh nhn BMTH d dy, tc gi
Trn Minh Thng [11] ghi nhn tui mc bnh trung bnh l 53,2; trong nghin
cu Nguyn Thanh Sng [9], tui mc bnh trung bnh l 55,1 11, ghi nhn v
tui mc bnh trong cc nghin cu tng ng vi ghi nhn ca chng ti.
Chia 109 bnh nhn thnh 2 nhm trn v di 40 tui, chng ti nhn thy
khng c s khc bit v gii tnh (p = 0,877), ng thi v tr bu c nhm bnh
nhn trn v di 40 tui cng tng i ging nhau, khc bit gia cc v tr khng
c ngha thng k (p = 0,910).
Phn tch s phn b tui mc bnh theo tng v tr bu, chng ti ghi nhn
nh sau:
- BMTH thc qun: tui trung bnh theo tng v tr bu thay i t 47
55, trong bnh nhn BMTH thc qun duy nht trong nghin cu ny c
tui thp nht l 47 tui, ph hp vi nghin cu ca M. Miettinen. Theo tc gi
ny, BMTH thc qun c khuynh hng xy ra bnh nhn tui tr hn so
vi BMTH ti c quan khc [125].
- BMTH d dy: trong 46 trng hp BMTH d dy ca nghin
cu ca chng ti, s bnh nhn tr hn 40 tui v tr hn 21 tui ln lt l 7 v 1
104
trng hp (chim 15% v 2%). T l ny tng t so vi kt qu phn tch 1765

trng hp BMTH d dy ca M. Miettinen ln lt l 9,1% v 2,7% [94].
- BMTH rut non: tui trung bnh ca BMTH rut non trong
nghin cu ca chng ti l 53, ph hp vi cc tc gi khc, nh nghin cu ca J.
A. Crosby, tui trung bnh l 55 tui. [37]
- BMTH i trng: theo tng hp ca S. Kase v cng s [76], tui
trung bnh ca dng ny l 60, nghin cu ca chng ti l 54, c phn tr hn.
- BMTH trc trng: theo M. Meittinen v cng s, BMTH trc
trng thng xy ra tui t 50 60 v rt him gp bnh nhn < 40 tui [93].
Nghin cu ca chng ti ghi nhn c ch c 7 trng hp BMTH trc
trng nhng tui li dao ng t 33 - 75, v trong s trng hp bnh nhn <
40 tui l 2 (chim 1,8%),
Nh vy, tui mc bnh trong nghin cu ca chng ti cng tng t
nh ghi nhn ca tc gi khc, k c khi xem xt phn b tui theo tng v tr bu.
4.1.3- V tr bu
Theo y vn, tn sut ca BMTH xy ra nhiu nht d dy (60-70%), k
tip l rut non, ri n i-trc trng, v rt him gp thc qun (<3%) [36],
[44], [104].
Tng hp mi y ca X. Zhao v cng s nm 2012 [139], bu m m
ng tiu ha c th xut hin bt k v tr no trn ng tiu ha, khong 5070% BMTH c xut pht t d dy, rut non l c quan gi v tr th hai, vi
20-30% bu xut pht t hng-hi trng. Nhng v tr t gp hn bao gm trc
trng (5-15%) v thc qun (<5%). Nhng trng hp BMTH mc treo, mc
ni cng nh ty tng cng c bo co nhng rt him gp [139].
Hng Kin [7] ghi nhn BMTH thng gp d dy (34,9%) v rut
non (25,4%).
105
Kt qu t nghin cu ca chng ti ghi nhn BMTH gp nhiu nht vn

l d dy (42,2%), k tip l rut non (36,7%), ri n i-trc trng (14,7%), thc
qun t gp nht (0,9%). Ngoi ra cn ghi nhn thm 6 trng hp (5,5%)
BMTH ti mc treo (Bng 3.11). Nhng t l ny kh ph hp vi y vn, trong
d dy v rut non l 2 c quan thng gp nht i vi bu m m ng
tiu ha [2], [6], [9]. [139].
Theo y vn, BMTH phn b trong d dy vi t l nh sau: phn thn v
chim 40%; hang v chim 25% v mn v chim 20% [125]. BMTH pht sinh
t thnh d dy bt ngun ti hoc gia lp c thnh v lp c nim, n c th pht
trin theo cc hng hoc l nh vo trong lng d dy, hoc l pht trin hng ra
ngoi thanh mc hoc theo c hai hung [82]. Khong 60% bu m m d dy
nm di nim mc, v c khuynh hng pht trin nh vo trong lng d dy;
30% bu nm di thanh mc v 10% xut pht t cc lp cn li trong thnh d
dy [94], [125].
Trong 50 trng hp bu m m rut non c J.A. Crosby v cng s
kho st [37] th thy t l phn b a phn l hng trng (34%) v hi trng
(30%). Theo Blanchard v cng s [116], th BMTH rut non xut pht t lp
c nim ca thnh rut. Bu on D2 t trng th thng c khuynh hng pht
trin y li vo trong lng rut. Trong khi, cc v tr cn li th bu c khuynh
hng pht trin ra pha ngoi [116].
4.2- Triu chng lm sng
Thi gian khi bnh tnh t lc c triu chng lm sng n khi nhp vin.
Chng ti ghi nhn thi gian khi bnh trung bnh l 3,8 thng, ngn nht l 1 thng
v di nht l 13 thng. iu ny cho thy y l bnh c din tin tng i nhanh.
Trng hp BMTH thc qun duy nht trong nghin cu ca chng ti c
thi gian khi bnh l ngn nht (1 thng), c l v triu chng nut nghn khin
bnh nhn phi nhp vin sm hn so vi BMTH v tr khc. So vi nhng v
106
tr bu khc th BMTH d dy c thi gian khi bnh trung bnh tng i

lu hn (7,4 thng).
a s cc tc gi u ghi nhn au bng l triu chng thng gp nht [6],
[76], [125]. Trong nghin cu 35 bnh nhn bu m m ng tiu iu tr ti
BV Bch Mai, tc gi Mai Trng Khoa [6] ghi nhn triu chng au bng chim t
l nhiu nht (68,6%). Nghin cu ca chng ti cng khng ngoi l, a phn bnh
nhn u ghi nhn c tnh trng au bng vng thng v hoc au bng vng
quanh rn (63 trng hp, 58%). Triu chng au bng c th gii thch do s pht
trin nhanh ca bu gy cng khoang phc mc, hay khi bu tin trin xm ln
cc tng ln cn nh lch-gan-ty, thm ch c th do bu cho di cn gan hay
gieo rc bng,
Theo nghin cu ca P.J. Roberts v cng s, khong 10% trng hp bu
s c trn lm sng [115]. Tuy nhin nghin cu ca chng ti, bu vng
bng s c chim t l ln n 49,5% (54 trng hp), trong c n 32 trng
hp bu km di ng. iu ny cho thy a phn bnh nhn n vin kh tr,
bu ln n mc c th s chm trn lm sng.
Qua thm khm, BMTH d dy thng t di ng hn so vi
BMTH rut non. C n 5 trn tng s 7 trng hp BMTH trc trng
khm s c bu qua thm khm hu mn (chim 71%), tng t c 4 trn tng
s 6 trng hp BMTH mc treo khm bng s c bu (chim 67%). Nh
vy bn cnh triu chng au bng thng gp nht, th bu vng bng s c
cng l triu chng ng lu tm.
Ngoi triu chng bng au hay km theo s thy bu th cc triu chng
khc t gp nh nut nghn v nn ra mu cng c ghi nhn, s bnh nhn cn li
ch biu hin nhng triu chng m h nh mt mi, chn n, bun nn, n kh
tiu, Khng c trng hp no phi m cp cu v l do ngoi khoa nh xon
hoc v bu hay tc rut.
107
Nghin cu 55 bnh nhn BMTH ti bnh vin a khoa Massachusetts

[61], cc tc gi nhn thy 26% trng hp c xut huyt tiu ha, 14% trng hp
au bng, di 10% trng hp s c bu trn lm sng v ch c 3% trng
hp bu ln gy tc rut. Theo mt nghin cu khc ti Trung Tm Ung Th
Memorial Sloan-Kettering [91], kho st trn 200 bnh nhn th xut huyt tiu ha
cng l triu chng thng gp nht. Mandeep S. Saund v cng s [119] cho rng
c khong 15 - 50% trng hp bnh nhn BMTH c triu chng di cn r
rng vo thi im chn on.
BMTH on tiu ha trn c khuynh hng gy ra cc triu chng ca
mt khi u nh tc nghn, cn bu on tiu ha di th thng gy ra cc
triu chng to bn, ri lon thi quen rut [17].
-
BMTH thc qun: nhng bu c kch thc nh hu nh khng gy

ra triu chng g ng k. Triu chng BMTH thc qun kh in hnh
khi bu ln vi biu hin tnh trng kh nut, chn p gy tc nghn hoc
c cc triu chng ca mt bu trung tht.
BMTH d dy: biu hin lm sng chnh l xut huyt tiu ha trn,
au bng, s thy bu trn lm sng. Trong nghin cu thc hin trn 1765
bnh nhn BMTH d dy [94], M. Miettinen v cng s nhn thy gn
55% trng hp c triu chng xut huyt tiu ha trn, 12% trng hp i
tin phn en cp, 4% trng hp nn ra mu, 2% trng hp c c hai triu
chng trn. Cc triu chng khc nh chy mu m gy thiu mu, v suy
nhc cng thng thy trn cc bnh nhn ny. C 17% bnh nhn biu
hin au vng thng v, khong 4% trng hp bu ln s c trn lm
sng nhng khng c triu chng. Ngoi ra tc gi ny cng nhn thy mt
t l nh bu b v gy xut huyt trong bng, hoc bu ln gy tc
nghn ng tiu ha [94].
108
Nhng theo mt nghin cu ti Vin Ung th Roswell Park [108], cc triu

chng au bng, s thy bu trn lm sng v xut huyt tiu ha xut hin vi t
l ln lt l 41%, 38% v 28%.
-
BMTH rut non: kh chn on v triu chng m h v khng c

hiu, do vy rt t khi c chn on xc nh trc khi phu thut. Triu
chng thng gp nht l xut huyt tiu ha v au bng. i khi
BMTH on D2 t trng c th chn p hoc xm nhim vo ty gy ra
vng da [114]. Trong nghin cu trn 39 bnh nhn BMTH rut non v
rut gi, J. Horowitz v cng s [108] nhn thy cc triu chng xut hin
vi t l nh sau, au bng 44%, s c khi bu trn lm sng 38% v
xut huyt 31%.
J.A. Crosby v cng s [37] thc hin mt nghin cu trn 50 trng hp
BMTH rut non. Cc tc gi nhn thy cc triu chng lm sng xut hin
vi t l nh sau: au bng, 74%; s thy khi u trn lm sng, 72%; xut huyt
tiu ho, 44%; bn tc hoc tc rut hon ton, 44%; st cn, 16% v triu chng
ca ng tit niu l 12%.
-
BMTH i trng: triu chng khng c hiu, a s bnh nhn c s

thay i thi quen ca rut hoc nhng triu chng bn tc rut. Cc triu
chng khc t gp nh au bng, xut huyt tiu ha i khi c th khm
thy mt khi bu ln trn lm sng [44].
BMTH trc trng: triu chng thay i ty vo kch thc bu. Khi
bu nh (<5 cm) th thng c pht hin tnh c khi thm khm tin lit
tuyn nam gii hoc khm ph khoa n gii. Ngc li, khi bu ln
(>5 cm) th xut hin cc triu chng xut huyt trc trng, to bn, tc rut,
cm gic au hoc y trong trc trng hoc cc triu chng ca ng tit
niu [83], [113], [125].
109
Qua thm khm c th s thy bu thnh bn hay thnh sau ca trc

trng. Khi xm nhim bng quang, bu c th gy ra cc triu chng ca d bng
quang trc trng [83].
Nhn chung, lm sng khng c nhng triu chng c hiu, v th cn c s
h tr thm v mt cn lm sng chn on bnh l ny.
4.3- Triu chng cn lm sng
4.3.1- Siu m
Vi tin b y hc gn y, siu m kt hp ni soi cho kt qu rt kh quan,
gp phn trong chn on bu ng tiu ha ni chung v bu m m ng
tiu ha ni ring. V th siu m bng hin nay khng l s la chn ti u tr khi
bu t n kch thc ln, bi v cht lng hnh nh s gim i do s c mt
ca nhng bng hi trong rut hay tng rng [60].
Hnh 4.18: Hnh nh siu m BMTH rut non

D vy, trong iu kin Vit Nam, siu m bng vn ng vai tr nht nh
gp phn khng nh trong chn on BMTH. Trong nghin cu ca chng ti,
100% bnh nhn u c siu m bng v c n 86 bnh nhn pht hin c
bu bng qua phng tin ny (chim 79%), 7 trng hp c pht hin bu
xm ln cc tng ln cn nh lch-gan-ty (8%), hn na siu m cn gip pht
hin 23 trng hp di cn gan (27%), a phn l bnh di cn a hai thy.
110
i chiu kt qu m hc sau cng, chng ti nhn thy siu m cho kt lun

BMTH chnh xc n 74% (81 trng hp). Nhng trng hp cn li cho siu
m tm nhn nh l: bu mc treo, bu sau phc mc, ung th trc trng, ung
th rut non, ung th bung trng. L do l v bu m m ng tiu ha trn
siu m cho nhng hnh nh thay i mi lc khc nhau l do kch thc ca tn
thng cng nh c hay khng km theo nhng hoi t trong bu. Thm vo ,
nhng lot hay hoi t vi lp nhy ph ln trn cng gp phn lm thay i t
nhiu c im hnh nh ca bu trn siu m [60], [66].
Trong nghin cu ca chng ti, kch thc bu trn siu m thay i kh
rng t 2 - 30,5 cm (trung bnh l 10 cm), a s bu c mt hn hp (77%),
mt s c km hnh nh tng sinh mch mu (36%). Nhn chung, d khng c
nhng triu chng c hiu trn siu m phn bit vi nhng tn thng khc
trong bng, nhng bu m m ng tiu ha th hin trn siu m l mt khi
bu ln, c mt hn hp, c ha nang, hoi t trung tm, c tng sinh mch
mu.
Nh vy, siu m tuy l xt nghim hu dng nhng vn cn nhiu hn ch,
rt cn kt hp thm nhng phng tin khc cng nh kinh nghim khi quan st
i th ca cc phu thut vin a ra chn on sau m chnh xc hn.
Hnh 4.19: Hnh nh siu m qua ni soi d dy.

Ngun: http://www.eusatlas.ro/page73~astric+tumors_Gastrointestinal+stromal+tumors.html
111
4.3.2- Ni soi tiu ha

i vi nhng trng hp bnh nhn xut huyt tiu ha, au bng hoc c
nhng triu chng gy tc nghn ng tiu ha, ni soi l phng tin thng
c thc hin sm chn on BMTH [44], [92].
Nghin cu ca chng ti c 31 trng hp c ni soi tiu ha trc m,
bao gm ni soi d dy (24 trng hp), ni soi khung i trng (3 trng hp), ni
soi trc trng (3 trng hp) v ni soi thc qun (1 trng hp).
Hnh 4.20: Ni soi d dy

Tuy nhin, trong 31 trng hp ny, ch 14 trng hp pht hin c c
bu qua ni soi (45%). iu ny c th gii thch l do c im ca BMTH
qua ni soi ch l hnh nh khi di nim i lp nim mc trn lng bn trn.
Theo m t ca Pidhorecky v cng s [108], thnh thong c vi trng hp
BMTH gy lot hay xut huyt lp nim mc ng tiu ha do p lc ca
bu gy hoi t. Trong nghin cu ny, nhng trng hp thy c bu l do
bu to, xm ln nim mc vi hnh nh i th qua ni soi thng l lot (6 trng
hp), chi ming ni la (4 trng hp) hoc thm nhim (4 trng hp).
Tt c 14 trng hp ny u c sinh thit v lm ha m min dch. Tuy
nhin, ch c 7 trng hp (50%) c kt qu l bu m m ng tiu ha vi
CD117 dng tnh. Nhiu nghin cu khng nh rng nhng mu sinh thit bu
ng tin cy c c t ni soi truyn thng th y kh khn bi v phi nh v
112
ng v tr bu ngay bn di lp nim mc cn trn lng [124]. y l l do

chnh m kt qu sinh thit qua ni soi hin nay cho hiu sut thp hn 50%. Vic
lp li sinh thit ngay ti v tr sinh thit ln trc c th lm tng hiu sut chn
on nhng khng nhiu [66].
Nghin cu ca chng ti cng cho thy nhng hn ch . Vi 17 trng
hp BMTH d dy c ni soi, ch c 5 trng hp pht hin c bu (do
bu xm ln nim mc to lot), v 4 trng hp cho kt qu sinh thit l
BMTH vi CD117 (+). Mt trng hp khc l BMTH i trng, c
chn on l bu i trng sigma qua siu m v chp ct lp vi tnh, tuy nhin ni
soi ch ghi nhn c l bu vo lng i trng, kt qu sinh thit ch thy m
vim. Tng t vi 7 trng hp BMTH trc trng, qua soi ch pht hin
c 2 trng hp bu chi si vo lng trc trng v tr cch b hu mn 4-6
cm, cn li 5 trng hp ch thy bu vo lng trc trng.
Nhng hn ch trn mt phn l do tt c bnh nhn chng ti u c thc
hin ni soi truyn thng, khng c trng hp no c ni soi kt hp vi siu
m u d. Nguyn nhn phn ln l do y l k thut cn kh mi v t tin.
i vi trng hp BMTH rut non, vic s dng vin nang ni soi t
thch hp (Hnh 4.18, 4,19).
Hnh 4.21: vin nang ni soi

Ngun: http://en.wikipedia.org/wiki/
Capsule_endoscopy
Hnh 4.22: BMTH rut non (hnh

chp qua ni soi bng vin nang)
Ngun: http://www.casesjournal.com
/content/3/1/39
113
4.3.3- X quang ng tiu ha c cn quang

Chp i quang kp c th dng trong chn on BMTH i vi nhng
trng hp bu c kch thc ln cho hnh nh trn phim [60].
Hnh 4.23: X quang d dy cn quang cho thy khi chong ch b cong ln

Nghin cu ca chng ti c 34 trng hp (chim 31%) c thc hin
chp X quang ng tiu ha cn quang. l cc trng hp c xc nh v
tr bu bng siu m hay chp ct lp vi tnh. Nhng trng hp khng c chp
X quang ng tiu ha cn quang l nhng trng hp khng nh c bu
ng tiu ha hoc bu ti pht, khng c du hiu chn p ng tiu ha.
Chn la dng thuc cn quang ng ung hay bm qua hu mn hoc c
hai ph thuc vo biu hin lm sng v hnh nh hc ca bnh nhn. Nhng bnh
nhn c triu chng ban u l nut nghn nn c s dng thuc cn quang
ng ung. Nhng bnh nhn c biu hin to bn hay i cu phn dt, hay nhng
triu chng khc c lin quan n i trng, trn siu m hoc chp ct lp vi tnh
ngh bu nm i-trc trng th nn thc hin bm thuc cn quang qua hu
mn [60]. Trong nghin cu ny c 1 trng hp chp thc qun cn quang do
bnh nhn nut nghn, 9 trng hp chp i trng cn quang do phn ln bnh
nhn c triu chng mt rn.
114
Ch c 14 trong s 34 trng hp (41,2%) trong nghin cu ca chng ti

trn phim X quang cn quang cho hnh nh khi chon ch. Tng t nh
Yamashita v cng s nm 2001 m t [137], BMTH cho hnh nh khi nh
vo trong lng ng tiu ha vi ranh gii r rng so vi nim mc bnh thng xung
quanh. B mt ca lp nim mc trn bu thng trn lng tr nhng trng hp
hnh thnh lot do s pht trin ca bu ngay bn di.
Mc d X quang a ra nhng hnh nh gi chn on nhng khng
a ra kt lun. Nhng phng tin khc lit k bn di vi c hiu cao hn
s cho thng tin nhiu hn, nht l thng tin v nhng c quan ln cn c quan
mang bu.
4.3.4- Chp ct lp vi tnh
Mc du chp cng hng t c nhiu u im hn so vi chp ct lp vi
tnh v cht lng hnh nh, bnh nhn t b phi nhim x cng nh thun tin cho
nhng trng hp khng th dung np thuc cn quang tnh mch. Tuy nhin, chp
ct lp vi tnh hin nay vn l la chn u tay cho vic tm sot bu m m
ng tiu ha cng nh nh gi giai on bnh. Chp ct lp vi tnh nh gi
ton b bng tt hn, c bit l tng rng [121]. Trong nghin cu ca chng ti,
c 80 trng hp c chp ct lp vi tnh c cn quang (chim 73%); trong c
n 52 trng hp chp ct lp vi tnh chn on bu m m ng tiu ha ph
hp vi chn on m bnh hc sau cng (73%), t l ny l kh cao. Bn cnh
nhng thng tin v v tr v kch thc bu, chp ct lp vi tnh cn c th cho
thy hnh nh bu xm ln cc c quan ln cn, cng nh c th gip tm nhng
nguyn pht khc, k c hnh nh di cn xa [60]. Nghin cu ca chng ti c 5
trng hp chp ct lp vi tnh cho thy bu xm ln c quan ln cn nh gan,
lch, ty, c honh,, v 18 trng hp bu cho hnh nh di cn gan.
Theo y vn, hnh nh ca BMTH trn phim chp ct lp vi tnh l khi
tn thng dng c b r bt thuc cn quang. Vi nhng tn thng ln trn 15
cm, c th kt hp thm hnh nh hoi t ca bu, xut huyt, hoc nhng thnh
115
phn thoi ha i km [2], [121]. Nm 2003, Ghanem v cng s thc hin chp
ct lp vi tnh cho 20 trng hp BMTH nguyn pht v 16 trng hp
BMTH ti pht [60]. Cc tc gi m t nhng c tnh ca BMTH trn
chp ct lp vi tnh, chia chng thnh 3 nhm kch thc nh (<5 cm), trung bnh (5
10 cm), v ln (> 10 cm). Nhng trng hp BMTH kch thc nh c ranh
gii r rng, khi bu ng nht, phn ln bu pht trin vo trong lng ng tiu
ha; dng bu kch thc trung bnh c ranh gii khng u, mt khng ng
nht, c th pht trin ra ngoi hay vo trong lng ng tiu ha; cn BMTH c
kch thc ln thng ranh gii khng r, mt khng ng nht, xm ln ti ch,
di cn xa hay gieo rc phc mc.
60 trng hp chp ct lp vi tnh pht hin c bu trong nghin cu ca
chng ti c kch thc thay i t 2,4 - 30 cm. 80% bu c mt hn hp (48
trng hp). 5 trng hp bu xm ln c quan ln cn v 18 trng hp bu
cho di cn gan trn chp ct lp vi tnh, hu ht nhng trng hp ny u c kch
thc bu ln hn 10 cm, iu ny ph hp vi y vn [60], [121].
Tuy nhin, vai tr ca chp ct lp vi tnh vn c nhng hn ch. Chp ct
lp vi tnh l phng tin chn on bng hnh nh, cho chn on giai on kh tt
nhng c th cho nhng nhn nh cha ph hp v bn cht bu nh 7 trng
hp BMTH d dy c chn on nhm l ung th d dy (5 trng hp) v
ung th gan tri (2 trng hp) V th, cn c thm nhng phng tin khc h
tr thm gip cho vic chn on bu r rng hn. T , c th gip vic iu tr
chnh xc c.
116
Hnh 4.24: Chp ct lp vi tnh BMTH rut non

4.4- Chn on trc m
Trong nghin cu ny, ngoi cc trng hp c m v c kt qu
CD117 (+) ti cc bnh vin khc (37%), nhng trng hp cn li, chng ti
chn on c trc m l bu m m ng tiu ha 51/69 trng hp
(73,9%) da vo s kt hp cc yu t lm sng, cn lm sng v kt qu ha m
min dch vi CD117 (+) [140].
Theo y vn, chn on BMTH trc m, cc bc s lm sng cn c
nhiu kinh nghim trong vic khai thc bnh s, tin cn gia nh, khm lm sng
v nhng tiu chun trn hnh nh hc [60], [131]. Thng thng khng khuyn co
vic sinh thit trc m c kt qu m bnh hc cho nhng tn thng nghi ng
BMTH trn lm sng nhm nh gi kh nng bu c th m c hay khng.
Tuy nhin, cn sinh thit khng nh chn on trc m vi nhng trng hp
ngh n BMTH nhng bnh di cn xa hoc bu qu kh nng phu thut,
nhm mc ch cn nhc s dng liu php nhm trng ch trc m c th
phu thut ly bu nhng trng hp tn thng ln tin trin ti ch ti vng
[60].
Chn on trc m l BMTH t t l 73,9% l iu ny rt ng khch
l; nh gip ch rt nhiu cho vic nh gi i th v nh gi giai on
trong cuc m cng nh cn nhc kh nng iu tr nhm trng ch sau ny.
117
Ti thi im chn on, chng ti ghi nhn c 34 bnh nhn c di cn

gan v/hoc gieo rc bng, chim t l 31,2% cc trng hp (Bng 3.17). Theo y
vn [40], [91], BMTH thng cho di cn xa vo gan hoc gieo rc phc mc, t
khi cho di cn xng v phi. Trong mt nghin cu ca Trung tm Ung th
Memorial Sloan-Kettering [39] vi 200 bnh nhn, trong s cc trng hp di cn
xa, di cn gan chim t l 65%, sau l di cn n phc mc vi 21%. Rt him
gp di cn hch bch huyt, di cn xng hoc di cn phi.
4.5- iu tr
4.5.1- Phu tr
iu tr BMTH thi im hin ti cn mt i ng iu tr a m thc
bao gm c phu tr v ni khoa. Tuy nhin, phu tr vn ng vai tr l iu tr ch
lc [19], [22]. Phu tr vi mc tiu hng u l ct trn bu vi b din ct m
tnh, bo v tnh ton vn ca v bao bu, trnh v bu hoc xut huyt [68],
[110].
Trong s 109 trng hp bu m m ng tiu ho trong nghin cu, c
tng cng 66 trng hp c iu tr trit , chim t l 60,6%. T l ny tng
ng vi mt s nghin cu trc y (Bng 4.44).
Bng 4.44: Cc nghin cu bo co v t l phu thut trit [34], [38]
Thi gian nghin
S lng bnh
T l phu thut
cu
nhn
trit
Akwari v cs
1950 1974
108
48,1%
Shiu v cs
1949 1973
38
52,6%
McGrath v cs
1951 1984
51
58,8%
Ng v cs
1957 1997
191
51,8%
DeMatteo v cs
1982 1998
200
40%
Tc gi
Tuy nhin, cc nghin cu hin nay cho thy t l phu thut trit cao hn
[14], [109].
118
Mt nghin cu ti i hc Cairo ca nhm tc gi Ai Cp thc hin trn

127 trng hp BMTH t nm 2000 n 2009, vi cc c im v dch t
tng ng v kch thc bu ln hn so vi nghin cu ca chng ti (kch
thc trung bnh l 18 cm, thay i t 5 n 42 cm), kt qu cho thy t l phu
thut trit l 74% (94 trng hp), trong c 81 trng hp l bu nguyn
pht, 3 trng hp di cn v 10 trng hp ti pht [14]. y l mt kt qu kh
quan hn so vi nghin cu ca chng ti. Nghin cu ti Litva ca E. Poskus bo
co nm 2014 trn 44 trng hp BMTH, cho thy t l phu thut trit t
din ct m tnh kh cao, ln ti 97,7% (43 trng hp) [109]. Mt nghin cu khc
ti Thu in trn 259 trng hp BMTH, th t l phu thut trit cng t
85,9%, trong cc trng hp bu nhm nguy c rt thp v nguy c thp (kch
thc bu nh) c t l phu thut trit l 100%, cn nhng trng hp bu
lan trn, c di cn xa th t l phu thut trit cng t 17,2% [102].
Hnh 4.25: Phu thut ct BMTH d dy (c km ct lch)
i vi BMTH d dy, t l phu thut trit cng t 60,9%. Phn

ln cc trng hp c phu thut ct rng bu (19/28 trng hp, chim
67,8%) vi b din ct cch bu 2 cm, 8 trng hp c ct d dy bn phn c
hoc khng km theo ct cc tng b xm ln, ch 1 trng hp ct d dy ton phn
km ct lch.
119
Tc gi Nguyn Thanh Sng ghi nhn qua 70 trng hp BMTH d

dy c iu tr BV Ch Ry [9], cho thy t l ct rng bu v ct d dy rt
cao (91,4%). iu ny c l l do bnh nhn n vin sm vi kch thc bu
trung bnh nh hn ghi nhn ca chng ti (8,7 cm so vi 9,5 cm). Ngoi ra, trong
s 46 trng hp BMTH d dy trong nghin cu ca chng ti c 5 trng
hp bu xm ln cc tng ln cn v 8 trng hp bu cho di cn gan.
i vi nghin cu ti i hc Cairo, phn ln bnh nhn c ct d dy
bn phn (chim t l 92,4), nhng trng hp cn li c phu thut ct d dy
ton phn km ct tng b xm ln (i trng, lch, tu). S khc bit ny c th do
quan im iu tr khc nhau, tuy nhin trong nghin cu tc gi cng nhn mnh
mc ch chung ca phu thut BMTH l t phu thut trit v mt i th,
trnh v bu v t din ct m tnh [14]. y cng l mc tiu phu thut chng
ti t ra khi iu tr BMTH.
Trong mt nghin cu khc ch trn 25 trng hp BMTH t nm 1987
n 2004 ca tc gi L. Boni, trong 10 trng hp BMTH d dy, th phu
thut ct rng bu chim 60%, ct d dy bn phn chim 30%. Kt qu ny cng
tng ng vi chng ti. Tuy nhin, trong nghin cu ny kch thc bu nh
hn, 56% trng hp bu < 5 cm, ch c 20% trng hp bu t 5 10 cm [22].
Trong nghin cu ca I. Hassan bo co nm 2008, th c ti 84% cc trng hp
BMTH d dy ch phu thut ct rng bu, ch 14% c ct d dy bn phn
hoc ct d dy ton phn [65]. Nghin cu ca E. Poskus ti Litva bo co nm
2014 trn 35 trng hp BMTH d dy, th t l ct rng bu cng chim ti
91,4%, ch c 3 trng hp ct d dy bn phn [109]. Trong nghin cu ca chng
ti, c 3 trng hp b v bu trong lc phu thut ct rng do bu b. y l
mt yu t tin lng xu cho bnh l ny, c phn loi l nhm nguy c ti pht
cao (theo tiu chun b sung ca VYTQG Hoa K).
i vi BMTH rut non, t l phu thut trit cng t 67,5%, cn
li l nhng trng hp ch lm phu thut tm b. Cc nghin cu khc u cho t
120
l phu thut trit ct on rut non cao hn nghin cu ca chng ti. Nghin
cu ti Ai Cp th c ti 40/41 trng hp BMTH rut non c phu thut
trit (chim 97,5%) [14]. Nghin cu ca E. Poskus th 100% cc trng hp u
c phu thut t din ct m tnh [109]. Nghin cu ca I. Hassan th 85%
trng hp BMTH rut non c phu thut ct on rut [65]. Mt nghin
cu ti i Loan trn 100 trng hp BMTH rut non, th ch c 85% trng
hp c phu thut trit , t din ct m tnh, nhng trng hp cn li l c di
cn, bu ln dnh vo cc tng quan trng hoc cho lan trn bng [136].
Nhn chung, BMTH i trc trng t gp, chim t l chung t 3 5%
trong ton b cc v tr. Bu i trng thng ln vo thi im chn on, v
tnh di ng nhiu ca i trng [55]. Trong nghin cu ny ca chng ti ch c 9
trng hp BMTH i trng, trong ch c 3 trng hp c phu thut
trit (ct i trng phi v ct trc), 6 trng hp ch m hu mn nhn to do
bu ln, di cn gan. Trong 7 trng hp BMTH trc trng trong nghin
cu ny c 4 trng hp c lm phu thut ct trc v phu thut Miles, 3
trng hp ch lm hu mn nhn to. Mt nghin cu ti i Loan trn 10 trng
hp BMTH trc trng (t nm 1990 n 2007), cho kt qu 8/10 trng hp
c phu thut trit , 2 trng hp cn li cng c ct bu tuy nhin khng
t din ct an ton [27]. Nghin cu ti Ai Cp th c 12/18 trng hp bu i
trc trng c phu thut trit [14].
BMTH thc qun l trng hp him gp, cng chim t l <5%, v t
c ti liu trn th gii v bnh l ny [55]. Nghin cu ca chng ti ch c duy
nht 1 trng hp BMTH thc qun, vi kch thc kh ln l 7 cm, bu
cho di cn gan lc chn on nn ch lm phu thut tm b m d dy ra da nui
n. Nghin cu ti Ai Cp cng c 7 trng hp BMTH thc qun, trong 5
bnh nhn c lm phu thut trit (phu thut Ivor-Lewis), tuy nhin tc gi
khng cp kch thc trung bnh ca BMTH thc qun [14].
121
Nghin cu ca chng ti c 6 trng hp BMTH mc treo, trong 4

trng hp c ct rng bu vi b din ct 2 cm. Nghin cu ca E. Poskus th
ch c 2 trng hp BMTH mc treo trong s 44 trng hp BMTH, c 2
trng hp ny u c phu thut trit ct rng km ct on rut non tng
ng [109].
Nhn chung, t l phu thut trit trong nghin cu ca chng ti cn
tng i thp hn so vi cc nghin cu khc. iu ny c l l do a s bnh
nhn trong nghin cu ca chng ti n vin tr, khi bu ln v cho di cn xa;
ch c 68,8% bu giai on khu tr (Bng 3.17).
- Kt qu gii phu bnh sau m
+ Kch thc v v tr bu
Kch thc trung bnh ca bu nguyn pht ghi nhn trong ln m u l
12,3 5,7 cm, thay i t 3 n 32 cm, vi 57,8% bu nm trong nhm > 10 cm.
Nhn chung, bnh nhn c bu >5 cm chim ti 93,6%. Ti d dy v rut non,
bu >10 cm cng chim u th (55% v 69,6%). Trong nghin cu ny ca chng
ti khng c trng hp no bu nh 2 cm. y l mt trong nhng yu t quan
trng c nh hng n ti pht v sng cn. Vi kch thc bu > 5 cm, bnh
nhn thuc nhm nguy c ti pht trung bnh n cao.
Theo y vn, BMTH c th c kch thc rt thay i, t di 1 cm, n
trn 40 cm, trung bnh l 5 cm [20]. Mt nghin cu hi cu c c mu ln ti Hn
Quc trn 747 trng hp BMTH nm 2001 v 2002 [77], cho thy kch thc
bu trung bnh l 6,1 cm, thay i t 0,2 n 53 cm, trong nhm kch thc
chim t l cao nht l nhm t 2 5 cm (37%). Kch thc bu trung bnh trong
nghin cu ti Litva nm 2014 cng ch 4,4 cm [109]. Cn nghin cu ti Thu
in ca B. Nilsson th kch thc trung bnh bu l 7 cm, thay i t 0,5 n 35
cm [102]. Mt nghin cu khc ti Phn Lan ch thc hin trn 335 bnh nhn
BMTH c th phu thut trit , th kch thc trung bnh bu l 8 cm, phn
ln bnh nhn trong nghin cu cng thuc nhm kch thc <5 10 cm [117].
122
Kch thc bu trung bnh trong cc nghin cu nh hn theo ghi nhn ca chng
ti kh nhiu (p < 0,05). iu ny cho thy bnh nhn trong nghin cu ca chng
ti hu ht n khm tr, khi c triu chng, bu t kch thc ln.
Tuy nhin mt nghin cu ti Ai Cp bo co nm 2012 trn 127 trng hp
BMTH cho kt qu kch thc bu trung bnh l 18 cm (thay i t 5 n 42
cm) [14], ln hn trong nghin cu ca chng ti (p < 0,05).
Tm tt kt qu cc nghin cu c trnh by trong bng 4.45.
Bng 4.45: Kch thc bu trung bnh trong cc nghin cu
Nghin cu
Kch thc trung bnh Nhm kch thc chim t

l cao nht
Chng ti (2015)
12,3 cm
>10 cm
7 cm
6,1 cm
2 - <5 cm
Rutkowski (2007) [117]
8 cm
>5 10 cm
Al-Kalaawy (2012) [14]
18 cm
Poskus (2014) [109]
4,4 cm
Nilsson (2005) [102]

Kim (2005) [77]
BMTH d dy trong nghin cu ny ca chng ti c kch thc thay

i t 4 n 25 cm, trung bnh l 12,9 5,4 cm. Theo y vn, da trn cc nghin
cu c mu ln, kch thc trung bnh BMTH d dy l 6 cm, c th thay i
t vi milimt n trn 40 cm [11], [95]. Trong nghin cu ca chng ti, 38% cc
trng hp bu nm b cong ln, v 28% bu nm b cong nh, t gp nht
l bu hang v (Biu 3.2).
Theo ghi nhn ca tc gi Nguyn Thanh Sng [9], kch thc trung bnh ca
bu d dy l 9,7 7,5 cm v bu thng gp thn v (52,9%) tng t nh ghi
nhn ca chng ti (p > 0,05).
123
Tc gi V c Truyn (bnh vin C Nng) [13] cng ghi nhn mt

khi BMTH d dy c kch thc 17 cm, xm ln vo lch, ui ty, i trng
ngang v c phu thut ct d dy cng vi cc tng b xm ln
i vi BMTH rut non, kch thc trung bnh t 13,0 4,6 cm, thay
i t 2,5 n 32 cm. Nghin cu ti i Loan trn 100 trng hp BMTH
rut non, ghi nhn kch thc trung bnh l 8,8 cm, thay i t 3 n 30 cm. V tr
thng gp l hng trng (chim 63%), ch c 19% gp t trng, v 17% hi
trng [136]. Trong nghin cu ca chng ti, phn ln gp hi trng chim
47,5%, hng trng 42,5%, t trng ch gp 10% (Biu 3.3). iu ny cng cho
thy kt qu tng ng gia hai nghin cu. Tuy nhin, chng ti ghi nhn bu t
tng sinh mch mu, iu ny khc bit vi nghin cu ti i Loan, cc tc gi ghi
nhn 90% c tng sinh mch mu nhiu, v c 3 trng hp c xm nhp mch
lymph, y cng l mt trong nhng yu t tin lng xu, nh hng n sng
cn ton b. S khc bit i th ny c th do s khc bit v vi th.
BMTH thc qun trong nghin cu ca chng ti ch c 1 trng hp,
kch thc bu l 7 cm. Theo y vn, phn ln cc BMTH thc qun c
bo co u c kch thc >5 cm [95].
BMTH i trng c gn nh chia u cho cc v tr i trng phi,
i trng ngang, i trng tri v i trng sigma (Biu 3.4). BMTH trc
trng gp ch yu 1/3 di (Biu 3.5).
+ Vi th v ho m min dch:
109 trng hp u c kt qu vi th l bu m m ng tiu ho, vi
CD117 (+). Ngoi ra bu cng c phn ng dng tnh vi cc th th khc nh
SMA, S100, CK, Vimentin.
Theo y vn, tng hp t nhiu nghin cu, t l CD117 dng tnh chim
90-95%, CD34 dng tnh 60 85%, 30 40% dng tnh vi SMA, ch 5%
dng tnh vi S100, v 1-2% dng tnh vi Desmin [2], [75].
124
Hnh 4.26: Nhum Ha m min dch cho thy biu l qu mc ca CD117
So snh vi cc nghin cu khc c tm tt trong bng 4.46.

Bng 4.46: Kt qu ho m min dch ca BMTH
Nghin cu
Chng ti
(2015)
K.M. Kim
(2005) [77]
M. Miettinen
(2006) [96]
E. Poskus
(2014) [109]
CD117
CD34
Vimenti
Desmin
Actin
(+)
(+)
n (+)
(+)
(+)
100%
59,6%
11,9%
100%
82%
95%
80%
79,5%
75%
S100 (+)
CK (+)
29,3%
34,9%
3,7%
29,2%
20,2%
<5%
30%
20,5%
22,7%
22,7%
Theo nghin cu ca tc gi K.M. Kim ti Hn Quc trn 747 trng hp

BMTH [77], bu BMTH c kho st thm cc th th CD 34, khng c
trong nghin cu ca chng ti. Tc gi cho rng CD34 (+) c lin quan ti nguy c
c tnh cao ca BMTH, v thng thy trn BMTH rut non, iu ny gii
thch ti sao BMTH rut non thng l nguyn nhn t vong thng gp nht
i vi BMTH, d chim t l nh hn BMTH d dy [77]. Tuy nhin,
theo tc gi Kang Yoon Koo [75] th CD34 dng tnh cao nht thc qun v i
125
trng (95%), thp rut non v cc v tr ngoi ng tiu ho. Tc gi ny khng

cp n nh hng ca CD34 n mc c tnh ca bu [75].
Ngc li, SMA l yu t lin quan ngc n nguy c c tnh cao ca
BMTH, v thng gp BMTH thc qun [77]. Tc gi Kang Yoon Koo
li kt lun SMA thng dng tnh cao bu rut non [75]. T l dng tnh ca
SMA trong nghin cu ca chng ti so vi cc tc gi khc cng kh tng ng.
T l dng tnh ca SMA cao nht BMTH mc treo, tuy nhin ch c 6
trng hp BMTH mc treo nn thng k ny khng mang ngha.
S100 trong nghin cu ca chng ti dng tnh n 34,9% cc trng hp,
cao hn so vi tc gi K.M. Kim, v cao hn hn so vi cc nghin cu ti cc nc
phng Ty (ch dng tnh <10%) [77]. S100 dng tnh thay i tu theo v tr
bu, thng gp rut non, v him khi dng tnh i trng. Trong nghin cu
ca chng ti, ch c 3/9 trng hp BMTH i trng c S100 (+). Vai tr ca
S100 trong i vi nguy c c tnh ca BMTH cha c cp.
Thng k ca M. Miettinen nm 2006 cho thy ch 95% BMTH dng
tnh vi CD117, 80% dng tnh vi CD34, 30% dng tnh vi SMA, v dng
tnh vi Desmin c t l rt thp <5% [96].
- Phn b v ch s phn bo:
Chng ti ghi nhn c 31,2% cc trng hp c ch s phn bo thp ( 5/50
QTL), 11,0% trng hp c ch s phn bo trung bnh (6-10 phn bo/ 50 QTL) v
c 57,8% trng hp c ch s phn bo cao (> 10/50 QTL) (Bng 3.22)
Nghin cu ca Ng Quc t [2] cho thy 55,7% trng hp c ch s phn
bo thp ( 5/50 QTL). T l ny cao hn ghi nhn ca chng ti (p < 0,001).
Nhm c ch s phn bo cao (> 10/50 QTL) chim 30,5%, thp hn ghi nhn ca
chng ti (p < 0,05).
126
Nghin cu ti Phn Lan trn 335 trng hp BMTH phu thut c,

th chim 51,1% cng l nhm c ch s phn bo thp, cao hn nghin cu ca
chng ti [117].
So snh vi nghin cu ti Ai Cp (2012) cho thy nhm c ch s phn bo
thp ch chim 18,8%, nhm c ch s phn bo t 6-10/50 QTL chim 52,8%, v
nhm c ch s phn bo >10/50 QTL chim 28,4% [14].
BMTH rut non c 32,5% c 5 phn bo/50 QTL, v 67,5% c > 5
phn bo/50 QTL. Nghin cu ca Ting-Jung Wu v cng s ti i Loan cho kt
qu tng t vi 69% c ch s phn bo cao >5 phn bo/50 QTL [136].
- nh gi nhm nguy c ti pht:
Da theo nh gi nhm nguy c ti pht ca tiu chun b sung ca
VYTQG Hoa K, trong nghin cu ny, chng ti ghi nhn phn ln bnh nhn l
thuc nhm nguy c ti pht cao (72,5%), c 22,9% thuc nhm nguy c ti pht
trung bnh v ch c 4,6% thuc nhm nguy c ti pht thp; khng c trng hp
no l nhm nguy c rt thp (Bng 3.24). iu ny cng ph hp, v phn ln
bnh nhn trong nghin cu thuc nhm c kch thc bu >5 cm.
So snh vi cc nghin cu khc c tm tt trong Bng 4.47.
Bng 4.47: Nguy c ti pht BMTH theo cc nghin cu
Nguy c
Rt thp
Thp
Trung bnh
Cao
4,6%
22,9%
72,5%
13,6%
29,1%
21,4%
34,4%
20,3%
52,8%
18,2%
15,9%
Nghin cu
Nghin cu ny
K.M. Kim (2005) [77]
Rutkowski (2007) [117]
E. Poskus (2014) [109]
23,3%
31,8%
34,1%
Trong cc nghin cu ca Kim ti Hn Quc [77], ca Poskus ti Litva [109]

kch thc bu trung bnh u nh hn ghi nhn ca chng ti. Ring nghin cu
127
ca Poskus ch chn nhng trng hp BMTH nguyn pht phu thut c, c

kch thc trung bnh kh nh. Kch thc bu l mt trong nhng yu t quyt
nh nguy c ti pht nn trong cc nghin cu ca h, t l nhm nguy c thp v
rt thp chim kh cao.
Nghin cu ca B. Nilsson ti Thu in trn 259 trng hp chia thnh 5
nhm nguy c, tc gi ny tch ring nhng trng hp bu cho di cn xa, gieo
rc bng vo thi im chn on. Kt qu ca nghin cu ny cho thy c 13,9%
thuc nhm nguy c ti pht rt thp, 37% thuc nhm nguy c thp, 23% thuc
nhm nguy c trung bnh, v 26,1% thuc nhm nguy c cao, kt qu ny cng gn
tng t vi tc gi Kim, v kh quan hn nghin cu ny ca chng ti [102].
Nghin cu ca Rutkowski trn 335 trng hp BMTH c kch thc
cng gn tng ng vi nghin cu ca chng ti, v ch s phn bo cng tng
ng, nn kt qu phn nhm nguy c ca nghin cu ny tng ng vi nghin
cu ca chng ti, vi 52,8% cc trng hp l nguy c cao [117].
Nh vy trong thc t lm sng, vic nh gi nguy c ti pht theo tiu
chun b sung ca Vin Y t Quc gia Hoa K cho thy n gin v d p dng
hn.
4.5.2- iu tr nhm trng ch sau m
Imatinib l iu tr tiu chun i vi BMTH tin trin ti ch, khng
phu thut c v BMTH c di cn xa [106]. Th nghim lm sng pha III
Z9001 ca Nhm phu thut vin ung th i hc Hoa K trn BMTH c kch
thc 3 cm, phu thut trit , c dng Imatinib 400 mg/ngy so vi gi dc.
Kt qu cho thy gim nguy c ti pht 16%. T kt qu ny, nm 2008 C quan
Qun l Thc phm v Dc phm Hoa K cng nhn Imatinib 400 mg/ngy
nh l iu tr h tr tiu chun cho BMTH thuc nhm nguy c ti pht cao
[32].
128
Imatinib l thuc c dung np tt, cc tc dng ph thng nh. Mc

nng ca tc dng ph tng dn theo liu thuc s dng. Xut tc dng ph mc
nh l kh thng gp qua nhiu nghin cu (99%) [1], [41].
Ti thi im nghin cu ca chng ti, Imatinib ch c dng cho bu
m m ng tiu ho vi cc ch nh: sau m cn bu, di cn xa, gieo rc
bng, bu ti pht khng m c (Bng 3.31). Chng ti c 75 trng hp c
iu tr sau m bng Imatinib, vi 12% l nhng trng hp cn bu sau m,
54,6% l nhng trng hp ti pht ti ch, v 33,4% l c di cn xa (di cn gan,
lan trn bng). a s c iu tr khi u vi liu 400 mg/ngy (74 trng
hp). Ch c 1 trng hp c t bin exon 9 c iu tr khi u vi liu
Imatinib 600 mg/ngy. Thi gian iu tr trung bnh l 10,8 thng, thay i t 4 n
12 thng.
Tc dng ph khi iu tr Imatinib t gp, chim t l chung t 8 15%,
trong ph mi mt l tc dng ph thng gp nht, chim 28%, tip theo l thiu
mu chim 20%, mt mi chim 18,7%,. nh hng ca thuc gy tiu chy,
bun nn, ni mn, au nhc c/xng, chim t l khng nhiu. Tc dng ph
trong nghin cu nhn chung l nh (Bng 3.35).
Ghi nhn ca tc gi Phm Xun Dng v cng s [1], cc tc dng thng
gp khi iu tr bng Imatinib l thiu mu, ph, gim bch cu, tng men gan vi
a s l mc 1 v 2 nn bnh nhn vn dung np tt Imatinib.
Hng Kin ti bnh vin K [7] ghi nhn cc tc dng ph thng gp ca
Imatinib l ph mi mt (38,1%) v ph mt (31,7%.)
So snh vi nghin cu pha II ca G. D. Demetri trn 147 trng hp
BMTH iu tr vi Imatinib liu 400 600 mg/ngy th tc dng ph thng
gp nht cng l ph, sau l bun nn v tiu chy [43]. Trong mt nghin cu
khc, nghin cu pha III ca Dematteo thc hin trn 230 trung tm ti M v
Canada, tng s bnh nhn trong nghin cu l 713, th tc dng ph thng gp
nht ( nhm c s dng Imatinib mesylate) ph mi mt, sau l mt mi, tiu
129
chy, Hu ht cc tc dng ph ny ch mc 1 hoc 2, cc tc dng ph

3, 4 chim khong 31%. a s cc nghin cu u kt lun Imatinib l thuc an
ton v d dung np [42].
- nh gi iu tr nhm trng ch:
Sau iu tr Imatinib ln u, chng ti ghi nhn c 42,6% cc trng hp
p ng vi Imatinib liu 400 mg/ngy; 21,4% cc trng hp bnh n nh v
36% bnh tip tc tin trin (Bng 3.32). Cc trng hp bnh tin trin c
tng liu Imatinib t 600 800 mg/ngy.
Sau khi kt thc nghin cu, chng ti nh gi tnh trng p ng vi iu
tr Imatinib sau khi tng liu i vi cc trng hp bnh tin trin nh sau:
13,3% cc trng hp c p ng hon ton, 45,4% c p ng mt phn, 16%
bnh khng i v 25,3% bnh tin trin (Bng 3.33). Nh vy t l p ng chung
vi Imatinib l 58,9%. Kt qu ny cho thy vic tng liu Imatinib ln 600 800
mg/ngy vn cho p ng vi cc trng hp bnh tin trin khi iu tr vi liu
Imatinib 400 mg/ngy.
Theo nghin cu ca Mai Trng Khoa v cng s [6] thc hin trn 35 bnh
nhn BMTH, 60% bnh nhn c p ng vi iu tr Imatinib (57,1% p ng
mt phn), 34,2% bnh khng i v 5,8% bnh tin trin.
Mt nghin cu th nghim lm sng pha III c thc hin trn 649 trng
BMTH ti 148 trung tm M v Canada nm 2008 ca tc gi Charles D.
Blanke (nghin cu S0033), vi tiu ch la chn l nhng trng hp BMTH
khng c iu tr trit bng phu thut (phu thut cn bu, c di cn xa)
[21]. Nhng bnh nhn ny c phn b ngu nhin vo 2 nhm iu tr vi liu
Imatinib 400 mg/ngy v 800 mg/ngy, iu tr cho ti khi bnh tin trin hoc c
tc dng ph khng dung np c. Vi nhm iu tr Imatinib 400 mg/ngy th t
l p ng hon ton t 5%, t l p ng mt phn t 40%, bnh khng i t
25%, v c 12% bnh tin trin hoc t vong, v 10% cc trng hp khng th
nh gi.
130
Nh vy, kt qu ca chng ti v tc gi Blanke cng kh tng ng, vi

t l p ng hon ton thp, phn ln bnh nhn c p ng mt phn. T l bnh
khng i, hoc c tin trin cng chim mt phn khng nh. Nhng trng hp
ny c tng liu Imatinib ln gp 1,5 hoc gp 2 ln t hiu qu iu tr. Kt
qu ny cng tng t vi mt nghin cu lm sng pha III Chu u, mt nghin
cu kh ln v uy tn ca T chc Chu u v Nghin cu v iu tr Ung th,
thc hin trn 946 bnh nhn BMTH tin trin, cng c phn b ngu nhin
vo hai nhm s dng Imatinib 400 mg v 800 mg mi ngy. T l p ng hon
ton, p ng mt phn, bnh khng i, bnh tin trin ln lt l 5%, 45%, 32%,
v 13% [132].
Mt nghin cu khc ti Hn Quc nm 2012 c thc hin bi tc gi
Kang Hye Jin trn 370 trng hp BMTH ti 20 trung tm Hn Quc (nghin
cu KGSG) [74], vi tiu ch l bnh tin trin ti ch, khng phu thut c, di
cn xa, hoc ti pht, iu tr vi Imatinib 400 mg/ngy. Phn ln bnh nhn trong
nghin cu c ti pht hoc di cn xa (97,2%). Kt qu thu c vi 6,4% p ng
hon ton, 53,5% p ng mt phn, 36,6% bnh khng i, v 3,4% bnh tin
trin. T l p ng chung l 60% [74]. So vi nghin cu ca chng ti th t l
p ng hon ton thp hn, tuy nhin t l p ng chung kh tng ng gia hai
nghin cu. iu ny l ph hp v dn s nghin cu ca chng ti v tc gi Kang
cng kh tng t, vi phn ln cc trng hp l ti pht v di cn xa. Nghin cu
ny cn phn tch nh hng ca t bin gen c-KIT ln p ng vi Imatinib v
cng a khuyn co nhng trng hp c t bin exon 9 nn c iu tr vi
Imatinib liu cao.
Trong nghin cu 63 bnh nhn BMTH giai on mun c iu tr
Imatinib ti bnh vin K, tc gi Hng Kin [8] ghi nhn t l p ng mt phn
vi Imatinib l 54%.
Bng 4.48 trnh by tm tt so snh gia cc nghin cu, cho thy mt cch
r rng hn v s tng ng v t l p ng khi dng Imatinib 400 mg/ngy.
131
Bng 4.48: So snh v t l p ng vi Imatinib gia cc nghin cu

Nghin cu
MT. Khoa
C.D. Blanke
H.J. Kang
ny
(2014) [6]
(2008) [21]
(2012) [74]
p ng hon ton
13,3%
2,9%
5%
6,4%
p ng mt phn
45,4%
57,1%
40%
53,6%
Bnh khng i
16%
34,2%
25%
36,6%
Bnh tin trin
25,3%
5,8%
12%
3,4%
T l p ng tnh chung trong nghin cu ca chng ti (58,7%) khng

khc bit c ngha thng k so vi cc tc gi khc (p > 0,05). Tuy nhin, t l
bnh tin trin trong nghin cu ca chng ti (25,3%) cao hn so vi nghin cu
ca Mai Trng Khoa (5,8%) [6], C.D. Blanche (12%) [21] v H.J. Kang (3,4%) [74]
(p < 0,05). iu ny c th l do dn s nghin cu ca cc tc gi ny l nhng
bnh nhn c m trit v c iu tr Imatinib i vi nhm nguy c cao nn
c tin lng tt hn.
4.6- Theo di v kt qu iu tr
Phu thut ct bu trit vi b din ct an ton l phng php c la
chn hng u i vi BMTH nguyn pht c th m c. Tuy nhin, c mt
iu kh r rng l BMTH thng c nguy c ti pht, ty thuc vo tng phn
nhm nguy c m c th c t l ti pht cao hoc thp. Gn mt na cc trng
hp BMTH phu thut trit c ti pht hoc di cn xa [117].
Chng ti theo di c 96 trng hp trong s 109 trng hp. Thi gian
theo di thay i t 1 68 thng; thi gian theo di trung bnh l 35,0 16,3 thng.
Trong s 66 trng hp c phu thut ct bu trit c 36 trng hp
ti pht (chim t l 54,5%). Trong , c 14 trng hp ch ti pht ti ch
132
(21,2%), 4 trng hp c di cn gan v ti pht ti ch (6,1%); 9 trng hp di cn

gan (13,6%) v 9 trng hp gieo rc bng (13,6%).
So snh vi 2 nghin cu ti Ai Cp v Phn Lan:
Bng 4.49: T l ti pht/di cn sau phu thut
Nghin cu
Di cn xa
T l ti
Ti pht
Ti pht ti
SCKBTP
pht
ti ch
ch + di cn
54,5%
21,2%
6,1%
13,6%
39,2%
45,1%
3%
2,7%
39,4%
37,8%
45,7%
29,8%
6,38%
9,6%
46,5%
5 nm
ny
Rutkowski
(2007) [117]
Al-Kalaawy
(2012) [14]
Nghin cu ca Rutkowski [117] trn 335 trng hp BMTH c iu

tr phu thut trit , th t l ti pht chung l 45,1%, vi thi gian theo di trung
bnh 31 thng. Trong t l ti pht ti ch kh thp, cn li 39,4% l di cn xa (di
cn gan, phi, lan trn bng). Kt qu ny cng tng ng vi chng ti v t l
ti pht chung, tuy nhin t l di cn xa trong nghin cu ny cao hn chng ti
nhiu, c l do thi gian theo di di hn. Tc gi cng a ra t l sng cn khng
bnh ti pht 5 nm l 37,8%, vi thi gian sng cn khng bnh trung bnh l 37
thng. Kt qu ny li tng ng vi ghi nhn trong nghin cu ca chng ti.
Nghin cu ca Al-Kalaawy ti Ai Cp [14] c t l ti pht chung cng
tng ng vi nghin cu ca chng ti v c vi nghin cu ca Rutkowski
[117]. Tuy nhin, phn ln cc trng hp ch ti pht ti ch, t l di cn xa thp
hn so vi nghin cu ca chng ti v Rutkowski. Vi thi gian theo di di hn
(thi gian theo di trung bnh l 57 thng), kch thc bu ln hn, nhm c ch
s phn bo 5/50 QTL chim t l cao hn so vi nghin cu ca chng ti, nhng
nghin cu ny li t t l di cn xa thp hn.
133
Nghin cu ca Al-Kalaawy ti Ai Cp [14] cng cho thy ch tnh sng cn

cho nhng bnh nhn c phu thut trit , th t l sng cn ton b 5 nm l
53,4%, t l sng cn khng bnh 5 nm l 46,5%. Thi gian sng cn khng bnh
trung bnh l 43 thng. Nghin cu ca chng ti c t l sng cn ton b 5 nm
i vi nhm bnh nhn c phu thut trit l 84,3% , t l sng cn khng
bnh ti pht 5 nm l 39,2%, thi gian sng cn khng bnh ti pht trung bnh l
30,7 thng. Nh vy, tuy c t l ti pht chung cng gn tng t nhau, nhng t
l sng cn ton b 5 nm ca nghin cu ny thp hn nghin cu ca chng ti
(53,4% so vi 84,3%). iu ny l do chng ti iu tr nhm ch bng Imatinib
cho nhng bnh nhn c phu thut trit b ti pht.
Nghin cu ti Thu in ca B. Nilsson [102] cho thy t l ti pht trn
nhng trng hp c phu thut trit l 17,1%, t l ny kh thp, trong ch
c 2,3% l ti pht ti ch, 14,8% di cn xa. Kt qu ny cng thp hn ghi nhn
trong nghin cu ca chng ti. S khc bit ny l r rng v phn ln bnh nhn
trong nghin cu ca Nilsson thuc nhm nguy c ti pht thp v rt thp [102].
Nghin cu ny cng cho kt qu trung v thi gian sng cn ton b l 10,9 nm
(gn tng ng 131 thng), y l kt qu rt kh quan, ring nhm nguy c rt
thp v nguy c thp th thi gian sng cn ton b l trn 16 nm. Trong nghin
cu ca chng ti th thi gian sng cn ton b trung bnh ch t 54,9 2,2 thng.
iu ny c th cho thy vai tr ca phn nhm nguy c ti pht i vi BMTH
rt c ngha trong tin lng bnh.
Mt nghin cu khc ca Dematteo trn 127 trng hp BMTH nguyn
pht ti ch c phu thut trit , vi thi gian theo di trung bnh l 5,2 nm,
tc gi cho thy t l sng cn khng ti pht 1 nm l 83%, sau 2 nm l 75% v
63% sau 5 nm. T l ti pht chung l 33,1% [41], thp hn so vi nghin cu ca
chng ti. iu ny ch yu do tc gi Dematteo ch tp trung trn nhng trng
hp BMTH nguyn pht ti ch, nn phu thut c thc hin trit hn (ct
d dy bn phn, ct d dy ton phn, on chu, phu thut Miles), v v th t l
cn st bu kh thp, ch 15%.
134
- BMTH rut non:

Nghin cu ca T.J. Wu (i Loan) trn 100 trng hp BMTH rut
non ch iu tr bng phu thut, khng c iu tr h tr vi Imatinib cho kt qu
thi gian sng cn trung bnh ca nhm c phu thut trit l 123,3 thng so
vi 12 thng ca nhm phu thut khng trit hoc c di cn xa. Trong s 85
trng hp phu thut trit , c 44 trng hp ti pht (chim 51,8%), thi gian
ti pht trung bnh l 20,5 thng. T l sng cn khng bnh tin trin l 85,2% sau
1 nm, 53,8% sau 3 nm, v 43,7% sau 5 nm [136]. c lng t l sng cn
khng bnh tin trin 5 nm i vi BMTH rut non trong nghin cu ny ca
chng ti l 21,4%, thp hn so vi nghin cu ca Wu, iu ny l do bnh nhn
ca chng ti n vin tr, t l phu thut trit thp hn nn hiu qu iu tr
cha cao.
4.7- Cc yu t tin lng
BMTH c tim nng ti pht sau phu thut. iu ny chu nh hng
ca nhiu yu t khc nhau. Khi hiu bit r v cc yu t mang ngha tin lng
ny trn bnh nhn c BMTH nguyn pht phu thut c, s gip nh lm
sng phn tng nguy c ph hp, nhm c mt l trnh theo di sau m v xem xt
iu tr h tr. Kh nng lm tr hon hoc ngn chn ti pht vi ho tr h tr
ngy cng tr nn quan trng hn t khi c Imatinib mesylate [41]. Chnh v th cc
nghin cu ln vn tp trung tm ra cc yu t c nh hng n t l ti pht v t
l sng cn.
T khi A.P. Stout v cng s ch ra s lng phn bo l mt yu t tin
lng cho BMTH, c rt nhiu tiu chun c tm thy v cho thy c mi
lin h vi sng cn v ti pht bu, bao gm: v tr, kch thc bu, ch s phn
bo, hoi t bu, cc tnh cht xm ln, c triu chng hay khng, loi m bnh
hc, c di cn hch hoc di cn xa, . [23].
Theo cc phn tch n bin v nh hng ca cc yu t khc nhau ln sng
cn ton b, chng ti ghi nhn yu t kch thc bu v mc phu thut c
135
nh hng c ngha thng k. C th, t l sng cn ton b 5 nm ca bnh nhn

c kch thc bu < 5 cm, t 5-10 cm v > 10 cm ln lt l 100%, 77,3% v
55,4% (p= 0,035). T l sng cn ton b 5 nm ca nhm bnh nhn c phu
thut trit l 84,3%, cao hn nhm bnh nhn ch c phu thut tm b 47,7%
(vi p< 0,001).
Theo nghin cu ca Dematteo (2007) ti M trn 127 trng hp
BMTH, phn tch n bin cho thy cc yu t l v tr, kch thc bu, v ch
s phn bo c th tin on t l sng cn ton b [41]. Cc yu t ny khi c
phn tch a bin cng cho thy y l nhng yu t lin quan c lp n t l ti
pht, c th l bu c ch s phn bo 5/50 QTL, c ng knh 10 cm, v v
tr ngoi d dy. Phn tch a bin trong nghin cu ca chng ti ch ghi nhn mc
phu thut l yu t duy nht c ngha tin lng c lp i vi sng cn ton
b. iu ny c th do c mu trong nghin cu ca chng ti nh hn. Cc yu t
nh hng n kh nng ti pht ca BMTH c cp nhiu trong cc
nghin cu c mu ln khc, trong im chung nht l yu t kch thc bu
v ch s phn bo, cn v v tr bu th cha r rng [79], [136], [23]. Nh vy c
th thy kch thc bu v ch s phn bo l yu t tin lng quan trng v
c khng nh bng phn nhm nguy c ti pht theo tiu chun b sung ca
VYTQG Hoa K.
BMTH d dy thng c tin lng tt hn so vi BMTH rut
non hay BMTH i-trc trng [41].
Kt qu ny cng tng ng vi nghin cu ca Rutkowski ti Phn Lan
[117]. Nghin cu ca chng ti, cng cho t l sng cn ton b 5 nm ca bu
ti d dy cao hn so vi cc v tr khc, tuy nhin kt qu ny cha t ngha
thng k (p=0,278). V tr bu c nh hng khng r rt n tin lng sng cn
v ti pht, mt vi nghin cu thy c ngha, mt vi nghin cu th khng ghi
nhn c ngha [23].
136
Yu t gii tnh l mt trong nhng yu t c nh hng khng r rng ti

tin lng sng cn ca BMTH. Nghin cu ca chng ti cho thy gii n c
t l sng cn ton b 5 nm tt hn so vi gii nam (77,8% so vi 63,6%, vi p=
0,313).
Ghi nhn trong nghin cu ca Rutkowski Phn Lan trn 335 bnh nhn,
khi phn tch n bin cho thy cc yu t l nhm nguy c trung bnh hoc cao, ch
s phn bo >5/50 QTL, bu >5 cm, v tr ngoi d dy, gii nam, din ct cn st
bu hoc v bu, v c gii phu bnh l loi t bo hnh thoi hoc hn hp t
bo, th c nh hng xu hn n sng cn. Khi phn tch a bin th ch cn 5 yu
t c nh hng, l ch s phn bo > 5/50 QTL, bu >5 cm, gii nam, din ct R1
hoc v bu, v v tr bu ngoi d dy [117]. Nghin cu ny cng cho kt lun
khng nh vai tr ca yu t ch s phn bo v kch thc bu l yu t tin
lng c in c gi tr nht.
Mt nghin cu khc Ai Cp ca tc gi Al-Kalaawy trn 127 trng hp
BMTH ch iu tr phu thut, c theo di trong 57 thng (thay i t 14 n
108 thng), cho thy bng phn tch n bin cc yu t l kch thc bu, ch s
phn bo, bu d dy c nh hng n sng cn. Cn cc yu t tui, gii, din
ct khng nh hng tin lng. Khi phn tch a bin, th yu t v tr bu ngoi
d dy v kch thc bu ln s cho nh hng xu n sng cn [14]. Trong phn
tch a bin, chng ti ghi nhn ch c yu t mc phu thut l c tin lng
c lp i vi tnh trng sng cn ton b, cn cc yu t tui ( 40 v > 40), gii
tnh (nam v n), ch s ECOG (=1 v =2), v tr (d dy v ngoi d dy), s phn
bo (5, 6-10 v >10/50QTL), kch thc bu ( 5 cm, >5-10 cm v > 5 cm) v
nhm nguy c ti pht (thp, trung binh v cao), khng c tin lng c lp n
tnh trng sng cn ton b (Bng 3.43).
Chng ti tin hnh nh gi nh hng ca phn nhm nguy c trong nhm
nhng bnh nhn c phu thut trit i vi sng cn: trong 66 bnh nhn
c phu thut trit , c 11 bnh nhn thuc nhm nguy c thp, 02 bnh nhn
137
thuc nhm nguy c trung bnh v 43 bnh nhn thuc nhm nguy c cao. Chng
ti ghi nhn t l sng cn ton b khng bnh ti pht 5 nm ca nhng bnh nhn
thuc nhm nguy c thp-trung bnh cao hn 24,6% so vi cc bnh nhn thuc
nhm nguy c cao (58,6% so vi 34,0%). Mc d khc bit ny khng c ngha
thng k (p = 0,268), nhng cng cho thy vai tr ca vic phn nhm nguy c
ti pht theo tiu chun b sung ca VYTQG Hoa K. T cho thy s cn thit
phi iu tr h tr sau m i vi nhng bnh nhn thuc nhm nguy c cao.
4.8- Hn ch ca lun n
Do y l mt bnh him, s mu thu thp trong nghin cu ny cn t, ng
thi vi phng php nghin cu hi cu nn vic so snh vi cc cng trnh khc
cn hn ch, c bit l khi so snh theo mt s v tr bu trn ng tiu ha
(thc qun, i-trc trng v mc treo).
oOo
138
KT LUN
Qua nghin cu 109 trng hp bu m m ng tiu ha c iu tr
ti bnh vin Ung Bu TP H Ch Minh t 2006 - 2010, chng ti rt ra cc kt
lun sau:
1- Bu m m ng tiu ha thng gp nam gii hn, tui mc bnh trung
bnh l 51,9 tui. Bu thng gp d dy v rut non; cc v tr khc him gp
hn l i-trc trng, mc treo v thc qun. Gn 50% bnh nhn khm c khi
bu vng bng vi kch thc trung bnh l 12,3 cm. Hnh nh siu m v chp
ct lp vi tnh cho thy khi bu ln, c hoi t, ha nang v tng sinh mch mu.
Chn on BMTH da vo cc triu chng lm sng, hnh nh hc v gii phu
bnh vi CD117 (+). C 72,5% cc trng hp thuc nhm nguy c ti pht cao.
2- Phu thut trit ct rng bu vi b din ct an ton chim 60,6% cc trng
hp. C 54,5% bu ti pht sau phu thut trit . Cc trng hp sau m cn
bu c iu tr bng Imatinib, vi liu iu tr l 400 mg mi ngy. Imatinib c
vai tr quan trng trong iu tr BMTH. T l p ng vi Imatinib l 58,7%
(13,3% p ng hon ton v 45,4% p ng mt phn).
3- T l sng cn ton b 5 nm l 69%, thi gian sng cn ton b trung bnh l
54,9 thng. i vi cc bnh nhn c phu thut trit , t l sng cn khng
bnh ti pht 5 nm l 39,2%. i vi cc bnh nhn c phu thut tm b, t l
sng cn khng bnh tin trin 5 nm l 18,4%. Mc phu thut l yu t tin
lng c lp i vi tnh trng sng cn ton b.
oOo
139
KIN NGH
Trong thc t lm sng, nn ngh n chn on bu m m ng
tiu ha khi cc triu chng lm sng v cn lm sng cho thy khi bu
bng ln, c mt hn hp v c tng sinh mch mu.
Do mc phu thut l yu t tin lng c lp n sng cn ton
b, v vy khi phu thut cn ch ct trn khi bu vi b din ct an
ton, trnh lm v bu hay gieo rc bu.
oOo
DANH MC CC CNG TRNH NGHIN CU

LIN QUAN N LUN N:
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S t nguyn tham gia:
+ Ngi tham gia c quyn t quyt nh, khng h b p buc tham gia
+ Ngi tham gia c th rt lui bt k thi im no m khng b nh hng g
n vic iu tr/ chm sc m h ng c hng.
Trong trng hp l ngi v thnh nin, suy gim tr tu hoc mt kh nng,
vic ly bn chp thun tham gia t ngi i din hp php.
Tnh bo mt:
S liu c bo co di dng tng hp, cc thng tin nh danh s c
gi kn v s khng s dng ngun tin ny cho mc ch no khc.
II. CHP THUN THAM GIA NGHIN CU:

Ti c v hiu thng tin trn y, c c hi xem xt v t cu hi v
thng tin lin quan n ni dung nghin cu ny. Ti ni chuyn trc tip vi
nghin cu vin v c tr li tho ng tt c cc cu hi. Ti nhn mt bn sao
ca Bn thng tin cho i tng nghin cu v chp thun tham gia nghin cu ny.
Ti t nguyn ng tham gia.
Ch k ca ngi tham gia:
H tn..Ch k.
Ngy thng nm
Ch k ca ngi lm chng hoc i din hp php (nu p dng):

H tn..Ch k.
Ngy thng nm
Ch k ca Nghin cu vin :
Ti, ngi k tn di y, xc nhn rng bnh nhn/ngi tnh nguyn
tham gia nghin cu k bn chp thun c ton b bn thng tin trn y, cc
thng tin ny c gii thch cn k cho ng/B v ng/B hiu r bn cht,
cc nguy c v li ch ca vic ng/B tham gia vo nghin cu ny
H tn..Ch k.
Ngy thng nm
PH LC 4
PH LC 5
BNH VIN UNG BU TP. HCM
PHNG K HOCH TNG HP
____________________________________________________
XC NHN DANH SCH BNH NHN TRONG NGHIN CU

Ngi yu cu xc nhn: BS Dip Bo Tun
STT
H V TN
TUI
GII TNH
Nam
S H S
NGUYN TH M.
30
15487/06
NGUYN TH H.
60
15831/06
H TH H.
52
15978/06
L MINH T.
75
20845/06
NGUYN VN A.
53
53/07
TRN VN H.
54
1433/07
TRN VN X.
56
2044/07
NGUYN TH KIM L.
50
PHAN NH L.
33
2477/07
10
TRN T.
57
4191/07
11
LNG VN H.
40
4542/07
12
PHAN XUN K.
50
4600/07
13
NGUYN TH TUYT M.
46
14
L .
67
8406/07
15
NGUYN DUY K.
47
14636/07
16
PHM S.
54
15384/07
17
PHAN NH H.
69
17991/07
18
INH G.
42
18658/07
19
NGUYN VN S.
42
21366/07
2062/07
8194/07
20
HUNH VN T.
45
22350/07
21
PHAN VN M.
48
24503/07
22
V AN N.
39
4813/08
23
CAO THANH .
43
10318/08
24
NGUYN TH HNG G.
56
25
NGUYN VN B.
58
26
NGUYN TH MINH N.
58
27
TRN VN T.
52
28
L TH N.
54
25973/08
29
H VN L.
32
26695/08
30
TRN VN U.
37
31
L TH S.
58
32
NGUYN TH C.
28
15142/09
33
TRN VIT B.
29
16458/09
34
L TH L.
48
35
H S.
35
19392/09
36
TRNG PH H.
37
22637/09
37
NGUYN VN H.
54
25062/09
38
L S T.
54
26101/09
39
PHM THANH L.
55
28089/09
40
NGUYN VN .
44
29330/09
41
PHM TUN S.
52
19421/09
42
V NGUYN PHNG T.
34
19358/09
43
TNG TH HNG V.
57
11378/09
44
CHU TH .
54
9389/09
45
NGUYN TH A.
51
20793/09
46
NG KIM P.
53
18372/09
47
TH H.
36
28652/09
X
X
16167/08
23443/08
X
X
17254/08
16170/08
2138/09
X
7293/09
16911/09
48
NGUYN VN Q.
56
24790/09
49
TRNH VN G.
49
7735/09
50
TRNH VN T.
41
21852/09
51
KHA PHC T.
53
52
NGUYN NGC L.
54
18856/09
53
PHM VN H.
55
2425/09
54
NGUYN VN A.
36
28955/09
55
TRNG TH K.
40
14717/09
56
NGUYN TH M.
55
10554/09
57
V TH U.
39
28588/09
58
NG TH B.
51
24171/09
59
O VN K.
70
3750/09
60
TRN VN T.
50
2364/09
61
NGUYN VN T.
45
14836/09
62
TRN TH C.
54
29584/09
63
L TH T.
58
13003/09
64
TRN TH H.
52
10936/09
65
NGUYN TRNG H.
40
2291/09
66
PHAN THANH C.
58
25466/09
67
NGUYN HU L.
68
5174/09
68
NGUYN VN T.
56
12740/09
69
CAO VN L.
55
3762/09
70
TNG VN T.
64
18021/09
71
H T.
56
16988/09
72
NGUYN VN .
55
26845/09
73
BI XUN Q.
62
19904/10
74
V NGUYN HOI L.
19
16672/10
75
NGUYN TH T.
59
401/09
2769/10
76
HUNH NGC K.
69
77
ON L Q.
62
78
TRN TH N.
73
1884/10
79
NGUYN TH B.
49
4929/10
80
THCH TH C.
47
1056/10
81
PHM NH L.
72
17943/10
82
L H.
54
27320/10
83
PHNG TH D.
43
84
NGUYN CNG T.
60
21574/10
85
NGUYN HOI A.
53
19735/10
86
NGUYN VN C.
46
25833/10
87
TRN TH NGC N.
33
24435/10
88
PHM C.
63
17149/10
89
NGUYN TH T.
65
25160/10
90
L TH L.
73
8048/10
91
V TH L.
74
27335/10
92
PHM VIT V.
54
22364/10
93
TRN VN N.
68
12457/10
94
VNG CNG H.
56
14515/10
95
QUAN VN X.
62
7689/10
96
DNG HU H.
46
13048/10
97
BI THI L.
68
26412/10
98
NG TH L.
51
99
PHM NH V.
55
20289/10
100
TRN R.
56
12256/10
101
HUNH NG THANH D.
45
46785/10
102
L TH X.
56
103
CAO VN N.
54
19750/10
X
X
15104/10
27632/10
27381/10
10475/10
15965/10
104
NGUYN VN A.
57
3274/10
105
NGUYN C T.
52
27945/10
106
NGUYN THANH V.
67
15795/10
107
TRN TH M.
60
108
NGUYN HNG M.
39
109
TRANG M L.
44
21074/10
15972/10
X
TP. H Ch Minh, ngy
4166/10
thng
nm 2016
TRNG PHNG KHTH

DiepBaoTuan LA

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B GIO DC V O TO

THNH PH H CH MINH NM 2016

Ngi hng dn khoa hc:

THNH PH H CH MINH - NM 2016

Ti cam oan y l cng trnh nghin cu ca ring ti. Cc s liu,

1.5- Tin lng v sng cn ......................................................................................40

3.4- Chn on trc m ...........................................................................................67

Phu thut ni soi

Sng cn khng bnh tin trin

Sng cn khng bnh ti pht

Vin Bnh hc qun i (Hoa K)

Vin Y t Quc gia (Hoa K)

Ngha ting Vit

Armed Forced Institute of

Vin Bnh hc Qun i (Hoa

American Joint Committee on

Hip hi Ung th Hoa K

American Society of Clinical

Hi Ung th Lm sng Hoa K

Chronic myelogenous leukemia

The Eastern Cooperative

Epidermal Growth Factor

Th th yu t tng trng biu b

European Organization for

Research and Treatment of Cancer Ung th Chu u

European Society of Medical

Hip Hi Ung Th Ni Khoa

Food and Drugs Administration

C quan Qun l Thc Phm v

Fine Needle Aspiration

Chc ht bng kim nh

Gastrointestinal autonomic nerve

GastroIntestinal Stromal Tumors

The Glivec International Patient

Chng trnh Quc t h tr bnh

nhn dng Glivec

Magnetic Resonance Imaging

Chp cng hng t

Bnh khng thay i

National Comprehensive Cancer

Mng li quc gia (Hoa K)

ton din v ung th

National Institute of Health

Vin Y t Quc Gia (Hoa K)

Bnh tin trin

PDGFRA Platelet-Derived Growth Factor

ngun gc Tiu cu loi anpha

Positron Emission Tomography

Chp ct lp phng x psitron

Sng cn khng bnh tin trin

Sng cn khng bnh ti pht

Stem Cell Factor

Tyrosine Kinase Inhibitor

Thuc c ch Tyrosine Kinase

Total Mesorectal Excision

Ct ton b mc treo trc trng

Tumor - Node Metastasis

Bu nguyn pht Hch vng

Union for International Cancer

Hip hi Quc t Chng Ung th

Vietnamese Patient Assitance

Chng trnh H Tr Bnh nhn

World Health Organization

BNG I CHIU THUT NG VIT ANH