Benh Hoc Ung Thu

BNH HC UNG TH
TI LIU SU TM TNG HP DCH
Gii thiu Information Mc lc
Bin son ebook : L nh Sng
I HC Y KHOA H NI
Trang web : www.ykhoaviet.tk
Email : Lesangmd@gmail.com, bachkhoayhoc@gmail.com
in thoi : 0973.910.357
THNG TIN
THNG BO V VIC XUT BN BCH KHOA Y HC 2010 :
Theo yu cu v nguyn vng ca nhiu bn c, khc vi Bch Khoa Y Hc cc

phin bn trc, bn cnh vic cp nht cc bi vit mi v cc chuyn khoa
mi,cng nh thay i cch thc trnh by, Bch Khoa Y Hc 2010 c chia ra lm
nhiu cun nh, mi cun bao gm mt ch ca Y Hc, nh th s gip bn c
tit kim c thi gian tra cu thng tin khi cn. Tc gi xin chn thnh cm n tt
c nhng { kin ng gp ph bnh ca qu{ c gi trong thi gian qua. Tt c cc
cun sch ca b sch Bch Khoa Y Hc 2010 bn c c th tm thy v ti v t
trang web www.ykhoaviet.tk c L nh Sng xy dng v pht trin.
NG H :
Tc gi xin chn thnh cm n mi s ng h v mt ti chnh gip cho Bch
Khoa Y Hc c pht trin tt hn v ngy cng hu ch hn.
Mi tm lng ng h cho vic xy dng mt website dnh cho vic ph bin ti liu
hc tp v ging dy Y Khoa ca cc c nhn v Doanh nghip xin gi v :
Tn ngn hng : NGN HNG U T V PHT TRIN VIT NAM
Tn ti khon ngn hng : L nh Sng
S ti khon : 5111-00000-84877
CNH BO :
TI LIU NY CH MANG TNH CHT THAM KHO nhm mc ch nng cao hiu bit v Y
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on v t iu tr bnh, nht l vi nhng ngi khng thuc nghnh Y . Tc gi
ebook ny khng chu bt c trch nhim g lin quan n vic s dng thng tin
trong cun sch p dng vo thc tin ca bn c. y l ti liu su tm t
nhiu tc gi khc nhau, nhiu cun sch khc nhau, cha c kim chng , v th
mi thng tin trong cun sch ny u ch mang tnh cht tng i . Cun sch ny
c phn pht min ph vi mc ch s dng phi thng mi, bt c hnh vi no
lin quan n vic mua bn, trao i, chnh sa, in n cun sch ny vo bt c thi
im no u l bt hp l . Ni dung cun ebook ny c th c thay i v b
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GII THIU
B sch ny c L Sng su tm , bin dch v tng hp vi mc ch cung cp

mt ngun ti liu tham kho hu ch cho cc bn sinh vin y khoa, v tt c nhng
ai c nhu cu tm hiu, nghin cu, tra cu , tham kho thng tin y hc.
Vi tiu ch l b sch m , c xy dng da trn ngun ti liu ca cng ng ,

khng mang mc ch v li, khng gn vi mc ch thng mi ha di bt kz
hnh thc no , nn trc khi s dng b sch ny bn phi ng { vi nhng iu
kin sau . Nu khng ng { , bn khng nn tip tc s dng sch :
B sch ny c cung cp n tay bn , hon ton da trn tinh thn t nguyn
ca bn. Khng c bt kz s thng lng, mua chuc, mi gi hay lin kt no gia
bn v tc gi b sch ny.
Mc ch ca b sch phc v cng tc hc tp cho cc bn sinh vin Y khoa l

chnh, ngoi ra nu bn l nhng i tng ang lm vic trong nghnh Y cng c
th s dng b sch nh l ti liu tham kho thm .
Mi thng tin trong b sch u ch c tnh chnh xc tng i, thng tin cha
c kim chng bi bt c c quan Php lut, Nh xut bn hay bt c c quan c
trch nhim lin quan no . V vy, hy lun cn trng trc khi bn chp nhn mt
thng tin no c cung cp trong b sch ny.
Tt c cc thng tin trong b sch ny c su tm, tuyn chn, phin dch v sp

xp theo trnh t nht nh . Mi bi vit d ngn hay di, d hay d d cng u l
cng sc ca chnh tc gi bi vit . L nh Sng ch l ngi su tm v phin
dch, ni mt cch khc, ngi gip chuyn ti nhng thng tin m cc tc gi bi
vit cung cp, n tay cc bn .
B sch ny l ti liu su tm v dch b i mt sinh vin Y khoa ch khng phi l

mt gio s tin s hay mt chuyn gia Y hc dy dn kinh nghim,do c th c
rt nhiu li v khim khuyt khng lng trc , ch quan hay khch quan, cc ti
liu b tr c th cha hp l{ , nn bn cnh vic thn trng trc khi thu nhn
thng tin , bn cng cn c k phn mc lc b sch v phn hng dn s dng
b sch s dng b sch ny mt cch thun tin nht.
Tc gi b sch in t ny khng chu bt c trch nhim no lin quan n vic s

dng sai mc ch , gy hu qu khng tt v sc khe, vt cht, uy tn ca bn v
bnh nhn ca bn .
Khng c chuyn mn , khng phi l nhn vin y t , bn khng c ph p t s

dng nhng thng tin c trong b sch ny chn on v iu tr. T trc ti
ny, cc thy thuc IU TR BNH NHN ch khng phi l IU TR BNH. Mi
ngi bnh l mt thc th c lp hon ton khc nhau, do vic b nguyn xi
tt c mi thng tin trong b sch ny vo thc tin s l mt sai lm ln . Tc gi s
khng chu bt c trch nhim g do s bt cn ny gy ra.
V l b sch cng ng, to ra v mc ch cng ng, do cng ng , b sch ny c
pht trin c hay khng mt phn rt ln, khng ch da vo sc lc, s kin tr
ca ngi to ra b sch ny , th nhng ng gp, xy dng, gp {, b sung, hiu
chnh ca ngi c chnh l ng lc to ln b sch ny c pht trin. V mt
mc tiu tr thnh mt b sch tham kho y khoa tng hp ph hp vi nhu cu v
tnh hnh thc tin trong lnh vc y t ni ring v trong cuc sng ni chung . Tc
gi b sch mong mi bn c nhng li ng gp chn thnh mang tnh xy
dng, nhng ti liu qu{ m bn mun san s cho cng ng , v mt tng lai tt
p hn. l tt c nim mong mi m khi bt u xy dng b sch ny , ti vn
kin tr theo ui .
Ni dung b sch ny, c th ch ng trong mt thi im nht nh trong qu kh

v hin ti hoc trong tng lai gn. Trong thi i cch mng khoa hc cng ngh
tin nhanh nh v bo nh hin nay, khng ai bit trc c liu nhng kin thc
m bn c c c th p dng vo tng lai hay khng . tr li cu hi ny, ch
c chnh bn thn bn , phi lun lun khng ngng-T MNH-cp nht thng tin
mi nht trong mi lnh vc ca i sng, trong c lnh vc y khoa. Khng ai c
th, tt nhin b sch ny khng th, lm iu thay bn.
Nghim cm s dng b sch ny di bt kz mc ch xu no, khng c ph p

thng mi ha sn phm ny di bt c danh ngha no. Tc gi b sch ny
khng phi l tc gi bi vit ca b sch , nhng mt rt nhiu cng sc, thi
gian, v tin bc to ra n, v li ch chung ca cng ng. Bn phi chu hon
ton trch nhim vi bt kz vic s dng sai mc ch v khng tun th ni dung b
sch ny nu ra.
Mi l{ thuyt u ch l mu xm, mt cun sch hay vn cun sch cng ch l l{

thuyt, ch c thc t cuc sng mi l cun sch hon ho nht, bn khng
phi l c gi m l din vin chnh. V Bch Khoa Y Hc cng ch l mt ht thc
nh, vic s dng n xo nu hay nhn ging l hon ton ty thuc vo bn c.
V ngi to ra ht thc ny s vui mng v c truyn thm ng lc tip tc
c gng nu bit rng chnh nh bn m bit bao ngi khng cn phi xp hng
ch cu tr.
Mi ng gp lin quan n b sch xin gi v cho tc gi theo a ch trn. Rt

mong nhn c phn hi t cc bn c gi cc phin bn sau c tt hn.
Knh chc bn c, gia quyn v ton th ngi Vit Nam lun c sng trong
khe mnh, cuc sng ngy cng m no hnh phc.
Lng, Ngh An. Thng 8/2010
ABOUT
ebook editor: Le Dinh Sang

Hanoi Medical University
Website: www.ykhoaviet.tk
Email: Lesangmd@gmail.com, bachkhoayhoc@gmail.com
Tel: 0973.910.357
NOTICE OF MEDICAL ENCYCLOPEDIA PUBLICATION 2010:
As the request and desire of many readers, in addition to updating the new articles
and new specialties, as well as changes in presentation, Medical Encyclopedia 2010
is divided into many small ebooks, each ebook includes a subject of medicine, as this
may help readers save time looking up informations as needed. The author would
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DONATE
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MC LC
THNG TIN
ABOUT
1. I CNG V UNG TH
2. DCH T HC UNG TH
3. C CH BNH SINH & QU TRNH TIN TRIN T NHIN CA BNH UNG TH
4. NGUYN NHN UNG TH
5. D PHNG UNG TH
6. THM KHM KHI U
7. CHN ON BNH UNG TH
8. CHT CH IM UNG TH
9. IU TR PHU THUT BNH UNG TH
10. IU TR TIA X BNH UNG TH
11. HA TR UNG TH
12. IU TR GIM AU TRONG UNG TH
13. IU TR TRIU CHNG K GIAI ON CUI
14. CHNG TRNH PHNG CHNG BNH UNG TH VIT NAM GIAI ON 2002-2010
15. UNG TH V
16. UNG TH TY
17. UNG TH TUYN D DY
18. UNG TH I TRNG V TRC TRNG
19. UNG TH NG MT NGOI GAN
20. UNG TH GAN NGUYN PHT
21. UNG TH PHI
22. UNG TH THC QUN
23. U LYMPHO KHNG HODGKIN
24. UNG TH TUYN GIP
25. U TRUNG THT
26. UNG TH THANH QUN
27. UNG TH AMIAN KHU CI
28. UNG TH CC XOANG MT
29. U BUNG TRNG
30. UNG TH C T CUNG
31. UNG TH NGUYN BO NUI
32. UNG TH NIM MC T CUNG
1. I CNG V UNG TH
PHNG PHNG I HC Y DC HU
I. NH NGHA
Trong thi i ngy nay mc d khoa hc c nhng tin b vt bc c bit l

trong lnh vc sinh hc phn t, tuy nhin nh ngha bnh ung th l g vn
khng d dng.
Tuy nhin chng ta c th nh ngha ung th nh l qu trnh bnh l trong mt

s t bo thot ra khi s kim sot, s bit ha sinh l ca t bo v tip tc nhn
ln. Nhng t bo ny c kh nng xm ln v ph hy cc t chc chung quanh.
ng thi chng di tr v n pht trin nhiu c quan khc nhau v hnh thnh
nn di cn, ui cng ung th gy t vong do:
- Cc bin chng cp tnh nh: xut huyt t, chn p no, ngt th .
- Tin trin nng dn tin n ri lon chc nng ca cc c quan do khi di cn

nh thiu nng h hp, suy chc nng gan thn.
- S thoi trin dn dn, ko di dn n suy kit v cui cng bnh nhn t vong.
II. QU TRNH TIN TRIN T NHIN CA UNG TH
Mi loi ung th u c s tin trin khc nhau, tuy nhin nu ung th khng
c iu tr th s din bin qua cc giai on sau:
1. Giai on kh i u
1.1. Bc kh i u
Thng xy ra rt nhanh, sau khi cc t bo tip xc vi cc tc nhn gy ung th:
tc nhn vt l, tc nhn ha hc, tc nhn virus. Cc tc nhn ny gy ra thng
tn DNA ca t bo khng hi phc.
1.2. Giai on thc y
Do tip xc lin tc, ko di vi cc cht gy ung th lm n nh v duy tr thng

tn u tin.
Bc kh i u v giai on thc y chng ta ch bit c qua m hnh th

nghim v
nhng nghin cu v dch t ung th ngi.
1.3. Giai on tin trin
Cc t bo nhn ln khng kim sot c, pht trin c lp, mt kh nng bit

ha, xm ln cc b v cho di cn.
Hnh 1: S giai on kh i u
d phng giai on kh i u sinh ung th ngi ta phi bo v trnh tip xc
vi cc tc nhn gy ung th nh thuc l, benzol, nhiu loi ha cht khc nhau, tia
phng x, virus v.v.
2. Ung th tin trin
S tin trin ca bnh ung th gii thch c bn cht ca bnh ung th l g: khi
u pht trin cc b ti ch, xm ln ti vng v cho di cn ton thn.
Khi tin trin ung th xy ra, c nhiu bin php chng li s tin trin :
+ Sng lc v iu tr cc thng tn tin ung th.
+ Sng lc v iu tr nhng ung th kch thc cn nh (ch yu bng phu thut

hoc tia x).
+ iu tr tch cc cc ung th ang cn ti ch (thng kt hp vi iu tr h tr
ha tr liu hoc ni tit tr liu).

Hnh 2: Cc giai on tin trin ca ung th
3. Ung th di cn
Di cn ung th l tnh trng cc t bo ung th tch ri ra khi u nguyn pht

n c tr v pht trin thnh khi u c quan khc qua cc ng khc nhau:
ng bch huyt, ng mu, ng k cn.v.v.
Di cn theo ng bch huyt
+ Loi ung th biu m thng di cn n cc trm hch bch huyt khu vc. Khi
khi u tin n thnh bch huyt, t bo ung th xm ln nhanh chng qua thnh
bch huyt v c h thng lu thng bch huyt mang ti trm hch u tin.
Khi cc t bo ung th i n hch ngi ta nhn thy phn ng c hiu gi l
vim bch mch mn tnh c hiu (specific chronic lymphadenitis).
[1] T bo ung th ri khi u tin pht chy dc theo mch bch huyt hng v
hch v tinh
[2] Hch phn ng tiu dit t bo ung th
[3] T bo ung th li trong hch khng c phn ng
[4] T bo ung th chy qua hch v tinh m khng c phn ng c hiu

[5] T bo ung th pht trin v xm nhp hch bch huyt
[6] T bo ung th ph v v v xm ln t chc chung quanh
[7] T bo ung th lan n hch k cn
[8] Tc gy ph n bch mch

1. Khi cc t bo ung th bong ra khi khi u, chng tri dc theo dng chy ca h
thng bch huyt n hch v tinh.
2. Phn ng ca h bch huyt c th tiu dit cc t bo ung th.
3. T bo ung th li trong hch bch huyt m khng c phn ng g, gi l di cn

vi th.
4. i khi t bo ung th i qua hch v tinh m khng c phn ng c hiu no
5. Ngc li t bo ung th nhn ln, xm nhp ton b hch bch huyt, to ra

hnh nh u c hiu (hch cng, khng au, c nh).
6. Hch c nh l do t bo ung th ph v bao v xm ln ti cc t chc chung

quanh.
7. Cc t bo ung th c th di tr ti hch k cn to ra hin tng vim h

bch huyt dng ung th (carcinomatous lymphangitis).
8. Nhng thng tn trn hnh 8 gii thch tnh trng bch huyt v ph bch huyt.
S hin din ca di cn bch huyt trn mu bnh phm phu thut, hoc s xm
ln hch bch huyt l c hiu ca ung th ang tin trin. Tin lng thng
ngho nn v cc nh ung th hc phi tnh n iu tr kt hp x tr, ha tr, ni
tit, min dch sau phu thut.
Di cn theo ng mu:
+ Cc loi ung th ca t chc lin kt (ung th xng, ung th phn mm)
thng di cn theo ng mu n cc tng xa nh gan, phi, no.

Hnh 5: Ung th di cn theo ng mu
Di cn theo ng k cn:
+ Di cn hay i dc theo mch mu v thn kinh, theo li t b cn tr , in hnh l

ung th d dy lan qua lp thanh mc vo bng gy di cn bung trng.
+ Dao m, dng c phu thut c th gy gieo rc t bo ung th ra ni khc trong

phu thut nu m trc tip vo khi u.
III. D PHNG UNG TH

Mc du c nhng tin b rt ln trong lnh vc iu tr ung th trong hai thp k
qua, nhng ung th vn cn l mt bnh kh c th iu tr khi.
Tuy vy khong 50% trng hp bnh ung th c th phng trnh c. D phng

ung th l mt vai tr mi rt quan trng i vi tt c cc thy thuc trong th k
21. ch ng
phng chng ung th, thy thuc phi tnh n kha cnh lun l v t do c
nhn, cc chnh sch phng chng tch cc phi da vo c s kin thc khoa hc.
1. Vai tr ca thuc l
Ngi ta chng minh c thuc l gy ra nhiu loi ung th:
+ Bng cc nghin cu v dch t hc.
+ Bng nhng nghin cu v thnh phn cha trong thuc l.
+ Bng s khm ph ra s thng tn gen c hiu ca t bo khi u v t bo

bnh thng nhng ngi ht thuc.
+ Bng s pht trin nhng kin thc c bn v s chuyn ha ca amines ca

thuc l.
Qua nghin cu dch t hc v sinh hc c s lin quan r rt gia thuc l v cc

ung th sau y:
+ Phi
+ Thanh qun
+ Khoang ming
+ Vm mi hng
+ Bng quang
Nghin cu v thnh phn cha trong thuc l ngi ta tm thy hn 4000

loi ha cht, mt s ha cht chnh gy ra ung th:
+ Polycyclic aromatic hydrocarbons
+ Nitrosamines
+ Heterocyclic hydrocarbons
+ Benzen
+ Radioactive 210-polonium
Tt c nhng ha cht c trn c th gy ra s kh i u v thc y qu trnh sinh

ung th. Phng php d phng tch cc nht l khng nn ht thuc l i vi
nhng ngi cha ht c bit l tr em, vi nhng ngi ht phi c hnh thc
h tr ngi ht thuc t b thuc l v cc bin php nhm gim thiu tc
hi ca thuc l nh cm ht thuc ni cng cng, in hnh logo ln bao thuc.v.v.
2. Yu t di truyn
T vn v di truyn: l mt phng php mi trong iu tr ung th. Ngi ta

phi xem xt nhiu kha cnh khc nhau c thi x l{ ng n. Mc ch ca
thm khm di truyn trong ung th l:
+ nh gi nguy c di truyn ca ung th vi mc ch xc nh c hay khng c di

truyn.
+ a ra nhng chnh sch sng lc ph hp vi nguy c ung th .

+ Khi c ch nh c th thc hin nghin cu phn t v gen di truyn.
+ Gii quyt yu t tm l lo lng ca bnh nhn v nguy c di truyn.
+ C k hoch theo di thi gian di cho c nhn v gia nh ca h.
3. Ho d phng trong ung th
Ngi ta nhn thy rng mt s loi thuc gip d phng ung th:
+ S dng Tamoxifen (anti-estrogen) d phng ung th v trng hp c nguy c
cao v yu t gia nh. Nghin cu ln Hoa kz cho kt qu tt.
(NSABP Breast cancer prevention trial P-1)
+ S dng mt s loi thuc khng oestrogen khc (raloxifen) phng long

xng nhng ph n mn kinh gip d phng ung th ni mc t cung (ASCO
2005).
+ S dng cc thuc khng androgen (finasteride) d phng ung th tin lit

tuyn.
+ S dng cc thuc khng vim non-steroid d phng ung th i trng.
IV. SNG LC UNG TH
Mc ch ca sng lc ung th l pht hin nhng trng hp ung th cha

c biu hin lm sng bng cch s dng cc test chn on hoc cc phng php
khc c th p dung c rng ri trong cng ng. Kt qu ca sng lc thng
phn thnh 2 nhm: 1 nhm khng pht hin ung th v v nhm kia c nhng biu
hin nghi ng cn c nhng xt nghim chuyn khoa chn on xc nh.
Mt phng php sng lc c hiu qu phi chng minh c s gim t l t vong

nhng bnh nhn c sng lc so vi nhng bnh nhn khng c sng lc.
Loi ung th l t ng chn sng lc l:

+ Loi ung th c t l t vong cao trong cng ng
+ C mt thi kz tin lm sng rt di
+ Pht hin c giai on sm, iu tr c hiu qu

+ Pht hin c bng cch s dng test c nhy v c hiu cao, gi c xt
nghim va phi v t gy c hi cho c th c th lm lp li nhiu ln.
Trong thc t hin nay ch c mt s t loi ung th c li ch thc s khi thc hin
sng lc: ung th v, ung th c t cung, ung th da, ung th i trc trng, ung
th tin lit tuyn mc du vn cn mt s tranh ci v mt s k thut thc hin.
Li ch m sng lc ung th mang li bao gm:
+ Ci thin c tin lng cho bnh nhn nh vo pht hin sm qua sng lc
+ Gim thiu cc phu thut ct b rng ri lm mt chc nng.
+ Lm yn lng nhng ngi c test sng lc m tnh.
+ Lm gim chi ph trong iu tr ung th.

+ Cui cng tt nhin lm gim t l t vong thng qua chnh sch sng lc.
V. CHN ON UNG TH
Mi v tr ung th c cc triu chng pht hin khc nhau, tuy nhin mi triu
chng pht hin u xut pht t sinh l bnh hc, c bit l s pht trin c
trng ca mi loi khi u.
Khi cc triu chng xut hin r, thy thuc nn thc hin mt s th tc chn
on:
+ Thc hin chn on cng sm cng tt, thm khm v thc hin cc th thut
trnh gy au n, lo u cho bnh nhn.
+ Nhanh chng sinh thit khi u c chn on xc nh v gii phu bnh.
+ Yu cu kim tra v lm sng v cn lm sng nh gi ung th ang tin

trin ti ch hay di cn xa.
+ Chn on chnh xc giai on bnh.

+ Kim tra li chn on nhanh v chnh xc quyt nh phng php iu tr
thch hp nht. Chn on chm dn n iu tr chm v bnh nhn mt i c hi
iu tr khi bnh, kt qu iu tr cng xu i.
VI. XP GIAI ON BNH TRONG UNG TH
Xp giai on bnh trong ung th c nhiu mc ch:
+ D on c tin lng ca bnh.
+ Ch nh iu tr ph hp vi giai on bnh.
+ So snh kt qu iu tr gia cc nhm bnh nhn tng i ng nht.
+ Nghin cu kt qu iu tr theo giai on bnh

Thy thuc phi thc hin chn on bnh v chn on giai on trc khi ra
bt kz phng php iu tr no, mc ch chung l:
+ Trnh nhng s iu tr khng cn thit. V d :Thc hin phu thut khi bnh
nhn c di cn.
+ a ra phng php iu tr thch hp hn
Xp giai on da ch yu vo cc d kin v lm sng v cn lm sng. Nhng

yu t chnh cn c xp loi nh sau:
+ Mc ca xm ln khi u ti ch
+ Mc di cn xa
+ Loi gii phu bnh ca ung th vi nh gi bit ha ca loi ung th .
+ C th s dng nhiu loi cht ch im khi u.

+ Trong mt tng lai gn cc cht ch im v gen v nhng bt thng khc v
proten c th tr thnh cc yu t xp giai on.
+ Cui cng l tnh trng ton thn ca bnh nhn.
VII. CC PHNG PHP IU TR UNG TH HIN NAY
1. iu tr phu thut
Trong mt thi gian di phu thut c xem l phng php duy nht iu tr
ung th v n nay n vn cn c xem l hn tng trong iu tr ung th hin
i.
Nhng tin b vt bc trong k thut m, trong gy m hi sc hon thin

kt qu ca phu thut.
Theo mt s tc gi Timothy.J.Eberlein, Jonh M.Daly th ngy nay 60% n 75%

cc bnh nhn ung th c iu tr bng phu thut v cc k thut ngoi khoa
cn c s dng chn on, xp hng cho hn 90% cc bnh ung th. Khong
chng 1/2 bnh nhn ung th giai on m c c th p dng phu thut trit
cn. Phu thut c th phi hp vi cc phng php iu tr khc nh x tr, ha
tr, ni tit, min dch v.v.
Nhng nguyn tc chung trong phu thut ung th:

+ Phi tho lun phng php iu tr a m thc trc khi phu thut (thng l
hi chn vi cc bc s x tr v ha tr).
+ Tng trnh r rng bin bn phu thut
Cc u im ca phu thut ung th:
+ Cc loi u c tnh khng c s khng sinh hc i vi k thut ngoi khoa.
+ Phu thut khng c tc dng c tim nng sinh ung th.

+ Phu thut c kh nng iu tr mt s ln ung th giai on ti ch v ti
vng.
+ Phu thut cho php nh gi mc xm ln ca khi u cng nh xc nh c

tnh m hc ca khi u lm c s cho xp loi v ch nh iu tr.
Cc nhc im ca phu thut ung th:
+ Phu thut c th c cc bin chng e da n tnh mng bnh nhn hoc
lm mt chc nng sinh l{ mt s c quan. Bc s phu thut cn cn nhc mc

rng ca phu thut trnh tn thng nhng c quan quan trng v l mt
trong nhng nguyn nhn tht bi ca phu thut.
+ Nhng tn thng c tnh vt qua giai on ti ch v ti vng th vai tr

ca phu thut khng cn ph hp.
Cc loi phu thut gm
+ Phu thut chn on

+ Phu thut trit cn
+ Phu thut gii hn
V d : Phu thut ct mt phn v.
+ Phu thut lm gim th tch khi u
+ Phu thut thm st
+ Phu thut ti pht v di cn
+ Phu thut triu chng
+ Phu thut ti to
+ Phu thut gim au
2. iu tr tia x
iu tr tia x l s dng tia bc x ion ha iu tr ung th, l phng php

iu tr th 2 sau phu thut c p dng hn 100 nm nay.
Chng ta phn bit 2 loi iu tr tia x:
+ Tia x ngoi : Ngun phng x nm ngoi c th gm cc my iu tr tia x

nh cobalt, gia tc
Ngi ta phi thc hin m phng bnh nhn trc khi x tr. S dng mt my
Xquang c bit c tt c tnh nng ca mt my x tr, tr ngun phng x c
thay bng u n pht tia X gip xc nh khu vc s c chiu x (trng chiu)
trn ngi bnh nhn, gip cho vic iu tr c chnh xc hn.
Trong thi i ngy nay iu tr tia x c nhng tin b vt bc c bit,cc

quang t v m in t nng lng cao ngy c s dng nhiu hn, k thut
tnh liu v iu tr ngy cng tinh vi hn. Vi s pht trin cc kin thc su v vt
l phng x, sinh hc phng x cng vi vic pht trin h thng vi tnh trong lp k
hoch iu tr lm cho iu tr tia x chnh xc hn, hiu qu iu tr c tng
ln ng k gp phn cha khi hn 50% s ca ung th mi c chn on.
Hnh 6. iu tr bng my x ngoi
+ Tia x p st: Ngun phng x c t trong c th bnh nhn. Cc ng v

phng x c s dng l cc ngun mm c th un nn c nh Cesium 137,
Iridium 192 hoc Radium226. Ngui ta chia ra 2 loi:
Ngun phng x kn bao gm:
+ X tr p st k (interstitial brachytherapy) ngun phng x t trong khi u
+ X tr p st cc hc (endocavitary brachytherapy): ngun phng x t trong
cc hc t nhin ni khi u ang pht trin.

X tr p st t s dng n thun ngoi tr mt s ung th giai on rt sm,
thng
thng l phi hp vi tia x ngoi v cc phng php iu tr khc.

Hnh 7: iu tr bng my x trong
+ Ngun phng x dng lng: Cht phng x c tim trc tip vo bnh nhn
i vi mt s ung th c bit: I131, P32, St 189.
3. iu tr ho cht
T khi bt u tin trin, ung th c th cho di cn, do cc phng php iu

tr ti ch v ti vng nh phu thut v x tr thng khng mang li hiu qu. S
dng cc thuc iu tr ung th c bit l cc ha cht chng ung th c th ngn
chn c tin trin ca ung th. Ha cht chng ung th u l nhng cht gy
c t bo. iu tr ha cht da trn s p ng khc bit nhau gia t bo ung
th v t bo lnh. c trng tng tr ng ca ung th c nh h ng rt ln n
p ng vi ha tr. Cc hiu bit v ng hc t bo, s tng tr ng ca khi u,
sinh hc ung th l cn bn cho cc nguyn tc ha tr lm sng.
3.1. Cc ch nh ca ha tr ung th:
Ha tr gy p ng (induction chemotherapy) p dng i vi cc loi ung th

giai on mun.
Ha tr h tr (adjuvant chemotherapy) sau khi iu tr phu thut, tia x cc
ung th ang cn ti ch v ti vng.
Ha tr tn h tr (neoadjuvant chemotherapy) ha tr c thc hin trc khi

iu tr ti ch v ti vng.
Ha tr ti ch: nhm mc ch lm tng nng thuc ti khi u bng cch bm

thuc
vo cc xoang, hc ca c th hoc bm thuc trc tip vo ng mch nui khi u.
Ch nh iu tr ha tr cn da vo nhiu yu t nh giai oi bnh, loi bnh hc,

tui ca bnh nhn, cc phng php c iu tr trc , th trng bnh
nhn xc nh ch nh c th ca ha tr. Phi lun lun cn nhc mt bn l li
ch ca ha tr v mt bn l c tnh v nhng nguy him c th xy ra.
Bn cnh kh nng c th iu tr khi mt s ung th, ha tr c th gip lm gim

thiu mt s triu chng lin quan n ung th v t lm tng cht lng cuc
sng v ko di thi gian sng thm cho bnh nhn ung th.
4. Cc phng php iu tr khc
Ngoi cc phng php iu tr chnh nu trn cn nhiu phng php iu tr khc

c nghin cu trong nhng nm gn y.
4.1. iu tr min dch: c 2 loi chnh

Min dch th ng khng c hiu: Interferon v interleukin
Min dch ch ng khng c hiu: Bm BCG vo trong bng quang

4.2. iu tr ung th hng ch (Targeted cancer therapy)
iu tr ung th hng ch l s dng cc loi thuc ngn chn s pht trin v lan
rng ca t bo ung th bng cch cn tr cc phn t c hiu lin quan n qu
trnh sinh ung th v s pht trin ca khi u. B i v cc nh khoa hc gi cc phn
t ny l phn t ch (moleculer targets), nn cc phng php iu tr ngn cn
chng gi l iu tr hng ch phn t (moleculerly target therapies). iu tr
nhm vo ch phn t l phng php iu tr c hiu qu hn cc phng php
iu tr hin nay v t gy c t bo hn.
Hu ht cc trng hp iu tr ung th hng ch l cc th nghim tin lm

sng, mt s ang trong giai on th nghim lm sng v mt s khc c
FDA ng { a vo iu tr. iu tr ung th hng ch c th s dng n thun
hoc kt hp vi nhau hoc kt hp vi cc phng php iu tr khc nh ha tr
liu.
iu tr ung th hng ch bao gm nhiu loi thuc, mt s c lit k di y:
+ Thuc tc ng cc phn t nh (small molecule) ngn cn nhng enzyms c

hiu v GFRs (Growth Factor receptor) lin quan n s pht trin t bo ung th.
Nhng thuc ny cng cn c gi l thuc c ch dn truyn tn hiu.
+ Gleevec: (STI-571 hoc imatinib mesilate) l loi thuc tc ng vo cc phn t

nh c FDA cho php s dng iu tr ung th t bo m ca ng tiu ha
(mt loi ung th him gp ca ng tiu ha) v mt vi loi bnh bch cu ty mn.
+ Iressa: (ZD1839 hoc gefinitib) c FDA chp thun trong iu tr ung th

phi khng phi t bo nh. Thuc ny tc ng vo yu t th th pht trin biu
b (epidermal growth factor receptor), yu t ny c to ra qu nhiu b i nhiu
loi t bo ung th. Nhng
loi thuc tc ng vo cc phn t nh khc ang c nghin cu th nghim
lm sng ti Hoa
Kz.
Thuc gy ra cht t bo theo lp trnh : (Apoptosis-inducing drugs) lm cho cc t

bo ung th tri qua cht theo lp trnh (t bo cht do ngn cn nhng protein lin
quan trong qu trnh):
+ Velcade (bortezomib): c FDA chp thun iu tr a u ty khng p

ng vi cc phng php iu tr khc. Velcade gy ra cht t bo ung th bng
cch ngn cn enzyme gi l proteasome, enzyme ny gip iu ha chc nng v
s pht trin t bo.
+ Genasense (oblimersen) l thuc gy cht t bo theo lp trnh, c nghin cu

iu tr leukemia, non-Hodgkin lymphoma, cc khi u c. Genasence ngn cn
s sn xut ra mt protein gi l BCL-2, protein ny thc y s tn ti ca t bo
khi u. Bng cch ngn cn BCL-2, Genasence lm cho t bo ung th d tn
thng hn vi cc thuc chng ung th.
Khng th n dng, cc vaccin chng ung th, cht c ch tng sinh mch v
iu tr ung th bng gen (gen therapy) c xem l cc phng php iu tr
hng ch b i v chng ngn cn s pht trin ca t bo ung th.
+ Trastuzumab (Herceptin)
+ Rituximab (Mabthera, Ritusan)

+ Alemtuzumab (Mabcampath, campath)
+ Cetuximab (Erbitux)
+ Erlotinib (Tarceva)
iu tr chng tng sinh mch:

+ Bevacizumab (Avastin)
+ Thalidomide
iu tr chng proteasome:
+ Bortezomibe
Cng ngy cng c nhiu loi thuc mi khc c nghin cu v p dng vo iu

tr.
VIII. TIN LNG BNH
Tin lng bnh ung th ph thuc vo nhiu yu t, mt s yu t chnh dng

nh gi tin lng sau y:
+ Giai on bnh: Bnh giai on sm tin lng tt, nu c iu tr
kp thi c may khi bnh cao. Tri li bnh giai on mun iu tr ch ko di

thi gian sng thm v gim nh triu chng cho ngi bnh.
+ C quan b ung th: C nhng loi ung th tin lng tt l loi ung th d pht
hin giai on sm, tin trin chm nh ung th da, ung th gip trng, ung th
c t cung, ung th v, ung th khoang ming, ung th i trc trng.
Ngc li cc loi ung th ca cc tng quan trng kh pht hin sm, kh iu

tr, tin trin nhanh nh ung th phi, ung th gan, ung th no, ung th
xng.v.v.tin lng xu.
+ Tnh cht c tnh ca t bo ung th: T bo ung th c c tnh thp tin lng
tt. Tri li c tnh cng cao tin lng cng xu.
+ Th trng ngi bnh: ngi bnh cng gi ung th tin trin chm li nhng th
trng yu khng th thc hin iu tr trit c nn tin lng xu.
TI LIU THAM KHO I. TI LIU TING VIT
1. i hc Y H Ni, 1999. Bi ging ung th hc, NXB Y hc , H Ni.
2. L nh Roanh, 2000. Bnh hc cc khi u, NXB Y hc, H Ni, trang 5-9.
3. Nguyn Chn Hng v CS, 1986. Din bin t nhin ca bnh ung th. Trong:
Ung th hc lm sng, tp I, ti bn ln th nht, Trng i hc Y Dc Tp HCM,
trang 79-112.
4. UICC, 1995. Ung th hc lm sng, NXB Y hc, H Ni, trang 22-44.
II. TI LIU TING ANH
1. Alani R.M and Munger, 1998. Human Papilloma Viruses and Associated
Malignancies. J clin
Oncol; 16: 330-337.

2. Chambers AF, Hill RP, 1998. Tumor Progression and Metastasis in: The Basic
Scinece of
Oncology 3rd editon. The MacGrawHill.; chaper 10, 219-239

2. DCH T HC UNG TH
I. I CNG
Dch t hc l mn hc nghin cu v s phn b v nhng yu t lin quan n

bnh tt trong mt qun th dn c. Dch t hc cung cp nhng thng tin c gi
tr v cc m hnh v nguyn nhn sinh bnh.
Ti cc nc pht trin, cng vi s gia tng tui th trung bnh th bnh ung
th l nguyn nhn gy t vong th hai sau bnh tim mch. Hin nay, nhiu quc
gia ang pht trin, t l ung th ghi nhn c thp hn nhiu, hu ht do t l t
vong cao hn v cc bnh nhim trng v chn thng. Vi s gia tng kim sot
St rt v Lao mt s nc ang pht trin, t l ung th c trng i s tng
ln.
Dch t hc ung th phn nh st s phn b yu t nguy c cc nc khc nhau.
Cc loi ung th thng gp tnh chung c 2 gii nam v n, c tnh hng nm

trn ton cu cho thy khong 10,9 triu ca ung th mi mc v khong 6,7 triu
ngi cht vi ung th (2002)
Thng k cho thy cc bnh ung th thng gp trn th gii l:
- Ung th phi: lun chim t l cao nht c cc nc pht trin v ang pht
trin ( khong 13,5% ), bnh c mi lin quan cht ch vi thuc l.
- Ung th v: chim t l 11,5%, l bnh ung th hng u ph n
- Ung th i trng: chim t l 10,2%, lin quan n ch n nhiu cht bo v t

rau qu.
- Ung th d dy: 9,34%, nguyn nhn chnh do vi khun Helicobacter Pylori, c mi

lin quan cht ch vi cc thc n p mui nh: cc loi da mui, tht mui, tht
hun khi
- Ung th gan nguyn pht:chim t l 6,26%, hai nguyn nhn thng gp l

bnh vim gan siu vi ( HBV, HCV) hoc n cc loi ng cc nhim nm Aspergillus
- Ung th tin lit tuyn: thng gp ngi cao tui, l bnh ung th nam gii
hng u ti cc nc pht trin, chim t l 6,79%
- Ung th c t cung: chim t l 4,93%, HPV c coi l th phm hng u cho

bnh ung th ny ( 82% )
Ti VN, hng nm c khong 100.000-150.000 trng hp mi mc ung th v

khong
70.000 ngi cht do ung th.
VN, qua nghin cu TPHCM v H Ni cho thy 10 loi ung th thng gp

Bng 1: Cc bnh ung th thng gp 2 gii
TH T Nam N
1 Gan C t cung
2 Phi V
3 D dy i trc trng
4 i trc trng Phi
5 Tin lit tuyn D dy
6 Hc ming Gan
7 Vm hu Bung trng
8 Thc qun Tuyn gip
9 Lymphm Thn t cung
10 Bnh bch cu Bnh bch cu
II. MT S KHI NIM TRONG DCH T HC UNG TH
1. Xut (Incidence)
c tnh bng s ca ung th mi xut hin trong mt qun th dn c, thng

c tnh theo s ca ung th mi mc mi nm trn 100.000 dn. y l ch s tt
nht ca tn sut mc bnh ung th.
Ngi ta c lng tng s ca ung th mi mc trn th gii nh sau:
Nm 2002: 10,9 triu (vi 24,6 triu ngi sng chung vi ung th ) Nm 2020:
16 triu ( vi 30 triu ngi sng chung vi ung th )
T l mi mc thng c dng cung cp nhng d liu v s xut hin ung th
trong qun th dn c theo nhm tui, gii tnh, chng tc...ngi ta c th tnh t
l mi mc cho ton b dn c hoc tng b phn ca qun th dn c vi nhng
c trng phn b khc nhau.
2. T sut (Mortality)
S ca t vong trn 100.000 dn mi nm.
Tnh hnh t vong do ung th: cc nh dch t hc ghi nhn nm 2002, trn th
gii c
6,7 triu ca t vong do ung th, l nguyn nhn gy t vong th hai cc nc

pht trin sau bnh tim mch v ng th ba cc nc ang pht trin sau
bnh nhim trng v bnh tim mch.
T l t vong do ung th ngy cng cao ph thuc vo hai nguyn nhn chnh:
- Yu t nhn chng hc: tui th ca con ngi ngy cng tng m s ung th
hay gp nhng ngi c tui.
- Kh nng v chn on tin b hn nh m nhiu loi ung th c chn

on trc lc cht.
Tuy nhin, nhiu nc, cc thng k chnh thc cha cng b mi loi t vong.
3. T l mc bnh ton b (Prevalence)

L con s c tnh ton b s ngi mc bnh ung th ( tt c cc v tr ung th
hay gp li mt v tr no ) v nhng ngi ny sng ti mt thi im nht
nh hoc mt thi im nht nh trong khong thi gian xc nh, thng tnh
bng s ca ung th trn 100.000 dn
Ch s ny dng nh gi gnh nng v bnh tt ca cng ng.
Tng theo t l mi mc v khong thi gian trung bnh m bnh ko di.

III. S THAY I DCH T HC UNG TH
1. Xu hng gim
Xu hng gim ung th c t cung mt phn do s p dng rng ri xt nghim t

bo c t cung, iu tr cc thng tn tin ung th tng cng cc iu kin v
sinh cho ph n, sinh c k hoch v t l ct t cung ton b tng ln cng vi
s pht hin vacxin d phng ung th c t cung.
S gim i ca ung th d dy lin quan n s ci thin v sinh dinh dng, iu

tr c hiu qu vi khun Helicobacter Pylori cng nh n nhiu thc n cha cc cht
chng oxy ho.
S gim i ca bnh u lympho c tnh, ung th tinh hon, i trng do s ci

thin ca cht lng iu tr
2. S tng thm
S gia tng ca ung th phi, ung th bang quang c quy kt do tng tiu th
thuc l.
Xu hng tng thm ca ung th v v ung th tin lit tuyn l do tui th

ca con ngi ngy cng tng.
Tng ln ca ung th da do thi quen tm nng.

IV. S DAO NG CA T L MI MC THEO CC YU T NHN KHU
1. Tui
L yu t quan trng nht xc nh nguy c mc bnh ung th. i vi hu ht ung

th loi t bo biu m th t l mi mc tng r rt theo tui.
Mi quan h gia tui v t l mi mc biu th hiu qu tch ly qua qu trnh

tip xc vi cc tc nhn sinh ung th theo thi gian.
Tuy nhin, khng phi bao gi cng quan st c hin tng ny.
- T l mi mc ca bnh bch cu lympho c nh cao tui 3-4.
- i vi ung th v, s gia tng chm dn sau tui mn kinh v t l mi mc ung

th c t cung rt thp sau 50 tui.
Khi so snh t l mi mc ca cc bnh ung th gia cc quc gia i hi t l ny

phi c chun ha theo mt qun th dn c thun nht v cu trc tui ca cc
nc rt khc nhau, dn s chun c s dng rng ri nht l dn s th gii.
y l mt qun th dn c gi nh c cu trc tui nm gia qun th gi
ca cc nc pht trin v qun th tr ca cc nc ang pht trin.
2. Gii
Nam gii c t l mc ung th cao hn n gii i vi phn ln cc loi ung th

ngoi tr ung th tuyn v, ng mt, mt, i trng v tuyn nc bt. S
khc bit ny thng c quy kt do s khc bit v tnh mn cm m c ch
cha gii thch c.
3. Chng tc
S khc bit v tnh hnh mc ung th ca cc chng tc khc nhau trong cng mt
quc gia cho thy tnh mn cm di truyn v cc yu t vn ha c nh h ng ti
nguy c ung th. Phi hp cc nghin cu di c c th phn lp c vai tr ca
tng loi yu t ny.
4. Tn gio
Nhng ngi theo mt tn gio no c nhng np sng c bit nh h ng
ti c im bnh ung th nhm ngi ny.
V d: T l mc ung th v cao cc n tu. Ung th dng vt rt thp ngi Do

Thi do lut ct bao quy u lc cn tr.
5. Ngh nghip
Vin ung th quc gia v an ton ngh nghip Hoa Kz nm 1978 cng b rng
30% bnh ung th c lin quan n mi trng lm vic, trong 4-8% trng hp
ung th l do mi trng cng nghip. Php, hng nm c thm 7000-8000
trng hp ung th mi mc do ngh nghip.
Mi ngi nn thc hin ng quy tc bo h lao ng ca ngh mnh ang lm

s hn ch c nguy c mc ung th.
6. Hon cnh kinh t x hi
Gm nhiu yu t quan h tng h: nn gio dc, mc thu nhp, ch n ung,

mi trng sng v lm vic, cht lng cc dch v t vn v chm sc sc
khocng cha chng minh mt cch r rt cc ch s v hon cnh nh h ng
nhiu n nguy c mc bnh ung th.
7. Cc nghin cu trn cc qun th di c
Cho thy s kt hp vai tr ca cc yu t di truyn v mi trng i vi nguy c

ung th da vo vic so snh nguy c ung th ca nhm nhp c vi qun th gc
v qun th ni nhp c.
V. GHI NHN UNG TH
1. nh ngha
Ghi nhn ung th l qu trnh thu thp mt cch c h thng v lin tc s liu
v tnh hnh mc bnh cng nh c im cc loi ung th ghi nhn c nhm
h tr trong vic nh gi v kim sot gnh nng ung th trong cng ng.
Vic xc nh tnh hnh t vong do ung th trc ht phi c h thng thng k t

vong v s liu dn tc hc ng tin cy c th tnh ton c t l t vong.
nhiu quc gia ang
pht trin, chng nhn t vong thng khng c chng nhn ca thy thuc v
nguyn nhn t
vong.
2. Ghi nhn Ung th ti Vit Nam
2.1. Xut
Xut chun theo tui (ASR) ca tt c cc ung th ( ngoi tr ung th da ) l

144,94 cho nam v 102,91 cho n.
2.2. T sut
T sut chun theo tui ca tt c cc loi ung th ( ngoi tr ung th da ) l 115,76

cho nam v 66,14 cho n.
2.3. Cc loi Ung th thng gp
Bng 2: 10 bnh ung th thng gp Nam gii

Tha Thin Hu H Ch Minh
(2001-2004) (2003)
Tnh \ Thnh H Ni
ph
(2001-2004)
ASR Rank ASR Rank ASR Rank
Phi 39,8 1 10,8 3 29,5 1
D dy 30,3 2 14,4 2 15,3 3
Gan 19,8 3 16,4 1 25,4 2
i trc trng 13,9 4 4,9 4 16,2 4

V tr
Thc qun 9,8 5 1,7 9 4,0 8
Mi hng 7,8 6 1,5 12 4,2 7
U lympho c 7,2 7 3,8 5

Bnh bch cu 4,7 8 2,4 8 4,6 6
Bng quang 3,5 9 3,0 7
Vm hng 3,2 10 0,0 22 4,8 5
Li 1,9 14 1,6 10
Khoang ming 2,3 12 3,7 6
M mm 2,0 14 2,9 7
Ty 1,2 18 1,3 14
Tin lit tuyn 2,7 12 1,0 16 2,8 10
Nhau thai 1,3 17 0,9 12
Dng vt 1,8 14 1,5 13
Da 3,0 9
Tnh \ Thnh ph H Ni
(2001-2004)
Bng 3: 10 bnh ung th thng gp N gii
V 29,7 1 12,2 1 19,4 1
D dy 15,0 2 7,3 2 5,5 6

V tr
Phi 10,5 3 3,6 4 12,4 3
i- trc trng 10,1 4 3,4 5 9,0 4
(2001-2004) (2003)
C t cung 9,5 4 5,0 3 16,5 2
Tuyn gip 5,6 5 1,6 10 3,8 8

Bung trng 4,7 6 2,1 9 3,8 7
Gan 4,5 7 3,4 6 6,0 5
U lympho c 4,0 8 1,4 12
Bnh bch cu 3,4 9 1,4 11 3,2 9
Mi hng 3,3 10 0,5 18
M mm 1,4 13 2,6 8
Da 2,6 10
TI LIU THAM KHO
I. TI LIU TING VIT
1. Bi bo khoa hc:
1. Nguyn B c & Nguyn Chn Hng, 2002. Chng trnh phng chng ung th
giai on
2002-2010, Ti liu tp hun ghi nhn ung th, B Y t v Bnh vin K.
2. Sch:
1. i hc Y Khoa H Ni - B mn ung bu, 1999. Bi ging ung th hc, NXB Y

hc, H
Ni, trang 13-17.

2. Phm Thy Lin, 1999. Lm th no pht hin sm bnh ung th, NXB
Nng.
II. TI LIU TING ANH
1. American Cancer Society. Cancer fct and figures 2003.
2. Jensen, O.M.Parkin, D.M. Maclennan, R. Muir, C.S and Skeet, R.G (eds),
1991. Cancer
Registration: Principles and methods. IARC Scientific Publication, Lyon.
3. Oxford Handbook of Oncology 2002, pages 3-11.
4. Vincent T.DeVita, 1997. Principles & Practice of Oncology, pages 196-216.

3. C CH BNH SINH & QU
TRNH TIN TRIN T NHIN CA
BNH UNG TH
I. I CNG
- Ung th xy ra do s t bin trong DNA, dn n t bo tng sinh v hn ,

v t
chc, khng tun theo cc c ch kim sot v pht trin c th.
- Tnh cht c trng ca t bo ung th:
+ Trnh c apoptosis (cht theo chng trnh)
+ Kh nng pht trin v hn (bt t)

+ T cung cp cc yu t pht trin
+ Khng nhy cm i vi cc yu t chng tng sinh
+ Tc phn bo gia tng
+ Thay i kh nng bit ha t bo
+ Khng c kh nng c ch tip xc

+ Kh nng xm ln m xung quanh
+ Kh nng di cn n ni xa
+ Kh nng tng sinh mch mu
-Vi nhng hiu bit v vai tr ca Gen sinh ung v Gen nn bu cng cc khm
ph mi v s sinh mch ( angiogenesis ), cht t bo theo lp trnh (apoptosis), s
sa cha vn ling di truyn c th gip chng ta c c nhng hiu bit v c
ch sinh ung t lm c s cho mt liu php mi: liu php nhm trng ch
(targeted therapy).
II. GEN UNG BU
1. ng dn truyn tn hiu t bo
Cng vi s pht trin ca cng ngh sinh hc, vai tr ca tin gen sinh ung (proto-
oncogen) vi chc nng sinh l iu ha ng dn truyn tn hiu t bo nhn
cc kch thch cho s phn bo v cht theo lp trnh c hiu bit hon ton.
Da vo v tr trn ng dn truyn tn hiu t bo, ngi ta chia tin gen sinh ung
lm 4 phn:
- Cc yu t tng tr ng (growth factors)
- Cc th th ca yu t tng tr ng
- Cc tn hiu dn truyn (signal transducers) (Cc Protein G t bo cht)
- Cc yu t sao ch p nhn t bo (transcription factors)
Hnh 1: ng dn truyn tn hiu yu t tng tr ng.

Cc giai on ca s dn truyn tn hiu t bo
Cc yu t tng tr ng n gn vo cc th th c hiu trn b mt t bo. S

gn kt ny lm thay i dng ca th th v gy tc ng vo phn th th trong
bo tng, do tn hiu c hot ha xuyn qua mng t bo. Tn hiu ny lan
truyn qua t bo cht n nhn v gn vo im sao chp c bit ca DNA nh
cc phn t trung gian gi l Protein G. Tn hiu ny lm t bo thay i tnh trng
tng sinh ca n, c th chuyn t tnh trng phn chia sang ngh ngi hay cht
qua c ch gy cht t bo theo lp trnh.
1.1. Yu t tng tr ng
Cc yu t tng tr ng l cc phn t ha hc c trong mu hay trn b mt t bo

khc. V d:
+ Yu t tng tr ng xut pht t tiu cu ( Platelet Derived Growth Factor:

PDGF ).
+ Yu t kch thch cm (Colony Stimulating Factor: M-CSF )
1.2. Th th yu t tng tr ng
- Cc th th bao gm 3 phn:
+ Phn ngoi mng t bo: to mt v tr khuych i ha hc ch gn vi cc
yu t tng tr ng c hiu.
+ Phn trong mng t bo
+ Phn bn trong bo tng: l mt phn t c chc nng hot ng thay i khi

phn ngoi mng t bo c gn vi yu t tng tr ng, thong thng l mt
Tyrosin kinase.
- S t bin thng lm tng chc nng ca Tyrosin kinase, lm n gi tn hiu vo
bo tng lin tc ngay c khi khng c yu t tng tr ng gn vo phn ngoi
mng t bo ca th th, dn n vic t bo tng sinh c lp vi yu t tng
tr ng ca n.
1.3. Cc Protein G t bo cht (Cc tn hiu dn truyn)
- Cc Protein G l mt loi oncoprotein chuyn t dng khng hot ng thnh hot

ng khi nhn tn hiu t phn trong bo tng ca th th yu t tng tr ng.
1.4. Cc yu t sao ch p nhn t bo
Khi cc tn hiu t bo n gn vo v tr sao chp nhn t bo c hiu s lm thay

i trng thi kch thch phn chia t bo.
V d:
+ t bin ca tin gen sinh ung myc s gia tng kch thch phn chia t bo,
thng gp trong ung th tr em ( U nguyn bo thn kinh).
Liu php nhm trng ch ung th pht trin ng k qua s tin b v sinh hc
ung th, ngy cng hiu nhiu c ch dn truyn tn hiu iu ha t bo. T vic
s dng khng th n dng Trastuzumas (Herceptin) chng li phn ngoi t bo
th th erbB2 c gi tr trong iu tr ung th v di cn.
2. Cht t bo theo lp trinh

Cht t bo theo lp trnh l mt kiu cht t bo, l mt bin c ph thuc vo
nng lng c lp trnh (do gi l cht theo lp trnh). y l c ch quan
trng trong iu ha t nhin trong c th bnh thng duy tr cn bng gia t
bo sinh ra v cht i. Ngoi ra, v mt ung th th y l c hi sa cha
thng tn DNA ca t bo hay loi b t bo b t bin c tim nng sinh ung.
C ch iu ha cht t bo theo lp trnh rt phc tp vi s tham gia ca nhiu
gen ngn cn v thc y tin trnh ny: P53, Bcl2.
Cht t bo theo lp trnh v ung th: gia tng s lng t bo khng ph hp l

mt trong cc im mu cht ca qu trnh sinh ung. iu ny c th l do gia tng
s tng sinh hay gim t bo cht.
3. Yu t tng sinh mch
Ngi ta chng minh rng: cc bu c c kch thc 2 3mm vn trng thi

ng yn nu khng c mch mu nui, cc thng tn tin ung th din tin thnh
ung th xm ln v cc di cn xa l thuc vo s sinh mch.
C ch sinh mch trng lp trong s xm ln v di cn ca bu. Cc nh nghin

cu khuyn nn c s phi hp cc cht khng sinh mch vi ha tr qui c nhm
em li tc dng lm chm pht trin bu v ngn nga di cn xa.
4. C ch tng sinh dng t bo
Khi mt t bin xy ra gen tin sinh ung s to mt dng t bo c u th tng

sinh v sinh sn thnh mt clon t bo bu, kh i u cho mt ung th.
C 3 kiu t bin lm tng sinh mt dng t bo:
+ T bo t bin lm mt th th yu t tng tr ng: gy mt c ch kim sot

ngc dn n sn xut nhiu yu t tng tr ng. S tng sinh ny t gii hn b i
s chnh lch ca s lng yu t tng tr ng v s lng t bo.
+ T bo t bin sinh ra qu nhiu th th yu t tng tr ng v tng nhy cm

vi kch thch tng tr ng. T bo ny v t bo th h sau ca n tng sinh nh l
mt bu n clon, nu ly i yu t tng tr ng s lm ngng s pht trin ca
bu.
+ T bo t bin sinh ra qu nhiu yu t tng tr ng: t bo ny t nhy cm vi
chnh cc yu t tng tr ng ca n. T bo ny v th h sau ca n tng sinh nh
mt bu n clon c lp vi yu t bn ngoi, l mt bu c tnh r.
III. GEN NN BU
Gen nn bu c vai tr lm chm li s phn chia t bo, n hot ng cng

vi h
thng sa cha AND cn thit cho vic duy tr tnh n nh ca vn ling di truyn
Gen nn bu th ln, c hai bn sao ca gen phi b t bin mi khng

ngn cn
c s tng tr ng t bo b thng tn.
Khi gen nn bu b t bin, khim khuyt AND c th c di truyn qua

t bo mm v l nguyn nhn ca cc hi chng di truyn d b ung th
V d:
+ Mt s t bin gene BRCA1 v BRCA2 lin quan n tng nguy c ung th
v v ung th bung trng

+ Cc khi u ca cc c quan ni tit trong bnh a u tuyn ni tit (multiple
endocrine neoplasia - MEN th 1, 2a, 2b)
+ Hi chng Li-Fraumeni (sarcoma xng, ung th v, sarcoma m mm, u no)
do t bin ca p53
+ Hi chng Turcot (u no v polyp i trng)
+ Bnh polyp tuyn gia nh l mt t bin di truyn trong gene APC dn n

pht trin sm ung th i trng
+ U nguyn bo vng mc tr em l ung th di truyn

IV. C CH SINH UNG
Ung th c bn cht l s t bin khng sa cha c trong AND do s tc

ng ca cc yu t sinh ung ( ha hc, bc x, virus).
Kh i u ca c ch sinh ung l s hot ha gen sinh ung v s t bin mt d hp

t ca gen nn bu. To s tng sinh u th ca mt dng t bo c tnh v
pht trin bn vng trong c th nh s tng sinh mch, chin thng h thng
min dch ca c th ch c th xm ln rng v di cn xa.
Hnh 2: S c ch sinh ung
V. CC GIAI ON TIN TRIN CA UNG TH.
1. Giai on kh i pht
Bt u t t bo gc do tip xc vi cc tc nhn gy t bin, lm thay i khng

phc hi ca t bo.
Qu trnh din ra nhanh v hon tt trong mt vi giy v khng th o ngc

c. Tuy nhin ngi ta cha xc nh c ngng gy kh i pht.
Trong cuc i mt con ngi th c nhiu t bo trong c th c th tri qua qu

trnh kh i pht, nhng khng phi tt c cc t bo u pht sinh bnh. a s cc t
bo kh i pht hoc l khng tin trin, hoc l cht i, hoc l b c ch min dch
v hiu ha.
Hnh 3: Tc nhn t bin lm thay i khng hi phc DNA
2. Giai on tng tr ng, thc y, chuyn bin
y l cc giai on sau giao on kh i pht; bao gm s chn lc dng t bo, s

thay i th hin gen, s tng sinh ca t bo kh i pht. S tng sinh ca t bo
ung th cn mc nh, c tr mt m nh no .
3. Giai on lan trn
Tip theo cc giai on trn, ung th c th chuyn sang giai on lan trn. Giai
on ny c th ngn vi thng v cng c th ko di vi nm. giai on ny
khi u bnh trng, gia tng c th t 100 t bo n 1 triu t bo. Tuy nhin vn
cn qu nh pht hin bng phng php phn tch c.
Hnh 4: Khongcch thi gian gia ht thuc l v ung th phi
4. Giai on tin trin - xm ln- di cn
4.1. Giai on tin trin
c trng ca giai on ny l s tng ln ca kch thc khi u. ngi bnh

thng s lng t bo c to ra bng s t bo cht v lun gi mc hng
nh (khong 1012 triu t bo cht mi ngy v cn c thay th)
Khi b ung th, t bo sinh sn v hn dn n s ph v mc hng nh. Trong

giai on tin trin, chia ra hai giai on nh.
+ Giai on tin lm sng: y l giai on u, c th rt ngn vi thng nh u

lympho Burkit, cng c th ko di nhiu nm: Ung th trc trng, ung th phi,
bng quang, giai on ny c th ko di 15- 20 nm, c khi 40, 50 nm, chim 75%
thi gian pht trin ca bnh. Tuy cha c biu hin lm sng, nhng cng c th
pht hin da vo cc xt nghim cn lm sng.
+ Giai on lm sng: Trn lm sng ch pht hin khi khi u c kch thc trn
1cm3 (khong 1 t t bo), cn phi c 30 ln nhn i.
4.2. Giai on xm ln v di cn
4.2.1. Giai on xm ln
T chc ung th xm ln nh cc c tnh:
- Tnh di ng ca t bo ung th.
- Kh nng tiu m cc m k cn.
- Mt s c ch tip xc ca t bo.
4.2.2. Giai on di cn theo cc ng:
- Bch mch: gp nhiu trong ung th biu m. u tin c th lan trn theo ng
bch mch ti ch v i khi lm tc, ri lan n bch mch vng. Di cn thng
t gn n xa, qua cc trm hch, c khi nhy cc.
- Di cn theo ng k cn: cc t bo ung th i theo cc mch mu v thn

kinh, theo li t khi b cn tr nh: ung th d dy lan qua lp thanh mc vo
bng, n bung trng...
- Theo ng mu: gp nhiu trong ung th lin kt. Khi i theo ng mu, t bo
kt thc mao mch v tng tr ng . Cc kiu lan trn theo ng mu:
+ Kiu phi ( kiu I ): T mt ung th ph qun-phi, cc t bo bu i qua tnh

mch phi, vo tim tri, ri vo i tun hon cho cc di cn khp ni ( gan, no,
xng, thn, thng thn)
+ Kiu gan ( kiu II ): T mt ung th gan, cc t bo c tnh i vo tnh mch trn

gan, tnh mch ch di, tim phi, ri vo phi to thnh cc di cn phi. Sau
, cc t bo ny c th i vo i tun hon v l ngun gc ca cc di cn kiu
phi.
+ Kiu tnh mch ch ( kiu III ): T nhng ung th ca cc c quan khng dn lu

b i h thng ca nh: t cung, thn, cc t bo ung th i qua tnh mch ch,
n thng phi, ri sau i vo i tun hon nh di cn kiu I.
+ Kiu tnh mch ca ( kiu IV ): T cc ung th ca ng tiu ha, cc t bo c tnh

di chuyn n gan, cho di cn gan. T , n phi ( cho di cn kiu II ) ri vo
i tun hon ( cho di cn kiu I ).
TI LIU THAM KHO
I. TI LIU TING VIT
1. H Y H Ni, 1999. Bi ging ung th hc, NXB Y hc, trang 17-28
2. L Dnh Roanh, 2001. Bnh hc cc khi u, NXB Y hc, trang 45-87
3. Nguyn Chn Hng v CS. 1986. Din bin t nhin ca bnh ung th, trong Ung
th hc lm sng, tp I, ti bn ln th nht, Trng i hc Y dc Tp HCM, trang
79-112.
4. UICC, 1995. Ung th hc lm sng, trang 1-45.
II. TI LIU TING ANH
1. Ellis L. M, Fidder I, 1996. J Angiogenesis and Metastasis Eur. J. Cancer; 32: 2451
2461.
2. Kastan MB, Skapek SX, 2001. Molecular biology of Cancer: The cell cycle in
Cancer: Principles and Practice of Oncology 7th edition J.B. Lippincott Co.
Philadelphia, chapter 6, 91
109.
3. Krontiris, T. G 1995. Oncogenes N. Engl J. med. 333: 303 306.
4. Reed J.C, 1997. Dysregulation of Apoptosis in Cancer. J. clin Oncol 17: 2941-2953.
5. Reed J. C, 1999. Dysregulation of Apoptosis in Cancer. J. clin Oncol 17: 2941

2953.
6. Sandal T, 2002. Molecular aspects of the mammalian cell cycle and cancer The
oncologist, 7:
73 81.
7. Vincent T.De Vita, 2001. Principles & Practice of Oncology, pages 98-112.
8. Weiberg R. A, 2001. Cancer Biology and Therapy Road Ahead Cancer

Biology & Therapy:38
4. NGUYN NHN UNG TH
NGUYN TRN THC HUN
I. I CNG
Hin nay t l mc bnh ung th d bo ngy cng tng v kt qu cha khi bnh vn cn hn
ch do a s pht hin giai on mun. Mt s ung th ngay c giai on sm cng khng phi
cha lnh bnh. V vy, cch l t ng nht l phi bit cch d phng ung th.
Nguyn nhn sinh ung th rt a dng, ngoi mt s tc nhn c bit r gy ung th nh

thuc l, amian.. vn cn nhiu nguyn nhn gy ung th ang c nghin cu.
Nghin cu nguyn nhn ung th khng ch da trn s hiu bit cc qu trnh sinh hc lin quan
n bnh tt m cn da vo bng chng dch t hc m t v phn tch bao gm s gii thch
nhng khc bit quan st c v tn sut ca mt s loi ung th theo gii tnh, tui tc, hon
cnh kinh t x hi v a d.
Ngy nay nh nhng tin b vt bc ca khoa hc, c bit trong lnh vc sinh hc phn t
ngi ta bit r ung th do nhiu nguyn nhn sinh ra. Mt tc nhn sinh ung th c th gy ra
mt s loi ung th v ngc li mt loi ung th c th do nhiu nguyn nhn khc nhau. Hiu
bit v cc yu t nguy c gy ung th gip d bo nguy c mc ung th c cc bin php sng
lc pht hin sm, gio dc v t vn sc khe. Nguyn nhn sinh ung th gm 2 nhm chnh l
cc yu t mi trng v tc nhn di truyn.
II. CC NGUYN NHN MI TRNG

Vai tr ca cc yu t sinh ung th ngi c trong mi trng c bit n cch y hn
200 nm nh cc pht hin ca mt bc s ngi Anh tn l Percival Pott v s gia tng ung th
da bu nhng ngi th no ng khi vo nhng nm 1775. K t , cc bng chng v yu
t mi trng gy ung th c ghi nhn
ngy cng nhiu. Ngy nay, ngi ta bit nhiu loi ung th gy ra do yu t mi trng bao
gm cc tc nhn
vt l, ha hc, sinh hc. Chng tc ng t ngoi vo gy nn nhng t bin ca t bo v sinh

ung th.
1.Tc nhn vt l
Ch yu l bc x ion ha v tia cc tm.
1.1. Bc x ion ha
Ngun tip xc tia phng x t nhin ch yu t cc cc tia v tr, t hoc cc vt liu xy dng.
Ngun tip xc phng x nhn to ch yu l trong chn on Y khoa. T l tt c ung th do
tia phng x rt thp (khong 2% - 3%).
Cc bng chng dch t hc:
+ Cc nh Xquang u tin khng t che chn nn thng b ung th da v bnh bch cu.
+ Ung th tuyn gip gia tng r nhng ngi iu tr tia x vo vng c lc cn tr.
+ Ngy nay ngi ta thy rng bnh phi cc th m vng Joachimstal (Tip Khc) v Schneeberg
(c) quan st c t th k 16, chnh l ung th phi do s hin din ca qung en c tnh
phng x trong cc m.
+ Nguy c ung th phi tng cao trong cc nghin cu v th m Uranium v th m cng di

lng t phi tip xc vi kh radon v l do ngh nghip.
+ Nghin cu nhng ngi sng st trong v n bom nguyn t Hiroshima v Nagasaki Nht
Bn nm 1945 cho thy tng nguy c nhiu loi ung th c bit ung th mu th ty cp.
+ 10 nm sau s c r r tia phng x Chernobyl 1986, ngi ta nhn thy t l ung th gia tng
mnh, trong c bit tr em b ung th tuyn gip tng gp 10 ln.
Qu trnh phng x bn ra cc ht lm ion ha cc thnh phn hu c ca t bo to ra cc gc

t do. Chnh cc gc t do ny tc ng ln cc base ca ADN lm ri lon cc gen t bo to ra cc
bin d v t bin gy ung th, qui thai v d tt.
Tc ng ca tia phng x gy ung th ngi ph thuc vo 3 yu t quan trng:
+ Tui tip xc cng nh cng nguy him nht l bo thai v tr nh.
+ Mi lin h liu p ng: phi nhim cng cao v cng ko di th nguy c cng tng.
+ C quan b chiu x: cc c quan nh tuyn gip, ty xng rt nhy cm vi tia x.
1.2. Bc x cc tm
Tia cc tm c trong nh sng mt tri gm 3 loi A, B v C gy bng da, ung th da, lot gic mc
v c thy tinh th. Cng gn xch o tia cc tm cng mnh. Tia C gy t bin mnh nht
nhng c lc b i tng ozon. Tia B kch thch cc t bo da to ra sc t melanin lm rm nng v
da v tc ng trc tip ln ADN lm lp da lo ha sm v t bo b bin i thnh ung th. Tia
A do bc sng di nn t gy ung th da hn.
Cc bng chng dch t hc cho thy nhng ngi lm vic ngoi tri thng c t l ung th
t bo y v t bo vy ca da khu tr vng u, c cao hn nhng ngi lm vic trong nh.
i vi nhng ngi da trng sng vng nhit i t l ung th hc t cao hn hn ngi da mu.
Cn phi lu tro lu tm nng thi qu ca ngi da trng gy bng nng v tng nguy c ung
th da. Hin nay tng ozon ngy cng mng i do ngy cng c nhiu cht thi c hi t mt t,
s phun ca ni la lm
hy hoi tng ozon lm tng c v cng ln bin tip xc vi tia cc tm. Kt qu d bo

s gia tng tn
sut mi mc ca ung th da cng nh mt s bnh khc trong tng lai.
2. Tc nhn ha hc
2.1. Thuc l
Vai tr ca thuc l gy ung th c chng minh r rng bng:
+ Cc nghin cu dch t hc
+ Nghin cu cc thnh phn ca thuc l,
+ Pht hin cc tn thng di truyn c th cc t bo ung th v t bo bnh thng ngi

ht thuc l,
+ Hiu bit v s chuyn ha ca cc amine c trong thuc l.
Cc nghin cu dch t hc chng minh rng nhng ngi ht thuc l c nguy c mc cc ung
th phi, thanh qun, khoang ming, thc qun v bng quang. Nhng ung th ny t gp nhng
ngi khng ht thuc l. Quan st cng nhn thy mt s ung th khc cng ang gia tng
nhng ngi ht thuc l: ung th ty, thn, mi hng, d dy v ung th mu.
Thnh phn ca khi thuc l: C trn 4000 ha cht c trong khi thuc l trong 43 cht gy
ung th c nhn bit. Cc cht ny ch yu l:
+ Cc hydrocarbon thm a vng: c to ra t chy thuc l khng hon ton hay trong cc
khi v bi cng nghip
+ Nitrosamine: l cht gy ung th mnh nht ng vt th nghim v c vai tr ch yu trong

ung th phi, thc qun, ty, ming khi ht thuc.
+ Hydrocarbon d vng: c trong nha thuc l l nhng cht gy bin d mnh v sinh ung th
nhiu c quan khc nhau nh gan, phi
+ Benzene
+ Polonium-210 c hot tnh phng x
Trnh by u tin v mi lin quan gia ht thuc v tng t l ung th phi c bit n t mt
nghin cu ca-i chng c nm 1939. T ngi ta thc hin nhiu cuc nghin cu
ca - i chng ca ht thuc vi ung th phi tng gp 10 ln nhng ngi ht thuc so vi
nhng ngi khng ht thuc.
V sau nh vo cc thng k ca Doll Anh ngi ta mi khng nh thuc l l nguyn nhn ca

khong
90% ung th ph qun. Tnh chung thuc l gy ra khong 30% cc loi ung th ch yu l ung
th ph qun v mt s ung th vng mi hng, ung th ng tit niu. Ngoi cht Nicotin, trong
khi thuc l cha rt nhiu cht Hydrocarbon thm, trong cht 3-4 Benzopyren l cht gy ung
th trn thc nghim. Tuy nhin c ch sinh ung th ca thuc l cn c tip tc nghin cu.
Ngoi ra ht c xem l nguyn nhn ca nhiu bnh ph bin ngoi ung th nh bnh mch
vnh, bnh tt nghn phi mn tnh do thuc l...
Nhng bng chng gn y cho thy nguy c ung th phi gia tng nhng ngi khng ht
thuc khi h thng xuyn tip xc vi khi thuc thi ra t ngi ht thuc (v d khi thuc ca
nhng ngi ht thuc trong nh ).
2.2. Ch n ung v cc cht gy nhim thc phm
Ngi ta nhn thy c s khc nhau gia t l ung th ng tiu ha theo vng a l v theo thi
quen n ung. Nhng thay i nhanh chng v t l ung th d dy (gim) v t l ung th i
trng (tng) th h ngi Nht u tin di c sang M l bng chng r rng rng nhng thay i
mi trng v ch n ung lm thay i nguy c ca cc loi ung th ny.
Lm dng ru gy ung th: Lm dng ru l nguyn nhn lm tn hi sc kho ca nhn loi.

Hng nm ngi ta nhn thy khong 15-30% s bnh nhn nhp vin l do tc hi ca ru. Ung
ru nhiu lm tng t l
ung th cao ch sau thuc l. Nghin ru lin quan n cc ung th vng ming, hng, thanh
qun, thc qun v gan. Cng tiu th nhiu ru th nguy c ung th cng cao v ngc li nguy
c gim nu hn ch ung ru.
Cht bo v tht: Cc nghin cu cho thy vi ch n ung giu cht bo ng vt lm tng nguy
c ung th v v ung th i trc trng. cc nc pht trin, ni tiu th nhiu tht ngi ta
thy t l ung th i trng cao c ngha. Ngc li, ch n nhiu tri cy v rau xanh, qu
chn v nhiu si thc vt cho thy lm gim t l ung th i trc trng. T l mt s loi ung th
khc nh ung th h hng thanh qun, thc qun, phi v v cng gim nh.
Nhng cht gy nhim v cht ph gia trong thc phm: Tht c hong khi v p mui, cc loi
mm v da mui c rt nhiu mui Nitrat v Nitrit. Nitrat, Nitrit v Nitrosamin lm tng nguy c
ung th thc qun v d dy. Nitrosamin l cht gy ung th kh mnh trn thc nghim. Ngy
nay cc nc giu nh cc tin b v bo qun thc phm rau v thc phm ti sng bng cc
hm lnh, gian hng lnh, t lnh lm gim cc thc phm c cha mui Nitrat v Nitrit. T l
ung th d dy cc nc ny cng gim xung r rt.
Thc phm mc gy ung th: Go, lc l hai loi thc phm d b mc. Nm mc Aspergillus flavus
thng c go, lc mc tit ra c t aflatoxin, cht ny gy ra ung th t bo gan nguyn
pht. S t bin gen P53 c tm thy trong 53% cc trng hp ung th t bo gan nguyn
pht cc khu vc c c t aflatoxin trong thc phm.
Cc thc phm b nhim do thuc tr su c th gy cn bng pht ng c cp tnh. Tuy nhin

ngy nay ngi ta cha xc nh c mi lin h gia hin tng ny vi cc bnh ung th.
2.3. Cc ung th lin quan n ngh nghip
Theo cc nghin cu Php, phi nhim ngh nghip c th gy ra khong 3% t vong do ung th.
Cc nghin cu M nhng nm gn y c t l cao hn do phi nhim vi cc cht nh
amian, arsen, nickel, chrome, benzene v cc sn phm ca cng nghip ha du. Tuy nhin phi
nhim ngh nghip l kh nh gi do c s phi hp vi cc yu t khc nh thuc l v ru.
Tc nhn sinh ung quan trng nht trong vic gy bnh ung th ngh nghip ch yu l cc ha
cht v t gp hn l cc tc nhn khc nh vi rt, bc x ion ha. Vic nh gi ung th ngh
nghip trong dn s ch mang tnh cht tng i. Mt cng trnh nghin cu M cho thy rng
4% ung th c lin quan n ngh nghip. Mt s nh gi ca cc quc gia cng nghip ha khc
thy t l ny thay i t 2-8%... cc nc ang pht trin v cc nc mi cng nghip ha t
l ung th do ngh nghip cha c nh gi mt cch r rng. Cc ung th ngh nghip
thng xy ra cc h c quan tip xc trc tip vi cc nhn sinh ung th hay vi cc cht
chuyn ha cn hot tnh ca cc tc nhn ny.
Pott (1775) ln u tin m t t l ung th biu m da bu cao hn nhng ngi th co ng

khi, ng gi { mi lin quan vi ngh nghip v cho rng m hng l nguyn nhn. Hc n v
cc dn xut ca chng c trong du m cng c xem l cc cht sinh ng th. Tn sut ung th
da cao nhng ngi th nh si v th my l do h s dng nhng thit b c bi trn
bng du m c cht hydrocarbon thm l dn xut t anthracene.
Ung th ngh nghip thng hay gp nht ngy nay l ung th ng h hp. Ngi ta xc
nh mt s ha cht hay hn hp ha cht trong mi trng ngh nghip c lin quan nhn
qu vi bnh ung th phi. C quan nghin cu ung th quc t IARC nh gi 10 ha cht
hay hn hp khc nh l khi thi ca ng c Diesel, beryllium v cc hn hp ca n, tinh th
silica, cadmium v cc hp cht ca n c kh nng sinh ung th ngi. Amian c l l cht quan
trng nht gy ung th phi do ngh nghip. Ht bi (amian) s gy x ha phi lan ta
(asbertosis). Cc nghin cu t nhiu ni trn th gii cho thy s cng nhn cht do nhim
asbestos (asbertosis) th t l ung th phi hin din t 20-50% trng hp trong bu trung
m mng phi chim t l cao (thm ch thi gian tip xc khng di).
Ung th bng quang cng l mt trong cc ung th ngh nghip thng gp nht. Bt du t gia
th k XIX. Cng nghip nhum azo pht trin nhanh chng. Vo cui th k ny nhng trng
hp ung th bng quang u tin c pht hin cc th thng tip xc vi cht Anilin.
Cht Anilin t n khng sinh ra ung th ngi v ng vt nhng Anilin c cha nhiu tp cht
4-amindiphenyl c tnh sinh ung th. Cc cht chnh gy ra ung th bng quang trong k ngh sn
xut anilin l Benzidine, 2 naphthylamine v 4-aminodiphenyl.
Ht th Benzen c th lm c ch ty xng v gy ra chng thiu mu bt sn, nu tip xc
Benzen vi mc cao s gy ra bnh ung th bch cu ty cp. Ngoi ra n c th gy ra bnh
a u ty xng v u lympho c tnh. Sarcoma phn mm cng nhn tip xc vi cht dit c c
gc phenoxy; ung th thanh qun gp cc cng nhn tip xc vi hi acid v c mnh v ung th
cc xoang cnh mi gp cng nhn tip xc vi formaldehyd.
C quan nghin cu ung th quc t lit k 100 loi ha cht c th gy ra ung th biu m v
cc Sarcoma cc sc vt th nghim. Mt s ha cht ny c th gy ung th ngh nghip nhng
phn ln cn li cho n nay vn cha c bng chng.
2.4. Ha tr liu
iu tr ha cht chng ung th c th gy ra tn thng ADN v sinh ung th. Ngy nay nh
pht hin sm ung th v s dng nhiu phng php iu tr hiu qu nn thi gian sng thm
ko di hn. Mt s ung th iu tr khi nh pht hin giai on cha xm ln. V vy vai tr
sinh ung th do ha cht cn phi c cn nhc v c bin php sng lc nhng i tng ny.
Bng 1:Ung th lin quan n mt s thuc thng s dng trn lm sng
Tc nhn Cc ch nh Cc ung th phi hp
Cyclophosphamide Ung th cc loi UT bng quang, UT mu th ty cp
Melphalan a u ty UT mu th ty cp
Azathioprine, cyclosporine Bnh nhn ghp ty d U lymph c khng Hodgkin, ung th

gen da
Nitrogen mustard, Ung th cc loi UT mu th ty cp
procarbazine
Diethylstilbestrol Ph n UT m h, UT c t cung
Hot cht c cha iu tr chng au Ung th b thn

phenacetin
Bng lit k cc loi thuc hay s dng c nguy c gy ung th. Nguy c gy ung th do thuc gia
tng ph thuc vo cc yu t:
- Tui s dng: tui cng tr cng tng nguy c.
- Thi gian tim tng gia s dng thuc v pht trin ung th trung bnh t 5 n 10 nm ngn
hn so vi
40 n 50 nm trong phi nhim ha cht cng nghip.
- V s hin din ca cc yu t cng sinh ung th nh thuc l v phi nhim phng x
Thuc gy ung th nhiu nht l cc thuc chng ung th v cc loi thuc ny c chng
minh gy ung th thc nghim v cc loi ung th ch yu l ung th mu v cc loi u lymph c.
Ung th mu th ty cp l bin chng him ca cc thuc nhm alkyl. Suy gim min dch do
ha tr, thuc c ch min dch, AIDS lm tng nguy c mc u lymph c do nhim EBV.
Ngy nay, c nhiu thuc chng ung th hin i c hiu qu nn thi gian sng thm ca bnh
nhn ung th ko di hn v nhiu loi ung th c th cha khi do c pht hin sm v s
dng ha tr a phng thc nn vai tr sinh ung th do thuc ngy cng c ch c cc
bin php sng lc v pht hin sm cc ung th th hai nay.
3. Cc tc nhn sinh hc
Cc tc nhn sinh hc ung th ch yu l virus v mt s trng hp c vai tr ca k sinh trng v

vi khun.
3.1. Virus sinh ung th.
Cc oncogen u tin c pht hin virus. Sau ngi ta pht hin virus tch hp vo ADN ca
t bo vt ch bnh thng v iu ha s tng sinh t bo mm. Cc virus sinh ung th ny gy
nn ung th bng cch hot ha gen bnh thng bn trong t bo ch.
C 4 loi virus sinh ung th ngi c m t.
- Virus Epstein Barr (EBV):

+ Loi virus ny c Epstein v Barr phn lp u tin bnh nhn ung th hm di ca tr em
vng Uganda, v sau ngi ta cn phn lp c loi virus ny trong ung th vm mi hng, bnh
gp nhiu cc nc ven Thi Bnh Dng c bit l Qung ng, Trung Quc v mt s nc
ng trong c Vit Nam.
+ Virus Epstein-Barr thuc h Herpes c cho c vai tr bnh sinh ca 4 loi UT:
U lymph Burkitt.
Cc u lymph t bo B nhng ngi suy gim min dch, c bit nhng bnh nhn
HIV-AIDS v ghp c quan.
Mt s trng hp bnh Hodgkin. Ung th biu m vm hng.
- Ung th gan v vim gan siu vi :
+ Cc nghin cu dch t hc cho thy vim gan siu vi B (HBV) c mi lin h vi ung th gan
nguyn pht (HCC). HCC thng gp nhng vng nh Chu Phi, ng Nam v Trung Quc. C
80% trng hp HCC lin quan n nhim virus vim gan siu vi B. Virus vim gan B thuc loi virus
ADN, xm nhp vo c th gy vim gan cp, k c nhiu trng hp thong qua. Tip theo l thi
kz vim gan mn khng c triu chng. Tn thng ny s dn n x gan ton b v ung th t
bo gan. Ngoi ra x gan lm cho tin lng ca bnh ung th gan xu i rt nhiu.
Pht hin nhng ngi mang virus bng xt nghim HBsAg (+). S lin h gia virus vim gan siu
vi B v ung th t bo gan dn n ung th gan c th phng trnh c bng cch s dng
vaccine phng vim gan B.
+ Vim gan siu vi C (HCV): Mc d mi c ghi nhn l gy ra vim gan khng A, khng B. ngi
ta ghi nhn rng tn sut ung th gan nguyn pht gia tng gn y trong mt phn ca ngi
dn Nht l do c s nhim virus vim gan C mt cch thng xuyn. Vim gan do virus vim gan A
khng lin h vi HCC.
- Virus gy u nh (HPV) typ 16-18, -33, 39: Ly truyn qua ng sinh dc. Loi ny c coi l c
lin quan n cc ung th vng m h, m o v c t cung. Hin nay c vaccine phng bnh.
- Virus sinh u ARN: Mc d cc nghin cu v retrovirus gip hiu r hn v c s phn t ca
ung th nhng ch c mt loi retrovirus ngi, virus gy bnh bch cu t bo T ngi type I (
HTLV-1: Human T cell Leukemia Virus type I) c khng nh chc chn l nguyn nhn gy ung
th. HTLV 1 gy bnh bch cu t bo/u lymph t bo T thnh dch mt s vng ca Nht Bn v
Carib nhng cng pht tn mt s vng khc.
3.2. K sinh trng v vi trng
- Mi tng quan gia k sinh trng v bnh ung th c bit nhiu nht l tnh trng nhim
Schistosoma vi ung th bng quang v gia nhim sn l vi ung th ng mt. Ngi ta tm thy
nhiu nht Ai Cp, Irc, Xung v Zimbabu.
- Helicobacter Pylori: Ngy nay cng c nhiu bng chng v s lin quan ca nhim khun d dy
do H. pylori vi u lymph d dy v ung th biu m d dy. S lin quan ny r rng hn vi u
lymph d dy so vi ung th biu m d dy. Mi lin quan ny c chng minh bng cc
nghin cu dch t hc cng nh bng vic pht hin H. pylori phn ln u lymph d dy. Bi v u
lymph pht sinh trong m lymph thuc nim mc d dy (MALT: Mucosa Asociated Lymphoid
Tissue ) nn cn gi l u MALT (Maltoma). Nhng t bo B sinh ra cc u ny nm vng ra ca cc
nang lymph nn cn gi tn khc l u lymph vng ra (marginal zone lymphoma). C ch sinh u
ung th ca H. pylori cha tht r nhng c l do s tng sinh ca lymph T phn ng vi H. pylori
v cc t bo T ny hot ha mt qun th a dng cc t bo B bng vic ch tit cc yu t ha
tan.
III. CC NGUYN NHN BN TRONG
1. Yu t di truyn
T khong 15 nm tr li y nh nhng tin b trong lnh vc nghin cu sinh hc phn t

ngi ta bit c s lin h cht ch gia cc bin i vt liu di truyn v s xut hin mt s
bnh ung th.
Mt s tnh hung v mt di truyn: 80 - 90% ngi s b ung th do h mang gen gy hi U
wilms, ung th nguyn bo vng mc 2 mt v nhng bnh nhn a polip c tnh cht gia nh l
th d v cc loi ung th truyn theo tnh tri theo m hnh ca Mendel. Ung th tuyn gip th
ty ( loi ung th tuyn gip c tit ra Thyrocalcitonine) cng mang tnh cht di truyn r rt.
Nhng nm tr li y nh nhng nghin cu v gen, ngi ta phn lp c cc gen sinh ung
th (Oncogen) thc cht cc gen sinh ung th (proto-oncogen). Di tc ng ca mt vi tc
nhn no tin gen sinh ung th hot ha v bin thnh gen sinh ung th. T gen sinh ung
th m ha sn xut cc protein v men lin quan n qu trnh phn chia v bit ha t bo
theo xu hng c tnh, v d trong bnh ung th bch cu mn th ty, 90% t bo mm to huyt
c s chuyn on 9/22.
Mt lai gen quan trng khc v cc gen c ch ung th (Anti-oncogen). Khi c th vng mt cc
gen ny, nguy c mc ung th s tng cao. Mt s gen c ch sinh ung th quan trng l gen P53
ca bnh ung th lin bo vng mc mt, gen WT1 trong bnh u wilms, gen NF1 trong bnh a u
x thn kinh ca Recklinghausen. Ngy nay ngi ta c th tm ra c im a dng ca oncogen
hay cc chui DNA c hiu tiu biu cho cc cht nh du tnh "nhy" ca ung th. Cc h thng
mang tnh tng i ca ca cc cht nh du di truyn da trn s pht hin trc tip ca tnh
a dng chui DNA vi cc men c ch. Ngi ta c th lp ra bn lin kt gen chi tit ngi
bng cch da v cc h thng va nu.
Bc nhy trong lnh vc di truyn v cc nghin cu v gen s cho nhiu hiu bit kz th hn. Mt
s ung th di truyn:
1. Ung th i trc trng lin quan n di truyn: Trn 10% ung th i trc trng c lin quan
n yu t
di truyn gm cc loi bnh sau:
+ a polip c tnh gia nh: L hi chng tri trn nhim sc th thng c t l xy ra khong
1/10.0000 ngi. Hng trm n hng ngn polip khu tr thnh i trng v thng bt u
tui 30-40. Mt s polip tr nn ung th ha. D phng bng cch ct i trng ton b trc giai
on ung th ha.
+ Hi chng Gardner: Cng l hi chng biu hin a polip c tnh gia nh
+ Hi chng Turcot: Polip i trng kt hp u no

+ Hi chng Lynch: Ung th i trng khng polip phi hp vi nhiu loi ung th khc nh ung
th ni mc t cung, d dy, bng quang.
2. Ung th v c tnh gia nh: Di truyn trn nhim sc th thng, tnh tri nhng c tn sut
khong 4 n 10%. C 2 loi:
+ Ung th v di truyn: do t bin gen, c tn sut mc bnh cao
+ Gia nh ung th v: Do trong gia nh cng phi nhim yu t nguy c cao ung th v nhng c
th khng mang gen di truyn. Cc yu t ny ch yu l ch n, tnh trng kinh t x hi, nh
h ng ca hormone, tui lc c thai ln u. Ung th thng xy ra mun v ch vi thnh vin
mc ung th v.
3. Cc ung th tuyn ni tit c tnh gia nh: Gm cc loi ung a tuyn ni tit typ 1 v 2. Loi
ny t gp hn.
4. Cc ung th tr em: C c im khc ung th ngi ln. Hnh thi hc rt ging vi cc khi u
ca phi, xm ln nhanh ra xung quanh, di cn xa sm nhng rt nhy cm vi ha tr. Cc loi
thng gp:
+ Ung th nguyn bo thn kinh (neuroblastoma)
+ U Wilm
+ Sarcoma: thng gp sarcoma c vn
+ Ung th nguyn bo vng mc mt
2. Suy gim min dch v AIDS

Trn ng vt thc nghim s suy gim min dch lm gia tng nguy c b ung th. Ngi b
suy gim min dch mang tnh di truyn hay mc phi thng d b ung th v thi gian bnh
ngn hn.
nhng bnh nhn ghp c quan, s suy gim min dch do dng thuc c ch min dch v
corticoide liu cao l r nht. Theo di mt thi gian di 16.000 bnh nhn ghp thn v c iu
tr bng cc loi thuc c ch min dch ngi ta thy nguy c mc bnh u lympho c khng
Hodgkin tng 32 ln, ung th gan v ng mt trong gan tng 30 ln, ung th phi tng 2 ln, ung
th bng quang tng 5 ln, ung th c t cung gn 5 ln, cc melanoma c tnh v ung th tuyn
gip tng ln 4 ln. S suy gim min dch nng v ko di c bit trong ghp ty xng cn tng
cao nguy c nhim cc loi virus nh EBV, cytomegalovirus (CMV) v nhiu vi khun c hi cng
nh nhiu loi bnh do nm candida, aspergiluslm t l t vong do ghp tng ln ng k.
Ngi c HIV dng tnh, c bit khi chuyn qua giai on AIDS c nguy c rt cao mc sarcome
Kaposi, u lympho c khng Hodgkin v mt s ung th khc nh ung th vm, ung th c t cung.
Sarcome Kaposi c th xy ra bt c lc no sau khi b nhim HIV, tri li u lympho c khng
Hodgkin c khuynh hng xut hin c a suy gim min dch trm trng v nguy c c th gia
tng n 75 ln so vi ngi bnh thng. Ung th bnh nhn AIDS lm hn ch kh nng iu
tr v tin lng sng thm rt ngn.
3. Ni tit t
Mt s hormone c tim nng gy ung th. C 3 loi ung th lin quan.
1. Ung th v: Dng liu cao, ko di estrogen c th gy ung th v chut. Cc nghin cu

ng vt cng cho thy estrogen l mt cht sinh ung th. Cc bng chng ny gi rng nhng
ph n dung thuc trnh thai c th tng nguy c gy ung th. Nhiu nghin cu cho rng s dng
estrogen ngoi sinh khng c ngha gy ung th v tuy nhin cng c mt s tc gi cho rng tnh
an ton ca estrogen cha c chng minh.
2. Ung th ni mc t cung: Nhiu nghin cu bnh-chng cho rng s dng estrogen lm tng
t l ung th ni mc t cung. Tuy nhin nhiu nh khoa hc cho rng dung liu thp estrogen l
an ton i vi nhng ph n tin mn kinh v ph n ct b bung trng. Hu qu ca liu
thp estrogen gy bnh long xng v tng nguy c gy xng bnh l.
Cc nghin cu vn cn tip tc tm ra nguy c gy ung th ni mc ca estrogen.
3. Ung th tuyn m h: Vo nm 1947, ngi ta cho rng estrogen tng hp nh l DES

(diethylstilbestrol) dung np tt ph n c thai, an ton cho thai nhi v c hiu qu phng sy
thai nn c k n rng ri. Cho n khi c mt nghin cu vo nm 1977 cho thy nhng
ngi con gi ca nhng b m c iu tr bng DES tng t l lon sn m h v ung th nn
b cm v ngy nay bin chng ny khng cn xy ra.
4. Ung th tin lit tuyn: Yu t nguy c quan trng nht ca ung th tin lit tuyn l tui nhng
testosterone sau khi c chuyn ha thnh dihydrotestosterone l mt cht gy tng sinh nhanh
t bo ca tuyn
tin lit. V vy Dihydrotestosterone c th lin quan n chuyn dng c tnh v cc nghin cu
ang thc hin quyt nh s dng cht c ch sn xut Dihydrotestosterone c gim t l ung
th tin lit tuyn hay khng.
KT LUN
Thng qua bi ny chng ta nhn thy nguyn nhn gy ung th rt a dng, trong vai tr ca
yu t mi trng chim t l cao gy ung th ngi. Ht thuc l, phi nhim vi cc ha
cht gy ung th trong mi trng ngh nghip, phi nhim vi phng x gia tng nguy c gy
ung th. Ch n khng an ton, suy gim min dch, s dng thuc c t bo v s dng
hormone cng c vai tr tng nguy c ung th. Nhiu nghin cu thng k khng nh vai tr
ca yu t di truyn gy ung th ngi. Tuy nhin ung th khng ch c gy nn b i mt tc
nhn duy nht m c s tc ng b i nhiu yu t lm cho t bo bnh thng thay i thnh
t bo ung th. S chuyn dng t t bo bnh thng thnh t bo ung th xy ra khi mt hoc
nhiu oncogen c hot ha.
Mc tiu quan trng ca vic nghin cu nguyn nhn ca ung th l cung cp thng tin nhm
hng n vic d phng ung th. Xc nh c vai tr ca mt s yu t sinh ung th thng
gp nh thuc l, cc ph gia trong thc phm, cc virus sinh ung th l rt quan trng, t ra
cc phng php phng bnh tch cc nh phong tro phng chng ht thuc l, cc chng trnh
tim chng m rng phng vim gan B, nhm h thp t l mc bnh.
1. i Duy Ban. 2000. Phng bnh ung th.. Nh xut bn Y hc. Trang 47-122
2. Nguyn B c. 1999. Bi ging ung th hc.. Nh xut bn Y hc. Trang 28-34
3. L nh Roanh. 2001. Bnh hc cc khi u. Trang 87-97

4. Richard R. Love.1995. Cm nang ung bu hc lm sng (Ti liu dch t Manual of Clinical
Oncology). Trang:
71-123. Nh xut bn Y hc Tp HCM.
II. TI LIU TING ANH
1. Bruce D. Cheson. 2004. Oncology (Medical Knowledge Self-Assessment Program). pp 1-16.

ASCO.
5. D PHNG UNG TH
NGUYN VN CU
I. I CNG
Vn chn on v triu chng nhiu loi ung th c nhiu tin b vt bc

trong thi gian y, tuy nhin s ngi mc bnh v t vong do ung th cn cao v
d bo tip tc gia tng trong thi gian ti. Nu ung th c cha khi hu qu v
ti chnh v th lc v tnh cm vn bao trm qung i cn li ca ngi bnh.
Cc nh dch t hc c lng c khong 70-80% cc bnh ung th l do nguyn

nhn mi trng, do chng ta c th d phng c bnh ung th bng cch
ngn cn vic tip xc vi cc nguyn nhn gy ra ung th. V th v l thuyt chng
ta c kh nng lm gim t l mc bnh v t l t vong do ung th khong hn
80%.
II. S PHNG NGA BAN U (Phng bnh bc mt)
Phng nga ban u l nhm c gng, loi tr hoc gim ti a s tip xc vi

cc nguyn nhn gy ra ung th. y l phng php d phng tch cc nht.
1. Yu t nguyn nhn v phng nga

1.1. Ht thuc l
S nghi ng c mi lin h gia ht thuc l v ung th c cp n t

200 nm v trc. Bo co u tin nm 1795 nu ra mi lin h gia thuc l
v ung th mi. Cng
trnh nghin cu u tin nm 1928 kt lun l ung th gp nhiu hn nhng
ngi nghin thuc l. Trong thp nin 50 nhng cng trnh nghin cu Anh v
Hoa Kz chng minh mi lin h nhn qu gia ht thuc l v ung th phi. T
nm 1960 t l ht thuc l M, Canada, Anh, c gim t 42% cn 25% Tuy
nhin theo thng k ca T chc Y t Th gii t l ht thuc l cc nc ang
pht trin gia tng trung bnh hng nm khong 8%.
n nay ngi ta nhn thy thuc l gy ra 30% cc loi ung th, 90% ung th
phi,
75% ung th khoang ming, thanh qun, thc qun, 5% ung th bng quang. Do
ngi thy thuc phi t chc cc phong tro phng chng thuc l nhm tuyn
truyn cho nhng ngi nghin thuc gim dn n ngng ht .
+ Khuyn khch nhng ngi ang ht thuc ngng ht
+ H tr cho ngi bnh ngng ht
+ T chc thm khm theo di nh kz
+ Ch tuyn truyn i vi nhng thanh thiu nin cha bao gi ht thuc v

ph n mang thai.
1.2. Ch n
ng sau thuc l nhiu yu t dinh dng c xp nguyn nhn quan trng th
hai gy bnh ung th v t vong.
Ch n tiu biu Ty phng v mt s nc pht trin gm nhiu tht v cht

bo c lin quan vi ung th i trng. Nhiu nghin cu gn y nhn mnh
rng nguy c tng ln vi ch n t rau, t tri cy do thiu vi loi sinh t (A,C v
E), cc cht vi lng (selen, st), v cht si trong ch dinh dng .
cc nc ang pht trin, aflatoxin, mt sn phm ca nm mc trn thc n l
nguyn nhn chnh gy ra ung th gan; cc Nitrit v Nitrat trong thc phm hong
khi c vai tr lm gia tng t l bnh ung th thc qun, d dy.
Mi c gng ngn nga ung th hng n vic thay i ch n t tht, tng

cng n nhiu hoa qu, rau v cc loi vitamin nht l betacaroten. Trnh n
nhiu m , gia v v n cc thc n b mc.
1.3. Ha d phng
Ha d phng l ung mt ha cht, cc sinh t chng hn nhm ngn chn qu

trnh sinh ung th. Ha d phng ch mi thc s pht trin nhanh trong nhng
nm gn y. Nhiu ha cht khc nhau ang c dng nhm nh gi hiu qu
ca ha d phng: Retinoid v caroten, nhiu cht chng xy ha nh sinh t C v E,
Selen, calci, thuc khng vim khng steroid (NSAIDS) nh aspirin, sulindac v
tamoxifen, cht khng estrogen c s dng rng ri iu tr ung th v.
Hoa Kz mt th nghim ngu nhin nhm ngn chn ung th tin lit tuyn bng
finasteride, cht ngn cn 5-alpha reductase.
1.4. Virus
C 4 virus c bit l nguyn nhn gy ung th ngi l: Virus vim gan B, virus
Epstein-Barr, Virus bu gai ngi (human papilloma virus-HPV) v virus gy
bnh Bch cu T ngi. (HTLV)
Vim gan B cng vi nhim aflatoxin c xem l nguyn nhn gy hu ht ung th

gan nguyn pht cc nc Chu Phi v ng Nam . Chng nga rng ri vim
gan B cho tr mi sinh lm gim t l mc bnh v t vong do ung th gan
nguyn pht.
Nhiu vacxin cng ang lu hnh i vi virus Epstein-Barr, loi ny c coi l
nguyn nhn chnh gy ung th vm v limphoma Burkitt. Thuc chng dng cho
HPV v HTLV ang giai on kh i u.
1.5. Bc x mt tri
Bc x cc tm (UV) do phi nng qu c xem l tc nhn chnh gy ung th

da (c v khng c sc t), c bit lin quan vi cc sc dn c mu da sng. T l
ung th cao nht c v Ai-len. Cn tuyn truyn cho ngi dn trnh phi nng
qu mc, dng cc phng tin che nng (o, nn m), dng thuc bi bo v da.
1.6. Tip xc ngh nghip
Tip xc ngh nghip c xc nh sm nht trong s nguyn nhn gy ung

th. S lng cht sinh ung th c bit nhiu hn c l trong lnh vc cng
nghip. V d: Asbestos l cht sinh ung ngh nghip gy ung th phi v trong m
mng phi.
hu ht cc nc v sinh cng nghip v bo h lao ng c thc hin mt

cch nghim tc nhm h thp t l bnh nhn mc bnh ung th do ngh nghip.
1.7. Tc dng ph do dng thuc
Mt s phng php chun on hoc iu tr cng c tnh cht sinh ung th, c
bit l bng x tr v ha tr. Vi cht ni tit dng nga thai hay iu tr ph khoa
cng c nguy c sinh ung th v sau. V d: ung th m o nhng b gi c tip
xc vi diethylstilbestrol do ngi m s dng vo u thai kz lm gim cn
bun nn v nga da sy thai.
Thy thuc lm sng cn phi lu n cc cht sinh ung th c bit l cc ni

tit t n, cc cht chng ung th nhm c nhn Alkyl, phi c k hoch theo di
pht hin nhng ung th th pht do dng thuc hoc cc phng php iu tr gy
ra.
1.8. Yu t di truyn
Lch s gia nh t lu cng c xem l yu t nguy c hay gp ca mt s loi ung

th nh ung th v, ung th i trc trng, ung th vng mc mt, bnh kh da
nhim sc t. Chin lc d phng bc u nh dng Tanoxifen nh th nghim
ha d phng cho nhng ph n c tin cn gia nh mc ung th v. Ngoi ra
ngi ta cng phi lu d phng bc hai (chng trnh sng lc) i vi ngi c
tin s gia nh b ung th.
2. Nhng yu t nguy c khc
Bc x ion ha cng l yu t nguy c ca nhiu dng ung th, v d sau ln n m

bom nguyn t Nht, hoc sau tai nn l phn ng nguyn t Chernobyl.
Mt yu t nguy c ung th mi c bit gn y l t hot ng thn th, lm

vic v gii tr c th gip phng nga ung th i trng.
Nhiu ung th c bit c lin quan vi AIDS. Mi bin php ngn nga bnh
AIDS
cng l n lc d phng mt s bnh ung th.
III. SNG LC V PHT HIN SM ( D phng bc 2)
Sng lc l cch nh gi ton th dn s hay tng c nhn hon ton khe mnh v
mt lm sng, pht hin mt ung th tim n hay tin ung th, hu c th iu
tr khi. S sng lc da trn quan nim rng s pht hin sm ung th trc khi di
cn xy ra th hiu qu iu tr s tt hn l lc cc triu chng xut hin.
Mt ung th c xem l l t ng cho vic sng lc khi giai on tin lm sng

c th
pht hin c ca n tn ti kh lu trc khi cc triu chng xut hin v di cn

xy ra.
1. Sng lc ung th v
Ung th v l ung th ng hng u n gii cc nc pht trin cng nh

ang pht trin. Chng trnh sng lc ung th v lm gim t l t vong do ung
th ny.
Cc phng sng lc bao gm:
1.1. Khm lm sng tuyn v (CEB: clinical examination of the breast)
L mt phng php thng dng pht hin ung th v. Cc bc s chuyn khoa

khuyn nn khm lm sng tuyn v hng nm cho tt c ph n trn 40 tui
nh l mt phn ca s kim tra sc khe ton din .
1.2 T khm v (BSE: Breast self - examination)
L mt k thut t tn km v v hi i vi tuyn v. Thc hin t khm v mt

thng mt ln sau khi sch kinh. Nu ngi ph n c hng dn t khm v
cn thn s pht hin ra bnh khi u cn nh, hch di cn t hn nhng ngi khng
thc hnh t khm v. Do vy phng php t khm v nn c ph bin rng ri
trn cc phng tin thng tin i chng.
Hnh 1:Cc bc t khm v
Cc bc t khm v
1.3. Chp tuyn v (Mammography)
Phng php ny hon thin v mt k thut trong nhng nm gn y v

c p dng rng ri sng lc pht hin sm, cng nh chn on ung th v.
Vi ph n trn 40 tui trong nhm nguy c cao mi nm nn chp v khng chun
b
mt ln, ph n trn 50 tui nhy ca phim chp v vt hn 85% v c hiu

l 95-99%.
Hnh 2: Chp nh nh
2. Sng lc ung th c t cung
Ung th t bo gai ca c t cung thng pht trin theo sau d sn trong biu m
v ung th ti ch (CIN: Cervical intraepithelia neoplasia). Khong 20% cc thng
tn trn pht trin thnh ung th xm ln trong vng 20 nm. Cn c th pht hin
c bng xt nghim t bo bong. Nh th ung th c t cung c th phng nga
nu sng lc c tin hnh bng Paptest mt cch chnh xc hay t bo hc m
o mi nm mt n hai ln ph n trn 30 tui c gia nh.
T bo hc c t cung l mt bin php hu hiu phng nga ung th c t cung

xm ln v t vong do ung th c t cung. nhng nc p dng chng trnh
sng lc ung th c t cung bng Paptest t l cc trng hp ung th c t cung
xm ln gim 30%.
cc a phng khng c phng tin lm Paptest c th khm c t cung

bng m vt cho cc ph n trn 30 tui. Nu pht hin c nhng tn thng
nghi ng s chuyn n phng khm chuyn khoa chn on v iu tr.
C th kt hp khm bng mt vi lm th nghim Lugol soi c t cung phng

i cc thng tn c t cung, khot chp c t cung va chn on va iu
tr cc ung th tin xm ln.
3. Sng lc ung th i trng v trc trng
nhiu nc pht trin, ung th i trc trng ng hng th hai sau ung th
phi. V triu chng lm sng thng khng r rng nn bnh nhn n khm giai
on tng i tr. Tuy nhin vi s xut hin nhiu loi xt nghim sng lc ung
th i trc trng, theo l{ thuyt l ung th l{ t ng chn on bnh trc khi
c triu chng xut hin.
Chin lc sng lc nn nhm vo cc i tng c nguy c cao v tp trung vo

tui
50-70 tui.
Cc test sng lc.
+ Xt nghim mu tim n trong phn (FOBT: Fecal occult blood tests).
Pht hin hot ng Peroxidase ca huyt cu t. Cc xt nghim sng lc cho

thy khong 2% FOBT dng tnh v gi tr d don ca test cho c u tuyn lnh v
ung th gia 20-
30%. X t nghim dng tnh gi do thc n v thuc cng c xy ra.
+ Ni soi:
Soi i trng ? (Sigma) ln n 20cm s dng nh mt xt nghim n c hay

kt hp vi FOBT. Soi ton b i trng c u im l nhy v c hiu cao v
nhn c ton b khung i trng nhng gi thnh cao v nguy c thng rut (20/00
cc trng hp soi i trng) gii hn vic sng lc theo phng php ny. Ch
nn soi ton b khung i trng vi cc i tng c nguy c cao vi x t nghim
FOBT dng tnh.
Hnh 3: Ni soi v chp khung i trng c thuc
4. Sng lc cc ung th khc
4.1. Ung th hc t
y l loi ung th c th sng lc tt yu t nguy c l tin s gia nh, tin cn b

bng nng hay c tn nhang, cc nt rui trn c th. Phng php sng lc ch
yu l khm bng mt, khm t m vi nhng cn b y t c hun luyn tt.
4.2. Ung th phi
Hin cha c bng chng cho thy sng lc ung th phi bng chp Xquang phi
v t bo hc cht m c nh h ng n t l t vong, tuy nhin chp Xquang
phi nh kz hng nm cho nhng ngi nghin thuc l trn 45 tui c th pht
hin c u phi khi cn nh.
4.3. Ung th vm
c sng lc bng cch o lng khng th IgA ca virus Epstein - Barr nhng
vng c t l mc bnh cao.
4.4. Ung th hc ming v hu
Cc i tng c thi quen nhai thuc l v nhai tru, ht thuc v ung ru

u c nguy c cao. Vic thm khm bng mc kt hp vi cc chng trnh gio
dc cho dn chng gp phn vo vic pht hin ung th v cc tnh trng tin
ung th sm hn.
4.5. Ung th d dy
Chng trnh sng lc bng chp X.quang d dy v soi d dy c nh gi

cao
Nht.
Hn ch ca sng lc l gi thnh cao, do nn p dng cho nhm c nguy c cao (

tui, tim s vim lo t d dy mn tnh).
4.6. Ung th gan nguyn pht
Sng lc bng cch o v Alpha Foetoprotein trong huyt thanh nhng i tng
b
vim gan siu vi trng B.
Siu m c dng theo di cc trng hp c kt qu bt thng.
4.7. Ung th tin lit tuyn
3 xt nghim c kh nng pht hin bnh khi cha c triu chng l: thm khm
trc trng bng tay, siu m qua trc trng, khng nguyn c hiu ca tin lit
tuyn.
4.8. Ung th tuyn gip
Cc i tng c chiu x vo vng u c s c nguy c cao, cn phi c

thm khm nh kz, xt nghm calcitonin v Thyroglobulin.
III. KT LUN
Vic sng lc pht hin bnh ung th khi cha c triu thng c kt qu kh
quan i vi mt s loi ung th: ung th v, c t cung, d dy, i trng v ung
th hc t. c hiu qu, vic sng lc phi lm gim t l t vong v gim t l t
vong do cc chng trnh sng lc mang li ty thuc vo s pht trin cc chng
trnh sc khe ton dn.
1. i hc Y H Ni, 1999. Bi ging ung th hc, nh xut bn Y hc 1999, trang 34-

39.
2. Phm Thy Lin, 1999. Lm th no pht hin bnh ung th sm nht, nh

xut bn
Nng, trang 16-21.
3. UICC, 1995. Ung th hc lm sng 1995, trang 134-137
II. TI LIU TING ANH
1. International Agency for Research on Cancer. Working Group on Evaluation of

Cervical Cancer Screening Programmes: Screening for squamuos cervical cancer:
duration of low risk after results of cervical cytology and its plication for screening
policies 1985. BMJ; 293: 6599.
2. Kross LG, 1989. The Papanicolaou test for cervical cancer detection: a triumph
and a tragedy. JAMA; 261;737.
3. Mandel JS, Church TR, Ederer F, et all, 1999. Colorectal cancer mortality:
effectiveness of bienial screening for fecal occult blood. J natl Cancer Inst; 91: 434
6. THM KHM KHI U
I. I CNG
khi u d l lnh tnh hay c tnh cng cn phi c pht hin sm, phi c
thm khm t m c c mt chn on ng, chnh xc v c mt phng
php iu tr tt nht i vi cc khi u. c nhng chn on s b trc khi gi
n cc c s chuyn khoa th bt c thy thuc no cng c th lm c. Mt
khi u c th pht hin mt cch tnh c b i bnh nhn hoc c pht hin qua
nhng t khm sc khe hoc t chc khm sc khe hng lot ti cng ng.
1. nh ngha
Hin nay c rt nhiu nh ngha v khi u. Chng ta tham kho cc nh ngha m

c nhiu ngi chp nhn nht.
1.1. nh ngha ca Abedanet Khi u l mt t chc tn sinh, kt qu ca s tng

sinh khuych i t nhng t bo ca mt t chc trong c th, c chiu hng tn
ti v ln ln mt cch khng gii hn.
1.2. nh ngha ca Willis Theo Willis khi u l mt t chc khng bnh thng
pht trin v hn v vn tn ti mc du ly i nhng yu t kch thch.
2. Mt s c im chung
T nhng nh ngha trn ta rt ra mt s c im chung, c tnh cht c trng

sau :
U l mt t chc tn sinh (Neoplasme) nhng c cu trc mang c im ca t

chc
sinh ra n.
V d :
+ U v l lnh tnh (u x tuyn v) hoc l mt ung th, nhng bn cht ca n l

nhng t bo mang c im ca t chc tuyn v, hoc t chc ca ng dn
sa.
Cn phn bit u vi mt t chc nhim trng, m v lm sng cng s c mt

khi u, nhng thc cht n ch l mt t chc gi u b i v :
+ N ch lm thay i mt cu trc c t trc, n khng phi l mt t chc
tn sinh.
+ N c c im ca mt t chc nhim trng v tn ti gn lin vi qu trnh
nhim trng.
Tt c mi c quan trong c th u c th pht sinh u.
C nhng u khng c th pht hin c qua thm khm lm sng nht l nhng
u cn nh hoc nm su trong c th.
Mt c quan trong c th c th c u lnh v u c, c khi bao gm c u lnh v u c

cng tn ti trong cng mt thi im.
V d :
+ Trn mt tuyn v ca mt bnh nhn c th tn ti mt u x bn cnh mt ung

th v.
II. KHM U
Vic thm khm pht hin v nh gi mt khi u i hi phi t m, phi ton

din, c khi c tin hnh nhiu ln v phi kt hp gia lm sng v cn lm sng
1. Khm lm sng
1.1 Yu cu
Vic thm khm phi c tin hnh phng khm, hoc bung bnh vi
nhng iu kin cn thit theo nhng chuyn khoa.
Bnh nhn c th c khm t th nm, ngi hoc nhng t th c bit ty

thuc vo v tr ca u.
V d :
+ Bnh nhn c th ngi lc khm bu c, khm u.
+ Bnh nhn nm khm nhng u bng.

+ Bnh nhn nm t th sn khoa trong nhng thm khm khi u vng hu mn
trc trng hoc nhng u thuc sn ph khoa...
Phi bc l r vng nh khm, V d :
+ Khm v bu c : phi bc l r vng c, phn trn ca ngc.
+ Khm v : phi bc l r vng ngc, c v nch.
Phi khm nh nhng, theo mt trnh t nht nh v phi lun lun i chiu, so
snh vi
bn lnh.
1.2. Khm c th
1.2.1. Nhn
xc nh v tr ca u, c bit vi nhng khi u nm nng, bng mt thng

c th s b nh gi c.
Xc nh nhng thay i da v t chc ngay trn u hoc xung quanh u : c lot da,
chy mu, ph n, ph i cc mch mu xung quanh u hay khng.
S b xc nh c ranh gii, kch thc ca u.
1.2.2. S Vi cc khi u
Xc nh c kch thc, c th kt hp vi dng c, thc o nh gi

chnh xc kch thc ca khi u. Vi nhng u c tnh, vic nh gi chnh xc kch
thc ca khi u l mt yu cu cn thit c c mt phc iu tr thch
hp.
Xc nh mt : mm, chc, cng ...
nh gi ranh gii : Gii hn r thng gp trong cc u lnh.

S cn nh gi mc di ng ca u, nhng u khng xm ln vo cc t chc
k cn xung quanh th thng di ng.
Vi cc h thng hch lin quan : phi s k pht hin c hoc khng c

hch, s lng, mt ca hch, di ng v kch thc.
V d :
+ Vi cc bu gip : phi xc nh cc hch vng mng cnh, cc hch gai vng sau
c c n chm, cc hch cnh kh qun v vng thng n.
+ Vi cc u vng v : phi nh gi cc hch vng hm nch, hch v ngoi, hch

gia cc c ngc (hch Rotter interpectoral), hch thng n.
+ Vi cc u vng sinh dc ngoi, vng trc trng, tng sinh mn : Phi kim tra k
h thng hch vng bn v hch chu hai bn.
+ Vi cc ung th tiu ha, phi pht hin cc hch Troiser vng thng n
bn tri.
1.2.3. G
Ch yu nh gi cc u su vng bng, ngc, nhng thay i v kch thc ca

u, nhng c quan trong c u pht trin : u d dy, u gan, nhng u trong phc
mc v khoang sau phc mc, nhng u phi, nhng xut tit trong bng hoc
khoang mng phi do u ...
1.2.4. Nghe
Cng cn thit khi khm khi u phi, nhng u c biu hin chn p hoc ph i
mch mu: bu gip, cc u nm trn ng i ca mch mu ln...
2. Khm cn lm sng
Khm cn lm sng s b nh gi, mt chn on bc u. Tuy nhin mun

nh gi tht ng n, tht chnh xc th phi kt hp vi cc phng tin cn lm
sng h tr vi lm sng, tuy nhin cng ng cu kz i hi phi lm qu nhiu
xt nghim trng lp nhau, phin phc, tn k m v mt qu nhiu thi gi cho
bnh nhn.
2.1. T bo hc (cytologie)
T bo hc ra i th k trc, vo nm 1825 do bc s Lebert xut v chnh

Lebert cng l ngi xut ra phng php chn on t bo hc bng chc ht
kim nh v ngy nay vai tr ca n khng th thiu trong vic chn on, iu tr
v theo di, d phng i vi cc u v c bit l cc u c tnh.
y l mt phng php n gin, t tn km, d lm m bt c mt c s no
cng c th lm c v c th p dng c nhiu v tr ca u trong c th.
Phng php ny nhy, ng tin cy. S sai lch gia t bo v gii phu bnh
l l khng ng k. Theo gio s Nguyn Vng b mn Gii phu bnh Trng
i hc Y khoa H Ni v cc Gio s bnh vin K H Ni th chnh xc ca chn
on t bo so vi gii phu bnh l l khong t 80 - 90%.
Cc phng php t bo hc :
+ T bo bong : tc l tm t bo t cc cht bi tit (trong m, dch d dy, dch

bng, dch mng phi...) hoc tm cc t bo do pht knh trc tip t trn b mt
ca u bong ra tm t bo m o qua xt nghim papanicolaou).
+ T bo chc ht : dng bm tim vi kim nh, chc ht trc tip vo khi u,

hoc c th kt hp chc ht di s ch dn ca siu m. y l mt phng php
tt, tiu bn ly chnh xc.
Gi tr xt nghim t bo :
+ Nu kt qu (+) tc l tm c t bo chnh xc chn on, th n c gi tr

quyt nh chn on.
+ Nu kt qu (-) iu khng c ngha l ph nh chn on, v c nhng trng

hp (-) gi do chc khng ng ch.
Ngy nay ngi ta cn cp nhiu n nhng trng hp (+) gi, tc l nhng

trng hp nhm ln trong chn on, c bit i vi cc u c tnh, c th nhm
ln mt s trng hp c bit m hnh thi ca mt s t bo c thay i d nhm
vi hnh nh ca t bo ung th. Tuy nhin nhng trng hp ny vi t l khng
cao lm v cn ph thuc vo kh nng ca ngi c tiu bn.
2.2. T chc hc (Histologie)
N c gi tr chn on. N va nh gi c v mt hnh thi hc ca t bo

u, va nh gi c cu trc ca t chc m ca khi u. Tuy nhin mt xt
nghim ca t chc hc phi t yu cu :
Mu bnh phm phi ln lm c tiu bn v khi cn thit phi lm

nhiu tiu bn.
Phi ly ng ch yu cu.
Mt u lnh tnh c th bm sinh thit hoc bc u lm gii phu bnh l.
Mt u c tnh, nu c th nn bc trn u lm gii phu bnh l, hoc lm gii phu

bnh l tc th c mt kt qu ngay trn bn m v c phng thc gii phu
kp thi, trnh nhng di cn do phu thut gy nn, c bit nhng u : hc t c
tnh, K tinh hon ...
2.3. X quang
Rt c gi tr chn on cc khi u su : u phi, u d dy, thn, xng...
c bit hin nay vi nhng tin b ca trang b my mc v k thut ngy cng tin
tin, ngi ta c th pht hin kh chnh xc ngay c cc u su m lm sng
khng th vi ti c, v nhng u rt nh ng knh ch 1 cm.
Chp X quang c th n thun (chp khng chun b) hoc kt hp vi cht cn

quang (chp d dy, chp UIV thn, chp ty sng, chp mch mu, ng dn
sa...). C th p dng nhng phng php c bit chp ct lp TDM
(Tomodensitometry), chp ct lp vi tnh CT
(Computed Tomography), chp cng h ng t ht nhn MRI (Magntic
Resonnance Imaging), chp c kt hp vi ng v phng x (Scintigraphie) p dng
trong chp bu gip, thn ...
2.4. Siu m (Echographie)
Ngy nay c p dng rt nhiu pht hin chn on v theo di iu tr cc

khi u. Tuy rng n khng quyt nh chn on, nhng n gi , hng n mt
phng php chn on xc nh. Siu m l mt phng tin tt pht hin
sm v theo di cc khi u ca ng tiu ha, tit niu, h hp v u nm su trong
bng, lng ngc ...
2.5. Cc xt nghim v dch th
Bao gm cc xt nghim pht hin v theo di s tn ti v pht trin ca cc u

trong c th.
Cc xt nghim v mu trong cc loi ung th bch cu.
Pht hin mt s men bt thng xut hin khi c khi u trong c th:
+ Cht FP (Alphafoetoproteine) : l mt cht ch c trong thi kz bo thai v

lc mi khong 10.000-150.000 mcg/ml, ngi tr ng thnh cn khong 1-15
mcg/ml, c bit tng cao trong K gan nguyn pht.
+Khng nguyn bo thai ung th CEA cng l mt cht glycoprotine, c nhiu trong
ung th i trng, phi, d dy.
+ Phosphatase axit c nhiu trong ung th tin lit tuyn.
+ Hormon HCG ch im mt ung th rau thai v tinh hon, bnh thng trong
mu c 0,4 mcg/ml.
III. CN PHN BIT U LNH VI U C TNH
S phn bit gia mt u lnh tnh v u c tnh c mt ngha rt quan trng. S

phn bit nhiu khi rt d vi mt s u nh, tuy nhin c nhng trng hp rt
kh, phi kt hp cht ch gia thm khm t m v lm sng v cc phng php
cn lm sng mi phn bit c.
1. U lnh tnh
1.1. Lm sng
Phn ln u pht trin chm, c nhng u tn ti lc mi sinh (u mu). C nhng u

pht hin c trong qu trnh hnh thnh ca c th v cng tn ti lu nm vi
bnh nhn : bu c n thun, u b, u m , u xng lnh tnh ...
U thng c mt mm hoc chc.
+ Mt mm: bu gip, u mu, u b, u m v cc u phn mm lnh tnh khc ...
+ Mt chc v n hi: u x cc loi nh u x tuyn v, u x tin lit tuyn, u x

t cung.
Ranh gii thng r rng, v phn ln u c v x bao bc.

Thng di ng d v khng xm ln vo cc t chc k cn v khng di cn. Nu
c ct b u khng ti pht.
1.2. V mt t bo hc v t chc hc
V mt t bo hc: U lnh tnh c s tng sinh ca t bo v t chc m xung

quanh, nhng khng c s o ln cu trc ca t bo v s thay i hnh thi gia
cc t bo vi nhau.
V mt t chc hc : Trong u lnh tnh khng c s o ln cu trc ca t chc.

2. U c tnh
2.1. Lm sng
Khi c mt u c tnh pht hin trn lm sng, theo di tin trin thy u pht
trin rt nhanh. Bnh thng mt khi u khi pht hin c vi ng knh 1cm3
(tng ng 1 t t bo) v phi mt khong 7-10 nm. Nhng khi pht hin
c nh vy i khi pht trin n giai on ton pht ch l mt khong thi gian
rt ngn v d ung th gan, ung th d dy, ung th phi ...
Mt khi u thng rn.
B mt thng ln nhn, g gh do s pht trin khng u ca u.
Ranh gii khng r rng, t hoc khng di ng do thng hay xm ln ra cc t

chc k cn. Chnh v vy m khng th bc u m phi ct b u v rt d ti pht.
U c tnh thng di cn xa bng ba con ng : xm ln k cn, di cn theo bch

mch v ng mu.
2.2. V mt t bo hc v t chc hc
Xt nghim u c tnh v mt t bo hc phi da vo 4 tiu chun :

- S thay i ca nhn.
- Mi quan h ca nhn v nguyn sinh cht.
- Mi quan h gia cc t bo vi nhau.
Vi mt u c tnh, v phng din t bo hc, c nhng s bin i c trng : qu

sn, lon sn, d sn (tm thy cc nhn qui, nhn chia) v bt thc sn (tc l
khng c s pht trin y cc dng t bo t non n gi m ch yu ch thy
cc t bo non).
V t chc hc : thng c s o ln cu trc ca t chc u ( tc l c s xm ln
ca t chc c tnh v cu trc m xung quanh).
1. i hc Y H Ni, 1999. B mn Ngoi, Triu chng hc Ngoi khoa, trang 104

126.
2. L nh Roanh, 2001. Bnh hc cc khi u, nh xut bn Y hc, trang 129-136.

7. CHN ON BNH UNG TH
Mc tiu hc tp
1. Trnh by c cc phng php chn on ung th hin nay.
2. Nu c phng php chn on giai on theo TNM v mt s phng php

phn loi khc c p dng nh: FIGO, Ann-Arbor v Dukes.
Mi v tr ca ung th c cc triu chng pht hin c hiu cho v tr ,tuy

nhin hu ht cc triu chng pht hin xut pht t sinh l bnh hc v c bit l
s pht trin c trng ca khi u.
Mt khi nhng triu chng xut hin,ngi thy thuc nn thc hin mt s th
tc chn on :
Chn on cng sm cng tt, s dng cc phng php thm khm trnh gy au
n, kh chu cho ngi bnh nu c th c.
Nhanh chng thc hin sinh thit khi u a ra chn on chnh xc v gii phu
bnh
hc.
Kim tra v lm sng v cn lm sng xc nh khi u ang cn tin trin ti ch
hay
di cn xa.
Xc nh chnh xc giai on ung th.
a ra phc iu tr u tin da vo bnh n c iu tr trc .
Chn on mun dn n iu tr mun v ng nhin s nh h ng khng tt

n kt qu iu tr.
Kh i u iu tr nhanh v thch hp s to ra kh nng thnh cng tt nht cho
bnh
nhn.
I. CC HI CHNG CHN ON
1. Hi chng u
S xut hin khi u c th l triu chng pht hin duy nht, hoc l trc tip
hocnhng ri lon do khi u to ra.Khi ung th xm ln cu trc lnh ln cn,
khi u thng t di ng, b khng u, s thy cng.
Mt vi hi chng khi u nh sau: Mt khi u v
U no vi ph n no (to ra tng p lc ni s vi au u, nn ma v tai bin

mch
no).
Kh nut do khi u thc qun

Chn p niu qun v niu o do ung th tin lit tuyn
Hi chng bng quang b do ung th bng quang
Nhiu ri lon tiu ha gy ra do ung th i trng v ung th bung trng.
2. Xm ln cc b
Ung th xm ln cc b ti cc c quan lm thay i hnh th hoc ri lon chc

nng ca c quan .
Da mu da cam khi ung th xm ln ti da.
Ni kh do ung th thanh qun xm ln ti dy thanh m
Nut kh lin quan n ung th thc qun hoc ung th vng u mt c
y bng kh tiu lin quan n ung th d dy

To bn lin quan n ung th i trc trng
Khi khi u xm ln cc t chc ln cn, c th quan st c mt s triu chng

khc:
Ph n do chn p (cnh tay ph do xm ln ca ung th v, vim tc tnh mch do

khi u khung chu, bng bng do khi u bung trng, d dy hoc i trng, ph o
khoc do hi chng tnh mch ch, chn p tnh mch ch trn do u trung tht).
Kh th v xp phi trong ung th phi hoc di cn phi nng.
au do chn p dy thn kinh ngoi bin (au dy thn kinh ta do di cn xng

hoc xm ln khung chu).
Xm ln vo rn trong ung th bung trng (Syster Mary syndrome)
3. Hi chng xut huyt
Khi u tng tr ng ngy cng ln cn cc mch mu nui dng, s suy yu v h

thng mch mu dn n nui dng km gy hoi t, xut huyt ti khi u.
Ho ra mu trong ung th ph qun.

Nn ra mu v i cu phn en trong ung th d dy.
Tiu mu trong ung th bng quang, thn, niu qun hoc tin lit tuyn.
Xut tinh c mu trong ung th tin lit tuyn. Chy mu trc trng trong ung th
trc trng. Xut huyt m o trong ung th c t cung.
Dch bng xut huyt trong ung th bung trng hoc ung th ng tiu ha. Trn
dch mng phi xut huyt lin quan ti ung th di cn mng phi.
Trc mi trng hp xut huyt i hi phi thm khm ton b tm ra nguyn

nhn trnh b st.
4. Hoi t
Hoi t thng xy ra do h thng mch mu nui dng khi u ngho nn. N

thng to ra:
Vt thng chm lin
Nhim trng khi u
Mi rt hi (rt c trng trong ung th u mt c v ung th ph khoa) D t

ng hoc d xy ra sau khi iu tr tia x
Lot hch dnh da hoi t rt hi
5. Di cn xa
Khong chng 15% bnh nhn ung th khi n khm c di cn
Di cn hch thng n (hch Troisier) pht hin c ung th ng tiu

ha, ung th vng chu; hch bn trong ung th b phn sinh dc ngoi; hch c
trong ung th vng tai mi hng.
Di cn vo da trong ung th v, ung th thn. Di cn gan gy ra vng da, au gan.
Di cn phi (him khi gy ra kh th , thng pht hin c do chp Xquang phi

kim tra h thng).
Di cn no (thng gy nhc u, yu lit).
Di cn khc: di cn c th xy ra bt kz c quan no.

II. THM KHM LM SNG
Thm khm lm sng mt cch ton din l cch tt nht t c chn on

v xp giai on bnh mt cch chnh xc.
Trc tin nn cho bnh nhn c thi gian h trnh by v tnh hnh bnh
tt ca h, thy thuc kin nhn lng nghe c thm thng tin v th hin s
lich s v tn trng. Nhng cu hi v lm sng nn chnh xc, kn o v thn
thin. Mt cuc i thoi m l cch u tin to c s tin t ng v thn thin
vi bnh nhn. N cho php nh gi nhng suy ngh, nhng s hi, lo lng ca
bnh nhn v tnh hnh bnh tt ca h, n cng cho php hiu r hn hon cnh
ca bnh nhn, gia nh v x hi.
Thm khm lm sng nn nh nhng trnh nhng thao tc gy au n khng cn

thit.
Trong mt s trng hp ung th sau khi khm lm sng mt cch k lng c th
chn on v xp giai on ung th. i vi mt s trng hp kh hoc bnh

nhn khng cm thy thoi mi, c th gy m ton than (c bit vi nhng ung
th h sinh dc).
Thm khm lm sng khng k s gy lng ph thi gian v tin bc v nhng th

thut gy au n khng cn thit.
III.MT S TH THUT THM KHM LM SNG CHNH
Nhn v s nn v: i vi u v c th nhn thy u g ln, bin dng hnh th ca

tuyn
v, mt cn i gia 2 v hoc da v mu da cam do ung th v xm ln da
G 2 ph trng hoc nghe pht hin trng dch mng phi
Thm khm khoang ming chn on v xp giai on ung th khoang ming.
Thm khm thanh qun vi gng Clarke chn on ung th thanh qun
S mt cch h thng cc vng hch c bit l hch c, hch nch , hch bn
pht hin cc ung th di cn n h thng hch tng ng.
S v g vo vng gan lch pht hin gan lch ln. S nn bng pht hin u
bng hoc bung trng. Thm m o bng m vt pht hin ung th c t
cung.
Thm trc trng pht hin ung th trc trng hoc nh gi tnh trng ca
dy chng rng trong ung th c t cung hoc thm st khi u vng tiu khung
nh u bung trng. i vi nam gii thm trc trng cn pht hin ung th tin
lit tuyn.
S nn nh nhng v cn thn vng bu pht hin khi u tinh hon.
Thm khm thn kinh pht hin cc khi u di cn no.
IV. CN LM SNG
1. Xt nghim chn on hnh nh
Xt nghim chn on hnh nh thng c dng khng nh nhng tn

thng nghi ng qua thm khm lm sng v pht hin nhng thng tn mi, nh
vy thay i c v nh gi giai on bnh v kh nng iu tr.
1.1. Xquang phi
Phng php chp Xquang phi tuy n gin nhng rt hu ch chn on

ung th phi nguyn pht, ung th phi di cn, trn dch mng phi, kho st cc
bin chng nhim trng hoc x phi sau iu tr. Chp Xquang phi nn c s
dng cng rng ri cng tt.
Mt s hnh nh c th thy c trn phim Xquang phi:
+ Hi chng ph nang hoc xp phi
+ Khi u n c hoc nhiu khi u phi

+ Vim tc bch mch dng ung th
+ Cc hc trong phi
+ Khi u trung tht
+ Trn dch mng phi
+ Trn kh mng phi
+ Cc di cn xng
+ Xquang xng
Xquang xng c th pht hin ung th nguyn pht xng hoc ung th di
cn n xng vi 3 hnh nh khc nhau:
Cc thng tn hy xng: bin mt mt vng cu trc ca xng (di cn t

ung th thn, phi, ung th u c v mt s ung th khc).
Thng tn dy xng: S dy ln mt vng cu trc xng (di cn t ung th
v, tin lit tuyn v ung th tuyn gip).
Th kt hp: Va hy v dy xng.
Xquang xng thng cho php chn on nhanh cc trng hp thng tn

xng. Mt s hnh nh Xquang xng pht hin di cn xng:
+ Hy xng cc xng t chi
+ Hy xng vng xng chu
+ Hy xng t sng
+ Hy xng s
+ Thng tn dy ln vng xng chu
+ Thng tn dy ln ca xng ct sng

+ Thng tn dy ln ca xng s
Hnh1: Chp X.Quang
1.2. Mammography
Mamography l xt nghim ang dn u trong chn on ung th v. Ngi ta

hon thin dn v mt k thut trong 10 nm qua v nhng tin b hn na ang
trong qu trnh hon thin nh k thut s ha.
Ngy nay ngi ta c th pht hin khi u nh hn 4mm ng knh (khi u tin
lm sng)
vi nhng hnh nh c hiu v m , b khng r rng, khi m c hnh sao,vi

ha vi th.
Sinh thit khi u c thc hin vi h thng c nh cho chn on rt tt v
gii phu bnh trc khi phu thut.
Hnh 2: Chp nh nh
Hnh 3: Kt qu chp nh nh
1.3.Siu m
Siu m c ng dng nhiu trong chn on ung th. Siu m pht hin c cc
khi u ca cc c quan nh khi u gan, u thn, khi u bung trng, u t cung v.v.
Siu m cn c th cho bit c tnh cht ca khi u: dng c hoc dng

nang. Vi nhng u d c tn s cao, siu m cn c th nh gi c mc
xm ln ca ung th vo t chc chung quanh (ung th d dy, ung th i trc
trng...).
Chn on siu m d thc hin cc tuyn y t, gi c hp l, khng c hi. Tuy

nhin siu m kh thc hin i vi cc tng c khng kh v ph thuc vo kinh
nghim ca ngi c.
1.4. ng v phng x
ng v phng x l mt xt nghim thm d chc nng, cht lng hnh nh t ch
hn l thm d chc nng tht s. Tuy nhin, ung th khng ch l bnh l c th
to ra bt thng trn ng v phng x m cn mt s bnh l khc, do chng
ta phi thn trng gii thch nhng bt thng v nn i chiu vi bnh s lm
sng ca bnh nhn.
1.5. X hnh xng
X hnh xng cho php pht hin di cn xng trc khi bt kz triu chng
Xquang no xut hin v c th xem nh xt nghim sng lc pht hin di cn
xng. Cht nh du c tim vo l mt diphosphonate nh du vi
99Technetium. Ging nh Phosphorus ngi ta quan st thy cht ny c nh
nhng vng xng b thng tn: Vng callus xng nhng xng b gy, bnh
Paget ang tin trin, ung th di cn.
Tng liu phng x l rt thp (740MBq) khng gy nguy him g cho bnh nhn.
nhng vng xng b ung th di cn ta c th thy hnh nh tng c nh cht

phng x dng chm (punctiform hyperfixation). Tuy nhin hnh nh ny cng c
th quan st c nhng bnh l lnh tnh nh: vim khp, vim xng, di
chng sau chn thng.
V nguyn tc ch c nhng ung th di cn c phn ng to xng mi c nh cht

phng x nh du, tuy nhin hu nh tt c cc vng hy xng u km theo
qu trnh to xng ti thiu do gy ra c nh cht ng v phng x nh du.
Nhng ung th di cn xng pht hin c bng x hnh xng thng l ung th
v di cn, ung th tin lit tuyn di cn v ung th tuyn gip. X hnh xng c th
thay th cho chp Xquang xung. Nhng tn thng xng nguyn pht cho nhng
hnh nh r hn (v d nh Sarcom Ewing).
Trong nhng trng hp nghi ng nh thoi ha khp, hoc cc bnh l chuyn

ha v xng nh bnh Paget chng ta c th chp Xquang xng hoc cng
h ng t lm r chn
on.
Hnh 4: X hnh xng

1.6. X hnh tuyn gip
X hnh tuyn gip rt c a chung pht ha ln nhng nhn lnh v

loi b nhng bnh l khc ca tuyn gip to ra do s tng th tch ca tuyn.
S dng Iode phng x nh du ph hp sinh l hn, tuy nhin thi gian bn

hy ca Iode phng x di (8 ngy) gy phin phc trong vn bo v an ton bc
x. S dng Technetium99 c a chung hn v cho nhng hnh nh r nt v
nhn lnh v nhn nng v theo di nhng nhn gip khng c.
Vi hnh nh x hnh tuyn gip chng ta c th phn bit mt s bnh l sau:
+ Nhn lnh: Khng c c nh Technetium v nn lm thm cc xt nghim khc

chn on.
+ Nhn nng: Nhn to ra nhiu hormone
- Bu gip a nhn
- Vim tuyn gip
- Bnh l ni tit ca tuyn gip: Basedow, suy gip.

Iode123 o mc bt Iode ca tuyn gip v theo di nhng trng hp
iu tr ung th tuyn gip bng iode phng x.
Hnh 5: X hnh tuyn gip

1.7. Min dch phng x huznh quang
K thut ny s dng 1 khng th c hiu kt hp vi 1 khng nguyn hoc 1 m

c bit c nh du vi 1 ng v phng x. Khng th c hiu khng b hp
th b i khng nguyn tun hon v nu c th khng lm ri lon thm cc th
nghim v min dch ca khng nguyn.
K thut ny c s dng pht hin nhng vi di cn ca nhng bnh nhn

iu tr phu thut: Choriocarcinoma (HCG), di cn ca ung th tiu ha (ACE), ung
th bung trng (CA-125)v.v.
1.8. S dng ngv phng x trong lc m
Vi vic s dng u d phng x trong lc m, phu thut vin c th pht hin ra

nhng khi u khng th nhn thy c v thc hin c ct b hon ton (v d
ung th tuyn gip ti pht ti ch, ti pht ung th tiu ha vi th, d hch v tinh
(sentinel) vt hch trong ung th.
1.9. PETScan
PETScan l mt k thut hnh nh v chc nng, lin quan trc tip chc nng ca
mt c quan hn l hnh thi ca c quan . Cng ging vi Scintigraphy, chp
PETScan c thc hin bng cch tim mt cht ng v phng x c nh du,
thng thng ngi ta s dng 18- Fluoro-Desoxy-Glucose (18FDG), cht ny
khuch tn trong c th v c pht hin qua mt mng huznh quang c bit:
mt camera gn ng thi vo . Cht ng v phng x thng dng c thi gian
bn hy ngn (t vi pht ti vi gi). 18FDG ngy nay thng dng nht phc v
cho nhng nghin cu v lm sng. N l mt phn t glucose, mt nhm hydroxyl
v tr 2 c thay bng mt nguyn t phng x fluor (18F). T bo ung th c
s chuyn ha nng ng hn t bo bmh thng, cn nhiu glucose hn t bo
bnh thng. Khi18FDG xm nhp vo trong t bo, n khng chuyn ha
ging nh glucose bnh thng m li lu hn trong t bo. Khi cc t bo ung
th khng bit ha tin trin nhanh v nhn ln, chng s s
dng mt lng ln 18F-Glucose. S gia tng chuyn ha glucose ny cng c th
gp trong mt s bnh l nhim trng hoc vim hoc mt s loi t bo rt nng
ng nh t bo no hoc t bo c. Ngc li, mt vi khi u c tnh c th tiu
th glucose thp, c bit l khi u c c tnh thp hoc khi u hoi t. V vy
c hiu ca PET-Scan khng phi l tuyt i.
Cc ch nh ca PETScan:
+ Ch nh trong ung th
+ PET dng chn on ung th, nh gi giai on v theo di trong iu tr

c bit trong bnh Hodgkin, Non-Hodgkinlypphoma v ung th phi.
+ Chn on cc khi u c. c bit hu ch pht hin cc khi u di cn, cc
khi u ti pht sau khi c ct b.
Cc ch nh khc ca PETScan:
+ Ch nh trong mt s bnh l ca no b
+ Bnh l tim mch, bnh l x mch, bnh l v mch mu.

+ Bnh l v tm thn kinh.
+ Bnh tm thn.
V dc hc: Nghin cu v tp trung v thi tr ca thuc.

Hnh 6: My chp PET-Scan Hnh 7:Chp PET
Hnh 7: Ung th gan Hnh 8: Ung th di cn xng
1.10 Chn on ni soi
Ni soi l phng php khm cc hc t nhin v mt s ni tng ca c th nh

cc phng tin quang hc. K thut ni soi ngy cng pht trin nhanh chng,
hin i nh s tin b ca k thut quang hc, cng ngh in t vi mch.
Ni soi c v tr rt quan trng trong chn on ung th d dy, ung th i trc

trng, ung
th thc qun, ung th thanh qun, ung th ph qun, ung th bng quang .v.v.
Ni soi cho php tin hnh mt s th thut: sinh thit, ct polip, iu tr mt s tn
thng, bm thuc cn quang chp Xquang (chp ngc dng, chp ph qun).
Ni soi can thip ang pht trin nhanh chng v ang c p dng tin hnh
cc phu thut nh ct bung trng, ct ti mt, ct rut tha, vt hch chu, ct
t cung v ct i trng. Tng lai phu thut ni soi cn pht trin xa hn.
Hnh 10: Ni soi thp

1.11. Chp ct lp vi tnh ( CT-Scan)
Chp ct lp vi tnh l mt trong nhng phng tin chnh chn on ung th

trong hu ht tt c cc phn ca c th.
Nhng thng tn (u nguyn pht, hch nm nhng v tr su, u di cn) vi kch

thc
>1cm l tng i d pht hin.
Lm tng cn quang bng cch tim cc cht cha Iodine lm tng s hin th
mch
mu, thng tn do ung th d dng pht hin hn.
My chp ct lp hin i (Multislice) cho php ct cng nhng lt ct rt mng, vi

s nhim phng x ti thiu, thc hin trong mt thi gian rt ngn nh vy loi
b nhng artifact do c ng h hp lm gim kch thc ca nhng hnh nh bnh
l c th pht hin c.
Chp ct lp vi tnh c th pht hin nhng thng tn tng i su nh vy c

th dng
chp ct lp vi tnh hng dn chc sinh thit nhng khi u su trong c th.
Hin nay chp ct lp vi tnh l loi my tt nht xc nh th tch bia trong iu
tr tia x v tnh ton liu lng trc khi x tr.
Hnh 11: CT Scan

1.12. Chp cng h ng t (Resonance magnetic imaging)
Chp cng h ng t l phng php chn on hnh nh k thut cao, khng dng
tia x nn an ton cho bnh nhn. Nguyn l c bn l cc nguyn t trong c th
sau khi t trong t trng ca my s cng h ng vi sng v tuyn v pht ra tn
hiu.Tn hiu ny s c thu nhn v x l vi tnh to ra hnh nh. y l dng
sng in t khng gy tc hi cho ngi chp.
Chp cng h ng t cho nhng hnh nh rt r v bnh l{ thn kinh v xng. Ch

nh ca cng h ng t hn ch hn ch nh ca CT-Scan. Tuy nhin chp cng
h ng t ang lin tc tr nn nhanh v hiu qu hn, do ch nh ang tng ln
v dn dn khc vi ch nh ca CT-Scan. c bit nhiu nghin cu gn y ang
c thc hin theo di nhng thay i u tin c to ra do ha tr liu, x
tr v d bo p ng lm sng vi iu tr.
Mt ch nh khc rt c quan tm l theo di nhng khi u sau x tr (c bit

l ung
th v).
Hinh 12: MRI v

1.13. Mt s phng php chn on X.Quang khc
Phng php chp mch: trc y phng php ny t c s dng, hnh nh

cho thy s tng sinh mch rt mnh khi u (c bit trong nhng khi u thn v
no). Chp mch cng cn c s dng iu tr nh l nt mch hoc ha cht
ng mch.
Hnh 13: Chp mch

2. Chn on sinh hc
Mt s xt nghim sinh hc c i hi chn on chnh xc bnh ung th. V

d nh o gi tr ca -HCG chn on ung th rau thai, thyroglobulin trong ung
th tuyn gip.
Cc xt nghim sinh hc n gin khc l hu ch trong xp loi ung th (nghin cu

v di cn gan bng enzym gan (hepatic enzymology) hoc tnh trng ton thn
trc khi bt tay vo iu tr (cng thc mu, chc nng gan thn, oxymetry).
Nhng xt nghim khc nn c thc hin mt cch c h thng trong trng

hp c thay i v tnh trng ton thn, ri lon nc in gii, hoc kch thch
(v d nh tng Calci mu hoc tng Kali mu).
Cc xt nghim v cht ch im khi u (tumors markers) cng rt c quan tm

chn on v nh gi tin trin ca bnh hoc c tnh trong iu tr.
Cht ch im khi u l cht hin din trong mu, c th trong nc tiu hoc cc
dch khc ca cc bnh nhn ung th v khng c ngi kho mnh, do gi
s xut hin ca ung th.
Mt s cht ch im khi u chnh:
Cc protein ung th ca phi thai:(Oncofoetal proteins)
+ CEA: (Carcino embrionic antigen)
y l mt Glycoprotein hin din trong ng tiu ho, trong gan v tu ca

bothai gia thng th 2 v thng th 6 ca thai kz. Chng c t l rt thp trong
huyt thanh ca ngui bnh thng. CEA c th tng cao trong ung th ng tiu
ho, ung th v v ung th bung trng. Tuy nhin n cng tng trong mt s bnh
l lnh tnh nh x gan, thiu nng h hp v nhng ngi nghin thuc l nng.
+ AFP(Alphafoeto-protein)
l mt 1-globulin c to ra b i gan, rut non v ti Yolk trong thi kz bo

thai. Nng ca n tng cao trong ung th gan nguyn pht, trong ung th tinh
hon dng non- seminomatous hoc bung trng.
Hormones
+ HCG (Human Chorionic Gonadotropin)

Hormon ny c to ra trong thai kz b i cc t bo syncytiotrophoblastic ca nhau
thai. Nng ca n tng cao trong ung th rau thai, ung th tinh hon dng
non-seminomatous v ung th bung trng.
+ Thyrocalcitonin
y l mt calcium ca tuyn gip iu ho hormon, n tng cao mt cch c bit
trong ung th tuyn gip th tu, ngoi ra n cn c tit ra mt cch lc ch
trong ung th phi t bo nh.
Enzymes
+ Acidic Prostatic Phosphatase
c tit ra b i cc t bo ca tin lit tuyn bnh thng, chng ch yu tng cao

trong
di cn xng.
+ Alkaline phosphatase: nng trong mu ca n thng tng cao trong trng

hp di cn gan hoc di cn xng
+ LDH (Lactico-dehydrogenase)
y l mt enzyme ca c, nng ca n gia tng trong lymphoma, ung th tinh

hon
v ung th phi do di cn.

+ PSA (Protate specific antigen)
N l mt glycoprotein c ngun gc t t bo tin lit tuyn. PSA gia tng mt cch

c hiu trong ung th tin lit tuyn v u x tin lit tuyn.
Mt s yu t tin lng mi ang ni ln t nhng nghin cu v sinh hc phn t

v ang lm thay i phng php kim tra i vi mt s loi ung th.
3. Chn on gii phu bnh
Chn on ung th lun lun i hi m sinh thit v xt nghim gii phu bnh
(ngoi tr trong giai on cui khi s iu tr tch cc khng cn ngha).
Ngoi tr mt s trng hp t gp, khi bt u ch nh iu tr trit cn phi

c bng
chng gii phu bnh chn on l u c tnh (hoc t nht l chn on t bo hc).
Mt s trng
hp nhim trng ko di, mt s u lnh tnh v mt vi bnh him gp c th nhm
ln vi ung th. Tuy nhin, nhng sai lm trong s dng x tr v ha tr i vi
nhng trng hp nh vy s gy nhiu bin chng nng n.
m bo mt cch chc chn chn on ung th trc khi ch nh iu tr

phu thut, x tr hoc iu tr ha cht bt buc phi c kt qu gii phu bnh.
3.1. Xt nghim t bo hc
Xt nghim t bo bong: Nhiu loi ung th gy ra tit dch, do chng ta c

th ly cht dch tit lm xt nghim t bo nh dch mng phi, dch mng
bng, dch ty sng.
Chc ht khi u bng kim nh: l phng php chn on c gi tr v cho t l

dng tnh cao, c th thc hin i vi cc khi u nng v su trong c th. Vi
nhng khi u su c th chc di hng dn ca siu m.
Chn on t bo hc c nhiu u im nh nhanh, n gin, d thc hin, gi

r. Tuy
nhin vn cn tn ti mt s m tnh sai v dng tnh sai.
3.2. Sinh thit trc phu thut
Nhng tin b v lm sng mi y t c ngy cng nhiu chn on gii

phu bnh trc khi phu thut vi s s dng ni soi pht hin khi u v sinh
thit mt cch chnh xc. Tng t cc k thut Xquang can thip c th sinh thit
khi u bng kim.
Sau y l mt vi v d:
+ Ni soi thanh qun v sinh thit i vi ung th vng u mt c.
+ Ni soi ph qun vi u phi.
+ Ni soi d dy i vi u d dy.
+ Ni soi i trc trng i vi ung th i trc trng.

+ Soi c v thn t cung i vi ung th t cung.
+ Sinh thit u v, gan, thn, tin lit tuyn v cc u khc di s hng dn ca
siu m.
+ Sinh thit u v di s hng dn ca b phn c nh mammography.
3.3. Bnh phm m sinh thit
i vi mt s khi u nh sarcome phn mm, di cn phc mc do ung th bung

trng hoc khi u tinh hon, cc tc gi khuyn khng nn sinh thit do nguy c
pht tn t bo ung th ti c quan ln cn. Nghin cu i th bnh phm sinh
thit nn:
- M t y , chi tit nhng mu bnh phm khc nhau m phu thut vin g i
n.
- M t hnh nh i th (kch thc, mu sc, i th).

- Gii hn ca cc mc phu thut.
- M t tnh trng hch v lm tt c cc tiu bn v hch mt cch h thng.
- Ly mu ti m p ct lm tiu bn.
V. CHN ON GIAI ON
Chn on giai on l nh gi s xm ln v lan trng ca ung th bao gm

nh gi tnh trng ti ch, ti vng v tnh trng di cn xa. Chn on giai on
nhm cc mc ch sau:
+ Gip la chn phc iu tr thch hp vi tng giai on bnh
+ Gip nh gi tin lng bnh.
+ Thun li cho cng tc nghin cu khoa hc, trao i thng tin, so snh v nh
gi cc phng php iu tr.
1. Phn loi TNM T : U nguyn pht
To : Cha c du hiu u nguyn pht. Tx : Cha nh gi c u nguyn pht

Tis : Ung th ti ch
T1-4 : U theo kch thc tng dn hoc mc xm ln ti ch ca u nguyn

pht. N : Hch vng
No : Cha c du hiu xm ln hch vng
Nx : Cha th nh gi c hch ti vng
N1-3 :Mc tng dn s xm ln hch ti vng. M : Di cn xa
Mo : Cha c di cn xa
Mx : Cha nh gi c di cn
M1 : Di cn xa
1. B Y t - Bnh vin K, 1999. Hng dn thc hnh chn on v iu tr ung

th, nh xut bn Y hc, trang 7-15.
2. i hc Y H Ni, 1999. Bi ging ung th hc, nh xut bn Y hc, trang 39-45.
3. UICC, 1995. Ung th hc lm sng, trang 189-207.
II. TI LIU TING ANH
1.Vincent T. De Vita, Principles & Practice of Oncology, Part 2.

8. CHT CH IM UNG TH
I. T VN
Mi nm c hn 6 triu ngi cht v bnh ung th, 1.4 triu ca ung th mi c

chn on trn th gii. Theo nh gi ca T chc y t th gii (WHO), trong 20
mi nm ti cc con s trn s gia tng v ln n 10 triu trng hp t vong v
trn 16 triu ca ung th mi.
Vit Nam, bn cnh cc bnh nhim khun v suy dinh dng ngy cng gim
dn, th bnh ung th, bnh tim mch, tm thn ang c nguy c gia tng. Cc
loi ung th hay gp nc ta l ung th phi, d dy, v, gan, vm hng, i trc
trng, hch bch huyt, t cung, bung trng
Trong khi nhiu nc, chng trnh sng lc pht hin sm ung th t kt qu
tt, gp phn cha khi hn 50% bnh nhn ung th th nc ta a s ngi
b ung th khi c chn on giai on mun, t l cha khi bnh cn rt
thp. C hi cha khi bnh ung th chnh l lm sao pht hin sm ung th.
Cht ch im khi u c ngy cng c nhiu vai tr trong sng lc, nh gi gnh
nng ung th, tin lng bnh, theo di kt qu iu tr v d bo ti pht.
II. KHI NIM V CHT CH IM KHI U
1. nh ngha
Cc cht ch im ung th (CCUT) l nhng phn t t nhin c trong huyt

thanh, huyt tng v cc dch khc trong c th, hoc cc mu th ly t m ti
hoc m nhng paraffin xc nh s hin hu ca ung th, nh gi tin
lng bnh nhn hoc theo di s p ng ca bnh vi phng php iu tr.
Cht ch im ung th cn c tm thy bn trong t bo c t bo cht v

nhn v nhng cht ny lin kt vi mng t bo. CCUT thng c bn cht
protein, xut hin trong mu, nc tiu, trong cc cht dch, m ca c th ngi
bnh v thng khng xut hin r ngi kho mnh. S thay i nng ca
CCUT c lin quan mt cch chc chn ti s pht trin cc khi u c tnh ca c
th .
2. Phn loi
C hai loi ch im khi u chnh
2.1. Ch im t bo: L cc khng nguyn tp trung trn b mt ca mng t bo

nh trong bnh
Leucemie, cc ni tit t v c quan th cm ni tit trong ung th v

2.2. Ch im dch th: L nhng cht xut hin tp trung trong huyt thanh, nc
tiu hoc cc dch khc ca c th. Cc cht ny c tng hp v bi tit t cc
m ca khi u, c gii phng nh s phn hy t bo u hoc c to thnh
nh l s phn ng ca c th i vi khi u.
2.3. Phn loi cht ch im theo bn cht v cc ung th lin quan chnh
Bng 1. Phn loi CCUT theo bn cht v cc ch nh chnh

Cc loi cht ch im ung th Bnh lin quan chnh
Cc enzyme UT xng, gan v nhau thai
Alkaline phosphastase U lymph c, UT mu
Lactate dehydrogenase (LDH) Neuron specific antigen Prostatic Acid UT phi TB nh, u nguyn bo thn kinh
Phosphastase
UT tin lit tuyn
Prostatic Specific Antigen (PSA)
UT tin lit tuyn
Cc hormone
Adrenocorticotrophic Hormone (ACTH) Calcitonin
Human chorionic gonadotrophin
UT phi TB nh UT gip th ty Ung th

nhau thai
Khng nguyn thai ung th -Fetoprotein
Carcinoembryonic antigen (CEA)
UT gan nguyn pht

Khng nguyn carbohydrate
CA 15-3 UT v
CA 27-29 UT v (ti pht)

UT i trc trng
CA 125 UT bung trng v ni mc t cung
Receptor v cc cht ch im khc Estrogen v UT v
Progesteron Immunoglobulin Microglobulin
a u ty, u lymph c
a u ty, u lymph c t bo B
Cc cht ch im gen
Cc gen sinh UT: U nguyn bo thn kinh, UT mu th t
t bin gen N-ras t bin gen K-ras Khuych UT ty, UT my v u lymph

i gen c-erb B-2
UT v
Chuyn on c-myc
U lymph c TB B v T
Cc gen p ch ung th
Gen nguyn bo vng mc m

U nguyn bo vng mc mt
Gen P53
UT v, i trn
UT v
Gen BRCA 1 v 2
Genkhng
Cc WT1 nguyn nhm mu UT i trc trng, UT ty
U Wilm
CA 19-9 Cc UT tiu ha, bung trng
CA 72-4
III. TIU CHUN CA CC CHT CH IM KHI U
Cht ch im khi UT l{ t ng dng chn on ung th, gip sng lc, theo di
din tin UT. V vy CCUT l t ng cn c cc tiu chun sau:
+ C nhy v c hiu cao.
+ Nng thay i theo giai on bnh (phn nh c gnh nng ca ung th).
+ Tin lng c ung th.
+ D on ti pht.
Khi nim nhy v c hiu ca CCKUT:
+ c hiu: c hiu ca mt CCUT l t l % ngi khe mnh hoc c

bnh lnh tnh trong kt qu xt nghim ca h c kt qu m tnh mt cch
chnh xc.
+ nhy: nhy ca mt CCUT l t l % ngi bnh dng tnh chnh xc
vi CCUT.
nhy v c hiu cao c ngha:
+ C th pht hin rt sm t khi ch c vi t bo ung th xut hin.
+ c trng cho c quan c u.
+ Tng quan vi giai on ca khi u.
+ C gi tr d on tin cy.
Hin nay, rt tic cha c cht ch im khi u l{ t ng c y 100% tiu chun

v c hiu, tin cy chc chn, tnh c trng c quan v chn on chnh
xc giai on bnh. Tuy nhin, mt loi ch im khi u c nhng gi tr trn cc
tiu chun khc nhau v khi phi hp 2 hay nhiu th nghim li c thm nhiu gi
tr mi b sung ln nhau. PSA, PAP (Prostatic Acide Phosphatase) v Thyroglobulin
l nhng cht ch im c hiu cho c quan c u.
Nhiu cht ch im khi u c xem l c tng quan vi giai on pht trin ca
u, c nng tng cao nhng giai on mun. Tuy kh xc nh chc chn khi u
ang giai on no v i khi c s trng cho gia cc loi.
Tuy nhin, gi tr tin lng ca mt s cht ch im rt r v thng gn vi qu

trnh tin trin v kt qu iu tr. V d: hm lng CEA trc m ung th
i trc trng, 2
Microglobulin trong u lympho c khng Hodgkin v bnh a u ty.
CA 125 trong ung th bung trng cng cao th tin lng cng xu, kh nng ti
pht, di cn cng nhiu
nhy cm v c hiu ca mt cht ch im c tnh bng cng thc sau:

S ln dng tnh (+) tht
nhy =-------------------------------------------------
S ln (+) tht + S ln m tnh ( - ) gi
S ln m tnh ( - ) gi
c hiu =----------------------------------------
S ln (-) tht + S ln ( + ) gi
Mt s tiu chun quan trng khc l gi tr d on ca cc cht ch im khi u.

Gi tr d on dng tnh c ngha c kh nng c mt khi ung th no
xut hin m c th s dng 1 phc hp cc nghim php kim tra pht hin c.
Gi tr d on m tnh ch ra rng khng th c mt loi ung th no xut

hin nu kt qu xt nghim m tnh.
S ln m tnh (-) tht
Gi tr d on (-) = -------------------------------------
S ln (-) tht + S ln (-) gi
S ln dng tnh (+) tht
Gi tr d on (+) = ---------------------------------------
S ln (+) tht + S ln (+) gi
IV. NG DNG LM SNG CA CHT CH IM KHI U

1. Sng lc
a s cc cht ch im khi u hin nay khng c khuyn co dng trong sng lc

pht hin sm ung th do c hiu v nhy thp. Tuy nhin c th dng sng
lc cho nhng nhm ngi c nguy c cao. V d: -FP i vi bnh nhn x gan
c nhiu nguy c mc ung th gan nguyn pht, Calcitonin i vi nhm ngi
trong nhng gia nh c nhiu ngi ung th tuyn gip.
2. Chn on ban u
Thng thng ng dng ny t c s dng v thiu c hiu v nhy. Kt

qu m tnh hay dng tnh cng khng c gi tr quyt nh chc chn c hay khng
c ung th.
3. Xc nh c quan c khi u
PSA hoc PAP tng cao trong bnh u tuyn tin lit, thyroglobulin tng trong ung
th tuyn gip th ty. Sau phu thut ct b tuyn gip ton b nu thyroglobulin
tng tr li chng t bnh ti pht.
4. Xc nh giai on
Mt vi cht ch im khi u c nng lin quan n giai on bnh, phn nh

c gnh nng ung th. V d: CEA trong ung th i trc trng, CA 125 trong ung
th biu m bung trng
5. Tin lng
Mt s cht ch im khi u c gi tr tin lng: tp trung cao c gi tr tin

lng xu. o gi tr trc v sau iu tr s c th bit tin lng ca bnh. V d:
CEA, CA 125, CA
15-3, 2-Microglobulin
6. Kim tra kt qu iu tr v theo di
l ch nh quan trng nht ca cht ch im khi u, l cch kim tra sm v c

hiu qu kt qu iu tr bng phu thut, tia x, ho cht
- Cc ch im khi u tr v mc bnh thng chng t ly i ht hoc thoi lui

ton b khi u.
- Tn ti dai dng mc bnh l hoc tng ln sau thi gian ngn xung dc
chng t bnh vn cn tn ti hoc xut hin di cn.
- Tng ln tr li sau khi n nh mc bnh thng (v d sau phu thut),

chng t bnh ti pht.
Bng 2. Tm tt gi tr p dng lm sng ca mt s CCUT chnh:
Theo di sau iu tr
u tin
UT Theo di p
nguyn ng vi iu
pht tr
CCUT
CA UT v Sng
Khnglc Chn
Khng Theo di cc BN c Hu ch
27.29 on nguy c ti pht cao.
nh gi lng CA
27.29 mi 4 n 6
thng
CEA UT i Khng Khng BN c nguy c ti Rt hu ch

trc pht cao cn nh
gi CEA mi 2 n
3 thng trong t nht

trng
2 nm
CA 19- UT ty, Khng Gi Khng Hu ch
9 UT chn
on UT
ty
ng
AFP HCC, u Khng UT khng BN UT t bo mm Cn thit
mt
t bo r khng phi trong UT TB
mm nguyn seminome, XN AFP mm
khng pht bit v -hCG mi 1 n khng
phi ha km; 2 thng trong nm phi
semino BN x u, sau mi 3 seminom. Rt
me gan km thng vo nm th 2 c gi tr theo
khi u ri XN th dn di sau iu
gan tr HCC
Khi u t Khng UT khng Khi u t bo mm Thit yu i
bo r khng phi vi bnh
mm nguyn seminom; UT l nui nhn u t
non pht bit thai ngh n, o mc bo mm
semino ha km, -hCG mi thng/ln khng
-hCG
m, bnh bnh l trong 6 n 12 thng seminom
l phi phi thai hoc bnh l
thai nui thai
ngh n
CA 125 UT Khng Gi Xt nghim mi 3 Rt hu ch
bung chn thng trong 2 nm iu tr.
trng on khi u sau thc
u vng hin tha hn.
chu
BN mn
kinh,
bng c
tnh
ph n b
UT khng
PSA UT tin C UT
r khng Xt nghim PSA Rt hu ch
lit r
nguyn mi 6 thng trong
tuyn nguyn
pht. 5 nm u sau
pht, xt nghim hng
scan nm. Nu PSA tng
xng c tr li sau ct b
tn tin lit tuyn hoc
thng sau iu tr tia x
rng v lun cho thy ti
khi u pht.
tin lit
tuyn
Bng 3. Cht ch im UT nguyn pht, th pht v ti pht
PSA ton phn
Microglobulin
Thyroglobulin
Loi Ung th
CYFRA 21-1
PSA t do
CA 15-3
CA19-9
CA72-4
CA 125
Feritin
HCG
CEA
NSE
AFP
2
i trng
Ty
D Dy
Thc qun
Gan
ng mt
Bung trng
C t cung
Nguyn bo nui
UT phi TB nh
UT phi khng
phi
Tin lit tuyn

TB nh
Bng quang
Tuyn gip

U lymph c
UT + thiu mu
UT nguyn bo
cht ch du
: cc cht ch du nguyn pht : cc cht ch du th pht : cc
ti pht
Ch thch: CEA: Carcinoma Embryonic

Antigen.
FP: foetoprotein.
HCG: Human Chorionic

Gonadotropin.
CA 15-3: Cancer Antigen 15-3.
CA 19.9: Cancer Antigen 19.9
CA 72-4: Cancer Antigen 72-4
CA 125: Cancer Antigen 125
PSA: Prostate Specific Antigen
PAP: Prostate Acid Phosphatase
2 Microglobulin: Beta 2 Microglobulin

NSE: Neuron Specific Enolase
1. Nguyn B c. 1999. Bi ging ung th hc. Nh xut bn Y hc. Trang 58-64.
2. Nguyn Th Khnh, Phm T Dng. 2002. Xt nghim s dng trong lm

sng. Nh xut bn Y hc.
3. Richard D. Love, 1995. Cm nang ung bu hc lm sng (Ti liu dch t Manual
of Clinical
Oncology).. Nh xut bn Y hc, Trang 160-184
II. TI LIU TING ANH
1. David N. Lewin. 2000. Laboratory Medicine. Trang: 400 408.
2. Greg L. Perkins, Evan D. Later, 2003. Serum Tumor Markers.

9. IU TR PHU THUT BNH UNG TH
iu tr phu thut ung th bt u t thi c i v mt thi gian di phu

thut l phng php duy nht iu tr ung th. n nay phu thut vn l hn
tng trong cc phng php iu tr ung th hin i. Theo cc tc gi
Timothy.J.Eberlein hoc nhm tc gi John M.Daly th ngy nay c khong 60% n
75% bnh nhn ung th c iu tr bng phu thut v cc k thut ngoi khoa
cn c s dng chn on, xp giai on cho hn 90% cc bnh ung th.
Nhng tin b vt bc trong nhng nm gn y v k thut m, gy m, hi sc

ci thin mt cch ng k hiu qu ca phu thut. Ngoi ra, nhng nghin cu
v kt qu lm sng gn y cho thy phi hp phu thut vi cc phng php
iu tr khc lm tng hiu qu ca iu tr.
I. S LC LCH S
Phu thut ung th pht trin theo thi gian cng vi vic ng dng nhng thnh
tu trong lnh vc gy m hi sc, chng ta im qua vi mc lch s quan trng
sau:
- Albert Theodore Billroth ( 1829-1894 ) thc hin ln u tin ct d dy, ct thanh

qun v thc qun.
- William Stewart Halsted (1852- 1922) ra nguyn tc ct b ung th thnh mt
khi c bit l trong phu thut ct b ton b v trit cn thnh mt khi v sau
phu thut ny mang tn ng.
- Hugh Young (1870- 1945) thc hin phu thut ct trit cn ung th tin lit tuyn.
- Enrst Wertheim (1864- 1920) thc hin phu thut ct t cung trit cn nm 1904.
- William.E.Miles (1869- 1947) thc hin ct b trc trng trit cn qua ng

bng-tng sinh mn nm 1906.
- Evats Graham (1833- 1957) thc hin phu thut ct phi trit cn thnh cng
do ung th phi nm 1933.
Ngy nay nhng k thut phu thut hin i pht trin mt cch nhanh chng
nh vi phu thut, phu thut ni soi s ha hn nhiu thnh cng trong phu thut
ung th.
II. CC NGUYN TC CA PHU THUT UNG TH
1. Tho lun a phng thc iu tr trc khi phu thut
Ngoi tr nhng trng hp cp cu, bc s phu thut nn hi chn vi cc thnh

vin khc nh bc s x tr, bc s ho tr thng nht mt liu trnh iu tr cho
mi bnh nhn.
2. C kt qu chn on gii phu bnh trc khi phu thut

y l quan im quan trng nht trong phu thut ung th: phu thut vin phi
bit v loi m bnh hc ca khi u trc khi thc hin phu thut ct b.
Trong ung th v, phi c kt qu sinh thit bng kim hoc sinh thit m chng t
tnh cht c tnh ca nhng hnh nh nghi ng trn phim chp nh nh. i vi ung
th u c v mt s loi ung th khc nh d dy, phi, i trng thc hin sinh
thit qua ni soi trc khi phu thut.
Trong nhng trng hp hn hu khng th sinh thit c c th thc hin phu
thut thm d. Trong nhng trng hp phu thut vin nn kt hp vi bc s
gii phu bnh thc hin sinh thit tc th trc khi quyt nh ct b.
3. Vit bn tng trnh v phu thut
Bn tng trnh v phu thut l ti liu quan trng nht trong h s ung th
ca bnh
nhn. Bng tng trnh nn vit ngay sau khi m xong v nn m t chi tit mt s
ni dung sau:
+ M t chi tit nhng thng tn quan st c:
+ Kch thc ca khi u nguyn pht
+ V tr chnh xc ca khi u
+ Lan trn ti cc cu trc ln cn

+Dnh ca khi u vi c quan ln cn
+ Kch thc v v tr ca cc hch di cn
M t r rng cc thao tc thc hin trong phu thut
+ Nhng thao tc thc hin v khng thc hin do k thut hoc l do khc.
+ V tr chnh xc ca clip li trn din khi u ct b.
+ M t chnh xc khi u li sau phu thut, cc mu bnh phm c ly

lm xt nghim.
+ Cc mu bnh phm c bit lm xt nghim sinh hc phn t.
M t chnh xc hon thnh phu thut
+ M t r rng phu thut c hon thnh.

+ M t bn cht ung th ca phu thut (cc b mp ct).
+ V tr chnh xc v m t khi u li sau phu thut.

Chun b bnh phm xt nghim gii phu bnh
+ Ly cc b ng bnh phm ring cho tng mu bnh phm khc nhau
+ Cc mp ct ca bnh phm phi c nh du.
+ Mu bnh phm phi nguyn vn, khng nn ct nh ra.
+ Mu bnh phm phi c b vo dung dch bo qun (formalin hoc dung dch
mi khc) nu phi chuyn bnh phm trong thi gian di.
+ Mu bnh phm cho cc xt nghim sinh hc phn t phi c chuyn i ngay

v bo qun theo ch ring.
+ Mu bnh phm cho nui cy m phi bo qun trong mi trng c bit.
S chun b bnh phm cn thn nh vy gip cho cc nh gii phu bnh thc hin
c xt nghim c cht lng v tr li mt cch chnh xc kt qu gii phu
bnh v cc nh sinh hc thc hin cc xt nghim sinh hc chun mc hn.
III. CC LOI PHU THUT UNG TH

1. Phu thut trit cn
Quan nim ct b t chc ung th thnh mt khi
Trn quan nim t chc ung th thng xm ln, pht trin ra t chc chung
quanh, khng xc nh r ranh gii ca khi u nn phu thut trit cn l phi ct b
t chc ung th thnh mt khi gm: khi u, c quan mang khi u, t chc lin kt
chung quanh khi u cng vi h thng bch huyt v hch bch huyt vng. Kh
nng di cn hch vng l rt ln, do nn phu thut vt cc hch v tinh ngay c
khi v i th n cha c du hiu xm ln. Ti thiu nn vt hch mc I v ly ht
t chc lin kt nm gia khong u v hch.
Trong nhng trng hp kh khn c th thc hin ct b gii hn, ct b hon
ton khi u mt cch rng ri n gii hn b khi u khng tm thy t bo ung th.
Nh vy phu thut vin phi lin h vi bc s gii phu bnh trong lc m s
lm xt nghim sinh thit tc th xc nh xem b mp ct sch t bo ung th
cha.
2. Mt s phu thut trit cn chnh
i vi ung th tiu ho mt s phu thut trit cn c thc hin:
- Ct ton b thc qun trong ung th thc qun.
- Ct ton b d dy hoc ct rng ri d dy km vt ton b hch trong ung th

d dy.
- Ct na i trng phi trong ung th manh trng km theo vt hch cho n gc

ng mch i trng.
i vi ung th v: ct b ton b tuyn v km theo vt hch nch.
i vi ung th h sinh dc: ct b t cung ton phn km theo vt hch chu hai
bn l phu thut chun i vi ung th c t cung v ung th thn t cung.
Trong niu hc, i vi ung th tinh hon ct b ung th tinh hon qua ng bn,
gm buc thng tinh ln cao trnh pht tn t bo ung th.
i vi ung th bng quang nam gii, ct bng quang ton phn km ti to li

bng
quang.
3. Nhng hn ch ca ct b ung th thnh mt khi
Quan nim ct b ung th thnh mt khi i khi kh p dng trong mt s

trng hp, do gii thch nhiu tht bi trong phu thut.
i vi ung th bung trng, v lm sng t chc ung th thng xm ln lan to
phc mc lm cho phu thut rt kh khn. Mt s phu thut vin ngh ct b
hon ton phc mc, tuy nhin phu thut ny gy nhiu bin chng v ngi ta
t b .
Vi ung th tin lit tuyn, ct b ton b tin lit tuyn l phu thut trit cn, tuy
nhin phu thut vin mun bo tn dy thn kinh cng dng v tiu tin t ch
nn phi thc hin phu thut gii hn v iu tr x tr hu phu h tr.
Trong phu thut ung th vng u c gii hn cc mc gii phu rt gn gii hn

thng tn cn ct b, do khng cho php phu thut rng ri, cn b sung x tr
sau phu thut.
4. Vai tr ca vt hch trong phu thut ung th
Mc ch ca vt hch mt cch h thng trong phu thut ung th l xc

nh kh nng tin trin ca ung th. Hch b xm ln l mt yu t tin lng ng
tin cy: cng nhiu hch xm ln tin lng cng xu.
Vt hch c thc hin bt u t khi u v vt theo tng trm hch t mc mt

n cc mc k tip. Di cn hch cng xy ra tun t, hin tng nhy cc l rt
him.
Nhn chung, vt hch nn quan tm ti trm hch u tin, b i v qua khi trm
hch ny ung th xem nh c kh nng di cn. Nhiu nghin cu cho thy phu
thut vt cc hch b di cn hu nh khng lm thay i tin lng ca bnh
nhng cng trnh c chn p, au khi hch ln.
trnh nhng bin chng trong vt hch rng ri (nh ph bch mch chi trn v
chi di), nhiu nghin cu c thc hin vi nhng khi u nh, thng
nhng u ny khng c di cn hch, nh vy vt hch tr nn v dng (v d nh
khi u v nh hn 5mm, ung th c t cung xm ln vi th).
Trong phu thut ung th v nhiu nghin cu v hch gc (sentinel node), l hch
trm hch u tin c ch { nhiu nht. Ngi ta dng k thut pht hin
hch bng cch tim cht mu (Evans Blue) hoc bng ng v phng x chung
quang khi u, cht mu i theo h bch huyt v nhum xanh hch gc gip phu
thut vin d nhn bit bc hch lm sinh thit. Nu tim cht ng v phng x
ngi ta s dng u d phng x pht hin hch gc.
5. Phu thut ung th gii hn
Phu thut ct b rng ri ung th thnh mt khi cng gy ra nhiu tranh ci,
b i v theo quan st ngay c khi khi u ang cn ti ch, thc s c di cn m
lm sng cha pht hin c, do phu thut ct b trit cn khng lm thay
i c tin lng. V d v ung th v:
Cc nghin cu ngu nhin chng minh rng phu thut bo tn bng ct b

khi u v rng ri (mammary lumpectomy) n b mp ct khng cn t bo ung
th km x tr v sau m cng c kt qu ging nh ct b ton b v trit cn. Yu
t tin lng chnh l tnh trng ca hch v tinh. ng knh ca khi u c ct
b khng lm thay i nguy c di cn xa.
Khi hch nch dng tnh hoc khi u c bit ho km, iu tr ho tr h tr

hoc ni tit ng vai tr quan trng trong liu trnh iu tr.
6. Phu thut gim th tch khi u
i vi mt vi loi ung th, mong mun ca phu thut vin l phu thut lm
gim ti a th tch ca khi u trc khi s dng cc phng php iu tr khc nh
x tr hoc ho cht. in hnh l trong ung th bung trng v lymphom Burkitt.
7. Phu thut d phng
Cng ngy ngi ta cng xc nh c thm nhng bnh l m vi thi gian s pht
trin thnh ung th. iu tr khi nhng bnh l ny bng nhiu phng php
trong phu thut l mt phng php chnh s loi b c nguy c mc ung
th nh:
- H tinh hon lc ch d phng ung th tinh hon
- Ct b i trng trong vim lot i trng mn, bnh a polip i trng trong d
phng ung th i trng.
- Ct b polyp i trc trng trc tui 20, phu thut ct tn thng vim i trc
trng chy mu.
- Ct tuyn gip phng nga ung th tuyn gip th ty bnh nhn a u tuyn
ni tit MEN II.
- Ct b rng ri trong bnh l bch sn d phng carcinoma t bo gai.
- Ct b tuyn v hoc bung trng do nhng thng tn lnh bt thng nhng
gia nh c t l ung th v v bung trng cao.
8. Phu thut chn on bnh ung th

Phu thut chn on ch yu l thm d ly mu bnh phm lm xt nghim
m bnh hc. Gm cc loi: chc ht sinh thit, khot chp hoc phu thut ct b
sinh thit. Chn on chnh xc bng m bnh hc l c s lp k hoch iu tr
ung th mt cch chnh xc v hiu qu.
Chc ht bng kim nh xt nghim t bo hc.
Sinh thit bng kim ln (True-cut, Vim- Silverman, Franklin).
M sinh thit: C th ly trn khi u hoc ct mt phn lm xt nghim m bnh

hc.
M thm d i vi nhng khi u bng v d nh u mc treo rut, u c thnh rut
v.v. Mt s lu trong phu thut chn on:
- Ly mt mu m in hnh vi c b m bnh thng.
- Khng sinh thit vo m hoi t.
- Trnh gieo cy vo m bnh thng ln cn.
- ng rch da sinh thit phi nm trong phn m m s c ct b b i mt

phu thut iu tr tn gc tip theo sau.
- Cung cp nhng thng tin lm sng cn thit cho nh gii phu bnh.
9. Phu thut nh gi tin trin ca ung th
i vi mt s khi u, phu thut l mt cng c rt quan trng nh gi p

ng ca khi u i vi ho tr liu. Mt trong nhng in hnh l phu thut thm
st ln hai (second look laparotomy) trong ung th bung trng. Phu thut ny
c thc hin mt cch h thng nh ga p ng ca ho tr v kt thc
iu tr. Trong thc t ngi ta chng minh rng phu thut nh vy khng
thay i c thi gian sng thm ca bnh nhn, do phu thut m bng thm
st ln 2 ngy nay ch cn thc hin trong nghin cu lm sng.
Ngy nay ngi ta s dng Pet-Scan chn on trc khi phu thut, nh vy
trnh c phu thut khng cn thit.
10. Phu thut i vi nhng khi u ti pht v di cn
10.1.Phu thut khi u ti pht
Mt s khi u ti pht xy ra sau iu tr bo tn th nn thc hin phu thut trit

cn
- i vi ung th u c: ct ton b thanh qun sau iu tr bo tn ti pht.

- Trong mt s ung th ph khoa c iu tr bng x tr n thun ti pht: ct
rng ri vng chu i khi kh thi.
- i vi ung th v m ct u bo tn v (lumpectomy): khi ti pht mun xy
ra, ngi ta ngh ct b ton b v.
Tuy nhin trong mt s trng hp khi u ti pht sau iu tr tia x, khng th

ct b rng ri c th c th ct b khi u tm thi lm sch, gim au v gim
nh triu chng.
10.2.Phu thut nhng khi u di cn
Trong qu kh ngi ta khng thc hin phu thut i vi cc khi u di cn. Di cn

xy ra trong thng u hoc nm u sau phu thut chng t rng di cn c
trong thi gian phu thut, tuy nhin khi u qu nh chng ta khng th pht hin
c bng cc phng php thng thng.
Nhng nm gn y cc kin thc v sinh hc trong ung th dn hon thin v

ngi ta ngh ct b nhng khi u di cn vi nhng iu kin sau:
- Khi khi u nguyn pht n nh hoc bin mt
- Khi u ti pht xy ra phi cch ln phu thut u tin mt thi gian di, ti thiu
l 2 nm tr ln.
- Khi di cn l mt n c (c th 2-3 nhng nm chung mt ch).

- Khi phu thut tng i n gin khng nguy him n tnh mng bnh nhn.
11. Phu thut gim nh triu chng
Phu thut i vi di cn xng
Gy xng bnh l (do di cn) s c kt hp xng nh gy xng bnh thng

lm cho gy c bt ng tt. Mc khc di cn xng xy ra khng c ngha l
bnh nhn sp t
vong, n bo hiu bnh nhn ri vo giai on suy kit (nm lit gng, nguy c l
lot cc im tz, mt kh nng t phc v). iu tr tch cc s gip bnh nhn c
th phc hi c vn ng v trnh c cc bin chng do nm lu.
Cc tc gi khuyn nn phu thut phc hi nhanh chng gy xng bnh l khi

c th hi phc li vn ng cho bnh nhn. Mt s trng hp in hnh sau:
- Gy c xng i do di cn xng: phu thut thay khp hng
- Gy thn xng i: ng inh ni tu
- Xp ct sng: phu thut lm vng ct sng (corporeal cementoplasty)
S hin din ca cc khp gi l khng chng ch nh trong x tr.
Trong trng hp di cn ct sng c chn p tu (xut hin lit) phi can thip phu
thut sm trc 24 gi, sau 24 gi xut hin thng tn mch mu do chn p tu.
Nh vy chn on chn p tu nn c iu tr cp cu v nn chuyn nhanh
bnh nhn n phu thut vin m gii phng chn p v c nh. iu tr tia x
b sung cng c ch.
12. Phu thut tm thi
Phu thut tm thi c thc hin khi khi u gy ra tc nghn ng h hp,

tiu ho
hoc tit niu.
Mt s phu thut in hnh:
- M kh qun (i khi phi thc hin cp cu) i vi ung th u c hoc ung

th tuyn gip.
- Lm hu mn nhn to trong trng hp ung th ng tiu ho hoc bung

trng.
- M thng d dy nui dng i vi ung th thc qun hoc ung th u c.

- M thng niu qun hoc bng quang trong trng hp ung th tin lit tuyn
hoc ung th ph khoa.
- t shunts ni s trong trng hp tng p lc ni s.
trnh nhng chn tng v mt tm l cho bnh nhn trc khi phu thut,
phu thut vin nn gii thch r cho bnh nhn v gia nh. Phu thut khng nn
thc hin qu mun khi cc chc nng ca c th b thng tn, cng khng nn
thc hin qu sm bnh nhn kh chp nhn.
13. Phu thut lm sch
Phu thut lm sch cng c ngh thc hin khng phi mc ch iu tr m

ch lm cho bnh nhn thoi mi hn.
Cc khi u hoi t khng ch gy ra au, n cn c mi hi, chy mu, bn thu kh

nhn lm cho bnh nhn v gia nh khng thoi mi. Ch nh ct b u hoi t
em li s thoi mi cho ngi bnh.V du nh ct b v i vi nhng ung th v
l lot ra da, ct b nhng ung th rut non mc d c di cn gan, ct b cc
ng d.
14. Phu thut v ni tit
Phu thut v ni tit l phu thut ct b mt tuyn ni tit m cht tit ca n

lin quan n s pht trin ca khi u. Trong thc hnh ch c 2 loi ung th thng
hay thc hin:
- Ct b 2 bung trng trong ung th v c lin quan n ni tit nhng ph n

cn kinh nguyt.
- Ct b 2 tinh hon nhng bnh nhn ung th tin lit tuyn.

15. Phu thut to hnh
Hu ht cc phu thut ct b trong ngoi khoa u nhm vo mc ch bo tn

chc nng cc c quan ca c th khi c th c. Tuy nhin trong phu thut
ung th, m bo mp ct an ton phi ct b rng ri khi u, nh vy phu
thut ti to li tr nn l mt phng din rt quan trng trong phc hi iu tr
cho bnh nhn. i khi phu thut to hnh c thc hin cng mt lc vi phu
thut ct b.
- Ti lp lu thng tiu ho (rut, thc qun).
- To hnh bng quang bng cc quai rut trong ct bng quang ton b.
- To hnh thanh qun bng Prosthesis trong ct thanh qun ton phn.
- To hnh v sau phu thut ct v.
- Lm prosthesis tinh hon sau ct b tinh hon.
- Lm li mt gi sau phu thut ct b nhn cu.

Trong mt s trng hp phu thut to hnh c thc hin sau khi hon tt
cc iu tr h tr:
- To hnh v sau khi iu tr ho tr hoc x tr h tr sau phu thut.
- Trong ung th xng, to hnh li xng sau khi iu tr ho tr
Cui cng, mt s phu thut to hnh nhm mc ch sa cha li cc di chng do

iu tr:
- To hnh li xng hm sau khi xng hm b hoi t do x tr.
- To hnh phc tp sau cc phu thut rng ri vng u c.

16. Phu thut gim au
Phu thut gim au c ch nh trong nhng trng hp c bit khi m cc

thuc gim au iu tr khng c hiu qu. Chng l cc th thut gim au
c thc hin trong phng m:
- Kch thch thn kinh qua da
- Gy t qua tu sng
- Trong mt s t trng hp thc hin phu thut ct b thn kinh
17. Phu thut kt hp vi iu tr a m thc
Theo thng k ca mt s tc gi, khong 70% cc trng hp phu thut n

thun b tht bi thng do ti pht ti ch, ti vng hoc xut hin di cn sau m
(thng c vi di cn trc lc m). Do t c kt qu iu tr tt phi
kt hp iu tr a m thc ngha l s dng nhiu phng php iu tr b
khuyt cho nhau. Trong ung th ngi ta thng kt hp phu thut, x tr v cc
phng php iu tr ton thn gm ha tr, min dch, ni tit v cc phng php
khc.
Phi hp trc m: S dng x tr n thun hoc kt hp x tr v ha tr trc

m i vi mt s loi ung th nh ung th v giai on xm ln rng ti ch, ti
vng, ung th vng u c, ung th trc trng xm ln chy mu. Sau khi tia x khi
u nh li, chy mu to iu kin thun li cho phu thut trit cn.
Phi hp sau m: iu tr x tr sau m s lm gim nguy c ti pht ti ch i vi

mt s loi ung th: ung th v, sarcome phn mm, ung th u c v ung th
trc trng.
Phi hp phu thut v x tr sau m cn cho php iu tr bo tn ung th v

khi khi u cn nh (ct rng khi u + vt hch nch + x tr vo v v h thng
hch v trong, hch thng n. Trong sarcome phn mm c th ct u rng ri
km x tr bo tn chi.
IV. KT LUN
Vi nhng tin b nhanh chng trong lnh vc phu thut, x tr, ha tr v nhng
liu php mi nh min dch, ni tit tr liu, phu thut phi ng mt v tr c
bit h tr cho cc phng php iu tr trn. Bc s phu thut ung th phi
c hun luyn v x tr v ha tr a ra ch nh iu tr ph hp vi tng giai
on bnh.
Trong nhng trng hp phu thut phc tp, bc s phu thut ung th phi can
m v bn lnh, tuy nhin cng phi bit lc no nn dng li nhng ch cho
bc s x tr hoc bc s ni khoa ung th.
1. B Y t, Bnh vin K, 1999. Hng dn thc hnh chn on u tr ung th,

trang 15-24.
2. i hc Y khoa H Ni, 2002. Bi ging ung th hc, trang 68-74.
3. Nguyn Hng Ri, Ph c Mn, Nguyn Chn Hng, 2004. i cng phu tr
ung th-Ung bu hc ni khoa, nh xut bn Y hc, trang 72-86.
II. TI LIU TING ANH

1. Daly. J.M Bertagnolli. M, Decosse. J.j, Morton. D.l. Oncology. In: Mc graw-Hill
internatonal edition. Principles of Surgery. Pp297-360.
2. Rosenberg.S.A. Principles of Cancer Management: Surgical Oncology. Principles

& Practice of Oncology, 5th edition, pages 295-306.
10. IU TR TIA X BNH UNG TH
I. I CNG
iu tr tia x c p dng iu tr ung th hn 100 nm qua vi mc u tin

c nh du l Roentgen khm ph ra tia X nm 1895, sau ngi ta bt u p
dng tia X iu tr ung th. T ,iu tr ung th bng tia phng x pht
trin thnh mt chuyn khoa su trong Y hc.
Gia nh Curie pht hin ra cht phng x Radium nm 1898 v sau

Alexander Graham Bell gi s dng n trong iu tr tia x p st bng cch cm
trc tip vo khi u c tnh di dng cc cy kim. Sau ngun phng x bng
cobalt v caesium c a vo s dng. Cui nm 1940 tia x bng my gia tc
(linear accelerators) ra i v pht trin.
Thi gian u p dng iu tr tia x, ngi ta thiu cc phng php tnh

ton gii hn liu lng mt cch chnh xc. Quy nh n v chun ca phng x
u tin l liu gy ra da. Mt trong nhng yu t lm hn ch iu tr trong thi
gian ny l do mc chu ng ca da km, do ngi ta khng dm nng liu ln
cao.
Nhng tr ngi ban u c Courtard gii quyt nm 1934 bng cch p
dng tia x phn liu ngha l chia tng liu thnh nhng liu nh hn lm nn tng
trong lnh vc x tr cho n nay.
Vi s khm ph ra my chp ct lp vi tnh ca Godfrey Hounsfield, phng php

lp k hoch iu tr mi theo khng gian 3 chiu c thc hin v chuyn
hn phng php lp k hoch iu tr t 2 chiu sang 3 chiu. Bc s x tr v k s
vt l phng x khng cn b hn ch v liu lng b i v lp k hoch iu tr da
trn chp ct lp vi tnh cho php bc s o trc tip liu tia x cc v tr gii phu
da trn hnh nh ca cc mt ct ngang.
Trong vi thp nin tr li y, kz vng ca nhng k thut hnh nh mi nh cng

h ng t trong nhng nm 1970 v PET (positron emission tomography) trong
nhng nm 1980 cng nh s pht trin nhng my x tr c nng lng cao, cc
quang t v m in t c nng lng cao cng vi k thut s ha chuyn
iu tr tia x t khng gian 3 chiu thnh IMRT (Intensity Modulated Radiation
Therapy) thnh 4 chiu trong mt tng lai gn. Nhng tin b trong x tr em
li kt qu iu tr tt hn v t bin chng hn. Hin nay 70% bnh nhn ung th
c iu tr tia x nh mt phn trong liu trnh iu tr ung th.
II. CC LOI BC X ION HA
Trong nhng nm u ca th k 20 ngi ta pht hin ra rng mt vi cht c

trong t nhin b bin i t pht v cu trc ca chng lm cho chng tr nn
bn hn. Cc cht nh th c gi l cc cht phng x v s phn r phng x
c nh ngha l s bin i xy ra trong cc nhn ca nguyn t lm cho chng
bn hn.
Cc qu trnh phn r phng x dn n s pht x ca cc ht tch in v cc

tia. Hu ht s pht x l pht ra cc ht alpha, ht beta v tia gamma. Cc pht x
khc c th pht ra positron, tiaX, v rt him trng hp pht ra ntron.
Cc ht v cc tia c pht ra t s phn r phng x c nng lng bt
cc in t t nguyn t mi trng vt cht m chng i qua. Cc ht, cc tia ny
c xp loi l bc x ion ha. Nh vy bc x ion ha c nh ngha l mt
ht hoc mt tia bt kz c nng lng bt cc in t khi cc nguyn t,
phn t. Cc bc x ion ha bt kz t ngun no khi tc ng n c th con ngi
gy ra cc hiu ng sinh hc bc x lm tn thng cc t bo ca c th ngi.
1. Cc i lng v n v o
Nng lng ca bc x ion ha c o bng n v electronvolts(eV), l n v

rt nh ca nng lng. Mt electronvolt l nng lng thu c b i mt in t
khi gia tc qua hiu in th mt volt v mt cch ton hc bng 1,6x10-19 joules.
Trong thc t, n v ca nng lng bc x ion ha thng c biu din di
dng bi s ca electronvolt nh kiloelectronvolt (keV hoc 103 eV) hoc
megaelectronvolt (MeV hoc 106 eV).
2. Cc loi bc x ion ha
Cc pht x ph bin nht sinh ra t phn r phng x l cc ht alpha, cc ht beta

v cc tia gamma. Cc pht x khc c th bao gm cc ht positron, tia X v
rt him l cc ht neutron.
+ Ht Alpha: Ht alpha bao gm 2 proton v 2 neutron lin kt cht ch vi nhau.

N c th c coi l ht nhn ca nguyn t Heli c s khi nguyn t l 4u v
in tch l +2e. Ht alpha c biu din bng k hiu .
+ Ht Beta: ht Beta v c bn l ht in t m n c phng ra t cc ht nhn

phng x trong qu trnh phn r phng x. Chng c to ra khi 1 ntron trong
ht nhn chuyn thnh mt proton v 1 in t. Proton b gi li trong ht
nhn cn in t th c pht ra nh mt ht Beta. Ging nh cc in t, cc ht
beta c khi lng nh (xp x 1/1840 u, u l
n v khi lng nguyn t) v mt in tch m n l (tc l mt in tch
bng-1e). Chng
c k hin l .
+ Tia gamma: tia gamma l bc x in t c to ra t ht nhn ca mt nguyn

t. Bc x in t gm cc b nng lng cn gi l cc photon chng c truyn
di dng sng vi tc nh sng. Tia gamma khng c khi lng v in tch, n
c k hiu l .
+ Positron:Positron c to ra khi mt proton c bin i thnh 1 ntron v

mt in t dng( Positron). Ntron li trong ht nhn cn positron c
pht ra vi tc ln. Positron cng ging nh ht beta nhng khc bit chnh l
positron c mt in tch dng. V th cc positron c k hiu l + ch ra s
ging nhau v s khc nhau ca chng i vi cc ht beta.
+ Tia X : Ging nh tia gamma, tia X cng l tia bc x in t khng c khi lng
v in tch. Tuy nhin tia X khc tia gamma ch tia gamma c to ra b i s
bin i trong ht nhn ca mt nguyn t trong khi tia X c to ra khi in
t nguyn t b thay i v qu o.
+ Ntron (c k hiu l n) l ht c tm thy trong ht nhn ca mt nguyn

t vi s khi l 1u v khng c in tch.
III. C S SINH HC CA IU TR TIA X
C ch chnh xc ca s cht t bo do tia x l mt lnh vc ang c tch cc

nghin cu. Hin nay ngi ta tm ra mt s c ch sau:
Di tc dng ca bc x ion ho, trong t chc sng tri qua 2 giai on bin
i: giai on ho l v giai on sinh hc.
1. Giai on ha l{
Giai on ho l{ thng rt ngn, ch xy ra trong khong thi gian 10-16- 10-13

giy. Trong giai on ny cc phn t sinh hc cu to t chc sng chu tc dng
trc tip hoc gin tip ca bc x ion ho.
Di tc dng trc tip: bc x ion ho trc tip tc ng vo DNA trong nhn t

bo lm
DNA b t, gy lin kt lm cho t bo khng nhn ln c v cht.
Hnh 1: C ch sinh hc ca x tr
Di tc dng gin tip: bc x ion ho tc dng ln phn t nc (chim 75%

trong c th ngi) gy hin tng ion ho cc phn t nc to thnh cc ion H+
v OH-, cc hp cht c kh nng oxy ho cao HO2, H2O2, chng tc dng gin tip
ln DNA gy tn thng chng. Cc tn thng giai on ny ch yu l tn
thng ho sinh.
Tia phng x cng tc ng ln chu trnh t bo lm cho t bo tr nn gi yu v

cht theo lp trnh. Nhiu qu trnh hin nay bt u c lm sng t v vn dng
lm cho iu tr tia x ngy cng hiu qu hn.
2. Giai on sinh hc
Giai on ny c th ko di vi giy n vi chc nm sau khi b chiu x. Nhng tn

thng sinh ho giai on u nu khng c hi phc s dn n nhng ri lon
v chuyn ho, tip n l nhng tn thng v hnh thi v chc nng ca t bo.
Kt qu cui cng l nhng hiu ng sinh hc trn c th sng c biu hin ht sc
a dng.
Cc yu t nh h ng n sinh hc bc x
3. Liu chiu
Liu chiu l yu t quan trng nht quyt nh tnh cht v tn thng sau chiu x
Liu cng ln tn thng cng nng v xut hin cng sm.
Bng 1: Liu chiu
Liu Hiu ng
0,1Gy Khng c du hiu tn thng trn lm sng. Tng sai lc
nhim sc th c th pht hin c.
1Gy Xut hin bnh phng x trong s 5-7% c th sau chiu x.
2-3Gy Rng lng, tc, c thu tinh th, gim bch cu, xut hin
ban trn da. T
3-5Gy Gim bch cu nghim trng, ban xut huyt, xut huyt,
nhim
vong 10-30%khun, rng
s c th saulong tc.x.
chiu T vong 50% s c th
sau chiu x.
6Gy V sinh vnh vin c nam ln n. T vong 50% s c th
sau chiu x k c khi c iu tr tt nht.
4. Sut liu chiu
Cng vi mt liu hp th nh nhau, thi gian chiu ko di s lm gim hiu ng

sinh hc ca bc x. Nguyn nhn c gii thch b i kh nng t hi phc ca
c th cc mc liu khc nhau. Vi sut liu nh tc pht trin tn thng
cn bng vi mc hi phc ca c th. Tng sut liu th qu trnh hi phc gim
nn mc tn thng tng ln,hiu ng sinh hc s tng ln.
5. Din tch b chiu
Mc tn thng sau chiu x ph thuc rt nhiu vo din tch b chiu, chiu

mt phn (chiu cc b) hay chiu ton c th. Liu t vong khi chiu x ton thn
thng thp hn nhiu so vi chiu cc b.
6. Cc tn thng do phng x
6.1.Tn thng mc phn t
Khi chiu x, nng lng ca chm tia truyn trc tip hoc gin tip cho cc
phn t sinh hc c th ph v mi lin kt ho hc hoc phn ly cc phn t sinh
hc. Tuy nhin bc x ion ho kh lm t ht mi lin kt ho hc m thng
ch lm mt thuc tnh sinh hc ca cc phn t sinh hc.
6.2.Tn thng mc t bo
Khi b chiu x, cc c tnh ca t bo c th thay i c trong nhn v nguyn
sinh cht. Nu b chiu x liu cao t bo c th b ph hu hon ton.
Cc t bo khc nhau c nhy cm vi tia phng x khc nhau: Cc t bo non

ang tr ng thnh (t bo phi), t bo sinh sn nhanh, d phn chia (t bo c
quan to mu, nim mc rut, tinh hon, bung trng) thng c nhy cm
phng x cao. Cc t bo thn kinh, t bo lymph tuy thuc loi khng phn chia
nhng cng nhy cm vi tia phng x. Do vy
khng ch nh chiu x i vi ph n c thai, ang cho con b v c bit i
vi tr em nu khng bt buc.
6.3.Tn thng mc ton c th
Tn thng sm xut hin khi b chiu mc liu cao trong thi gian ngn (chiu
ton thn trn mc liu 500mSv).
IV. N V O BC X
V o bc x ion ho cng nh o lng bc x ni chung, hin nay tn ti hai h

thng n v: n v mi l n v h thng quc t cn gi l n v chun SI, n
v c l n v c bit. Nm 1974 U ban quc t v cc n v bc x
(International Commission on Radiation Units vit tt l ICRU ) ngh vic s
dng h thng quc t.
Trong o bc x tiu chun theo h thng quc t hin nay (SI), liu hp th bc
x c n v o l Joule trn kg, k{ hiu l J/kg.1 Joule trn kilgam (1 J/kg) l liu
hp th bc x m khi lng 1 kg ca cht b chiu x hp th c nng lng
bng 1 Joule ca bc x ion ho loi bt kz. n v 1 J/kg c gi l 1 Gray (k hiu
l Gy ); nh vy 1 Gy = 1 J/kg.
Bn cnh n v o chnh thng l Gray, ngy nay n v o ngoi h l Rad vn

cn c s dng rt rng ri trong lnh vc o liu hp th bc x.
1 Gy = 1 J/Kg = 100 Rad.
V. MC CH CA IU TR TIA X
1. iu tr tia x trit cn
Mc ch: Mc ch ca iu tr tia x trit cn l tiu dit hon ton cc t bo

ung th trong th tch c chiu x t c iu tr tn gc ca bnh ung th.
iu kin cn thit: Khng c di cn xa

Thi gian iu tr thng ko di nhiu tun b i v cn phi s dng liu dung np
cao trong khi phi bo v m lnh v nhm ti mc tiu khi u mt cch chnh xc.
iu tr trit cn, liu x tr cn thit kim sot khi u phi thp hn liu chu
ng ca cc c quan ln cn. Ranh gii gia thnh cng v tht bi l tng i
hp, do bt but phi thc hin k thut ht sc cht ch: phi cn nhc k gia
nguy c ti pht ti ch v nguy c hoi t nu chng ta tng hoc gim liu.
Ni chung, khi u pht trin nhanh nhy cm vi tia x hn l cc khi u xm ln.
Theo Pr.Jean-Pierre Gerard mc nhy cm ca nhiu loi khi u vi tia x nh

sau:
Bng 1: Mc nhy cm ca khi u vi tia x
Loi Ung th Liu trung bnh tiu dit khi u
Leukeamia 15-25 Gy
Seminoma 25-35 Gy
Dysgerminoma 25-35 Gy
U Wilms 25-40 Gy
Bnh Hodgkin 35-45 Gy
U lympho khng 35-55 Gy
Malpighian
Hodgkin carcinoma 55-75 Gy
Adenocarcinoma 55-80 Gy
Urothelial carcinoma 60-75 Gy
Sarcoma 60-90 Gy
Glioblastoma 60-80 Gy
Melanoma 70-85 Gy
2. iu tr tia x tm thi
Mc ch: lm gim s tin trin ca khi u xm ln rng ti ch hoc khi u

cho di cn khng th iu tr trit cn. iu tr nn rt ngn thi gian v liu
tng i thp hn liu iu tr trit cn.
3. iu tr triu chng
Mc ch: lm gim mt s triu chng chnh ca ung th giai on cui nh:
+ au: do di cn xng. Hiu qu gim au nhanh sau vi ln iu tr. Ngi ta nhn

thy rng 75% bnh nhn gim au mt phn hoc hon ton vo cui t iu tr.
+ Hi chng xut huyt.
+ Chn p: nh l chn p tu sng hoc r thn kinh. Chn p tu sng l mt

trong nhng cp cu ca iu tr tia x, iu tr cng sm cng tt ngay khi ngay khi
xut hin triu chng u tin. iu tr tng i c hiu qu nu bnh nhn cn
cm gic 2 chi di
VI. K THUT THC HNH X TR
iu tr tia x phi m bo nguyn tc liu ti khi u v che chn tt nht t

chc lnh
chung quanh. Thc hnh x tr lin quan n nhiu bc quan trng.
Ch nh iu tr tia x
Ch nh iu tr tia x c thc hin trong bui hi chn vi nhiu thy thuc ca

nhiu chuyn khoa khc nhau: Bc s x tr, bc s phu thut, bc s ni khoa ung
th, bc s gii phu bnh v bc s chn on hnh nh sau khi trnh by r rng
v khi u v tnh trng ton thn ca bnh nhn.
Mt vi bin php d phng trc khi x tr nn a ra tho lun tuz theo tnh
trng bnh
nhn:
- Chm sc v rng ming i vi cc ung th vng u mt c.
- Chm sc v dinh dng khi cn thit.
- S dng Corticoid tr liu trc khi tia x vo no.
- Lm cc xt nghim v mu, c bit l khi tia x vo mt th tch ln hoc tia x

sau iu tr ho cht.
- Lm cc xt nghim v Xquang c bit l CT-Scanner v cng h ng t xc

nh mt cch chnh xc th tch bia cn iu tr.
- i vi nhng bnh nhn b kch thch, au n phi dng thuc an thn, gim au
bnh nhn nm yn trong qu trnh iu tr.
- Vi nhng bnh nhn phu thut trc phi kim tra vt thng lin so
trc khi tin hnh iu tr tia x.
- Xc nh th tch bia
Xc nh th tch bia cn iu tr ph thuc vo cc yu t sau:
- Kch thc ca khi u (cn thm s phn tch ca cc bc s Xquang)

- Bn cht t nhin ca bnh ung th (v d: tia x mt cch h thng vo hch
thng n i vi cc ung th thc qun 1/3 trn).
- Bn tng trnh bin bn phu thut, bo co v xt nghim gii phu bnh hc

(ct b c hon ton khi u hay khng, xm ln v ca nhng hch ly ra lm xt
nghim hay cha.v.v.)
Tiu chun ca IRCU
Theo tiu chun ca IRCU (International Commission on Radiation Units

and
Measurements) ngui ta xc nh nhiu th tch iu tr tia x:

- Th tch bia th: GTV (gross target volume) lin quan n th tch r rng ca
khi u
- Th tch bia lm sng: CTV (clinical target volume) lin quan ti s xm ln ti cc

t chc chung quanh.
- Th tch bia lp trnh: PTV(planning target volume) lin quan ti bnh nhn, s di
chuyn ca khi u v s khng hon ho ca chm tia.
Lu rng cc m lnh nhy cm c th bao gm trong th tch bia lp trnh v to

thnh nhng nguy c chnh trong iu tr
S phn nh chnh xc ranh gii cn c chiu x, xem xt cc c quan c nguy
c b thng tn v liu lng chiu x l trch nhim ca bc s x tr v c s h
tr ca k s vt l phng x.
Di y l v d mt lp trnh iu tr ca ung th tin lit tuyn. Trc trng l mt

trong nhng c quan b nguy c chnh.
S ny c 4 trng chiu, trc trng tip nhn khong 85% liu chiu x (60-
65Gy) v
chm xng i tip nhn 50% liu chiu.
VII. LIU IU TR
Liu lng s dng trong iu tr tia x c o bng Gray (Gy). Theo qui c liu
iu tr thay i ty theo loi ung th v giai on ung th. i vi nhng trng
hp iu tr ng th trit cn, c bit liu iu tr cc loi ung th biu m c
thay i t 60 - 80 Gy.
Liu iu tr b tr thng trong khong 45Gy- 60Gy vi phn liu 1,8-2Gy (i vi

ung th v, ung th u mt c). Cc nh x tr ung th c th chn liu iu tr
da vo mt s yu t khc nh l bnh nhn ang iu tr ha tr kt hp, iu tr
x tr tin phu hoc hu phu v cn da vo mc thnh cng ca phu thut.
1. Phn liu iu tr
Tng liu iu tr c phn liu (tri di trong qu trnh iu tr) cho cc t bo

bnh thng c thi gian phc hi. Cch thc phn liu c th ha gia cc trung
tm iu tr x tr v ngay c theo c nhn cc bc s x tr.
Hoa kz, c, Chu u s phn liu sp xp i vi ngi ln l 1,8 - 2 Gy mi ngy,

5 ngy mi tun. Anh, phn liu thng thng l 2,67 - 2,75Gy mi ngy. i vi
tr em phn liu l 1,5 - 1,7Gy mi ngy.
Trong mt s trng hp, 2 phn liu mi ngy c s dng cui ca liu trnh
iu tr. Mt trong cc ch phn liu khc c bit l CHART (Continuous
Hyperfactionated Accelerated Radiotherapy ). CHART c dng iu tr ung
th phi, bao gm 3 phn liu nh mi ngy. Mc du c nhng thnh cng
ng k, CHART c th l mt cng vic cng thng cc khoa x tr.
2. Theo di iu tr
S gim st iu tr lin quan n iu kin k thut ca tia x, s dung np v hiu

qu thng do cc k s vt l m nhim.
Cc iu kin gim st k thut ca iu tr tia x:
+ K s vt l v k s in lm vic trong khoa x tr gim st cc thng s k

thut v h thng in ca my x tr.
+ H thng vi tnh kt ni vi my x tr kim tra thi gian iu tr v liu lng

ca mi trng chiu.
+ Bc s x tr kim tra t th chnh xc ca bnh nhn v chm tia phng x cc

bui iu tr u tin bng cch dng h thng n chiu laser(gammagraphies).
+ Trong cc bui iu tr tip theo k thut vin tip tc thc hin iu tr theo k
hoch
3. Theo di lm sng
Theo di bnh nhn trong sut qu trnh iu tr tia x l cng vic ca bc s tia x.
Khi bt u khm v iu tr ln u bc s tia x phi gii thch cho bnh nhn
phng thc iu tr v cc tc dng ph c th gp. Lo lng,bt an v trm cm
nn c xem xt v iu tr, nhng trng hp th trng km phi cho nhp vin
theo di v nn c ch v sinh, dinh dng hp l. Nn theo di u ng
trng lng ca bnh nhn. Theo di chnh xc kch thc ca khi u nh gi
hiu qu ca iu tr.
Nn c k hoch hi chn bnh nhn hng tun nh gi li p ng ca bnh

nhn vi iu tr (trng lng, th trng chung, cc c tnh v h to mu trong x
tr), cc phn ng ti ch. Bc s x tr cng phi nh gi v p ng ca khi u
cng nh cc yu t tm l lo lng ca bnh nhn.
Ngng iu tr tia x trong trng hp bnh nhn khng chu ng c.
Sau khi hon tt iu tr tia x, phi lm bn tng trnh chi tit v liu iu tr, k
thut iu tr s dng v p ng ca bnh nhn, bn tng trnh c g i n
cc thy thuc iu tr c lin quan v theo di.
VIII. IU TR KT HP
iu tr tia x c th kt hp vi phu thut, ho cht hoc iu tr ni tit.
iu tr tia x n thun: Ngoi tr mt s trng hp iu tr tia x triu chng,

iu tr tia x n thun c th thc hin mt s loi ung th: ung th u c,
ung th tin lit tuyn, ung th c t cung.ung th ng hu mn hoc bnh
Hodgkin.
Kt hp phu thut v x tr: thng c thc hin khi ung th ang cn giai
on ti ch v ti vng.
X tr hu phu: mc ch trnh nguy c ti pht ti ch, thc hin sau khi vt

thng lin so, thng khong 1 thng sau phu thut. V d x tr vo v sau m
ct 1/4 v, x tr vo vng c sau m ung th u c.
X tr tin phu: mc ch ca x tr tin phu l gim th tch ca khi u, bin

khi u khng ct c tr thnh khi u ct b c. Khong chng 2 thng sau x
tr, t chc x sau x tr gim nhiu thun li hn cho phu thut. V d nh x tr
tin phu trong ung th trc trng,c t cung.
Kt hp x tr v ho tr: nhn chung ho tr c ch nh khi khi u c kh nng cho

di cn cao. Ho tr cn c ch nh lm gim th tch khi u i vi nhng
khi u nhy cm vi ho tr trc khi phu thut hoc tia x.
Kt hp ho tr v x tr cng lm gia tng c tnh ca c 2 phng php iu
tr: c tnh trn h to mu, c tnh trn tim mch, c tnh trn phi.
Nhng phc iu tr mi c thc hin ci thin ti pht ti ch v trnh
phu thut ct b rng ri:
- Kt hp ho tr v x tr trong ung th thc qun.
- Kt hp x tr ngoi, x tr p st v ho tr i vi ung th c t cung giai on

mun trnh ct b rng ri vng chu.
- Kt hp x tr v ho tr trong ung th bng quang trnh ct bng quang.
- Kt hp x tr v ho tr trong ung th thanh qun sm bo tn ging ni.
X tr ton thn: X tr ton thn c ch nh chng thi loi mnh ghp trong
ghp tu xng i vi nhng bnh nhn iu tr ho cht liu cao trong bnh
bch cu cp. Bnh nhn nhn 1 liu 8Gy (liu gy cht ngi nu bnh nhn
khng c ghp tu kp thi). Liu tia x ny cho php ph hu cc t bo tu gy
thi loi mnh ghp.
IX. X TR P ST
Nguyn tc c bn: x tr p st l s dng ngun phng x t trong khi u pht

x. Nh vy khi u s nhn liu tia x cao nht v liu s gim nhanh ra t chc lnh
chung quanh.
Ngun phng x s dng l cc ngun mm c th un nn c nh Iridium 192

hoc Cesium 137 v k thut np ngun sau c c pht trin mt cch
nhanh chng trong x tr p st. Trc ht cc catheter rng c t vo bn
trong khi u vi gy t ti ch hoc gy m ton thn. V tr chnh xc ca catheter
v s phn b v liu lng c kim tra cht ch, sau tin hnh t ngun
phng x vo trong catheter.
u im chnh ca x tr p st l kh nng a liu phng x ln cao trong mt

th tch rt nh v liu gim nhanh ra ngoi vi khng nh h ng n t chc lnh
chung quanh. iu ny i hi cc bc s x tr c kinh nghim t mt cch
chnh xc catheter vo khi u v tnh ton chnh xc s phn b v liu lng.
Hnh: Dng c iu tr x trong
Cc phng php iu tr tia x p st
X tr p st xut liu thp: y l phng php iu tr x tr p st chun vi thi

gian x tr t 1 n 5 ngy vi sut liu thp (30-100cGy/gi). Liu im tip
xc ca ngun l cao nht nhng gim i mt cch nhanh chng (trong khong vi
mm), nh vy cho php bo v cc t chc lnh chung quanh.
Bnh nhn c gi li nm vi ngy trong phng tng c chn ch, c h

thng che chn bo v nhn vin y t trong qu trnh chm sc.
X tr p st sut liu cao: k thut ny s dng ngun gia tng hot phng x,
nh vy s gim thi gian tia x v gim thi gian bt ng bnh nhn.
Hnh: iu tr x p st ( Ung th c t cung )
Kt hp vi cc phng php iu tr khc: x tr p st ch l mt phn trong qu
trnh iu tr ung th. Thng thng x tr p st kt hp vi iu tr phu thut
(i vi phn ln cc ung th ph khoa), kt hp vi iu tr tia x ngoi (trong ung
th ph khoa hoc ung th tin lit tuyn) v mi y x tr p st cn kt hp vi
ho tr.
X.IU TR BNG NG V PHNG X (Radioisotope Therapy)
iu tr tia x c th thc hin qua ng tim truyn hoc bng ng ung. V d

nh chuyn Metaiodobenzynguanidine (MIBG) iu tr neuroblastoma, hoc
ung
Iode-131 iu tr ung th tuyn gip.
Nm 2002, c quan FDA ca Hoa kz cho php s dng Ibritumomabtiuxetan

(zevalin), l mt khng th n dng khng CD20 kt hp vi phn t Yttrium-90.
Nm 2003 FDA cho php Tositumomab Iodine-131 (Bexxar) kt hp vi mt
khng th n dng khng CD20. Nhng thuc ny l nhng tc nhn u tin
c gi l min dch phng x tr liu (radioimmunotherapy), chng c cho
php s dng iu tr bnh Non-Hodgkins lymphoma khng p ng vi cc
phng php iu tr khc
XI. CC PHN NG CA TIA X
iu tr tia x l phng php iu tr khng gy au. iu tr tia x triu chng vi

liu thp (v d iu tr tia x di cn xng ) thng rt t hoc khng gy ra triu
chng g. iu tr vi liu cao gy ra nhiu phn ng ph trong qu trnh iu tr .
Phn ng xy ra trong thi gian iu tr hoc 2-3 tun sau hon tt iu tr (phn
ng ph cp tnh), trong nhiu thng hoc nhiu nm sau iu tr (phn ng ph lu
di), hoc phn ng ph xy ra sau khi iu tr tia x li (phn ng ph tch ly).
Tnh cht, mc trm trng v thi gian ko di ca phn ng ph ty thuc vo
c quan tip nhn tia x, vo phng php iu tr (loi tia x, liu lng, sut liu
chiu, ha tr ng thi ) v ph thuc vo bnh nhn.
Hu ht cc phn ng do tia x l c th d on c. Phn ng ph thng gii
hn nhng vng b chiu x. Mt trong nhng mc ch ca iu tr tia x hin i
l lm gim phn ng ph ti mc thp nht v gip bnh nhn hiu c v i
mt vi nhng phn ng ph khng th trnh khi .
Bnh nhn thng c c phn ng cp v mn tnh, tuy nhin thy thuc quan tm
nhiu hn n phn ng mn tnh b i v phn ng cp tnh gy ra kh chu cho
ngi bnh nhng c th iu tr khi hon ton, phn ng mn tnh gy tn
thng t chc kh hi phc, ko di mn tnh v tin trin nng thm.
C 2 gi thuyt c a ra gii thch cho cc thng tn mn tnh. Mt l

thuyt cho rng thng tn mn tnh gy ra do s ph hu cc vi mch mu trong
qu trnh iu tr tia x, trong khi gi thuyt khc cho rng thng tn mn tnh do
s suy yu ca t bo mm sau x tr.
1. Phn ng cp tnh
Thng tn t bo biu m b mt (epithelial surfaces): cc t bo biu m b mt

nh da, khoang ming, vng hu hng, nim mc rut, nim mc ng tit niu.
Mc thng tn ty thuc vo s hi phc ca t bo biu m.
1.1.Da
Bt u tr nn mu hng v au sau vi tun iu tr v ko di sau khi kt thc

iu tr khong 1 tun v da c th b nt nhng thng hi phc nhanh chng.
Phn ng da c khuynh hng tr nn trm trng nhng vng c np gp ca da
nh np gp di v ph n, sau tai v cc im tz.
1.2.Cc biu m lt
Nim mc khoang ming, hu hng, thc qun v rut c th b thng tn do tia
x. Nu tia x vo vng u c, au v vim lot vng khoang ming, hu hng
thng xy ra. Nu trm
trng bnh nhn nut au, n ung km dn n suy kit. Mt mi v xy ra sm
trong tun th 2 iu tr km theo kh ming.
- Phn thp ca rut gi c th b nh h ng trc tip b i tia x do iu tr trc

tip vo vng hu mn trc trng, hoc b nhim x do iu tr tia x vo vng
khung chu nh tin lit tuyn, bng quang, c t cung .v.v. Triu chng c bit l
au, bng chng, tiu chy v nn ma.
1.3.Mu v c quan to mu
Biu hin lm sng l cc triu chng xut huyt, ph n,thiu mu. Gim lympho,
bch cu ht,tiu cu v hng cu. Xt nghim tu xng thy gim c 3 dng sm
nht l dng hng cu.
1.4.Sng ph
Sng n cc m mm c th gy ra nhiu triu chng trong qu trnh iu tr. Ph

no l bin chng thng xy ra trong khi iu tr tia x vo khi u no, hoc cc
khi u di cn ln no, c bit vi nhng trng hp c tng p lc s no trc
. i vi cc khi u gy cht hp gn hon ton khu knh (v d thc qun,h
hng thanh qun, kh qun, ng mt, trc trng), tia x c th gy ph n v tc
nghn hon ton. C th phng bng cch phu thut trc khi iu tr tia x
hoc dng steroids trong qu trnh iu tr tia x chng ph n.
1.5.V sinh
Bung trng v tinh hon rt nhy cm vi tia x, chng khng th to ra c giao

t sau khi hp th cc liu iu tr tia x thng thng, do cn che chn tt
khi iu tr tia x vo vng chu.
1.6.Mt mi ton thn

2. Phn ng mun
Cc phn ng mun lin quan n v tr, liu iu tr, th tch chiu x v thi gian
chiu x. Cc phng php iu tr khc nh l phu thut, ho cht lm trm
trng thm bnh lin quan n x tr
2.1. X ha
M b chiu x c xu hng tr nn t n hi thng do qu trnh so ha lan

ta.Tia x liu cao vo vng mt c gy x ho lm hn ch vn ng, gy kht hm
n ung kh khn.
2.2. Rng tc
Rng tc thng xy ra nhng bnh nhn x tr vo no. Khng ging nh

rng tc
trong ha tr, rng tc do x tr kh phc hi v thng ch gii hn vng b chiu

x.
2.3.Kh cc tuyn tit

Tuyn nc bt v tuyn l chu c liu khong 30Gy trong phn liu 2Gy mi
ngy. Trong iu tr x tr ung th u mt c thng s dng liu cao hn nhiu
do thng gy tn thng tuyn nc bt v tuyn l gy kh ming
(xerostomia) v kh mt (xerophthalmia) lm nh h ng trm trng cht lng
sng ca bnh nhn. Cc tuyn m hi cng ngng hot ng gy kh da v kh
vng m o khi tia x vo vng chu.
2.4. Nghn cc h thng bch huyt di da gy ph bch huyt, c th kt hp vi

cc giai on vim qung (erysipelas).
2.5 Suy nhc
Suy nhc l triu chng thng thng ca iu tr tia x v c th ko di vi

thng n vi nm . Thiu nng lng, gim cc hot ng v lun lun cm thy
mt l cc triu chng thng xuyn.
2.7. Ung th
Tia x c th gy ra ung th, v ung th th hai bt gp mt s t bnh nhn

sau iu tr tia x.
2.8. Phn ng ph do tch ly liu (Cumulative side effects): phn ng phdo tch
ly liu khng nn nhm ln vi phn ng mun. Phn ng ph do tch ly liu s
bin mt trong thi gian ngn cn phn ng mun c biu hin lu di. Tia x li
nhng trng hp ny cn ang tranh ci.
2.9.Phn ng v sinh th
Gim tui th, c thu tinh th, tn sut xut hin bnh ung th cao hn l ung
th mu, ung th da, ung th xng, ung th phi.
2.10. Phn ng v di truyn
Tng tn sut xut hin cc t bin v di truyn, d tt bm sinh, qui thai. Hiu
ng ny cn gi l hiu ng ngu nhin do bn cht ngu nhin ca n. Hiu ng
ny xy ra trong ton b di liu
TI LIU THAM KHO.
1. Nguyn B c, Nguyn Chn Hng, 2002. Cng tc phng chng ung th Vit
Nam v vai tr ca ghi nhn ung th trong cng tc phng chng ung th. Ti liu
tp hun ghi nhn ung th
2. Phm Thy Lin, 1999 Tnh hnh ung th Vit Nam, nh xut bn Nng.
3. Oxford Handbook of Oncology 2002, Epidermiology of cancer, pages 3-11.
11. HA TR UNG TH
I. I CNG
Ha tr ung th l mt trong cc bin php iu tr ung th mang tnh cht ton

thn. Bn cnh cc phng php iu tr ti ch-ti vng nh phu thut v x
tr, cc bin php iu tr ton thn ngy cng c nhng ng gp quan trng
trong iu tr v chm sc bnh nhn ung th.
Ha tr ung th thng c hiu nh l phng php iu tr ung th bng cc

thuc ha hc gy c t bo (cytotoxic drugs) phn bit vi iu tr ni tit
(hormonotherapy) dng cc tc nhn ni tit v iu tr sinh hc (biologic
therapy) dng cc tc nhn lm bin i p ng sinh hc (biologic modulators).
Thc ra s phn nh trn ch c tnh cht tng i v hiu qu ca tt c cc
bin php iu tr ton thn trn u thng qua c ch tc ng cui cng l lm
thay i p ng sinh hc ca c th theo hng chng ung th. Hn na, tt c
cc tc nhn iu tr ton thn (thuc gy c t bo, ni tit hay min dch,
sinh hc) u c bn cht ha hc. Do vy ngi ta thng pht trin khi
nim ha tr ung th nh l bin php iu tr ton thn bng cc thuc ha
hc, cu thnh mt ni dung rt quan trng ca ung th hc ni khoa.
II. VAI TR CA HA TR I VI CC LOI UNG TH
Vai tr ca ha tr khc nhau theo tng loi ung th v theo tng tnh hung lm
sng c th. Tuy vy ngi ta thng chia thnh cc nhm theo mc p ng
vi ho tr:
Nhm ung th c th iu tr khi bng ho tr
+Bnh bch cu lymph cp tr em
+U lymph Burkitt
+Ung th nhau thai
+Ung th t bo mm tinh hon
+Bnh Hodgkin v mt s u lymph c khng Hodgkin c m hc thp

hoc trung gian
+ U Wilms
+ Ung th t bo mm tinh hon
Nhm ung th ho cht c kh nng ko di thi gian sng thm cho ngi bnh
+ Ung th biu m tuyn v
+ Bnh bch cu lymph mn
+ Mt s u lymph c tnh khng Hodgkin
+ Ung th biu m bung trng
+ Ung th phi t bo nh
+ U qui tinh hon
+ Ung th vng u mt c
+ Bnh bch cu tu cp
Cc loi ung th ha tr c vai tr ci thin thi gian sng thm

+ Sarcom xng
+ a u tu
+ Ung th phn mm
+ Ung th d dy
+ Ung th bng quang
+ Ung th tin lit tuyn
+ Ung th phi khng phi t bo nh
+ Ung th phi t bo nh
Cc loi ung th t nhy cm vi ha cht
+ Ung th i trc trng
+ Melanome c
+ Ung th ty
+ Ung th thn
III. C CH CA HA TR UNG TH
hiu r c ch ca iu tr ha cht chng ung th, chng ta cn nm mt

s khi nim v s pht trin ca t bo v tc ng ca thuc ln cc t bo ca
khi u sau y:
1. Chu kz t bo
Tng hp DNA khng din ra lin tc m gin on t pha phn bo (mitosis)

n kz phn bo khc. Thi gian gia 2 ln phn bo c chia thnh mt s giai
on.
Bao gm 4 giai on hay 4 pha.
Pha G1: Thi gian t lc kt thc phn bo n khi bt u pha S. Giai on

ny t bo tp trung chun b tng hp RNA v cc protein chc nng c lin
quan.
Pha S: giai on tng hp DNA
Pha G2: khong thi gian ngn nhn t bo chun b cho s phn bo. Pha M:
giai on phn chia t bo
Pha G0 gm cc t bo khng tham gia chu kz t bo. y l cc t bo khng

p ng vi cc tn hiu kh i xng vic tng hp DNA m cc t bo pha G1
vn c. Tuy
vy cc t bo pha G0 vn tng hp RNA v cc protein chc nng, vn duy tr
chc nng ca t bo bit ha. Cc t bo pha G0 cn l ngun d tr v sn
sng i vo chu kz t bo, tham gia phn chia ti lp, gia tng dn s ca khi
ung th.
Hnh 1. Cc giai on phn bo-s khng ng b dn s t bo

2. ng hc ca t bo
Khi u thng khng thun nht m c to b i hn hp t bo ti cc giai

on khc nhau. C ba nhm c m t:
Cc t bo tham gia vo cc giai on phn chia tc l nhm t bo ang trong

chu kz t bo.
Cc t bo c kh nng tham gia vo cc giai on phn chia nhng cha

tham gia phn chia gi l cc t bo pha G0.
Cc t bo c loi ra sau mi chu kz t bo v khng th quay tr li chu kz t

bo gi l cc t bo cht t nhin.
S lng t bo thuc mt trong ba nhm trn thay i tuz tng khi u, tng
loi bnh ung th v tng c th ngi bnh.
3. Thi gian nhn i
Thi gian nhn i ca ung th l thi gian cn cho mt khi u tng gp i s

lng t bo. Nghin cu invitro cho thy thi gian ny dao ng t 15 gi cho
n 72 gi.
U Thi gian nhn i (ngy)
U lymph Burkitt 1.0
Ung th nhau thai 1.5
Bnh bch cu cp th lymph 3-4
Hodgkin 3-4
U qui tinh hon 5-6
Ung th v 60
Ung th i trng 80
Ung th phi khng phi t bo nh 100
4. Khi u ln
Lm hn ch kt qu ho tr b i v:
- Mt s lng ln t bo thi kz G0
- H mao mch nui dng u khng ng nht, mt s vng thiu mu nui
dng hoc hoi t nn thuc ho cht kh vo.
- Mt s lng t bo i hi phi iu tr nhiu t, hnh thnh s khng

thuc.
Chnh v cc nguyn nhn trn, nn trong mt s trng hp nh ung th bung

trng ngi ta tin hnh phu thut cng ph khi u (debulking surgery) lm
tng nhy cm ca u cn li vi ho tr.
5. Thi gian iu tr
Hnh 2: Mi lin quan gia s t bo khi ung th v cc t ha tr
Da vo s trn chng ta nhn thy mi mt chu kz ha tr s tiu dit s l

ng khng i tng s t bo ung th ch khng tiu dit mt s lng tuyt
i t bo. Chnh v vy ha tr phi c thc hin qua nhiu t gim dn
dn s t bo ung th. Kh nng
tiu dit ton b t bo ung th bng ha tr l mt iu rt kh thc hin v

bn cnh s tch t c tnh khi ha lu di cn c hin tng khng thuc ca t
bo bu. Tnh trng bnh n nh lu di trong nhiu trng hp l do vai tr
min dch chng ung th ca c th ngi bnh.
6. S khng thuc
C ch nh sau:
+ Dng thuc khng liu
+ Gim hot tnh ca tng loi thuc
+ Gim s cung cp cc cht chuyn ha.
+ Vy gim thiu s khng thuc cn chon la thuc da theo nguyn tc
sau:
+ Ch s dng thuc khi bit c tc dng vi loi t bo
+ Dng cc loi thuc c cc c ch khc nhau ln cc giai on khc nhau ca s

phn chia t bo
+ Liu lng thuc khng ging nhau
+ C tc dng hip ng chng ung th
III. PHN NHM THUC CHNG UNG TH
1. Nhm chng chuyn ho
Tc ng vo qu trnh chuyn ho cc cht pyrimidine v purine. V d 1. 5

Fluoro- Uracile (5FU) c ch sinh tng hp vng purine, c ch methyl ho axt
deoxyurydylic thnh axit thymidylic; 2. methotrexate c ch men kh
dihydrofolate reductase cn thit cho vic to cc folate kh vn l cc gc
methyl trong tng hp thymidine
- Methotrexate - Cytosine arabinos
- 6 Mercaptopurine - Gemcutabine
- 5 Fluorouracil
2. Nhm Alkyl ho, mutard nit
Cc nhm alkyl c trong cu trc phn t s gn vo cu trc i in t trong

DNA to ra cc lin kt cho gia 2 chui DNA v cc lin kt ngang gia cc baz
nit gn nhau lm c ch hot ng ca DNA.
- Chlorambucine - Cisplatine
- Mechlorethamine - Dacarbazine
- Cyclophosphamide
3. Nhm cc sn phm t nhin (cc khng sinh chng bu)
Nhm ny gy cn tr qu trnh sao chp axit ribonucleic (RNA) t lm ngng

tr tng hp protein.
- Adriamycine - Actinomycine D
- Daunorubicine - Mitomycine Cvv
4. Nhm cc alkaloid thc vt
Tc ng theo nhiu c ch:
- nh h ng hot ng ca thoi v sc trong qu trnh phn bo (cc vinca

alkaloids, nhm taxane)
- c ch enzyme topoiomerase I v II cn thit cho vic tho xon ca DNA trong

qu
trnh sao chp.
- Vincristine - Etoposide
- Vinblastine - Paclitaxel, docetaxel (nhm taxane)

5. Nhm cc thuc khc
Hot ng kiu enzyme thu phn protein (L-asparaginase, Hydrourea...)
Cn ch rng c ch tc ng ca cc ho cht chng ung th l khng c tnh

c hiu. Ho cht cng nh h ng n t bo v t chc m bnh thng nn
thng gy ra cc tc dng ph.
Hin nay ngi ta v ang nghin cu tm ra cc loi thuc c tnh c

hiu cao do c c ch chn lc hn da vo s tin b ca sinh hc ung th m
c th l gen sinh ung th v c ch hot ng ca n.
6. Cc phng php ha tr ung th khc
Ha cht iu tr di cn xng : Nhm Diphosphonate : pamidronate,

zoledronic
acid
iu tr min dich :
iu tr min dch th ng khng c hiu: interferon, interleukin

iu tr min dch ch ng khng c hiu : vaccine BCG bm vo bng quang.
Liu php iu tr nhm trng ch phn t : L phng php iu tr mi bao
gm
Cc khng th n dng : Trastuzumab (Herceptin) Rituximab (Mabthera,

Rituxan) Alemtuzumab (Mabcampath) Cetuximab (Erbitux)
Cc phn t nh hot tnh : Imatinib mesylate (Gliveec) Gefitinib (Iressa)
Erlotinib (Tarceva)
Cc cht chng tn to mch mu nui khi u : Bevacizumab (Avastin)
Thalidomide
Cc cht chng proteasome : Bortezomide (Velcade)
IV. CC CH NH HA TR UNG TH
Cc ch nh chnh bao gm:
Ha tr gy p ng: Ch nh cho cc ung th giai on tin xa
Ha tr h tr sau iu tr ti ch v ti vng cc ung th giai on sm

Ha tr tn h tr trc khi iu tr ti ch v ti vng cc ung th giai on sm
Ha tr ti ch nhm lm tng nng thuc c hiu qu ti v tr tn thng

bng nhiu k thut nh bm thuc vo cc xoang hc ca c th, bm thuc
vo ng mch
V. C TNH CA HA TR
Ha tr gy ra nhiu c tnh v c phn thnh 2 nhm chnh :
c tnh cp :
c tnh mun :
Cc thuc ha tr ung th u gy nn nhng tc dng phu bn cnh hiu qu

mong i l c ch tng tr ng t bo ung th. Cc t bo, t chc ca c th c
tc tng tr ng nhanh nh nim mc ng tiu ha, h to huyt, t bo
lp y biu m, t bo sinh dcthng c biu hin c tnh ha tr r rang
nht.
c tnh ca ha tr rt a dng v c phn theo mc nng t I n IV hoc

theo h c quan. C th phn loi c tnh ha tr theo th i im xy ra nh di
y:
Phn ng tc thi: sc phn v rt him xy ra. Mt vi lai thuc nh paclitaxel

hoc cc khng th n dng nh rituximabc th gy phn ng sc phn v
nn cn phi iu tr d phng trc v theo di cn thn trong khi s dng.
Cc phn ng sm: Xy ra trong vng mt vi ngy sau ha tr
Bun nn v nn ma
Mt mi, st, phn ng gi cm
Phn ng mun sau vi ngy n vi thng sau ha tr Gim sinh tu: Gim bch
cu, thiu mu, gim tiu cu Ri lon tiu ha: au bung, chn n, tiu chy, to
bn
H lng tc mng: rng tc, xam da, thay i mu sc mng
H thn kinh: D cm u chi, gim thnh lc
H sinh dc: Ri lon kinh nguyt, v kinh, v sinh
Qui thai
.
Cc phn ng mun: thng sau nhiu nm
V sinh
t bin di truyn Sinh ung th th hai Suy tim
X phi
Ngoi cc tc dng ph thng gp nh bun nn, nn ma, rng tc, suy tu

mi thuc ha tr c th c cc tc dng ph chuyn bit nn cn phi ch
khi phi hp cc thuc vi nhau. Thng ngi ta thng trnh phi hp cc
thuc c cng c tnh v trnh s dng cc thuc vt qu liu tch ly ti a
cho php trnh cc c tnh nng khng hi phc c.
VI. KT LUN
Ha tr l phng php iu tr ung th mang tnh cht ton thn. Nhng tin b
vt bc trong nhng thp nin va qua gp phn khng nh v nng cao vai
tr ca ha tr ung th. Cc tin b trong lnh vc sinh hc ung th v ang
hon thin phng php iu tr ny vi cc thuc mi c c ch tc ng mang
tnh c hiu hn, cc phng php nng hu hiu hn.
TI LIU THAM KHO
1. Nguyn B c. 2003. Ha cht iu tr bnh ung th. Nh xut bn Y hc.

Trang 11-56,
288-318
2. Nguyn Chn Hng. 2004. Ung bu hc ni khoa. Nh xut bn Y hc. Trang 111-
146.
3. Richard R. Love.1995. Cm nang ung bu hc lm sng (Ti liu dch t

Manual of
Clinical Oncology). Trang: 289-320. Nh xut bn Y hc Tp HCM.
4. David S. Fischer, M Tish Knobf, Henry J. Durivage, Nancy J. Beaulieu. 2003. The
cancer chemotherapy handbook. pp 1-15, 37-48. 479-511. Mosby press.
5. Jim Cassidy, Donald Bissett, Roy A J Spence OBE. 2002. Oxford handbook of
oncology. pp 135-180. Oxford press.
12. IU TR GIM AU TRONG UNG TH
I. I CNG
Bnh nhn ung th cn c gim au tt c cc giai on bnh ca h. Nhiu

nghin cu chng t rng khong 75% bnh nhn ung th giai on mun
u c au mc trung bnh hoc au d di.
Vit Nam c khong 79% bnh nhn ung th c au k t lc c chn on.

Nhiu
tc gi cho rng au bnh nhn ung th khng c nh gi ng mc b i nhiu

l do:
+ Thy thuc khng nh gi ng mc au ca bnh nhn.
+ Thy thuc nghi ng v cm gic au ca bnh nhn.

+ Bnh nhn khng bo s au n ca h v s lm phin thy thuc hay nu c
bo th khng c x tr g hoc i khi s s dng thuc gim au.
Tt c bnh nhn phi c iu tr khi c xut hin au lm gim s au n

v ci
thin cht lng cuc sng tt c cc giai on trong qu trnh bnh tt ca h.
Thuc iu tr au gm:
+ Loi b hon ton cn au hoc t nht cng lm gim mc trm trng ca
Cn au ti mt mc c th chu ng c.
+ Phng nga cn au ti pht
+ Lm gim au bnh nhn c th thc hin c cc sinh hot hng ngy.
iu tr gim au ty thuc vo p ng ca tng c th vi nhng phng

php nh: iu tr bng thuc, gy t, phu thut thn kinh, tm l hc. Song bi
ny ch yu tp trung vo iu tr bng thuc b i v trong lnh vc ny c s
hiu bit y v kinh nghim lm sng v phng hng iu tr chung cho tt
c bnh nhn ung th c au.
Cc th nghim cho thy rng thuc c hiu qu trong phn ln bnh nhn,
nu n c s dng chnh xc: ng thuc, ng liu vo ng giai on.
II. VI NT LCH S
Lch s pht trin ca iu tr triu chng bt u t th k 18
Baptiste Godinot thnh lp vin ung th u tin, nhn iu tr nhng khi u hoi
t, thi ra
Nm 1842 Jeanne Garnier, mt qu ph tr thnh lp hospice cng hin cuc

i ca h cho nhng bnh nhn khng th iu tr c.
Quan im chm sc triu chng hin i n t Cicely Saunders, b

thnh lp Christopher Hospice chm sc cho nhng bnh nhn ngho ang hp hi.
B l ngi u tin s dng Morphin iu tr au cho bnh nhn ung th giai
on cui.
Elisabeth Kuble- Ross, thy thuc thy s sng Chicago, b nghin cu cc bc

ca qu trnh hp hi v ku gi mi ngi gip h.
Pro. Maurice Abiven l ngi u tin a chng trnh ging dy chm sc triu
chng
vo cc trng i hc.
Cicely Saunders Elisabeth Kuble-Ross Pro. Maurice Abiven
III. CC NGUYN NHN GY AU
au nhng bnh ung th c th l do:
Gy nn b i chnh bn thn ung th (rt ph bin). Bn thn ung th gy au do

cc c ch :
+ Xm ln ti t chc phn mm.
+ Thm nhim ti ni tng.
+ Thm nhim ti xng.
+ Chn p thn kinh.
+ Tn thng thn kinh.
+ Tng p lc ni s.
Lin quan ti ung th: v d nh co c, sng n bch mch, to bn, vim lot do
nm
lu). M b thng tn do do bi nhim, do thiu mu cc b...

Lin quan ti iu tr ung th: v d nh au do so mn tnh sau phu thut, vim
nim mc do iu tr bng ha cht.
Gy ra b i mt ri lon ng thi: v d nh thoi ha ct sng, vim xng khp.
Nhiu bnh nhn ung th giai on mun, au nhiu do s phi hp ng thi

nhiu
nguyn nhn trn.
IV. NH GI V PHN LOI AU DO UNG TH
1. nh gi au
L mt bc quan trng c tnh cht quyt nh trong kim sot au do ung

th. Phi khm ton din, cn tm hiu thm c bnh khc cng i km vi ung th
hay khng, phi nh gi chc nng gan thn, theo di nh h ng ca thuc gim
au ln s hp thu, chuyn ha v bi tit. Phim X quang v CT-Scanner v cc vng
lin quan v x hnh xng cng cn thit so snh vi cc kt qu khm trc
y theo di din bin bnh v d on, tin lng bnh.
Khai thc bnh s ca cn au

Thi gian
- au bt u t khi no?
- Cn au ko di bao lu
- au xut hin thng xuyn hay au tng cn
V tr
- V tr au au, c th ch chnh xc v tr au
- au c lan i u khng?
Tnh cht cn au
- Bo bnh nhn m t cn au. au ging nh g: au nh kin b, nng rt, au

nh tn bn, au nh dao m.
- C gng phn bit au do cm gic v au do thn kinh
- Yu t lm du hay gy au: iu g lm du au hay au tng ln.
- Mc trm trng : au n mc no? Thng p dng thang im t 0-10.
0 : khng au v 10 l au tt bc
bnh nhn t chn im au ca mnh sau khi c hng dn. V d au
5/10 hoc 7/10 .v.v.
Thang im au:Thang im au dng nh gi mc trm trng ca triu

chng au. Thang im au gip bnh nhn m t mc trm trng cn au ca
h vi thy thuc v thang im au cn gip thy thuc trao i thng tin v kinh
nghim iu tr au vi cc ng nghip.
Tr em c th dng loi bng im c hnh nh d hiu hn.
V. PHN LOI AU DO UNG TH
1. au do cm gic
L loi au thng gp nht bt u t cc th th nhn cm gic au thn kinh

ngoi bin khi n b p, cng, ko hay b kch thch b i cc cht trung
gian ha hc nh prostaglandin phng thch t t chc vim (th d: mt ung
th xm ln vo m mm, u lm cng thy gan, ph hy xng).
au do cm gic thng chia thnh cc dng nh sau :

+ au nng (v d : try xc, si lot da, vim si lot da nim mc).
+ au su: au xng, khp.
+ au ni tng: bng, tng rng b kch thch do di cn, do nghn, sng hoc b vim
nhim do nhiu nguyn nhn khc nhau. au ny thng khng khu tr v c cm
gic nh b chn p.
2. au do thn kinh
au xut pht t chnh cc si thn kinh khi b kch thch b i p hay xm ln v

d : Ung th xm ln vo m ri thn kinh cnh tay.
Chn on bng cch :
+ Tm yu t bnh l c th gy tn thng hay kch thch cc trc v si thn
kinh.
+ Kim tra cc triu chng ca dy thn kinh: t tay, thay i cm gic, yu c

.v.v...
+ iu tr bng thuc gim au thng thng t p ng.
Hai dng au ny i hi iu tr vi cc loi thuc khc nhau. au do cm gic lun

p ng vi cc thuc gim au, bao gm thuc c ngun gc opioids. au thn
kinh c th gim au mt phn vi thuc v c ngun gc opioids v cn cho thm
cc thuc n nh mng t bo thn kinh v thuc c nh h ng ln cht dn truyn
(th d : thuc chng trm cm v thuc ng kinh).
VI. KHM LM SNG
Khm lm sng mt cch t m ton c th v h thng cc c quan s gip pht

hin ra cc nguyn nhn gy au. C gng trnh gy kh chu, au n cho bnh
nhn khi thm khm.
- V d nh khi t ngi dy s lm bnh nhn au n th thm khm 2 trng

phi pha sau lng bng ng nghe l khng cn thit.
- Khi cn au cn tr cc hot ng bnh thng, nn thc hin thm khm h

thn kinh mt cch h thng.
Cc xt nghim cn lm sng v chn on hnh nh
Cc xt nghim cn lm sng gip chn on c nguyn nhn gy au:
- Chp Xquang thng v chp ct lp vi tnh c th pht hin c khi u, gy

xng, chn p thn kinh hoc nhng nguyn nhn gy au khc.
- Chp x hnh xng pht hin ra au do di cn xng.
- Chp PET-Scan pht hin di cn.
- Sinh thit hoc xt nghim t bo hc c th pht hin u c tnh hoc vim.
- Xt nghim mu v xt nghim vi khun c th pht hin ra nguyn nhn nhim

trng.
- Xt nghim huyt thanh c th pht hin ra bnh thp khp, bnh t min.v.v.
VII. CCH DNG THUC GIM AU
1. Nguyn tc dng thuc gim au
- Theo ng ung : Dng n gin, d dng nht ngoi tr trng hp bnh nhn
khng th ung c hoc cn au qu trm trng phi cn tim hoc chuyn
c tc dng gim au nhanh.
- Theo bc thang: bc u tin l dng thuc khng c Opioide, nu au khng

gim th dng Opioide nh ri n mnh (morphin).
- Theo gi: khng ch n khi bnh nhn au mt cch chnh xc, nn cho thuc
gim au u n liu k tip c tc dng trc khi cn au xy ra.
- Theo tng c th: khng c liu chun cho nhng thuc Opioide, liu ng l liu
c tc dng gim au cho bnh nhn.
- Nguyn tc chung: ngn chn au tt hn l iu tr au.
2. Bc thang gim au
T chc Y t Th gii a ra khi nim bc thang gim au nh l mt cch khuyn

khch vic s dng thch hp cc Opioide gim au cc quc gia t s dng loi
thuc ny. Bng ny nhn mnh trong cc cn au d di cn cho thuc gim au
mnh (Th d : cc loi thuc Opioides) v khng gii hn liu ti a. Liu hp l l
liu mang li hiu qu gim au m khng c ri lon no do tc dng ph ca
thuc. Thuc Opioides l mt thut ng dng ch cc OPIATES c ngun gc t
nhin nh Morphin v loi Narcotic tng hp nh Methadone.
BC III au tt bc Morphin, Pethidine, Oxycodone
BC II au trung bnh Codeine, Tramadol, NSAIDS
BC I au nh Paracetamol, Aspirine, NSAIDS
3. Cc thuc gim au
iu tr cn au nh (bc I theo bc thang ca WHO):

Dng cc thuc gim au khng c opioid, c th kt hp cc thuc gim au
khc nu
nguyn nhn gy au do thn kinh.

3.1.Cc thuc Non-opioid
Thuc khng vim khng cha Steroid (NSAIDS) c nhiu loi, trong chm sc lm
du thng s dng.
+ Ibuprofen 400 mg-800 mg ngy 3 ln, liu ti a khng qu 2400mg/ngy.
+ Naproxen 250 mg-500 mg ngy 2 ln hoc ta dc 500 mg hay loi phng

thch chm 1000 mg.
+ Diclofenac 25 mg-75mg/mg ngy 2 ln, liu ti a 200mg/ngy
+ Indomethacin 25 mg-50 mg ngy 3 ln.
+Acetaminophen (paracetamol) 500-1000mg ngy 4 ln, ti a khng qu
4000mg/24 gi
y l cc thuc ph tr tt gim au km vi gim vim, c bit l au lin

quan n xng. Cc thuc Nsaids u kch thch d dy. Do nn ung sau khi
n v ung km cc thuc khng th th H2 (th d: Ranitidine 150 mg-2 ln/ngy
hay trc khi ng) hoc Sucralfate
1g - 4 ln/ngy c th bo v nim mc d dy, thn trng i vi nhng ngi

suy chc nng gan thn, cc bnh l v h to mu.
iu tr cn au trung bnh ( Bc II theo thang im ca WHO) S dng cc thuc

opioid nh:
+ Efferalgan codein (zandol) phi hp vi codein (30 mg codein + 500 mg
Paracetamol)
+ Codein photphate vin 30 mg l 1 loi thuc phin nh, c tc dng hip ng
gim au cng vi Aspirin hay Paracetamol, dng 60 mg/4-6 gi, liu ti a
360mg/ngy, d gy to bn nn thng xuyn dng km theo thuc nhun trng.
+ Dextro propoxyphene thng phi hp vi Paracetamol (Dextro Propoxyphene
30 mg + paractamol 400 mg) c dng cho cn au va phi, c tc dng gim au

tt.
+ Tramadol: l loi opiod tng hp, c tc dng gim au thn kinh trung ng,
dng ng ung c hiu qu, Tramadol mnh gp 2 ln codein vin 50 mg, t gy
bn.
iu tr cn au tt bc
S dng cc thuc pioid mnh
Trong trng hp cng cn au trm trng s dng cc thuc gim au bc I

v
bc II khng hiu qu th s dng cc thuc opioid mnh (nh Morphin), c th kt

hp vi cc thuc Non-steroid hoc cc thuc gim au thn kinh nu nguyn nhn
gy au do thn kinh.
+ Morphin sulfat
Liu ung: Bt u liu 5mg, nh gi li sau 60 pht. Nu cn au vn cn trm

trng, tng liu ln hng gi n khi c hiu lc gim au, cho liu lng ny mi 4
gi/ln. C th gia tng liu ln 50% hoc 100% nu cn au vn cn dai dng.
+ Morphin phng thch chm c kim sot (Skennan), phng thch Morphin
t t trong mt thi gian di v cho mt nng n nh vi liu lng u n.

Skenan c liu
10 mg, 30 mg, 60 mg. Skenan LP 2ln/ngy ung hoc bm qua sonde d dy. Vin
thuc phng thch chm t gy nn i so vi tim v ko di thi gian lm gim au
sut m. Thng cho 1 liu t 8-12 gi l an ton.
Trong trng hp s dng cc thuc Opioids ung cng khng c tc dng na,
iu tr cn au mt cch hiu qu phi dng Morphin tim, c th s dng tim
tnh mch hoc tim di da. Vi liu lng nh c tim Morphin di da 2-
5mg, nh gi hiu qu gim au sau khi tim 20 pht v tng dn liu n khi bnh
nhn ht au. Tip theo s chuyn thnh bc iu tr gim au c liu lng trn,
tim khong cch 4 gi/1ln.
Gi s liu bt u 5 mg, liu th hai 10 mg khng gim au nhiu, nhng vi liu

15 mg
Morphin tim di da 4 gi/1 ln, cn au c ct.
Tng s Morphin chch trong 24 gi: 15 mg x 6 = 90 mg.
Nu dng ng ung th nhn cho 3: 90 mg x 3 = 270 mg v liu tim tc dng gp

3 ln liu ung khi dng lu di.
Dng Morphin thng gy bun nn v bn nn km theo thuc chng nn

(metoclopramide 10 mg) km ch n chng to bn hoc cc loi thuc nhun
trng nh : Coloxyl vi Senna 2 vin ti, Oxid Magne 5g, ngy 2 ln.
M sng hay hoang t ng l mt tc dng ph thng xy ra khi cho Morphin

nhng n s nh i khi gim liu hoc sau khi dng 1 n 2 ngy. Nu vn cn
nghim trng, c th cho Morphin di da liu thp c th lm gim du hiu
ny. Nn dng phi hp xen k vi cc thuc khc nh Tylenol hoc Codein gia
cc ln tim Morphin.
+Fentanyl dn trn da: Fentanyl mnh hn Morphin gp 50-100 ln. Fentanyl
thm qua da nn c th dng di dng dn. Loi Fentanyl dn ny cung cp 1
lng thuc chm qua da ko di n 3 ngy.
Ch nh: Dng cho bnh nhn khng th ung thuc c do nn ma, kh nut,
hoc
bnh nhn c ri lon chc nng ng rut.

C ch hot ng: Fentanyl sau khi dn trn da s khuych tn vo lp m di da
v i vo mu. Ming dn nn dn vo vng c lp m di da nh vng bng,
vng ngc trn hoc vng mng. Ming dn Fentanyl phi mt 12 gi mi c tc
dng gim au, do trong 12 gi u phi dng cc loi gim au khc khng
ch cn au.
Chng ch nh:
+ Khng nn dng nhng bnh nhn suy mn khng c lp m di da.
+ Bnh nhn b st b i v s tng hp th thuc v gy ra ng c.
+ Bnh nhn ra m hi nhiu v ming dn s khng dnh.
+ Bnh nhn ngho khng c tin mua, nn dng morphin r hn. Mt s tc

dng ph hay gp nh vi Morphin
iu tr ct cn au
Bnh ung th thng tin trin theo thi gian lm cho ngng au ngy cng tng
ln, liu iu tr khng cn tc dng gim au, do ct cn au phi tng
liu thuc gim au. Liu tng thm thng khong 10% liu iu tr.
V d: Bnh nhn ang iu tr Morphin ung vi liu 10mg /4gi
-Tng liu trong ngy : 10mg x 6 = 60mg
-Liu tng ln : 10% x 60 mg = 6mg mi 4 gi
Liu tng ng
Liu tng ng thng dng chuyn i t mt opioid ny sang mt opioid

khc. Do s khc nhau v cu trc phn t ca mi loi opioid, bnh nhn t dung
np vi thuc mi nn thuc mi c chuyn i thng thp hn liu tnh ton
25-50%.
Bng 1 : Liu opioid tng ng
Thuc ng ung hoc ng Tim tnh mch hoc tim

trc di
Morphin 30 10
trng ( mg ) da (mg )
Codein 200 120
Hydro-Morphon 7,5 7,5
Pethidin 300 75
Fentanyl 0,1 ( mcg )
Oxycodone 20
Bng 2: Chuyn i t Morphin tim sang Fentanyl dn trn da

Hydrocone
Morphin tim (mg/24 gi) Fentanyl dn ( mcg/gi)
18-35 25
36-59 50
60-83 75
84-107 100
108-131 125
132-156 150
Chuyn i t codein sang Morphin

V d: Bnh nhn ang dng Codein 60mg/4gi nhng bnh nhn khng au, khi
chuyn sang dng Morphin chng ta tnh liu chuyn i nh sau:
-Tnh liu s dng Codein trong 24 gi:
60mg Codein/4gi = 360mg Codein/24gi
H s chuyn i t Codein ung sang Morphin ung nh sau: Liu Codein x 0,15 =
Liu Morphin
Nh vy liu Morphin s dng s l:
Liu Morphin = 360mg Codein x 0,15 = 54mg Morphin/ngy hoc 9mg/4gi
Liu chuyn i c tng ln 25-50% nh vy liu Morphin s dng s l
15mg/4gi
iu tr au do thn kinh:
+ Amitriptilin : Bt u vi liu 10-25mg, mt ln trong ngy vo bui ti. Liu ti

a
200mg/ngy. Qu liu e da ng c tim mch.
+ Gabapentin: Bt u vi liu 300mg vo bui ti, tng liu dn sau 3 ngy vi
300mg x 2 ln trong ngy, v 3 ngy k tip vi 300mg x 3 ln trong ngy. Liu ti

a khng vt qu 3600mg/ngy.
Ngng s dng Opioid:
iu tr opioid c th ngng li khi triu chng au c gii quyt. Nu bnh

nhn s dng opioid trn 2 tun th phi gim liu dn trc khi ngng hn
trnh hi chng dng thuc t ngt (Withdrawal syndrome). Hi chng ny biu
hin st, lnh run, tot m hi, bun nn v nn ma, au co tht bng, tiu chy,
au c, mt ng, chy mi nc v tng huyt p.
trnh hi chng ny, liu opioid nn gim dn trong 2-3 tun trc khi ngng
hn. Khi triu chng xy ra c th dng liu opioid cao hn liu iu tr trc
mt t.
Cc thuc gim au khc :
Dng Steroide: Corticosteroid c tc dng lm gim tm thi cc phn ng quanh

khi u, gim sng v co ko, do lm gim p cc m mm quanh khi u. Bng
cch gim phn ng vim ca khi u, gim sn xut Cytokines v Prosraglandins, cc
cht ny kch thch cc mt tn cng dy thn kinh cm gic gy au. V vy, Steroid
c gi tr i vi bt kz khi u no.
- Dexamethasone 4-16 mg/ngy ung 1 ln.
- Predmisolone 25-100 mg/ngy nn dng vo bui sng.
Dexamethasone c tc dng khng vim mnh hn so vi Predmisolone, n t gi

mui v tc dng ko di hn.
-Anticholinergic (dng trong co tht c trn ng tiu ha): Scopolamine

butylbromide 10-20mg/6-8gi.
+ X tr : Rt c gi tr gim au cc m tn thng ti ch do khi u gy ra.

+ Ha tr liu : Gp phn chnh vo vic lm gim au nh tc dng trc tip ln
khi u, lm gim au kch thc ca khi u v phn ng vim chung quanh.
+ Th thut gy lit thn kinh: l bin php trit nht i vi cn au d di.

Trc ht l phong b thn kinh tm thi bng gy t ti ch. Sau nu c ch
nh, mt s phng php nh phu thut ct b, chch Phenol hay Alcohol hay
hy thn kinh bng phng php ng kh c dng.
1. B Y t, Bnh vin K, 1999. Hng dn chn on v iu tr, NXB Y hc, trang

15-37.
2. i hc Y H Ni, 1999. Bi ging ung th hc, nh xut bn Y hc, trang 65-

80.
3. UICC, 1995.Ung th hc lm sng, trang 225-317
II. TI LIU TING ANH
1. Jim Cassidy,2002. Oxford Handbook of Oncology 2002, Pages 83-189.
2. Vincent T. DeVita, 2001. Principles & Practice of Oncology, Pages 236-296.

13. IU TR TRIU CHNG K GIAI ON
CUI
I. I CNG
Chm sc bnh nhn ung th giai on cui dnh cho ngi bnh trc khi t
trn khong 3 thng, khi m bnh tin trin c tin lng xu, m s iu tr tch
cc khng mang li hiu qu g. Trong giai on ny bnh nhn bt u xut hin
mt s triu chng do di cn ca ung th lm cho bnh nhn au n kh chu.
Mc ch ca iu tr l lm gim bt cc triu chng, em li s thoi mi, d chu

cho ngi bnh.
II. NN V BUN NN
Nn v bun nn ko di l nhng triu chng gy kh chu v thng gp nht

trong ung
th giai on cui. C th c nhiu nguyn nhn gy bun nn. Cc nguyn nhn

thng gp :
- Do s dng mt s thuc chng ung th, morphin iu tr gim au.

- D dy chng hi, b chn p b i khi u hoc b kch thch.
- Tt rut, bnh l gan.
- Kch thch tm l gy nn.

iu tr nn khng nn ch dng mt loi thuc quen thuc m phi tm nguyn
nhn gy nn v la chn thuc iu tr cho ph hp.
S chn la thuc ty theo nguyn nhn
Nguyn nhn iu tr
Thuc NSAID Bt u s dng thuc chng nn km theo thuc

Opioid
Thuc Opioids (60%) Thiethyperazine (torecan) 10 mg vin, ta

1-5-5
dc mg
hayhaloperidol 2-3 ln/ngy
tim 2 ln/ngy
Ha tr liu v x tr liu Ondansetron 4 mg- 2 ln/ngy
5-10 mg prochlorperazine (stemetil) 2-3 ln/ngy
Domperidone (motilium) 10 mg - 3 ln/ngy

Tng p lc ni s Dexamethasone 4-8 mg 2-3 ln/ngy
Trng bng y hi (do Metoclopramide 10 mg ln

10 mg metoclopramide 3 ln/ngy - Steroids
n 3 ln/ngy
tc dng ph ca thuc
Prochlorperazine 5 - 25 mg 3 ln/ngy
hoc do suy gim chc
nng gan)
Domperidone (motilium)
Cyclixine 25 - 10 10 mg 3 ln/ngy
mg - 3 ln/ngy
Bn v to thnh cc phn Thuc nhun

Cisapride trng -5-10
(prepulsid) nhiu
mgloi.
3 ln/ngy
Tc rut Nu tc rut thp, n ch t cht b (x) tt v
tiu ha c. Nu tc rut hi cao, nhn n,
ngm nh v ung Haloperidol
1,5-5 mg hay hyoscine butylbromide 20 mg 3

ln/ngy
Ri lon tin nh Prochlorperazine 5-25 mg 3 ln/ngy
Dexamethazone 8 mg truyn tnh mch

Lo lng ng vin, th gin
Hyoscine 1,5 mg trong 3 ngy lin tip
M d dy qua da bng ni soi

Diazepam 5-10 mg 2 ln/ngy
Tng Ca+ mu Truyn nc
Truyn dch midazolam 5-50 mg/24 gi

Tng Ur mu Chlorpromazine
Truyn dung dch25-50
muimg 3 ln/ngy
Haloperidol 1,5-5 mg - 3 ln/ngy

Biphosphonate
III. TO BN
To bn thng gp trong giai on cui ca bnh ung th do t hot ng, ung t
nc v ngay c mi trng chung quanh khng quen thuc. Suy yu cc c bng
v sn chu lm gim kh nng bi tit qua trc trng. Hn na, hu ht cc thuc
gim au mnh, thuc phin,
thuc chng trm cm, thuc khng cholin gy lit nh m ri thn kinh ca
rut v gy to bn, nn cho thuc nhun trng (nu cn).
Hi k v ghi h s u n v chc nng ng rut rt cn thit, thm khm trc

trng l phn quan trng ca vic nh gi ngi bnh giai on cui. Khi to bn
khng gim v bnh nhn khng nhn bit c th gy au bng, lm au tng khp
ni, tiu dm hay tiu chy gi, tc rut, vt v v a n trm cm. gip nhu
ng rut chng ta c :
1. Thuc lm tng khi lng phn
Cc loi thuc ny lm tng s kch thch ng rut vi lng dch cho vo c

duy tr u n v . Nhng i vi ngi bnh giai on cui ung vo t v cc
c yu, him khi h thch nghi v c th lm tng to bn.
2. Cc thuc lm mm phn
2.1. Lactulose
L loi thuc c tnh thm thu, n ko nc vo trong ng rut. S dng 10-30

ml 3 ln/ngy, nhiu ngi bnh khng thch v ngt ca thuc. Loi r tin hn l
dung dch Sorbitol- Sorbilax. Mt s ngi bnh thch mi ca mui Magne hn v
d : MgO hay MgSO4 c cng tc dng
2.2. Docusate
L loi thuc lm phn mm m n tc ng nh cht hot din, kch thch cc
cht bi tit v gip chng xm nhp vo phn. Vin Coloxyl 50 mg bt kz ngy
no m ng rut khng thng hay cho 2 ln/ngy; 3 ln/ngy; nu bn ko di.
2.3. Bisacodyl
L loi thuc nhun trng tip xc, kch thch cc cht t nim mc rut. Dorolax
5 mg
2 ln/ngy hay ti.
2.4. Phenolphthalein
L loi thuc kch thch nh, lm tng cc cht tit ca thnh rut.
3. Loi thuc du
Cht du Paraffin 10-20 ml (ti) gip tng phn d dng ngi gi hay bnh nhn
nng.
4. Loi thuc lm tng hot ng c trn

Senna lm tng s hot ng ca thnh rut bng tc dng trc tip ln c trn.
Coloxyl vi Senna (8 mg) vo bui ti.
Cm Senokot (15 mg cho 5 ml) v dng vin (5-7 mg) vin ta dc nh Glycerine
hay Bisacodyl (Durolax) gip kch thch s bi tit; tht tho nh git (th d
Microlax) c th c dng gia nh; tht tho vi nc m, Glycerine, du hay
Phosphates c th c iu dng thc hin ti nh theo y lnh bc s : cho 1
ngn tay c mang gng tay sch ly phn qua trc trng, nn cho thuc gim au v
an thn (nu cn). Chch Pethidine 25-100 mg tim tnh mch (ty thuc vo kh
nng hp thu thuc ca bnh nhn) v cho thm diazepam 5 mg hay
midazolam 5 mg gip ly phn d hn v khng lm bnh nhn kh chu.
IV. CC TRIU CHNG KHC
1. C chng
Trc ht cn tm nguyn nhn gy bng chng : khi u, gan to, chng hi, tc
rut, to bn. C chng do nguyn nhn c tnh c th tch t 10 lt dch hay hn
na gy cng tc thnh bng, hn ch hot ng c honh lm bnh nhn rt kh
chu.
C th dng cc thuc li tiu lm gim c chng nh : Spironolactone 50 mg 4
ln/ngy ; Furosemide 40-120 mg/ngy c th lm gim vim chung quanh khi u
v gim s xm nhp huyt thanh vo khoang bng. Chc ht bt dch mng bng
ch nn thc hin khi s cng chng gy tc bng, kh chu, b i v chc ht dch
mng bng s ly i mt s lng ln cht m c th lm ngi bnh yu sc v
suy nhc nhanh hn.
t ng ni mng bng - tnh mch ch : Thnh thong c lm trong cc tnh

hung c bit, v d : C chng nh trp do d t ng ngc
2. Kh th
Kh th thng chim 70% cc trng hp bnh nhn ung th giai on cui.

Cc nguyn nhn thng gp l cc bnh c tnh phi c th gy : chn p ng
h hp, xp thy phi hay nhim trng, tt nghn ph qun. Cc nguyn nhn ph
khc nh : trn dch mng phi, x phi, di cn phi rng, c chng, vim phi do
x tr, nghn mch phi, chn p mng ngoi tim cp.
Cn xc nh nguyn nhn iu tr cho ph hp, th d : Suy tm tht tri cho li

tiu, vim phi cho khng sinh, co tht ph qun cho Salbutamol hay thuc khng
vim dng kh dung
.v.v...
3. Cc triu chng n km, kh ming
Ngoi nhng triu chng thng gp giai on cui, nhng biu hin khc nh
suy nhc, kh ming v n km l 3 triu chng d a n suy sp cho bnh
nhn.
- n km :
+ Phn ln bnh nhn ung th t nhiu n ung km, a n suy nhc. Cn loi
tr cc nguyn nhn c th cha tr nh ta ming gy au ming, tng Ca+ mu,
to bn, nn do thuc. Ban u cho thuc chng nn nh
Metochlopramide 10 mg 3 ln/ngy hay
Dexamethazone 2-4 mg/ngy s gip nhiu bnh nhn n ngon v ci thin sc
khe trong mt thi gian. Megastrol Acetate (400 mg-800 mg/ngy) gip tng s
thm n nhng t tin.
+ Truyn tnh mch vi dung dch c nhiu nng lng v m thng c dng
Nam Triu Tin, Vit Nam, Nht v Trung Quc. Nhng tri li Bc M, Chu u
hay c h khng dng v t c bng chng chng minh rng s chuyn nng
lng v m c th ko di thm cuc sng cho bnh nhn.
+ Trong thc t rt c th khi khi u c nui dng tt n cng pht trin nhanh
hn.
- Kh ming : L triu chng thng gp lm bnh nhn kh chu, gy ra b i :
+ Cc yu t lin quan n suy nhc : mt nc, th bng ming, ta ming.
+ Cc yu t lin quan n iu tr : x tr vng mt, thuc an thn, thuc chng

trm cm, Phenothiazines, thuc chng co tht.
Nhm gim nhanh cc triu chng ny, cho sc ming thng xuyn 2 gi/1 ln vi
dung dch sc ming nc Soda hay Bicarbonate, iu tr nm Candida, ch ra li
d mt cch nh nhng vi mt bn chi mm v oxy gi ha long. Cung cp nc
qua cc dng nh ming da ti, nhai ko cao su, ngm ming nc nh,
ung nc bng ng nh git. Tt nht cho ngm vin sinh t C s kch thch tit
nc bt nhiu hn. Cho kem Vaselin hay du thc vt thoa mi thng xuyn.
Nu ming v bn cho sc ming vi Lidocaine ha tan vi Chlorhexidine.
1. i hc Y H Ni, 2001 Bi ging ung th hc, trang 93-94
2. UICC, 1999. Cm nang ung bu hc lm sng, nh xut bn Y hc.
II. TI LIU TING ANH
1. Palliative Care in Terminal Illness-second edition 1994

14. CHNG TRNH PHNG CHNG BNH
UNG TH VIT NAM GIAI ON 2002-
2010
Ngy 17 thng 6 nm 2002 Th tng Chnh Ph nc Cng ha x hi ch ngha

Vit Nam c quyt nh s 77/2002 Q-TTG v vic ph duyt Chng trnh
Phng chng mt s bnh khng ly nhim giai on 2002-2010 gm cc bnh v
tim mch, ung th, i tho ng, ri lon sc khe tm thn (ng kinh, trm
cm). Trong bi vit ny chng ti xin trnh by nhng ni dung chnh ca chng
trnh phng chng ung th giai on 2002-2010.
I. TNH HNH PHNG CHNG UNG TH HIN NAY
1. Tnh hnh bnh ung th trn th gii
- Theo c tnh ca t chc y t th gii (TCYTTG) hng nm trn th gii c khong

10 triu ngi mc bnh ung th (UT) v c 6 triu ngi cht do cn bnh ny.
Vn phng chng ung th (PCUT) lun lun c coi l mt trong nhng chin
lc u tin hng u v bo v sc khe ca TCYTTG. Ung th l nguyn nhn
t vong ph bin ng th hai cc
nc pht trin, tnh hnh mc bnh v t vong do ung th ngy cng tng, tuy
nhin hn mt na s bnh nhn ung th l cc nc ang pht trin. T l ny
s tng ln nhanh cng vi s pht trin kinh t, cng nghip ha, nhim mi
trng v gia tng tui th trung bnh, d kin n nm 2015, mi nm trn th gii
s c 15 triu ngi mi mc bnh ung th, trong hai phn ba l cc nc
ang pht trin.
- Ung th khng phi l bnh v phng cu cha, 1/3 bnh ung th c th phng
nga c; 1/3 c th cha khi c nu chn on sm v cng vi vic chm
sc h tr s lm tng cht lng sng thm cho 1/3 bnh nhn ung th cn li.
- Vn phng chng ung th lun c xem l mt trong nhng chin lc u

tin hng u ca TCYTTG vi 4 ni dung:
+ Phng bnh ban u
+ Sng lc pht hin sm
+ iu tr bnh c hiu qu
+ Chng au v chm sc triu chng
2. Tnh hnh ung th Vit Nam

- T l mc bnh v t vong do ung th hng nm cha c iu kin tin hnh iu
tra t
m v y trn phm vi ton quc. Tuy vy qua ghi nhn ung th H Ni

(1988-1994), thnh ph H Ch Minh (1990-1994), qua tham kho cc kt qu iu
tra mt s a phng trc y vi cc bo co PCUT Vit Nam ca mt s
tnh, i chiu vi nhng thng k ung th mt s nc trong khu vc ng
Nam , so snh thang tui Vit Nam vi cc nc, chng ti c tnh hng nm t
l mi mc ung th ca ngi Vit Nam t 100.000 n 150.000 trng hp v
khong 70.000 ngi cht do cn bnh ny. Trn thc t s bnh nhn ung th
c nhn iu tr cc bnh vin rt thp. Cc c s chuyn khoa c phng
tin mi nhn
iu tr c khong 7% s bnh nhn ung th. Cc c s y t khc Trung ng v
tuyn tnh iu tr ung th ch yu bng phu thut nhng a s bnh nhn khi ti
bnh vin giai on mun nn kt qu iu tr rt hn ch.
Cc loi ung th ph bin Vit Nam (t sut/100.000dn)
Tnh \ Thnh H Ni
Bng 2: 10 bnh ung th thng gp Nam gii
ph
(2001-2004)
Phi Thin Hu
Tha 39,8 1 10,8 3 29,5 H 1
Ch Minh
D dy
(2001-2004) 30,3 2 14,4 2 15,3 (2003)
3
Gan 19,8 3 16,4 1 25,4 2
i trc trng 13,9 4 4,9 4 16,2 4

V tr
Thc qun 9,8 5 1,7 9 4,0 8
Mi hng 7,8 6 1,5 12 4,2 7
U lympho c 7,2 7 3,8 5
Bnh bch cu 4,7 8 2,4 8 4,6 6
Bng quang 3,5 9 3,0 7
Vm hng 3,2 10 0,0 22 4,8 5
Li 1,9 14 1,6 10
M mm 2,0 14 2,9 7
Ty 1,2 18 1,3 14
Tin lit tuyn 2,7 12 1,0 16 2,8 10
Nhau thai 1,3 17 0,9 12
Dng vt 1,8 14 1,5 13
Da 3,0 9
Bng 3: 10 bnh ung th thng gp N gii

Tnh \ Thnh ph H Ni
(2001-2004)
V 29,7 1 12,2 1 19,4 1

D dy
(2001-2004) 15,0 2 7,3 2 5,5
(2003) 6
V tr
Phi 10,5 3 3,6 4 12,4 3
i- trc trng 10,1 4 3,4 5 9,0 4
C t cung 9,5 4 5,0 3 16,5 2
Tuyn gip 5,6 5 1,6 10 3,8 8
Bung trng 4,7 6 2,1 9 3,8 7
Gan 4,5 7 3,4 6 6,0 5
U lympho c 4,0 8 1,4 12
Bnh bch cu 3,4 9 1,4 11 3,2 9
Mi hng 3,3 10 0,5 18
M mm 1,4 13 2,6 8

Da 2,6 10
- Qua bng s liu hai min th nam gii cc loi ung th hay gp ging nhau,
l: ung th phi, d dy, gan, vm hng, i trc trng; ph n ung th c t
cung min Nam cao hn min Bc.
- Nhng ung th c t l mc cao hn so vi th gii: ung th vm hng, ung th

gan, ung th d dy, ung th c t cung (min Nam).
- Nhng bnh ung th c t l mc tng i thp so vi th gii: ung th tin lit

tuyn, ung th v, ung th da, ung th i trc trng.
II. MC TIU PHNG CHNG BNH UNG TH T NM 2002-2010
T nhn thc ung th l bnh ca x hi, l vn ca mi ngi, phng chng ung

th l nhim v ca Nh nc, ca mi gia nh v ca mi ngi dn.Cn phi
c chng trnh quc gia v PCUT di s ch o hot ng ca cp Nh nc v
phi hp ca nhiu ngnh, nhiu t chc v on th x hi.
1. Mc tiu chung
Lm gim t l mc, gim t l t vong v ci thin cht lng cuc sng cho bnh
nhn ung th.
2. Mc tiu c th
- Gim t l mc cc loi ung th c lin quan n thuc l xung 30% so vi nm
2000.
- Thc hin tim phng vim gan B cho 100% tr s sinh phng ung th gan
nguyn
pht.
- Gim t l t vong ca mt s loi ung th: v, c t cung, khoang ming, i trc

trng.
- Gim t l ngi bnh ung th giai on mun n c s chuyn khoa t 80%

xung cn 50% so vi nm 2000.
III. CC GII PHP
1. Kin ton mng li phng chng ung th
1.1. Tuyn trung ng v khu vc
u t nng cp cc bnh vin chuyn khoa u ngnh thnh cc trung tm hon

chnh va c kh nng thc hin cng tc phng bnh, cha bnh, nghin cu khoa
hc v o to.
1.2. Tuyn tnh
Thnh lp cc khoa ung bu trong bnh vin a khoa tnh hoc cc bnh vin
chuyn khoa ung bu thc hin tt vic khm, iu tr v phc hi chc nng
cho bnh nhn ung th, gim gnh nng qu ti cho cc Bnh vin tuyn trung
ng. Trung tm y t d phng, trung tm phng chng cc bnh x hi v trung
tm truyn thng gio dc sc khe c trch nhim thc hin cc hot ng lin
quan cng tc phng bnh ung th.
1.3. Tuyn huyn, x
Tp trung ch yu vo cng tc phng bnh ban u, ch trng n vic truyn

thng gio dc cho nhn dn bit cch phng chng v t pht hin sm mt s
du hiu ca bnh ung th kp thi gi bnh nhn ln tuyn trn chn on v
iu tr.
2. Lng ghp hot ng ca chng trnh PCUT vo chng trnh phng chng cc
bnh khng
ly nhim
Mc ch tit kim ti a ngun nhn lc, vt lc v ti chnh, nng cao hiu qu

hot ng ca chng trnh. Cc hot ng bao gm:
- y mnh vic thc hin cc bin php phng bnh ban u v gio dc sc
khe: y l chin lc kh thi v hiu qu nht i vi nhiu loi bnh trong
c ung th.
Phng bnh ban u tp trung vo vic gii quyt cc yu t nguy c gy ung th
nh: ht thuc l, ch n khng hp l, nghin ru, an ton tnh dc, sc khe
sinh sn...
- Ht thuc c xem l yu t nguy c quan trng nht gy bnh ung th Vit

Nam. Chng ht thuc l c th lm gim 30% cc loi ung th ngi nh: ung
th phi, ung th ng h hp, tiu ha trn, ung th d dy, ung th ty, ung
th bng quang.
- Vai tr ca dinh dng vi cc bnh ung th l rt r rng. Ci thin ch n

ung bng cch gim hp thu cc cht bo ng vt, trnh s dng thc phm c
nhim thuc, nhum mu cng nghip, thuc tr su dit c, thc phm mc v
nn tng cng tiu th nhiu rau qu.
- Tuyn truyn gio dc nhn dn nng cao nhn thc v phng nga v pht hin
sm ung th, c bit gio dc nhng bnh nhn ung th v cc du hiu bo ng
ca bnh pht hin sm v iu tr sm nhm gim t l t vong.
- Lng ghp phng bnh ung th vi phng cc bnh khng ly nhim tuyn y t
c s trong vic thc hin chm sc sc khe ban u.
- Gio dc v li sng lnh mnh trong cc chng trnh y t, trng hc, bnh vin,
ni lm vic...
- Phi hp chng trnh tim chng quc gia thc hin tim chng vaccine
vim gan B cho 100% tr mi sinh.
- Pht hin sm, nng cao hiu qu iu tr, chm sc, phc hi chc nng cho
ngi bnh ung th.
- Cng nh cc cng tc phng bnh ban u, vic chn on, iu tr chm sc,
phc hi chc nng cho ngi bnh cn lng ghp ti a nhng kh nng c th
gia cc bnh thuc nhm bnh khng ly nhim c lin quan cht ch vi nhau.
- Chn on sm cn c tin hnh ti cng ng theo hnh thc lng ghp vi
chng trnh dn s k hoch ha gia nh, chng trnh chm sc sc khe b
m tr em, chng trnh khm sng lc cho cc i tng c nguy c cao nhm
pht hin sm mt s ung th nh: ung th v, c t cung, da, khoang ming,
i trc trng, qua vic pht hin cc du hiu bo ng ung th.
3. Cng tc iu tr
- Tp trung nng cao cht lng v hiu qu iu tr ung th. Hin nay cng tc ny
ch yu tp trung tuyn trung ng nn cc bnh vin lun trong tnh trng qu
ti v vy cn ch trng nng cao trnh chuyn mn, u t trang thit b cho c
tuyn trung ng v a phng nng cao cht lng chn on, iu tr cho
ngi bnh.
- Nghin cu, theo di, gim st, nh gi dch t hc v trao i thng tin: thnh
lp cc n v nghi nhn thng tin cc tnh, thnh ph ln nh H ni, thnh ph
H Ch Minh, Hu, Nng, Thi Nguyn, Hi Phng, Cn Th... tin ti cc tnh
trong ton quc phi t chc ghi nhn ung th nh gi t l mc, cc c im
dch t hc ung th mi a phng.
- Nghin cu hon chnh cc phc iu tr ung th ngang tm vi cc nc trong

khu vc.
- Nghin cu m hnh chm sc bnh nhn ung th giai on cui, chng au v

chm sc triu chng ti cng ng.
- o to v pht trin nhn lc chuyn ngnh ung th, tuyn truyn hng dn,
cho nhn dn hiu v ng dng cch phng chng mt s bnh ung th.
4. Gio dc v o to
- L cng tc quan trng ca chin lc v cn c s phi hp cht ch, ng b vi

cc trng i hc, cao ng, trung hc y dc trong c nc gio dc nhng
ngi lm cng tc chuyn mn chm sc sc khe, c bit nhng cn b y t
trong lnh vc phng chng ung th.
- Cn xy dng cc chng trnh o to a dng, ph hp cho cc cp khc

nhau v xy dng h thng ti liu chun thng nht v hng dn chn on, iu
tr v phng bnh ban u i vi bnh ung th.
- Xut bn ti liu chuyn mn cho cn b y t v hng dn chn on v iu

tr ung th.
- Xut bn ti liu tuyn truyn ph bin kin thc cho nhn dn vi ni dung d
hiu v thc t h c th hiu v ng dng cch phng chng mt s bnh ung
th.
5. Xy dng chnh sch trong lnh vc phng chng ung th
- Lut v phng chng tc hi ca thuc l, v sinh an ton thc phm, phng chng
cc bnh ngh nghip, an ton bc x... nhm hn ch ti a nguy c mc bnh,
t vong, ng thi c chnh sch u i i vi ngi bnh.
- Huy ng s tham gia tch cc ca cc B, Ngnh v cng ng trong cng tc

PCUT.
6. Tng cng hp tc quc t

M rng, nng cao hiu qu hp tc quc t song phng, a phng vi cc nc,
cc t chc quc t, t chc phi chnh ph trong lnh vc phng chng cc bnh
khng ly nhim.
IV. KINH PH THC HIN
Ngn sch thc hin chng trnh PCUT bao gm cc ngun:
- Ngn sch nh nc.

- Ngun h tr ca cc t chc trong v ngoi nc.
- Vn vay t ngun ODA v cc qu h tr pht trin trong v ngoi nc (nu
c).
- Ngun ng gp ca ngi bnh di hnh thc vin ph v bo him y t.
VI. T CHC THC HIN
Chng trnh phng chng bnh ung th c chia ra lm 2 giai on:
1. Giai on 1: t 2002 2005
Tp trung vo:
- Thit lp v cng c mng li PCUT, trong tp trung u tin cho cc thnh ph
ln, khu th.
- Xy dng chng trnh o to, bin son v pht hnh h thng ti liu chun
hng
dn chn on, iu tr v phng bnh ung th.
- T chc tp hun, o to mi, o to li, nng cao trnh cho i ng cn b

y t t trung ng n c s .
- iu tra lp bn dch t v bnh ung th trong phm vi ton quc.
- Trin khai cng tc gio dc tuyn truyn v phng bnh v pht hin sm cho
cng ng.
- T chc khm sng lc pht hin sm v iu tr cho bnh nhn ung th ch yu

cc thnh ph ln.
- Ban hnh cc vn bn php quy, chnh sch h tr to iu kin cho vic thc
hin chng trnh PCUT.
2. Giai on 2
T 2006-2010:
- Hon thin mng li PCUT v qun l bnh nhn ung th t trung

ng n a phng.
- o to nng cao trnh c v phng bnh cng nh khm cha bnh

cho ton b i ng cn b thuc mng li PCUT.
- Trin khai pht hin sm, iu tr v t chc phng bnh trn phm vi
ton quc.
1. Nguyn Chn Hng. 2004. Ung bu hc ni khoa. Trang 194-206. Nh

xut bn y hc.
2. Phm Thy Lin. 1999. Tnh hnh ung th Vit Nam. Trang 16-44. Nh
xut bn Nng.
II. TI LIU TING ANH

1. Oxford Handbook of Oncology. 2002. Epidermiology of cancer. pp 3-11.
15. UNG TH V
1-i cng:
Ung th v l bnh l{ c tnh ph bin nht n gii. Cc yu t nguy c

ca ung th v:
Nguy c cao: Tui cao
Vng Bc M hay Bc u
Nng IGF-1 (Insulinlike Grow Factor-1) trong giai on mn kinh cao
Nng estrogen trong giai on mn kinh cao

Gia nh c m hay ch em gi b ung th v
Nguy c trung bnh: Mc sng cao
Sanh con u sau 30 tui
b ung th mt v
Tn thng lon sn v
Nguy c thp:
C kinh nguyt sm
Mn kinh mun
Bo ph sau mn kinh
Ch n nhiu m, c bit m bo ho
Cc yu t bo v chng li ung th v:
C kinh nguyt ln u sau 15 tui
Cho con b k o di hn 1 nm
B o ph trc mn kinh
Vn ng
Ch n m khng bo ho
Phn loi m hc ca ung th v: Ung th ng tuyn v
Ung th nang tuyn v
Ung th nm v: Bnh paget
Bnh Paget kt hp vi carcinoma trong ng tuyn Bnh Paget kt hp vi

carcinoma ng tuyn xm ln Carcinoma khng bit ho
Cc loi ung th v him gp khc: Cystosarcoma phyllode Angiosarcoma
Lymphoma
Ph v mng y l c im chnh ca carcinoma xm ln. Carcinoma ng
tuyn v xm ln chim a s cc tn thng c tnh ca tuyn v (70-80%).
Cc tn thng c tnh khng ph v mng y:
Carcinoma ng tuyn v khng xm ln (ductal carcinoma in situ-DCIS) l tn

thng tin ung th. DCIS c th hoi t trung tm, can-xi ho v s c
trn lm sng.
Carcinoma nang tuyn v khng xm ln (lobular carcinoma in situ-LCIS) t gp

hn nhiu so vi DCIS. LCIS thng khng hoi t, khng ng vi v khng s
c trn lm sng cng nh trn nh nh. LCIS c th c pht hin tnh c
trn mu gii phu bnh. Nhiu quan im cho rng LCIS khng phi l tn
thng c tnh.
Hin nay, cc phng php iu tr ung th tuyn v c chn la da vo

cc yu t sau: tui tc ca BN, tnh trng kinh nguyt, kch thc khi u,
receptor estrogen hay progresterol (ER/PR), bn cht ca t bo ung th v
nhn, thnh phn DNA, t trng tng tr ng (S-phase fraction), xm ln mch
mu, hoi t u
Vi phng php iu tr a m thc, phu thut kinh in on nh trit

cn (Halsted) dn
c thay bng cc phu thut c tnh cch bo tn hn.
2-Chn on:
2.1-Chn on lm sng:
Chn on lm sng ung th v da vo:
nh gi cc yu t nguy c
Hi k bnh s
Khm k tuyn v.
BN ung th v c th c triu chng sau:
S c khi u: 75% khi u c pht hin b i chnh BN Khi u pht trin

nhanh
Chy mu hay chy dch trong t mt nm v
au m mt bn v, au khng lin quan n kinh nguyt
St
Ri lon kinh nguyt
Khi khm v, cn ch { n cc du hiu sau: Tuyn v mt cn xng
Nm v b tht mt bn
Da trn khi u b nhu, i mu, hay ging nh da cam

Quan trng nht l s khi u. Ung th v c cc tnh cht sau khi s nn: Chc
K m di ng, i khi dnh vo c ngc ln
Gii hn khng r B mt khng u Thng khng au
Lun khm vng nch c th pht hin hch di cn.
2.2-Chn on cn lm sng:
2.2.1-Chp nh nh:
Chp nh nh l phng tin c chn la tm sot v nh gi ban u

mt trng hp ung th v.
Cc du hiu ca mt tn thng c tnh trn nh nh: hnh sao, b khng
u, m cn quang khng u, cu trc b bin dng, c m can-xi nh
hn 5 mm hay nhiu m t thnh m.
Thi x tr da vo kt qu nh nh:
Lnh tnh: chp li nh nh sau mt nm.
C th lnh tnh: chp li nh nh sau su thng. Nghi ng c tnh: sinh thit.
2.2.2-Siu m:
Siu m l phng tin thay th cho nh nh i vi cc BN tr, hay BN c

km theo bnh x nang v. Siu m c th chn on phn bit khi u c hay
nang. Siu m cng c th hng dn cho vic chc ht sinh thit.
Hnh nh ung th v trn siu m: khi c cu trc echo k m, tng m phi

sau, gii hn khng r, b a cung.
2.2.3-Chc ht sinh thit u (FNA: fine needle aspiration):
Chc ht sinh thit u l th thut chn on c chn la trc tin. Chc

ht sinh thit c gi tr
chn on cao ( nhy 90%, c hiu 98-100%).
Kt qu m tnh gi ca chc ht sinh thit s cao hn nu khi u nh hn 1

cm.
Do t l dng tnh gi thp (2%), tt c BN c kt qu chc ht sinh thit
dng tnh c xp m chng trnh.
K thut chc ht sinh thit:
Phng tin: kim chc ht, syringe 10 mL (c sn 1-2 mL khng kh)
Sau khi gy t ti ch, c nh khi u bng cc ngn tay ca bn tay tri, m

kim vo khi u, va chc va rt va ht trong mt khong cch khong 1 cm
cho n khi c t mu m hin din trong syringe (hnh 1). Ngng ht khi rt
kim.
Nu ht ra t bo: pht mu ln lam knh g i i phn tch. Nu ht ra dch,

dch s c g i i phn tch nu:
Dch l mu
Khi cm cn hin din sau khi ht ht dch
Nang ti lp nhanh sau khi ht ht dch

2.2.4-Sinh thit/ ct Hnh 1- Chc ht sinh thit kim nh (FNA)
trn u: Ch nh:
Khi u c
FNA:
Cho kt qu c tnh hay nghi ng c tnh
Chc ht ra mu
Nang ti lp nhanh sau chc ht
Nguyn
tc:
ng rch: hnh vng cung trn ra qung v nu khi u nm ln cn qung

v, hnh nan qut nu khi u nm di ngoi, hnh vng cung nu khi u
nm trn trong.
Ly trn u v mt lp m bnh thng quanh u (5-10 mm), khng lm ph v

cu trc u.
2.2.5-Sinh thit mt phn: Mc ch:
Xc nh ung th v
Xc nh cc tnh cht khc ca t bo ung th (bn cht t bo v nhn,

ER/PR) Lm tin cho vic chn la phng php iu tr.
Ch nh: khi u ln, khi u T4. Nguyn tc:
Sinh thit mt mu hnh mi cam
Cm mu k
Khng dn lu.
2.2.6-Sinh thit bng kim to (core needle biosy):
C gi tr chn on tng ng sinh thit mt phn.
2.2.7-Sinh thit hch nch tin tiu:
Mc ch ca sinh thit hch nch tin tiu l nhm nh gi giai on hch

nch trc khi quyt
nh c no hch nch hay khng.
Hch tin tiu (sentinel node) l hch u h thng dn lu bch mch, b di

cn trc tin.
K thut: dng cht nhum isosulfan blue hay cht keo c nh du phng x
tim vo khi u, xc
nh v sinh thit hch u tin b nhum mu hay c cht phng x (hnh 2).
Hnh 2- K thut tm hch nch tin tiu
2.2.8-Ct ng
tuyn v:
c ch nh cho cc trng hp chy dch trong hay mu t mt nm v m

khi u khng pht hin c trn lm sng cng nh trn nh nh. Trong cc
trng hp nh th, thng k cho thy 80% l lnh tnh (papilloma hay dn
ng tuyn v). 20% cho kt qu ung th v.
Phng php: lun ng thng tuyn l (4.0) vo ng tuyn v chy dch, ct

mt mu m hnh nn.
2.2.9-X t nghim tm cc cht nh du (CEA, CA 15-3, CA 27.29): t c gi tr
trong chn on ung th v
2.2.10-X t nghim gene BRCA-1 v BRCA-2:
c ch nh khi gia nh BN cng c ngi b ung th hay bn thn BN b ung

th bung trng km theo.
2.3-Chn on phn bit:
U si tuyn v (fibroadenoma): khi hnh cu hay bu dc, b mt phng, gii

hn r, mt
chc, khng au v di ng rt d dng.
U nh trong ng tuyn v: phn ln nm trung tm. Triu chng: chy dch

trong hay mu t
nm v. Chn on da vo siu m, FNA hay sinh thit ng tuyn v. Nang v:

khi c gii hn r v di ng. Chn on da vo siu m.
Bnh x nang v: nhiu khi cm ri rc hai bn v, c th km theo au hay

khng. Chn on da vo siu m. Ung th v c th pht trin trn v c
tn thng x nang. Trn lm sng khng th phn bit khi cm ca x nang
v vi khi cm ca ung th v. Nu khm thy mt trong s cc khi cm c
mt cng chc hn cc khi cn li, pht trin nhanh hn, c bit c hch
nch, nht thit phi ch nh FNA.
Nang sa tuyn v: thng gp trong giai on hu sn. Nguyn nhn do tc

mt nhnh no ca ng dn sa.
2.4-nh gi giai on (theo AJCC): Khi u:

o Tis: carcinoma ng tuyn v in situ, carcinoma nang tuyn v in situ, bnh
Paget ca nm v cha xm nhp vo m v. Cc tn thng ny c xem nh
cc tn thng tin ung th.
o T1: khi u nh hn hay bng 2 cm.
o T2: khi u ln hn 2 cm nhng nh hn hay bng 5 cm.
o T3: khi u ln hn 5 cm.
o T4: khi u xm ln vo thnh ngc hay vo da, khi u vim ty. Di cn hch:
o N0: khng di cn hch.
o N1: c di cn hch nch cng bn v hch cn di ng.
o N2: c di cn hch nch cng bn v hch c nh.
o N3: c di cn hch di n cng bn. Di cn xa:
o M0: khng di cn xa.
o M1: c di cn xa.
Giai on T N M
0 is 0 0
I 1 0 0
IIA 0 1 0
1 1 0
2 0 0
IIB 2 1 0
3 0 0
IIIA 0 2 0
1 2 0
2 2 0
3 1 0
3 2
IIIB 4 0 0
4 1 0
4 2 0
IIIC Bt kz 3
IV Bt kz Bt kz 1
3-iu tr:
3.1-Cc phng php iu tr:
3.1.1-Phu thut bo tn v:
C ba phng php phu thut bo tn v: Ct trn u (lumpectomy)
Ct mt thuz v
Ct v
3.1.2-Phu thut on nh: Cc phng php:
on nh n thun: ct b m tuyn v (bao gm nm v qung v), khng

no hch nch.
on nh trit cn ci bin: on nh + no hch nch mc I v II (nhm hch

ngoi v sau c ngc b ).
on nh trit cn ci bin ca Patey: on nh + no hch nch mc I, II, III

(nhm hch ngoi, sau v phi trong c ngc b ). Thng phi ct ngang hay
ct b c ngc b c th no c hch nhm III. So vi phu thut on
nh trit cn ci bin, phu thut Patey lm tng t l ph tay do tr bch
mch ln 3-10%.
Phu thut trit cn (Halsted): on nh + no hch nch mc I, II, III + ct b c

ngc ln v c ngc b .
Chun b trc m:
Quan trng nht l chun b tm l{ BN v bn lun vi BN v phu thut to hnh

v sau m.
Cho khng sinh trc m (cephalosporin th h 1). Cc bc ca phu thut

on nh trit cn ci bin:
1-Rch da hnh elip.
2-Tch hai vt da ti b ngoi xng c (pha trong), b trc c lng rng

(pha ngoi), b di xng n (pha trn) v b sn (pha di).
3-Ct b ton b m v km nm v qung v (pha trc) v mc ngc ln

(pha sau).
4-No hch nch:
M mc n-ngc tip cn n b ngoi c ngc b v b di tnh mch

nch.
Tm v bo tn thn kinh:
Bt buc phi bo tn: ngc di, ngc lng.
C th bo tn: gian sn-cnh tay, ngc gia, ngc bn. No hch vng h
nch (mc I ,II).
5-Dn lu vng m. Chm sc sau m:
Cho thuc gim au

Khng sinh: cho n 24 gi sau khi rt ng dn lu.
ng dn lu: thng c rt vo ngy hu phu 7-10. i khi ng dn lu c

th c gi n 1 thng, tuz thuc vo lng dch dn lu ra nhiu hay t.
Bin chng sau m: Chy mu
Hoi t vt da do thiu mu nui
Nhim trng vt m T dch vng m Ph bch mch tay
Tn thng thn kinh: thng gp nht l t vng nch v mt trong cnh tay,
do tn thng thn kinh gian sn-cnh tay. Tn thng m ri cnh tay
him gp.
3.1.3-Phu thut to hnh v:
Phu thut to hnh v l phn khng th tch ri sau phu thut on nh.
Thi im c th tin hnh phu thut to hnh v:
Tc th (ngay sau on nh): dnh cho ung th giai on I, II.
Tr hon (sau x/ho tr): dnh cho ung th tt c cc giai on. Phung
php:
t ti nhn to: c ch nh cho BN c v nh hay va, BN sc kho k m,

BN c thi gian sng cn li khng lu. Chng ch nh: BN s c x tr b
tc.
Dng m t thn (thng nht l vt da-c lng rng c cung).

3.1.4-Hormone liu php:
Ch nh: c s hin din ca ER v/hoc PR trn m ung th.
Tamoxifen iu tr b tc sau m: gim 50% nguy c ung th ti pht v 28%

nguy c t vong, l tr liu hormone c ch nh rng ri nht.
Ct b bung trng: cho hiu qu tng t nh ho tr b tc (gim 25% nguy

c t vong).
3.1.5-Ho tr:
Ho tr ci thin r rt tin lng sng ca BN b ung th v (ho tr b tc

gim 25% t l t
vong).
a ho tr chng t tnh u vit hn so vi n ho tr.
C di cn hch: ho tr b tc l ch nh bt buc. Khng di cn hch: tuz

thuc vo kch thc v bn cht m hc ca khi u m quyt nh c ho tr
b tc hay khng.
Cc phc :
CMF (tiu chun): cyclophosphamide, methotrexate, 5-fluouracil CAF:

cyclophosphamide, doxorubicin (Adriamycin), 5-fluouracil AC: doxorubicin,
cyclophosphamide
AC km theo b i paclitaxel (Taxol) AC km theo b i CMF
3.1.6-X tr: Ch nh:
Sau phu thut bo tn v
Sau on nh vi khi u to (kch thc hn 5cm) hay b ct cn t bo ung

th
Sau no hch: c trn 4 hch b di cn. Ch nh ny cn ang bn ci v kt
hp x tr v no hch nch s lm tng t l v mc ph bch mch tay.
3.2-Ch nh:
3.2.1-Giai on 0:
Carcinoma ng tuyn v in situ:
Phu thut bo tn v kt hp x tr, c kt hp hay khng vi tamoxifen
on nh, c kt hp hay khng vi tamoxifen
Phu thut bo tn v kt hp tamoxifen, c kt hp hay khng vi x tr
Carcinoma nang tuyn v in situ: Theo di
Tamoxifen
Cc th nghim ngn nga ung th v ang c nghin cu
on nh phng nga c hai bn
3.2.2-Giai on I, IIA, IIB, IIIA, IIIB, IIIC*(*: nu c th ct c):
iu tr theo phng php a m thc: kt hp iu tr ti ch, iu tr ton

thn v ho tr.
iu tr ti ch:
iu tr bo tn v (phu thut bo tn v, x tr, nh gi giai on hch

nch): i vi khi u nh hn 2 cm.
on nh trit cn ci bin, c kt hp hay khng vi to hnh v. X tr b tc

sau m
nu c di cn trn 4 hch hay c xm ln ngoi hch.
iu tr ton thn: cc phng php sau c th c chn la, tuz thuc vo

tui, trng thi kinh nguyt, tnh cht u (kch thc, bit ho, loi receptor),
di cn hch:
Tamoxifen
Ho tr
Ct bung trng
Tamoxifen + ho tr
Ho tr + ct bung trng
Tamoxifen + ho tr + ct bung trng

3.2.3-Giai on IIIB, IIIC (khng phu thut c), u vim ty:
iu tr trc tin: ho tr.
Nu c p ng: on nh, no hch, x tr sau m. C th phu thut bo tn

v nu p ng hon ton hay p ng tt.
3.2.4-Giai on IV:
Ch yu l ho tr, c kt hp hay khng vi hormone liu php.
Cn nhc phu thut (chn lc) cho mt s BN c tn thng di cn c triu

chng.
3.3-Kt qu v tin lng:
Kt qu chung cho ung th v: thi gian sng 20 nm: 75%. Giai on IV: thi
gian sng TB 18-24 thng.
16. UNG TH TY
1-i cng:
Hu ht (95%) ung th tu xut pht t phn ngoi tit ca tu. 80% ung th
tu l adenocarcinoma. Cc bnh l{ c tnh khc ca tu bao gm: ung th
nang tuyn (acinar cell carcinomas), ung th m lin kt ca tu
(sarcomas), ung th m bch huyt ca tu (lymphomas) v ung th t
bo o tu.
tui trung bnh ca BN b ung th tu l 70. Nam gii c tn sut mc bnh

cao hn n gii (t
l nam:n = 1,5:1).
Nguyn nhn: 40% do t pht, 30% c lin quan n thuc l, 20% c lin
quan n ch n ung (nhiu nng lng, t rau qu ti), 5% lin quan
n bnh vim tu mn, 5-10% lin quan n di truyn.
Tui tc l yu t nguy c quan trng nht. Tui cng cao nguy c mc bnh
cng ln.
V tr ca khi u trong ung th tu: 75% u v c, 15-20% thn, 5-10%

ui tu. Ung th u tu thng c triu chng xut hin sm hn ung th
thn v ui tu (triu chng ca chn p ng mt), do c c t l c
phu thut ct b cao hn v c tin lng tt hn
Ung th tu trc tin di cn n cc hch bch huyt quanh tu (hnh 1,2).

Tng b di cn xa thng nht l gan, k n l phi. Khi u cng c th xm
ln vo cc tng ln cn. Ch 20% BN b ung th tu c th c phu thut tr
liu.
Hnh 1-Dn lu bch mch ca tu (mt trc)
Ni chung, tin lng ca ung th tu ngho nn. Bnh kh c chn on

sm. a s BN n vi khi u khng th phu thut c.
Tin lng ca ung th tu s tt hn nu khi u nh hn 3 cm v khng c di

cn hch.
2-Chn on:
2.1-Chn on lm sng:
Hnh 2- Dn lu bch mch ca tu (mt sau)
Hai nhm triu chng thng gp nht nhng li kh phn bit vi cc bnh l{
khc: Chn n, mt mi, au m h vng thng v. i khi bun nn, nn i
St cn nhiu
Nu khi u u tu chn p vo ng mt, vng da tng dn (km nga v

phn bc mu) l triu chng ni bt. Vng da thng khng km theo au v
st, mt du hiu phn bit tc mt do khi u chn p ng mt v tc
mt do si mt. Khi u u tu chn vo ng tu c th gy triu chng tiu
chy, tiu phn m. Tuy nhin, tiu chy, tiu phn m thng t c {
cho n khi vng da xut hin. c bit, khi u mm mc tu c th chn
vo ng tu m khng chn vo ng mt.
au lin tc vng thng v, c bit nu au lan ra sau lng, l du hiu xu:
khi u xm ln vo m ri tng sau phc mc.
Cc triu chng khc, t gp hn:
Chn p, xm ln t trng: nn i, chy mu tiu ho trn Vim tnh mch

huyt khi di tr (du hiu Trousseau)* Tuz theo v tr ca khi u, khm lm
sng c th thy:
Da vng sm. C vt gi vng cng tay hay cng chn. Ti mt cng to (nh
lut Courvoisier)
Gan to v chc (x gan mt) Lch to (huyt khi tnh mch lch) Khi u
thng v
(*): Tnh trng huyt khi tnh mch nng xy ra nhiu v tr thay i (thng
thn mnh v chi di) v lp i lp li nhiu ln. 50% cc trng hp vim
tnh mch huyt khi di tr c pht hin c bnh l{ c tnh ca lp biu m
(carcinomas), c bit l ca tu v phi.
2.2.1-CA 19-9:
Tng trong 75-85% BN b ung th tu. Tng CA 19-9 trn 100 IU/mL (bnh
thng 33-37 IU/mL), nht l khi khng c vng da v bnh l{ tu lnh tnh
khc, c c hiu cao cho cc bnh l{ c tnh, nht l ung th tu.
CA 19-9 khng tng khng loi tr c ung th tu.
t nhy trong ung th tu giai on sm v cng khng th dng tm sot

ung th tu.
2.2.2-CEA:
Tng trong 40-45% BN b ung th tu.
Nhiu bnh l{ khc cng c tng CEA. Do CEA khng c hiu cho ung th
tu.
2.2.3-Chp in ton ct lp (CT):
CT scan th h mi (xon c) l chn la trc tin trong chn on ung th

tu. chnh xc ca vic nh gi kh nng phu thut trn CT xon c l
80%. Hnh nh adenocarcinoma ng tu: khi u gim m v k m tng
quang hn so vi m tu chung quanh (hnh 3). Nu khi u u tu: dn ng
tu hay ng mt hay c hai. Du hiu ca khi u qu kh nng phu thut:
xm ln ra ngoi tu, vo tnh mch mc treo trng trn.
A B
Hnh 3- A-Ung th u tu vi hnh nh khi u gim m . Hi lu tnh mch
ca-lch b khi u chn p, cho hnh nh m chim. B-Cng trn nhng lt
ct ngang qua thn tu cho thy ng tu dn rng v ch m tu b teo
2.2.4-X-quang ng mch:
Cc mch mu trong tu v quanh tu b tc hay b hp. Khng c hnh nh

tng sinh mch mu hay cc thng ni ng-tnh mch.
2.2.5-Siu m qua ni soi:
c xem l phng tin chn on ung th tu c nhy v c hiu cao

nht. Vi u d
7,5-12 MHz cho hnh nh c phn gii cao, siu m qua ni soi c th pht
hin 99-100% ung th tu.
Sinh thit tu qua siu m cng l mt li th ln ca siu m qua ni soi.
nh gi kh nng phu thut tng ng CT xon c.
2.2.6-Chp mt tu ngc dng qua ni soi (ERCP):
95% adenocarcinoma c biu hin bt thng trn ERCP: ng tu b b hp

hay b tc. Nu khi u u tu: ng mt ch cng cho hnh nh tng t
(hnh nh ng i). Cc du hiu bt thng trn, tuy nhin, khng c hiu
cho adenocarcinoma.
2.2.7-Chp cng h ng t (MRI):
MRI khng u vit hn so vi CT xon c. Tuy nhin, MRCP l phng tin
kho st ng mt v tu khng xm ln.
2.2.8-PET:
Phng php PET dng cht 18F-fluorodeoxy glucose (FDG) kho st hnh
nh ca khi u nguyn pht v cc di cn.
Mc ch PET: pht hin cc di cn tim n.
PET c th cho dng tnh gi trong vim tu cp.
2.2.9-Sinh thit:
Sinh thit trc phu thut l vn cn ang bn ci. Tuy nhin, vic xc
nh bn cht m hc trc ho tr hay x tr (trng hp khng phu thut)
l iu bt buc.
Sinh thit c th c thc hin di s hng dn ca: CT, siu m qua ni

soi, ERCP
2.2.10-Ni soi bng:
Nhiu bnh vin nh gi giai on qua ni soi bng trc khi c gng thc
hin mt cuc phu thut tr liu.
2.2.11-Cc x t nghim khc:
Khng c hiu, tuz theo th lm sng:
Vng da: tng bilirubin (ch yu trc tip), tng phosphatase kim, AST, ALT, -
GT Suy dinh dng: gim albumin, gim cholesterol
2.3-Chn on phn bit:
Tuz thuc vo triu chng ca BN khi nhp vin, cc bnh l{ sau cn c

chn on phn bit vi ung th tu:
Vim tu mn
Vim lo t d dy-t trng
Ung th d dy
Ung th gan thuz tri
Ung th vng quanh bng Vater
Ung th ng mt
Si ng mt
X hp ng mt
Nang ng mt
2.4-Thi chn on:
Trc mt BN ln tui, nhp vin vi triu chng st cn, mt mi, chn n,

au m h vng thng v, chn on ung th tu thng khng c t ra
trc tin v BN thng c ch nh siu m v ni soi thc qun-d dy-t
trng. Khi ni soi loi tr bnh l{ ca d dy-t trng v siu m khng cho
thy bt thng ca gan mt, CT l phng tin chn on c ch nh tip
theo.
Nu BN nhp vin v triu chng vng da, c nhiu bnh l{ cn c loi tr.
Trc tin, cn loi tr vng da trc gan v ti gan, ch yu da vo cc kt
qu x t nghim. K tip, cn loi tr si mt bng siu m hay ERCP. ERCP c
th chn on xc nh ung th vng quanh bng Vater cng nh ung th
ng mt. Tuy nhin, trong hu ht cc trng hp, chn on ung th tu
thng c t ra sau khi c kt qu CT.
CT c th nh gi giai on ung th tu vi chnh xc cao. Siu m qua ni

soi l phng tin chn on xc nh v nh gi nh gi giai on ung th
tu vi chnh xc cao nht. Ni soi xoang bng v m bng thm st l hai
phng tin nh gi giai on c chn la sau cng.
2.5-nh gi giai on (theo AJCC): Khi u:
o Tis: carcinoma in situ.
o T1: khi u cn khu tr trong tu v c ng knh ln nht khng qu 2

cm.
o T2: khi u cn khu tr trong tu v c ng knh ln nht hn 2 cm.
o T3: khi u xm ln ra ngoi tu nhng cha xm ln vo b mch thn

tng hay mc treo trng trn.
o T4: khi u xm ln ra ngoi tu v xm ln vo b mch thn tng hay mc

treo trng trn.
Hch:
o N0: cha di cn hch vng.
o N1: c di cn hch vng.
Di cn xa:
o M0: cha di cn xa.
o M1: c di cn xa.
nh gi giai on ung th tu (theo AJCC):
Giai on T N M
0 is 0 0
IA 1 0 0
IB 2 0 0
IIA 3 0 0
IIB 1 1 0
2 1 0
3 1 0
III 4 Bt k 0
IV Bt k Bt k 1
3-iu tr:
3.1.1-Phu thut trit cn:
3.1.1.1-Phu thut Whipple:
Phu thut ct khi t tu (phu thut Whipple) c xem l phu thut tiu
chun i vi ung th u tu. Ni dung ca phu thut Whipple bao gm ct
b u tu, t trng D1-D4, hang v, on cui ng mt ch, cc hch ln cn. S
ti lp ng tiu ho c thc hin bng cch ni v- hng trng. Phn thn
ui tu cn li v ng mt ch c ni vi mt on hng trng. S ct rng
hn thng khng c cc phu thut vin chp nhn, mc d, mt s trung
tm phu thut tu, mt on tnh mch ca hay tnh mch mc treo trng trn
c th c ct gh p nu khi u xm ln vo chng.
Mt bin th ca phu thut Whipple l phu thut ct khi t tu bo tn mn

v. Trong phu thut ny, phn hang v ng mn v c cha li. C hai loi
phu thut cho kt qu sng cn ngang nhau, nhng BN c bo tn mn v t
c triu chng ri lon tiu ho xy ra sau m hn.
nh gi kh nng khi u c th ct b c hay khng, quan trng nht l

xc nh xem khi u c xm ln vo ng mch thn tng, ng-tnh mch mc
treo trng trn hay tnh mch ca hay khng. Nu c xm ln, hu ht phu
thut vin khng phu thut. C di cn hch quanh tu cng l chng ch nh
tng i cho phu thut.
Cng vic chun b trc m bao gm:
Vic gii p ng mt (dn lu ng mt xuyn gan qua da, m ti mt ra da

hay t stent ng mt tm thi) khng lm thay i kt qu phu thut. Ch
nn t vn gii
p ng mt trc m nu BN b tc mt trong thi gian di, hay cuc m b
hon li v mt l{ do no , th d nh phi iu tr cc bnh l{ ni khoa v
tim mch.
Nng cao th trng (truyn m, truyn mu)
iu chnh ri lon cm mu ng mu vi vitamin K Khng sinh d phng
Chm sc sau m:
Gim tit d dy v gim tit tu: bin php hiu qu nht l khng n ung
qua ng ming. Cc loi thuc (c ch bm proton, somatostatin) c th
c cn nhc n.
Dinh dng qua ng tnh mch
Sau 5-7 ngy, nu khng c du hiu x d ming ni, bt u cho BN n ung

qua
ng ming. Mt s tc gi ch trng cho n sm, khi BN bt u c trung

tin. Bin chng v di chng phu thut:
Hi chng d dy chm tiu thot (25%) D tiu ho (d tu, d mt) (5%)
Chy mu
T dch sau m hay p-xe tn lu
y l phu thut ln, bin chng phu thut cao (30%). cc trung tm
chuyn khoa, t vong phu thut di 5%.
3.1.1.2-Ct b ton b tu:
Mc ch trnh m ung th cn st b ct. BN phi c tr liu b sung

bng insulin ngoi sinh sut i. V l{ do ny, phu thut ct ton b tu t khi
c chn la.
3.1.1.3-Ct thn v ui tu:
U thn v ui tu thng c chn on khi bnh giai on mun.

Vic ct b thn v
ui tu khng cho t l sng cao hn so vi khng phu thut.
3.1.2-Phu thut thuyn gim:
c ch nh cho cc khi u, thng u tu, khng th ct b c, gy

tc mt, tc t trng/hang v.
Mc ch phu thut l nhm gii p ng mt hay ti to s lu thng ng

tiu ho. Phng php phu thut:
Ni v trng: nu tc t trng, tc hang v
Ni ti mt-hng trng: nu tc mt
Thng phu thut vin thc hin c hai phng php phu thut trn.
3.1.3-Ho tr:
Ung th tu t nhy vi ho cht. Hai ho cht c s dng ph bin
nht l 5-FU v gembitacine.
3.1.4-X tr:
Cho p ng chm. 5-FU v gembitacine lm tng nhy ca t bo ung th

vi tia x.
3.2-Ch nh:
3.2.1-Giai on I:
Phu thut ct tu trit cn:
Phu thut ct khi t tu (phu thut Whipple)
Phu thut ct ton b tu nu cn thit cho b ct m tnh

Phu thut ct thn v ui tu khi khi u thn v ui tu
C th ho tr 5-FU v x tr sau m.
3.2.2-Giai on II:
C gng ct tu nu c th, kt hp hay khng vi ho tr 5-FU v x tr sau m
Ho-x phi hp cho cc khi u khng ct b c Phu thut ni tt (ni v

trng, ni ti mt-hng trng) t stent ng mt qua da hay qua ni soi
3.2.3-Giai on III:
Cc liu php gim au: x tr thuyn gim hay hu thn kinh bng ho cht
(alcohol 50%).
Ho tr thuyn gim vi gemcitabine ci thin tin lng sng r rt hn so vi

5-FU (t l sng 1 nm 18% ca gemcitabine so vi 2% ca 5-FU).
Phu thut thuyn gim
t stent ng mt qua da hay qua ni soi
3.2.4-Giai on IV:
Ho tr vi gemcitabine hoc 5-FU Cc liu php gim au

Phu thut thuyn gim
t stent ng mt qua da hay qua ni soi
i vi khi u khng th ct b c: T l sng 5 nm: 5%.
Thi gian sng TB: 4-6 thng
i vi khi u c phu thut ct b: T l sng 5 nm : 15-20%
Thi gian sng TB: 12-19 thng
17. UNG TH TUYN D DY
1-i cng:
D dy c gii hn phi trn b i vng ni thc qun-d dy (tng ng

vi c tht di thc qun) v phi di b i mn v (tng ng vi c tht
mn v). V mt gii phu, d dy c chia thnh cc vng chnh sau y:
vng tm v, vng thn v-phnh v v vng hang v
D dy c cung cp mu ch yu b i ng mch thn tng, thng qua bn

nhnh ng mch chnh: ng mch v tri, ng mch v phi, ng mch v
mc ni tri v ng mch v mc ni phi. Phn tm v v phnh v ca d dy
c th c cp mu b i cc nhnh nh ca ng mch di honh. Tnh
mch v tri v phi trc tip vo tnh mch ca, tnh mch v mc ni tri
vo tnh mch lch, tnh mch v mc ni phi vo tnh mch mc treo
trng trn.
D dy c mt h thng dn lu bch mch rt phong ph. Bch dch vng

trn pha b cong nh d dy v nhm hch trn d dy (bao gm hch v
tri v hch cnh tm v). Bch dch vng trn pha b cong ln d dy
v nhm hch ty-lch. Bch dch vng di pha b cong nh d dy
v nhm hch trn mn v. Bch dch vng di pha b cong ln d dy
v nhm hch di mn v. Bn nhm hch chnh ni trn v nhm
hch thn tng, sau tp trung vo ng ngc. Mc d phn nh rch ri bn
vng dn lu bch mch, khi u mt v tr bt kz trn d dy c th di cn
n bt kz nhm hch no trong lu vc d dy.
Ung th d dy:
L bnh l{ c tnh ph bin (ng hng th hai ti M).
Nhiu quc gia chu (Triu tin, Trung quc, Nht) c tn sut mc bnh rt
cao.
BN c tui 40-70. Tn sut mc bnh cao nht 65 tui. Nam c tn sut

mc bnh hi cao hn n.
Ngay c cc nc pht trin, a s BN nhp vin khi giai on mun

(80% BN
giai on III,IV). Phn loi ung th d dy:

Ung th tuyn d dy (adenocarcinomas) chim 90-95% Lymphoma d dy
ph bin th nh, sau adenocarcinomas (5%)
Cc loi ung th d dy khc (ung th t bo vy, adenocanthomas, u

carcinoid, u m
m) rt him khi xut hin
Bi ny ch yu cp n ung th tuyn d dy. Cc yu t nguy c ca ung

th tuyn d dy:
Nhim Helicobacter Pylori
Ln tui Nam gii Thuc l
Ch n: t rau v tri cy ti; n nhiu thc phm bo qun lu ngy

(mui, xng khi)
Polyp tuyn d dy
D sn kiu rut non ca d dy
Vim d dy mn tnh th teo
Vim d dy ph i (bnh M n trier) Thiu mu c tnh
Gia nh c ngi b ung th d dy

Bnh a polyp dng tuyn c tnh cch gia nh
S phn b ca ung th tuyn d dy: 40% khi u 1/3 di d dy, 40%

1/3 gia, 15% 1/3 trn, 5% lan rng trn 2/3 d dy.
Gii phu bnh:
V mt i th, phn loi ung th tuyn d dy theo Borrmann (1926) hin ti

vn cn gi tr, c bit i vi cc nh ni soi.Theo Borrmann, ung th tuyn
d dy c phn thnh 5 kiu:
Kiu 1: dng chi xi
Kiu 2: dng lo t, b g cao
Kiu 3: dng lo t, b phng
Kiu 4: dng thm nhim. Ung th d dy th linitis plastica c xp vo kiu

ny
Kiu 5: ung th d dy c c im khc bn kiu trn
V vi th, adenocarcinomas c cc loi t bo sau (tng dn theo mc c

tnh): t bo
ng, t bo nh, t bo nhy, t bo nhn, t bo khng bit ha. Din tin

ca ung th tuyn d dy:
Di cn: theo ng mu hay bch mch
Xm ln:
Xm ln trn i th: gii hn khi u c quan st bng mt thng nh hn

gii hn tht s ca khi u
Xm ln vi th: c s hin din ca t bo ung th trong h bch mch trn

thnh d dy khong cch kh xa tnh t gii hn ngoi ca khi u.
Xm ln vo cc tng ln cn: mc ni, i trng ngang v mc treo i trng

ngang, ty, t trng, c honh l cc tng thng b xm ln.
Gieo rc trong xoang phc mc: mt khi xm ln ra khi thanh mc d dy,

cc t bo ung th thng gieo rc t do trong xoang bng.
Bin chng ca ung th d dy: Thng khi u
Gy nght (tm v hay mn v) Chy mu
Tin lng ca ung th tuyn d dy ph thuc vo (theo AJCC: American

Joint Commission on
Cancer):
Mc xm ln ca khi u (T) Di cn hch (N)
Di cn xa (M)
2-Chn on:
2.1-Chn on lm sng:
Triu chng c nng trong giai on u rt m h, thng gp nht l triu

chng st cn (62%)
v au bng m (52%). Cc triu chng khc:
Nn i (32%) Chn n (32%) Kh nut (26%)

Tiu phn en (20%) Suy mn (17%)
au ging nh lo t (17%)
Mt t l nh BN nhp vin vi cc bin chng (thng, nght mn v, nght tm

v hay xut huyt tiu ho).
Khng c triu chng thc th trong giai on sm ca bnh. Trong giai on

mun, BN c th
c:
Thiu mu
Khi u thng v
Hch thng n tri (hch Virchow)
Hch quanh rn (hch Sister Mary Joseph) Nhim cng cng sau (mng
Blummer) U bung trng (u Brukenberg)
Gan to Bng bng Vng da
2.3-Chn on phn bit:
C nhiu bnh l{ cn c chn on phn bit vi ung th d dy (bng 1), ty

vo triu chng c nng v thc th khi thm khm BN.
Triu chng chnh Chn on phn bit

Chn n, st cn Ung th gan
Thiu mu, tiu phn en Cc
Unguth
lnh
tytnh ca d dy (polyp tuyn, polyp
tng sn, u c trn)
Lo t d dy chy mu
au bng Vim d dy
M tu lc ch d dy Lo t d dy-t trng
Vim tu
au bng d di Thng lo t d dy
Cn au qun mt
Nn i, nut nghn Vim
Nghttu
mncpv do lo t
Khi u bng Ung
Ung th
Nhi mugan
th mcqun
thc treo
Carcinomatosis Ung th
Di cn tu phc mc t cc bnh l{ c tnh
xoang
Bng 1- Chn on phn bit ung trong
th d
Ung vdy
th ngoi
i xoang bng
trng
X t nghim: thiu mu (42%), mu n trong phn (40%), gim protein huyt

tng (26%), bt thng chc nng gan (26%).
CEA, AFP, CA 19.9: tng trong giai on mun, do khng c gi tr chn on

sm.
X-quang d dy vi Barium: l phng tin chn on hnh nh c in (hnh 1).

X-quang d dy vi Barium khng phn bit ung th d dy dng lo t vi lo t d
dy lnh tnh. Mc d gi tr chn on ung th d dy ca X-quang d dy c
th ln n 90%, X-quang d dy ch nn c ch nh cho nhng BN c triu
chng nghi ng nhng khng c cc yu t nguy c.
Hnh 1- Hnh nh ung th d dy vng hang v (A) v hang-thn v (B) trn X-
quang d dy
Ni soi d dy ng soi mm c gi tr chn on cao nht ( chnh xc 95%).

Nu sinh thit nhiu v tr v sinh thit nhiu ln trn cng mt v tr, chnh
xc c th t 98%.
Siu m qua ni soi l phng tin nh gi chnh xc mc xm ln ca

khi u trn thnh d dy v di cn hch ln cn. Siu m qua ni soi khng c
gi tr chn on di cn hch xa hay di cn gan
CT (hoc MRI): l phng tin c chn la nh gi giai on ung th d

dy. Tuy nhin, CT khng c kh nng pht hin cc hch di cn, cc khi di
cn gan hay xoang phc mc c kch thc di 5 mm. chnh xc trong vic
nh gi giai on ung th ca CT c th thay i t 25-86%.
V mt chn on, trn CT, vi thuc cn quang tnh mch v trong lng d
dy, adenocarcinoma d dy c cc hnh nh sau (hnh 2):
Mt ch dy ln khu tr thnh d dy, c hay khng km theo lo t trn b
mt. Mt khi xi vo lng d dy
Thnh d dy dy lan to, lng d dy b hp li.
Hnh 2- Hnh nh ung th d dy vng hang v T3 (A) v T4 (B) trn CT
Ni soi bng dnh cho cc di cn gan hay phc mc m CT khng pht hin
c. Ni soi bng kt hp vi siu m ngay trc khi phu thut v ra
xoang bng tm t bo ung th l phng tin chnh xc nht gip phu thut
vin chn la BN cho phu thut trit .
2.4-nh gi giai on (theo AJCC) (bng 2): Khi u:
o T1: carcinoma xm ln ti lp c nim hay di nim mc.

o T2: carcinoma xm ln ti lp c (a) hay di thanh mc (b)
o T3: carcinoma xm ln qua lp thanh mc nhng cha xm ln vo cc

tng ln cn
o T4: carcinoma xm ln vo cc tng ln cn (gan tri, tu, c honh, i

trng ngang, thnh bng, phc mc, rut non, lch, tuyn thng thn,
thn).
Hch:
o N0: cha di cn hch vng
o N1: di cn 1-6 hch vng
o N3: di cn hn 15 hch vng
Di cn xa:
o M0: cha di cn xa.
o M1: di cn xa
nh gi giai on ung th d dy theo AJCC (bng 2):

Giai on T N M
0 is 0 0
IA 1 0 0
IB 1 1 0
2a/b 0 0
II 1 2 0
2a/b 1 0
3 0 0
IIIA 2a/b 2 0
3 1 0
4 0 0
IIIB 3 2 0
IV 1-3 3 0
4 1-3 0
Bt kz Bt kz 1
3-iu tr:
3.1.1-Phu thut:
Phu thut ct d dy km no hch c xem nh l mt phng php iu tr

trit cn duy nht.
3.1.1.1-Ct d dy:
C ba phng php ct d dy chnh: Ct bn phn di d dy
Ct bn phn trn d dy
Ct ton b d dy
Vic ct phn d dy c khi u phi m bo sao cho b ct khng c t bo ung
th. bo
m iu ny, b ct phi cch gii hn ca khi u 5-6 cm.
3.1.1.2-No hch:
Vn no hch hin nay cn nhiu bn lun. Theo phn loi carcinomas d dy

ca Nht (JCGC-Jappannese Classification for Gastric Carcinoma), lu vc hch
ca d dy c phn lm 16 nhm (c nh s t 1-16). Hch di cn trong
mt nhm bt kz c th l hch N1 n N3 hay M tuz thuc vo v tr tng i
ca nhm hch so vi v tr ca khi u (hnh 3, bng 3).
T cch phn nhm hch di cn ni trn, cc phu thut vin Nht phn chia
vic no hch trit cn trong ung th d dy ra lm ba cp :
No hch cp 1 (D1): ly i cc hch N1. C th: ct d dy km no hch D1 l

ct d dy kt hp ct b ton b mc ni ln v mc ni nh. Nu b ct d
dy sch (khng c t bo ung th), phu thut ny cn c gi l phu
thut trit cn cp 1 (phu thut R1)
No hch cp 2 (D2): ly i cc hch di cn N1 v N2. Theo nh ngha tng t

chng ta c phu thut R2. Ni dung: ct d dy, ct b ton b mc ni ln v
mc ni nh, lt ht l thanh mc ca hu cung mc ni (bao gm c l trc
ca mc treo i trng ngang), lt trn cc nhnh ng mch chnh ca d dy
(thn tng, v tri, gan chung, lch), lt trn cung gan. Nu c di cn nhm
hch s 10 v 11, phu thut lun km theo ct lch v ct ui tu
No hch cp 3 (D3): no hch D2 kt hp lt trn ng mch ch on sau

tu.
1-Cnh tm v 7-M v tri 14v-TM mc treo trng trn
phi
8a-Gan chung 14a-M mc treo trng
2-Cnh tm v trc trn
tri
8p-Gan chung 15-i trng gia
3-B cong nh sau
16a1-Khe M ch
4sa-V ngn 9-M thn tng
16a2, b1-Cnh M ch,
4sb-V-mc ni 10-Rn lch gia
tri
11p-Lch gn 16b2-Cnh M ch, di
4d-V-mc ni
11d-Lch xa 12b,p-Gan-t trng sau
phi
12a-Gan-t 13-Sau ty
5-Trn mn v
trng tri
6-Di mn v
Nhm hch Giai on di cn hch
1/3 trn 1/3 gia 1/3 di
1 1 1 2
2 1 3 M
3 1 1 1
4sa 1 3 M
4sb 1 1 3
4d 2 1 1
5 3 1 1
6 3 1 1
7 2 2 2
8a 2 2 2
8p 3 3 3
9 2 2 2
Hnh
10 3, bng 3- S phn b2cc nhm hch3v nh gi giaiMon di cn hch
trong ung th d
11p 2 2 2
dy (theo JCGC)
11d 2 3 M
12a 3 2 2
Cc phu thut vin Nht cho rng:
12b,p 3 3 3
13 MMM 3 3
Phu thut ct d dy cng trit , c hi sng ca BN cng cao. Theo cng b
14v
ca M 3 2
14a
Komada (1982) t l sng 5 M M M R2
nm sau phu thut M l 39% so
M vi
MM 18% ca phu
thut R1.
15 3 3 3
16a1 M M M
Phu thut c gi l trit cn khi hch c ly i trong phu thut trn
16 a2, b1
mt mc so vi nh gi di cn hch. Th d, nu di cn hch c nh gi l
16b2
N1, khi phu thut nhm hch N2 s c ly. V th, R2 (ct d dy km no
hch D2) c xem l phu thut tiu chun trong iu tr ung th d dy, ngay
c khi ung th giai on sm.
Tuy nhin, theo nghin cu ca cc phu thut vin u-M:

Tin lng ca ung th d dy ph thuc vo s lng hch b di cn hn l
nhm hch b di cn.
So vi phu thut ct d dy km no hch gii hn (D1/R1), phu thut ct d

dy km no hch m rng (D2/R2) khng ci thin t l sng cn ca BN b ung
th d dy. Ngc li, tai bin v bin chng hu phu ca phu thut R2 cao
hn nhiu so vi phu thut R1.
Hin nay (9/2006), phng php phu thut iu tr ung th d dy tiu chun
Hoa kz l ct d
dy km no hch D1.
3.1.2- X tr v ho tr:
X tr v ho tr khng c tc dng iu tr trit cn. X tr hay ho tr b tc

ring l cng khng c s ci thin kt qu ng k. Tuy nhin, nu ho-x b
tc, tin lng sng cn ca BN s c ci thin.
Phc ho tr: da trn 5-FU (fluorouracil ) v leucovorin. Tng liu x tr: 45

Gy
3.2-Ch nh:
3.2.1-Ung th giai on I,II:
Ct d dy. C th chn mt trong cc phng php phu thut sau:

Ct bn phn di ca d dy, nu khi u khng tm v hay phnh v.
Ct bn phn trn d dy hay ct ton b d dy, nu khi u di tm v hay

phnh v. Ct thc qun km phn trn d dy (ct thc qun khng m ngc,
phu thut Ivor-
Lewis), nu khi u tm v.
Ct ton b d dy, nu khi u n lan phn ln d dy v cch mn v (hay tm
v) di 6 cm.
No hch vng. Ch ct lch khi lch b xm ln trc tip.
X-ho b tc sau m nu c di cn hch (T1N1) hay c xm ln ti lp c

(T2N0).
3.2.2-Ung th giai on III:
Phu thut vi ch { trit cn nu nh qu trnh thm st trong lc phu thut

khng c di cn hch lan rng.
X-ho b tc sau m.
3.2.3-Ung th giai on IV: Ho tr thuyn gim vi:
Fluorouracil
FUP (fluorouracil, ciplastin)
FAP (fluorouracil, doxorubicin, ciplastin) FAM (fluorouracil, doxorubicin,

mitomicin-C) ECF (epirubicin, ciplastin, fluorouracil)
X tr: c th lm thuyn gim triu chng chy mu, au hay b tc.
Liu php laser, t stent xuyn qua khi u, ni v trng, m d dy ra da, m

hng trng ra da i vi khi u gy tc.
Ct d dy thuyn gim: c th c ch nh cho khi u gy tc hay chy mu.
Sau phu thut trit cn, BN c th c cc bin chng v di chng sau: Chy
mu (ming ni, xut huyt ni)
Vim tu cp
Tn thng ng mt
X d (mm t trng, ming ni)
p-xe tn lu, t dch trong xoang bng (nu c no hch m rng)
Suy dinh dng, lao phi, hi chng Dumping, hi chng quai n, hi chng
tro ngc, thiu vitamin B12, rng xng
T vong phu thut: 1-2%.
Nu iu tr tm thi, thi gian sng trung bnh 4-18 thng.
T l sng sau 5 nm: 30-50% nu bnh giai on II, 10-20% nu bnh giai
on III.
3.4-Tm sot ung th:
Chp d dy c cn quang hay ni soi d dy ng soi mm i vi BN ln hn

50 tui hay c cc yu t nguy c.
18. UNG TH I TRNG V TRC

TRNG
1-i cng:
1.1-i cng v polyp i trng:
Polyp l mt ch nh ln trn b mt lp biu m ca i trng. Polyp i

trng c th c cung hay c chn rng. V mt bn cht m hc, polyp i
trng c th xut pht t lp biu m (polyp tuyn, polyp tng sn) hay lp
m m (hamartoma).
ngi trn 60 tui, polyp i trng chim t l khong 10%.
Polyp i trng c th c chia lm ba nhm chnh: polyp tng sn (90%),

polyp tuyn (10%) v cc hi chng a polyp (t l khng ng k). Cc hi
chng a polyp c th c chia thnh hai nhm: cc hi chng a polyp c
yu t di truyn v cc hi chng a polyp khng c yu t di truyn.
Polyp tng sn:
Thng gp on cui i trng v trc trng
Kch thc thng nh hn 5 mm
Hnh dng ph bin: trn, nh, khng cung
Khng c nguy c chuyn dng sang c tnh
Polyp tuyn:
c chia lm ba loi: tuyn ng (tubular), tuyn nhung mao (vilous) v tuyn

ng-nhung mao (tubulovilous). Polyp tuyn c th gp bt kz on no trn
i trng v c cung. Polyp nhung mao tp trung ch yu trc trng v
khng cung.
90% c kch thc nh hn 1,5 cm
Nguy c c tnh ph thuc vo: kch thc (ln hn 2 cm) v thnh phn
nhung mao trong polyp (polyp nhung mao c nguy c c tnh cao nht)
Hi chng a polyp c yu t di truyn: Hi chng a polyp tuyn:
Hi chng FAP (Familial Adenomatous Polyposis Syndrome) Hi chng

Gardner
Hi chng Turcot
Hi chng a polyp m m:
Hi chng Peutz-Jegher (PJ)
Hi chng a polyp ngi tr (FJP-Familial Juvenile polyposis) Bnh Cowden
Hi chng Ruvalcaba-Myhre-Smith
Hi chng a polyp khng c yu t di truyn: hi chng Cronkhite-Canada.
1.2-Cc hi chng c yu t di truyn trong ung th i trc trng:
1.2.1-Hi chng Lynch:
Cn gi l Ung Th i Trng Do Di Truyn Khng Phi a Polyp

(HNPCC- Hereditary
Nonpolyposis Colorectal Cancer).
Hi chng Lynch chim 5% cc trng hp ung th trc trng.
Nguyn nhn ca hi chng ny c xc nh: c s t bin ca mt

trong nm gene Sa
Li Bt Cp Nhim Sc Th (Mismatch Repair Genes: MLH1, MSH2, MSH6,

PMS1, PMS2).
Ngi c HNPCC c nguy c mc cc bnh l{ c tnh ca i trc trng (70-
80% trong sut cuc
i), ni mc t cung (30-60%), bung trng, d dy, rut non, niu qun,
tuyn b da.
chn on hi chng Lynch, trc tin cn ngh n kh nng c th c hi

chng ny. Tiu chun chn on cht ch nht hin nay l tiu chun
Amsterdam:
C ti thiu ba ngi trong ph h mc ung th i trng, v
Mt ngi l trc h ca mt trong hai ngi cn li, v
t nht c mt ngi b ung th i trng tui di 50.
20% ngi b HNPCC c t bin gene t pht.
Chn on xc nh HNPCC da vo x t nghim mu xc nh s t bin ca

cc gene ni trn
1.2.2-Hi chng a polyp tuyn c tnh cch gia nh (FAP): Ti M, hi chng

FAP c tn sut 1/6000-1/30000.
Nguyn nhn ca hi chng FAP l do c s t bin gene APC, mt li gene

c vai tr c ch s hnh thnh ca khi u tn sinh i trng. Ngoi hi
chng FAP, s t bin ca gene APC cn xy ra trong hi chng Gardner v
hi chng Turcot.
tui bt u xut hin triu chng ca hi chng FAP l 16. BN c chn
on hi chng
FAP trung bnh tui 36.
Chn on hi chng FAP da vo:
U qui trong xoang bng hay vng sau trc trng
Soi y mt: ph i lp biu m sc t vng mc
Chn on da vo hnh nh trn ni soi: hng trm n hng ngn polyp

i trng, nhiu polyp d dy (polyp phnh v v polyp tuyn hang v), t
trng (polyp tuyn, tp trung ch yu vng quanh bng Vater).
BN c hi chng FAP c nguy c b ung th i trc trng (100% khi n tui

40), ung th d dy, ung th t trng (4%), ung th tuyn gip, u h thng
thn kinh trung ng v hepatoblastoma.
1.2.3-Hi chng Peutz-Jegher:
Hi chng Peutz-Jegher c tn sut 1/60000-1/300000.
Nguyn nhn hi chng Peutz-Jegher l do c s t bin gene STK11.
tui bt u xut hin cc triu chng ca hi chng Peutz-Jegher l 25.

Chn on hi chng Peutz-Jegher da vo:
Cc polyp (hamartoma) ri rc trong ng tiu ho, nhng tp trung ch yu
rut non
Cc sang thng sc t da v nim mc khoang ming
U tinh hon (u t bo Sertoli)
Ngi c hi chng Peutz-Jegher c nguy c mc cc bnh l{ c tnh ca: ng

tiu ho (t thc qun n trc trng, cao nht l i trng), tu, phi, v,
c t cung, bung trng.
1.3-i cng v ung th i trc trng:
Ung th i trc trng l bnh l{ c tnh ph bin (ng th ba ti M).
Hu ht ung th i trc trng l adenocarcinoma. Cc bnh l{ c tnh cn li

bao gm carcinoid, lymphoma v sarcoma
Mt iu quan trng cn bit l hu ht ung th i trc trng (93%) xut

pht t mt polyp tuyn ca i trng. Thi gian chuyn t mt polyp lnh
tnh sang c tnh trung bnh khong 3-5 nm.
Khng c s khc bit v gii tnh cc BN b ung th i trng. i vi ngi

b ung th trc trng, nam gii c t l mc bnh cao hn n gii. tui b
ung th i trc trng ph bin nht l 70-80.
Hu ht ung th i trc trng c lin quan n cc yu t ngoi cnh. Ch mt
s t do di truyn.
Ung th i trng xch ma v trc trng chim 50% cc trng hp ung th i
trc trng. Ung th i trng xung c t l thp nht (hnh 1).
Hnh 1- Phn b ca ung th i-trc trng (s liu 1996 ti M)

3% BN b ung th hai v tr tr ln trn khung i trng v trc trng.
Yu t thun li ca ung th i trc trng: ch n ung t cht b, nhiu tht,

m ng vt v cholesterol.
Yu t nguy c ung th i trc trng: Ln tui
Polyp tuyn i trng
Di truyn
Bnh vim lo t i trng
Ung th i trc trng l mt trong s t bnh l{ c tnh c tin lng kh tt.

Khong 50% BN b
ung th i trc trng c th c phu thut trit cn.

1.4-Gii phu i trng v trc trng:
i trng v trc trng c cung cp mu nui b i cc ng mch khc nhau.

c th tin hnh phu thut ct mt on i trng hay trc trng, cn phi
hiu r s cung cp mu cho on (hnh 2, bng 1):
M chnh M nhnh on i trng

Mc treo trng Hi-manh trng-rut tha Manh trng
trn
Mc treo trng i
i trng
trng phi
tri i
i trng
trng ln
xung
di i trng gia i trng ngang
Xch-ma
Trc trng gia i
1/3 trng xch-ma
di trc trng
Trc
Trc trng
trng trn
di 2/3 trn trc trng
Bng 1, hnh 2- S phn on v cung cp mu nui ca i v trc trng
A-Manh trng
B-i trng ln
C-i trng ngang
D-i trng xung
E-i trng xch-ma
1-M mc treo trng trn
2-M hi-manh trng-rut tha
3-M i trng phi
4-M i trng gia
5-M mc treo trng di
5a-M i trng tri
5b-M i trng xch-ma

Mt s c im gii phu ca trc trng c lin quan n phu thut ung th
trc trng:
Trc trng di khong 12 cm, tnh t b trn ng hu mn n ni gip vi i

trng xch- ma.
Mt sau trc trng c lp m kh dy, c gi l mc treo trc trng. Cc t

bo ung th c th n lan trong mc treo trc trng xa hn l n lan trong
thnh trc trng.
Trc trng c bao ph b i l tng ca mc ni chu (mc trc trng). Lp

mc tng ny c tc dng lm cho ng khu ni trc trng c kn.
Phi trc, trc trng lin quan vi tin lit tuyn, ti tinh, bng quang (nam)
hay vch sau m o (n). C mt lp mc (Denonvillier) ngn cch gia tin
lit tuyn v ti tinh vi trc trng.
Phi sau, trc trng lin quan vi xng cng. Mt trc xng cng c
ph b i l thnh ca mc ni chu (mc trc xng cng). Mc cng chu
(mc Waldeyer) ni mc trc xng cng vi mc trc trng. Gia mc cng
chu v mc trc xng cng c m ri tnh mch trc xng cng v cc
nhnh thn kinh cng.
Phc mc ch ph 2/3 trc v hai bn trc trng. Ni m np phc mc t
mt trc trc trng lt ln ph mt sau bng quang c gi l ngch trc
trng-bng quang. Ngch trc trng-bng quang cch ra hu mn khong 7,5
cm (cch b trn ng hu mn 3-4 cm), bng chiu di ca mt ngn tay. Khi
thm trc trng, ngn tay chm vo khi u c ngha l khi u 1/3 di trc
trng.
Dn lu bch mch ca i trng v trc trng i theo cc cung mch chnh.

Dn lu bch mch i trng v 2/3 trn trc trng ch i theo mt hng.
Dn lu bch mch
1/3 di trc trng c th i theo nhiu hng: ln trn (vo nhm hch cnh
ng mch ch), sang bn (vo nhm hch chu trong) hay xung di (vo
nhm hch bn).
Phu thut ung th trc trng c lin quan trc tip n hot ng chc nng
ca c tht v hot ng sinh dc.
2-Chn on:
2.1-Chn on lm sng:
2.1.1-Ung th i trng:
Triu chng ca ung th i trng thay i ph thuc vo v tr ca khi u. BN

b ung th i trng phi c th nhp vin v:
Thiu mu thiu st (do chy mu r r t khi u) St cn
Khi u bng
Triu chng thng gp ca ung th i trng tri:
au bng, to bn
Thay i thi quen i tiu
Tiu mu
40% BN ung th i trng nhp vin vi khi u gy tc hay thng i trng.

Chn on tc rut do ung th i trng hay ung th i trng thng da vo:
Tui tc ca BN
Tin cn: au bng m , thay i thi quen i tiu.
Khi u gy tc: hi chng tc rut thp (to bn, chng bng).

Khi u i trng thng biu hin di hai th lm sng: p-xe trong xoang
bng v vim phc mc ton din. Nu khi u va gy tc rut va b thng,
BN s nhp vin trong bnh cnh sc nhim trng nhim c rt nng.
X-quang bng khng sa son: Tc i trng (hnh 3):
on trn ch tc: i trng chng hi
on di ch tc: khng c hi trong i trng
Nu van hi manh trng h : cc quai rut non chng hi v c mc nc hi
Thng i trng: lim hi di honh
Hnh 3- Hnh nh tc i trng trn X-quang bng ng khng sa son. Trn

X-quang, ch tc c d on t ch ni i trng xung-i trng xch-ma
tr xung.
Hnh 4- Hnh nh tc rut do ung th i trng trn X-quang i trng. V tr
tc ch ni i trng xung-i trng xch-ma
CT l phng tin chn on c chn la chn on xc nh nguyn

nhn (ung th i trng) trn BN c hi chng tc rut hay vim phc mc. X-
quang i trng c ch nh hn ch trong tc i trng do ung th i trng.
Khi nghi ng ung th i trng thng, chng ch nh chp X-quang i trng
vi Barium.
2.1.2-Ung th trc trng:

BN b ung th trc trng c hai triu chng chnh l tiu mu (60%) v thay i
thi quen i tiu
(43%).
Khi bnh tin trin, BN c th c:
au do khi u gy bn tc hay tc rut, do khi u xm ln vo m ri thn

kinh vng chu v trc xng cng, do thng khi u gy vim phc mc.
Tiu khng t ch, do khi u xm ln vo c tht hu mn. Tiu gt but, do

khi u xm ln vo bng quang.
Thm trc trng l thao tc quan trng v c tnh cch bt buc trc bt kz
biu hin bt thng no ca vng hu mn-trc trng.
Mc ch ca vic thm khm hu mn trc trng l nhm: Pht hin khi u

trc trng
nh gi tng i mc xm ln vo c quan ln cn
nh gi chc nng c tht
nh gi kh nng bo tn c tht
BN b ung th trc trng c th nhp vin v hi chng tc rut. Chn on tc

rut do ung th
trc trng bao gm:

Hi chng tc rut thp
Thm trc trng c th s c khi u bt lng trc trng. Nu khi u nm

2/3 trn, thm khm trc trng c th khng s ng khi u, nhng du hiu
mu bm theo gant rt c gi tr trong chn on.
X-quang bng khng sa son: chng hi rut non v ton b khung i

trng (chn
on phn bit: lit rut).
Cng ging nh trng hp tc rut do ung th i trng, CT l phng tin

chn on c la chn cho tc rut do ung th trc trng. Ni soi trc
trng vi ng soi cng c th c ch nh thay cho CT. Khng c ch nh
chp X-quang i trng khi lm sng chn on tc rut do ung th trc trng.
Cn ch { l nu thm khm trc trng s c khi u bt lng trc trng,
ngoi X-quang bng khng sa son, khng cn thit phi ch nh thm bt
c phng tin chn on no khc.
2.2-Chn on phn bit:
Tuz theo triu chng khi BN nhp vin, cc chn on phn bit c th l:
au bng qun, thiu mu, tiu mu bm hay mu : Polyp i trc trng
Vim ti tha i trng
Vim i trng mn
Hi chng Rendu-Osler-Weber
Tr
Lc ni mc t cung
Khi u bng:
Lao hi manh trng
Ung th d dy Ung th gan Ung th tu
Hi chng tc rut:: Xon i trng

Hi chng Ovilgie
Hi chng vim phc mc:
Vim phc mc rut tha
Thng lo t d dy-t trng
2.3.1-X-quang i trng vi Barium: Hnh nh:
Khi nh vo lng i trng vi ng b khng u
Lng i trng b hp li (hnh 4,5)
pht hin khi u giai on sm, cn chp i quang k p.
Hn ch ca X-quang i trng trong chn on ung th i trng:
Kh pht hin ung th giai on sm v kh chn on phn bit vi polyp i

trng
Kh pht hin c tn thng vng hi-manh trng v bng trc trng

chnh xc ca X-quang i trng trong chn on ung th i trng l 70-
85%.
2.3.2-Ni soi i trc trng km sinh thit (hnh 6):
L tiu chun vng trong chn on v tm sot cc bnh l{ c tnh ca i

trc trng.
ng soi cng c s dng chn on v sinh thit tn thng trc trng.

ng soi mm c s dng chn on v sinh thit tn thng khung
i trng. ng soi mm c chiu di ngn (60 cm) dng soi i trng xch-
ma hin nay t c ch nh.
2.3.3-CT (hoc MRI):
t khi c ch nh chn on xc nh ung th i trng, tr cc trng

hp sau: BN khng chp nhn ni soi i trng
BN khng gi c bar{t Tc rut do u i trng Thng u i trng
Hnh nh ca ung th i trng trn CT (hnh 7):
Khi c m m mm, nh vo lng i trng
Dy thnh i trng (> 6mm) Hp lng i trng
Hnh 5- Hnh nh ung th i trng Hnh 6- Hnh nh ung th i trng

trn X- quang i trng qua ni soi
i trng
Ch nh ph bin nht ca CT:
nh gi giai on ung th i trng
Pht hin ung th ti pht hay di

cn
Hnh 7- Hnh nh ung th i trng trn CT: A-ung th i trng ngang, B-ung
th ch ni xch- ma-trc trng
2.3.4-Siu m qua ng trc trng:

Hin nay l phng php c chn la nh gi mc xm ln qua
thnh trc trng (
chnh xc 72-94%) v nh gi di cn hch vng ( chnh xc 73-86%).
2.3.5-Chp cng h ng t qua ng trc trng (endorectal surface-coil MRI):
C gi tr tng ng hay cao hn siu m qua ng trc trng trong vic

nh gi mc xm ln qua thnh trc trng v nh gi di cn hch vng.
2.3.6-Siu m bng:
Siu m c ch nh pht hin di cn gan. Hnh nh di cn gan trn siu

m l cc khi echo dy ri rc trong nhu m gan.
2.3.7-PET:
PET t khi c ch nh trc phu thut. Sau phu thut, c th phn bit
ung th ti pht hay so x ti vng ming ni, PET l ch nh u tin.
2.3.8-CEA:
CEA t khi tng BN ung th i trng k m bit ho. Nu tng trc phu
thut, CEA c th c dng nh gi mc trit cn ca cuc phu
thut v pht hin ung th ti pht. Cn nh rng CEA cng tng trong mt s
trng hp khc (bnh l{ gan mt tu, ht thuc l)
2.3.9-CEA scan:
CEA scan i khi c ch nh pht hin di cn xa. Phng php chp lp
lnh x-min dch ny s dng cc khng th ca CEA c nh du ng v
phng x pht hin cc t chc sn xut CEA trong c th. Vai tr ca CEA
scan trong vic pht hin di cn xa cn ang c bn lun.
2.4-Thi chn on:
BN b ung th i trc trng c th nhp vin v cc bnh cnh lm sng sau:

Khi u bng
Hi chng thiu mu km st cn Hi chng ri lon tiu ho di Hi chng

xut huyt tiu ho di Hi chng tc rut
Hi chng vim phc mc
Di cn th pht gan, phi..c pht hin tnh c
chn on xc nh ung th i trc trng, ni soi i trc trng (ng soi

mm hay cng, tuz thuc vo tn thng nm thp trc trng hay cao trn
khung i trng) l ch nh u tin v c tnh cch bt buc. Ni soi gip
chn on xc nh v hnh nh cng nh v gii phu bnh, v y l phng
tin duy nht c th tin hnh sinh thit khi u.
i vi BN b ung th trc trng, ngay c sau khi c ni soi ng soi cng,

BN cng cn c ni soi ton b khung i trng vi ng soi mm pht
hin cc tn thng c tnh ng phi hp.
CT hay MRI c th c ch nh chn on xc nh ung th i trc trng

thay th cho ni soi, nu BN khng hp tc tin hnh ni soi, BN c cc
chng ch nh ni soi (bnh l{ ti tha i trng, khi u i trng thng). Vai
tr chnh ca CT hay MRI l nh gi giai on ung th i trng sau khi c
chn on xc nh.
i vi BN b ung th trc trng, ngoi CT v MRI, siu m qua ng trc trng

(v gn y l MRI qua ng trc trng) cng c th c ch nh v c xem
l phng tin nh gi mc xm ln ca khi u qua thnh trc trng chnh
c chnh xc cao nht.
tm kim cc di cn xa, cc x t nghim sau y c th c ch nh: X-

quang ngc thng
Siu m bng
X t nghim chc nng gan
PET
CEA scan
X hnh xng
CT s no
Ngay c khi t c gi tr chn on, CEA cng nn c x t nghim cho tt c

cc BN b ung th i trc trng, lm c s cho vic theo di v nh gi
tin lng sau ny.
Khi BN nhp vin v hi chng tc rut thp, X-quang bng khng sa son l
ch nh trc tin. X-quang bng xc nh c tc i trng nhng khng
chn on c nguyn nhn. Hn na, X-quang khng phn bit c tc
on cui ca i trng v trc trng vi hi chng gi tc i trng cp (hi
chng Ovilgie). gii quyt c cc vn nu trn, cn phi c CT bng.
Phi rt cn thn khi ch nh chp X-quang i trng i vi nhng BN c hi

chng tc rut thp. nhng BN c st, bch cu tng, bng n au khu tr,
chng ch nh chp X-quang i trng.
Nu thm khm trc trng s c khi u bt lng trc trng, ngoi X-quang
bng khng sa son, khng cn thit phi ch nh thm bt c phng tin
chn on no khc.
Khi lm sng nghi ng khi u i trng thng, CT l phng tin chn on
c chn la trc tin. iu cn ch { l BN c khi u thng km tc i
trng thng nhanh chng ri vo trng thi sc nhim trng nhim c v d
hu s rt nng n nu khng c can thip phu thut kp thi. Thng
thng vic thm khm lm sng trn nhng BN nh th a ra quyt
nh can thip phu thut ngay m khng cn phi tn thi gian lm CT
bng, thm ch c siu m bng.
2.5-nh gi giai on:
C nhiu cch phn loi ung th i trc trng. Phn loi c in nht l phn
loi ca Dukes, c p dng ph bin trong nhng nm ca thp nin 30.
Trong nhng nm tip theo sau , c nhiu ci bin t phn loi ca Dukes,
trong phi k n phn loi ca Astler-Coller (ph bin trong nhng nm
thp nin 50) (hnh 8) v MAC (ci bin ca phn loi ca Astler-Coller)
Hnh 8- nh gi giai on ung th i trc trng theo Astler-Coller
Ngy nay, phn loi c p dng ph bin nht l phn loi theo TNM ca
American Joint
Committee on Cancer (AJCC) (bng 2) and the International Union against

Cancer (UICC). Khi u:
o Tis: carcinoma in situ
o T1: carcinoma xm ln ti lp di nim mc
o T2: carcinoma xm ln ti lp c
o T3: carcinoma xm ln qua lp c nhng cha qua lp thanh mc (hay xm

ln vo m quanh trc trng phn ngoi phc mc)
o T4: carcinoma xm ln vo cc tng, cu trc ln cn hay thng

Hch:
o N2: di cn 4 hch vng tr ln
Di cn xa:
o M0: cha di cn xa.
o M1: di cn xa
nh gi giai on ung th i trc trng theo AJCC (bng 2):
Giai on T N M Dukes* MAC**

0 is 0 0
I 1 0 0 A A
2 0 0 A B1
IIA 3 0 0 B B2
IIB 4 0 0 B B3
IIIA 1-2 1 0 C C1
IIIB 3-4 1 0 C C2/C3
IIIC Bt kz 2 0 C C1/ C2/C3
IV Bt kz Bt kz 1 D
(*) Dukes: Phn loi theo Cuthbert Dukes
(**) MAC: Ci bin ca phn loi theo Astler-Coller

3-iu tr ung th i trng:
3.1.1-Phu thut ct i trng:
Ct i trng l phng php duy nht iu tr ung th i trng.
Ct i trng qua ni soi ci thin cht lng cuc sng ca BN mt thi gian
ngn sau m (t
au) nhng kt qu lu di ca ct i trng qua ni soi so vi m m ang

c nghin cu. Chun b trc m ct i trng:
Chun b i trng:
Ngy nay, chun b i trng vi polyethylene glycol (PGE) v natri phosphate

hin nay thay th phng php tht tho i trng c in. Natri phosphate
lm cho BN d chu hn nhng c th gy ri lon nc v in gii (tng natri
v phosphate, gim kali v canxi huyt tng).
Khng sinh:
Erythromycin base 1 gm x 3 (U) v neomycine 1 gm x 3 (U) Ciprofloxacin 400 mg

x 2 (U)
Metronodazole 500 mg x 3 (U)

Cho khng sinh d phng: cephalosporin, th h 2 hay 3, c ph tr vi khun ym
kh. Nguyn tc phu thut ct i trng do ung th i trng:
Khc vi ct i trng trong cc bnh l{ lnh tnh ca i trng, ct i trng

trong ung th i trng l ct theo s phn b ca ng mch chnh cung cp
mu cho on i trng c khi u (hnh 9).
Cc nguyn tc khc ging nh ct i trng trong cc bnh l{ lnh tnh ca i

trng: Phi chun b tt i trng trc m
Sau khi ct, hai u i trng cn li phi c ti mu tt
Ni i trng kz u nu i trng c chun b tt

Hnh 9- S khc nhau trong gii hn ct i trng trong ung th i trng (a)
v trong cc bnh l{ lnh tnh ca i trng (b)
Cc bc chnh trong phu thut ct i trng trong ung th i trng:
nh gi giai on:
nh gi khi u (v tr, kch thc, mc xm ln)
nh gi di cn hch (v tr, s lng)
nh gi di cn xa (xoang bng, gan)
Tm v kp ct cung mch chnh cung cp mu cho on i trng c khi u

Di ng i trng
Ct on i trng tng ng vi ng mch c tht, sao cho hai m p ct

vn c ti mu tt.
Ni hai u i trng hay lm hu mn nhn to i trng.
K thut khng ng n (no touch) khng ci thin tin lng ca cn

bnh.
Bin chng sau m: ngoi cc bin chng ngoi khoa ni chung, c hai bin
chng cn c nhn mnh:
Cc bin chng nhim trng: nhim trng vt m, p-xe tn lu
X/d ming ni i trng
Cc bin chng khc, lin quan n phu thut: Tn thng t trng
Tn thng niu qun
Tn thng lch
Tn thng mch mu: mc treo trng trn, mc treo trng di, t tu, v
mc ni phi
Tn thng niu qun
Tn thng m ri thn kinh h v
Cc phng php ct i trng:
Ct i trng trit cn (hnh 10):

Ct i trng tri: ct i trng xch-ma, i trng xung v i
trng ngang bn tri
Ct i trng tri m rng: ct i trng xch-ma, i trng xung v

i trng ngang
Ct i trng phi: ct 10 cm cui hi trng, manh trng, i trng

ln v i trng ngang bn phi
Ct i trng phi m rng: ct 10 cm cui hi trng, manh trng, i

trng ln v i trng ngang
Ct ton b i trng: ct 10 cm cui hi trng, manh trng, i trng

ln, i trng ngang, i trng xung, i trng xch-ma, mt phn hay
ton b trc trng.
Ct on i trng (khi u cha c di cn hch hay ct i trng c tnh

cht thuyn
gim)
:
Ct hi-manh trng Ct i trng gc gan Ct i trng ngang Ct i

trng gc lch
Ct i trng xch-ma
Hnh 10- Cc phng php ct i trng trit cn
3.1.2-Ho
tr:
T giai on III ca ung th trc trng, ho tr b tc lm ci thin tin lng
sng ca BN b ung th i trng.
Cc phc :
AIO (acid folic, fluorouracil, irrinotecan): irrinotecan (100 mg/m2) TTM trong 2
gi ngy 1, leucovorin (500 mg/m2) TTM trong 2 gi ngy 1, sau
fluorouracil (2000 mg/m2) TTM trong 24 gi. Liu trn cho mi tun v cho
lin tc 4 tun trong mi nm.
FOLFOX4 (oxaliplatin, leucovorin, fluorouracin): oxaliplatin (85 mg/m2) TTM

trong 2 gi ngy 1, leucovorin (200 mg/m2) TTM trong 2 gi trong ngy 1 v 2,
sau fluorouracil (400 mg/m2) TM bolus v ri fluorouracil (600 mg/m2)
TTM trong 22 gi ngy 1 v 2. Liu trn lp li mi 2 tun.
FOLFOX6 (oxaliplatin, leucovorin, fluorouracin): oxaliplatin (85-100 mg/m2)

TTM trong 2 gi ngy 1, leucovorin (400 mg/m2) TTM trong 2 gi ngy 1, sau
fluorouracil (400 mg/m2) TM bolus v ri fluorouracil (2400-3000 mg/m2)
TTM trong 46 gi. Lp li mi 2 tun.
FOLFIRI (acid folic, fluorouracil, irrinotecan): irrinotecan (180 mg/m2) TTM

trong 2 gi ngy 1, leucovorin (400 mg/m2) TTM trong 2 gi ngy 1, sau
fluorouracil (400 mg/m2) TM bolus ngy 1 v ri fluorouracil (2400-3000
mg/m2) TTM trong 46 gi. Lp li mi 2 tun.
IFL (Saltz) (irrinotecan, fluorouracin, leucovorin): irrinotecan (125 mg/m2),

fluorouracil (500 mg/m2), leucovorin (20 mg/m2) TM bolus. Lp li mi tun
trong 4 tun cho mi 6 tun.
NCCTG (fluorouracin, levamisole): fluorouracil (450 mg/m2) TM bolus mi

ngy t ngy 1-
5 mi tun trong 4 tun, kt hp vi levamisole 50 mg ung 3 ln mi ngy
trong 3 ngy lin tip cho mi 2 tun.
NCCTG (fluorouracin, leucovorin liu thp): fluorouracil (450 mg/m2),

leucovorin (20 mg/m2) TM bolus mi ngy trong 5 ngy cho mi 4 tun.
NSABP (fluorouracin, leucovorin liu cao): fluorouracil (500 mg/m2),

leucovorin (500 mg/m2) TM bolus mi tun trong 6 tun cho mi 8 tun.
3.1.3-X tr:
X tr thuyn gim: hin ti cha c vai tr tiu chun trong iu tr b tc sau

phu thut ct i trng.
3.2-Ch nh:
Giai on I: ct i trng
Giai on II:
Ct i trng
Khng iu tr b tc, tr khi BN ang nm trong nhm nghin cu
Giai on III:
Ct i trng trit cn
Ho tr b tc sau m vi fluorouracil (5-FU) v leucovorin trong 6 thng (phc

NCCTG
hay NSABP)
X tr b tc: hin ti cha c vai tr tiu chun trong iu tr b tc sau phu

thut ct i trng trit cn.
Giai on IV:
Ct on i trng nu khi u c th ct c
Ni tt qua ch tc nghn hay chy mu.
Ct b khi di cn bit lp (gan, phi, bung trng) dnh cho mt s BN chn

lc.
Ring khi di cn gan khng ct c: hu khi u bng nhit, bng sng cao
tn hay ho tr qua ng mch gan.
Ho tr thuyn gim: cc phc kt hp 5-FU v leucovorin vi irrinotecan
(FOLFIRI, AIO, IFL) hoc oxaliplatin (FOLFOX4, FOLFOX6) c xem nh cc
phc chun.
3.3-iu tr tc rut do ung th i trng: Ch nh:
Bn tc i trng: tht tho, nu thnh cng: sp xp m chng trnh Tc i

trng hon ton hay tht tho tht bi: phu thut bn khn Tc i trng, do
v manh trng: phu thut cp cu
Chun b trc m:
iu chnh ri lon nc v in gii iu tr cc bnh l{ ni khoa nu c

Truyn mu Hb > 9 g/dL
Cho khng sinh
t thng d dy (nu phu thut cp cu hay bn khn)
Phng php phu thut: tuz vo nh gi giai on trong lc phu thut v

ton trng ca BN, c th lm hu mn nhn to trn dng, ni tt i trng,
ct rng hay ct on i trng c khi u. Sau khi ct i trng, nu u ct
trn hi trng, c th ni hai u ngay. Nu u ct trn i trng, c th
a hai u ra ngoi hoc ni ngay sau khi ra i trng trn bn m (hnh
11).
Hnh 11- Ra i trng trn bn m: sau khi ct i trng, u xa ca i trng
c ni vi mt ng c khu knh ln (loi ng th ca my gy m). u kia
ca ng nm trong mt chu t di sn, cnh bn m. Ct rut tha, lun
thng Foley qua gc rut tha. Truyn dung dch mui sinh l{ (NaCl 0,9% hay
Ringer Lactate) vo i trng qua thng Foley. Vut nh dc theo khung i
trng y phn theo ng vo chu.. Sau khi ra sch i trng, rt b thng
Foley v ng ra, khu buc gc rut tha, ni i trng.
3.4-iu tr ung th i trng thng: Nguyn tc iu tr:
Hi sc nhanh vi dch truyn
Khng sinh: cephalosporin th h ba kt hp aminoglycoside v metronidazole
Phu thut khn cp
Ni dung phu thut: ct on i trng c khi u, a hai u ra ngoi lm

hu mn nhn to, ra bng, dn lu xoang bng.
4-iu tr ung th trc trng:

4.1.1-Phu thut:
4.1.1.1-Phu thut ct khi u:

Phu thut ct khi u l loi phu thut bo tn trc trng.
Phu thut c th thc hin qua ng hu mn (hnh 12) hay qua ng xng ct
(tip cn trc trng t pha sau)
Hnh 12- Phu thut ct khi u bo tn trc trng trong ung th

trc trng
Ch
nh:
Khi u T1, 1/3 di trc trng. i khi c th c ch nh cho khi u 1/3

gia trc trng (phu thut ny cn c gi l ct khi u trc trng qua ng
hu mn qua ni soi)
Khng chim qu 1/3 chu vi thnh trc trng
bit ho: tt hay trung bnh
C siu m qua ni soi v khng pht hin hch di cn (0-12% khi u T1 c di

cn hch). K thut:
Ct ton b thnh trc trng c khi u, cch b ngoi khi u 1 cm.
Khu li thnh trc trng. Nu ct khi u qua ng hu mn, c th h m p

ct. Kt qu: t l ti pht ti ch 0-40%.
4.1.1.2-Phu thut ct trc:
Cn gi l phu thut bo tn c tht. C hai loi phu thut bo tn c tht:

phu thut ct trc v phu thut ct trc thp. Phu thut c gi l ct
trc thp nu sau khi ct, ming ni trc trng nm bn di ngch trc
trng-bng quang.
Ch nh: khi u 2/3 trn ca trc trng. Mt s nguyn tc chnh v mt k

thut:
Di ng trc trng, i trng xch-ma, ln ti i trng gc lch. Tht v ct

ng mch mc treo trng di
Phi trn khi u: ct ti ni gip gia i trng xch-ma v i trng xung

(hnh 13). Phi di khi u:
i vi khi u 1/3 trn trc trng: gii hn di ( ct trc trng v mc treo

trc trng) cch khi u 5 cm.
i vi khi u 1/3 gia trc trng:
Gii hn di ct trc trng cch khi u ti thiu 2 cm (i vi t bo ung

th c bit ho tt) hay 5 cm (i vi t bo ung th c bit ho k m).
Gii hn di ct mc treo trc trng l 5 cm. Mt s phu thut vin

ngh ct b ton b mc treo trc trng (TME-total mesorectal excision)
gim thiu t l ti pht ti ming ni sau m (hnh 14).
Hnh 13- Gii hn ct on i trc trng trong phu thut ct trc
Hnh 14- Gii hn ct b ton b mc treo trc trng trong phu thut ct
trc
Nu ming ni nm bn di ngch trc trng-bng quang, c th cn to

hnh i trng lm gim s ln i tiu hng ngy. To hnh i trng c th
l to ti ch J (J pouch) hay x dc khu ngang on i trng cch ming ni
6 cm (hnh 15).
Hnh 15- K thut to hnh i trng (A-x dc khu ngang, B-to ti i trng
hnh ch J) lm gim s ln i tiu hng ngy trong phu thut ct trc.
Ni i trng trc trng cn li, bng stapler vng hay bng tay (hnh 16,17).
Nu m p ct di st b trn ng hu mn, ni trc trng vi ng hu mn
qua ng hu mn.
Hnh 16- K thut ni i trc trng bng stapler trong phu thut ct trc.
Bin chng sau m:
Quan trng nht l x-d ming ni. T l x d ming ni sau phu thut bo
tn c tht kh cao: 15% (3-11% nu ming ni 1/3 gia trc trng, 20% nu
ming ni 1/3 di trc trng). V l{ do ny, nhiu phu thut vin m hu
mn nhn to hi trng tm thi nu ming ni 1/3 di, dc bit nu BN
c x tr hay ho tr trc m. Khng c s khc bit v x-d ming ni
gia ni bng stapler hay bng tay.
Cc bin chng khc: B tiu tm thi Lit dng

4.1.1.3-Phu thut ct trc trng qua ng bng v tng sinh mn (phu thut
Miles) (hnh 18): Ch nh:
Ung th trc trng 1/3 di
Khng th thc hin phu thut bo tn c tht (u xm ln c tht hay vo

vng chu, ri lon chc nng c vng c sn trc phu thut)
Ni dung: cuc phu thut c thc hin b i hai -kp: -kp phu thut ng
bng:
Di ng i trng xch-ma v trc trng
Ct hai dy chng bn ca trc trng

Ct ngang ni gip gia i trng xch-ma v i trng xung, ng tm u
di, a u trn ra ngoi lm hu mn nhn to.
-kp phu thut ng tng sinh mn: Khu kn ng hu mn
Ct dy chng hu mn-cng, vo khoang trc xng cng
Ct c nng hu mn
Tch trc trng ra khi tin lit tuyn hay m o, rt b trc trng ra ngoi
Khu li tng sinh mn
Bin chng:
Chy mu l bin chng ng ngi nht, nht l chy mu t m ri tnh

mch trc xng cng.
B tiu
Lit dng
Tn thng bng quang, ti tinh, niu o

Hnh 17- Cc phng php ni i-trc trng bng stapler trong phu thut
ct trc: Ni tn-tn, mi khu ti (trn)
Ni tn tn sau hai ln ng stapler (tri)
Ni tn bn sau khi to hnh i trng thnh ti ch J (phi)

Hnh 18- Gii hn ct on i trc trng trong phu thut Miles
4.1.1.4-Phu thut on chu:
Ni dung ca phu thut on chu: ct b trc trng km theo cc tng ln

cn (bng quang, tin lit tuyn, t cung, bung trng, thnh sau m o).
4.1.1.5-Hu mn nhn to: Ch nh:
Tc rut do ung th trc trng, khi u cn ct b c: lm hu mn nhn to

i trng xch-ma. Sau 2 tun tin hnh phu thut trit .
Khi u khng th ct b c: hu mn nhn to i trng ngang.
4.1.2-X tr:
Khc vi ung th i trng, x tr c vai tr kh quan trng trong iu tr ung

th trc trng. X tr trong lng trc trng:
Ch nh tng t nh ct khi u qua ng hu mn.
Mc tiu: s dng tia x c cng cao, tp trung vo mt vng nh trn

thnh trc trng, ni c khi u. Qu trnh iu tr c chia thnh vi t.
Thi gian iu tr trung bnh ca phng php ny l 60 ngy, vi tng liu
chiu x 9-15 Gy.
Kt qu: t l ti pht ti ch 30%, t l sng 5 nm: 76%. X tr b tc trc

m:
u im: gim giai on khi u, tng kh nng phu thut, tng kh nng bo
tn c tht, gim nguy c ti pht sau m.
Nhc im: tr hon cuc phu thut, lm cho vic nh gi giai on tr

nn khng chnh xc, lm tng nguy c xy ra bin chng sau m.
X tr sau m:
u im: BN c phu thut kp thi, vic nh gi giai on chnh xc, gim

nguy c
ti pht sau m.
Khuyt im: khng kim sot c s gieo rc t bo ung th trong thi gian
phu thut; m bu st b thiu mu s t nhy vi tia x; nu c bin chng
phu thut, x tr b tc s b tr hon.
Cha c bng chng r rng ca vic ci thin tin lng sng ca x tr b tc
trc hay sau m. Tuy nhin, x tr b tc (trc hay sau m) lm gim r rt
t l ti pht ti ch.
4.1.3-Ho tr: (xem phn iu tr ung th i trng)
4.2-Ch nh:
4.2.1-Giai on 0:
C th chn la mt trong 4 phng php sau: Ct khi u qua ng hu mn
Ct khi u qua ng xng ct
X tr trong lng trc trng
X tr vng
4.2.2-Giai on I:
C th chn la mt trong 3 phng php sau: Phu thut ct trc
Phu thut ct trc trng qua ng bng v tng sinh mn
Phu thut ct khi u (ng ng hu mn, ng xng ct). Phu thut ct khi u
(vi b ct khng c t bo ung th) kt hp ho-x b tc sau m, theo mt
s tc gi, cho kt qu tng ng phu thut ct trc v phu thut ct
trc trng qua ng bng v tng sinh mn
4.2.3-Giai on II:
C th chn la mt trong 3 phng php sau, kt hp vi ho-x b tc sau

m: Phu thut ct trc
Phu thut on chu
4.2.4-Giai on III:
C th chn la mt trong 4 phng php sau, kt hp vi x tr trc m v

ho-x b tc sau m:
Phu thut ct trc
Phu thut on chu
Ho-x thuyn gim
4.2.5-Giai on IV:
C th chn la mt trong 4 phng php sau, kt hp vi ho-x b tc sau
m:
Ct ni on trc trng c khi u vi tnh cch thuyn gim, ni tt qua khi u

hay lm hu mn nhn to trn dng
Ct cc khi di cn bit lp gan, phi, bung trng
Ho-x thuyn gim
4.2.6-Ung th trc trng ti pht:
Ct khi u ti ch vi mc ch trit cn hay thuyn gim
Ct cc khi di cn bit lp gan, phi, bung trng
X tr thuyn gim Ho tr thuyn gim Ho-x thuyn gim

t stent qua ch hp qua ni soi
4.3-Kt qu v tin lng: T l sng sau 5 nm:
Giai on I: 90% Giai on II: 75% Giai on III: 50%
Giai on IV (nu c di cn xa): 5%
T l ti pht: 5-30%. Ti pht thng xy ra trong 2 nm u sau phu thut.

Thng l ti pht ti ch.
5-Tm sot ung th i trc trng:
Cc phng tin tm sot ung th trc trng: X t nghim tm mu n trong

phn
X-quang i trng
Ni soi trc trng, ng soi cng
Ni soi i trng xch-ma
Ni soi khung i trng: hin nay l phng tin c ch nh ph bin nht

BN trn 60 tui, BN b vim lo t i trng trn 10 nm: ni soi i trng mi 3-
5 nm BN c hi chng a polyp:
Hi chng Lynch (HNPCC):
Ni soi i trng mi 2 nm, bt u t nm 20 tui, sau mi nm khi tui

trn
40.
Siu m qua ng m o v sinh thit nim mc t cung mi 1-2 nm, bt u

t
nm 25-35 tui.
Siu m h niu v x t nghim nc tiu mi 1-2 nm, bt u t nm 30-35

tui. Hi chng FAP:
Ni soi i trng mi nm, bt u t nm 10 tui
Ni soi d dy-t trng mi 1-3 nm, bt u t nm 20-25 tui
Thm khm tuyn gip v h thn kinh trung ng hng nm
19. UNG TH NG MT NGOI GAN
1-i cng:
Ung th ng mt l bnh l{ c tnh him gp, chim khong 2% tng s cc

trng hp ung th. Tuy nhin, ung th ng mt l bnh l{ c tnh ph bin
th nh ca gan mt, ch ng sau ung th t bo gan.
90% ung th ng mt nguyn pht l ung th ng mt ngoi gan, trong
60-80% l ung th ng ba ng gan (khi u Klatskin), 25% l ung th on
cui ng mt ch (bao gm ung th bng Vater).
Nam gii v n gii c nguy c b ung th ng mt ngang nhau. tui

cng cao, nguy c b
ung th ng mt cng ln.
90% ung th ng mt l ung th ng tuyn (ductal adenocarcinoma). Phn

loi ung th ng ba ng gan theo Bismuth (hnh 1):
T{p I: khi u gii hn ng gan chung
T{p II: khi u xn ln vo ng ba ng gan
T{p IIIa v IIIb: khi u xn ln vo ng gan phi hay ng gan tri on trong gan
T{p IV: khi u xn ln vo ng gan phi v ng gan tri on trong gan

Hnh 1- Phn loi ung th ng ba ng gan theo Bismuth
Cc trng hp bnh l{ gy vim hay kch thch ng mt k o di c xem

l nguyn nhn ca ung th ng mt. BN b vim ng mt x ho nguyn
pht, mt bnh l{ vim khng r nguyn nhn ca ng mt, c nguy c b
ung th ng mt 40%. 25% BN b nang ng mt bm sinh s b ung th
ng mt sau ny. Nhim k{ sinh trng mn tnh ng mt (Clonorchis
sinensis v Opisthorchis viverrini) cng l yu t nguy c ca ung th ng
mt (bng 1).
Vim ng mt x ho nguyn pht
Nang ng mt bm sinh Nhim k{ sinh trng ng mt Si ti mt, si gan
Ho cht:
Thuc cn quang
Cht phng x
Cht sinh ung th (arsenic, dioxin, nitrosamines, polychlorinated biphenyls)

Thuc (thuc nga thai, methyldopa, isoniazid)
Ngi mang mm bnh thng hn mn tnh
Bng 1- Cc yu t nguy c ca ung th ng mt
Ung th ng mt c c tnh din tin chm, xm ln ti ch l ch yu.

Ung th ng mt cho di cn xa trong giai on tr ca cn bnh.
Biu hin lm sng ch yu ca ung th ng mt l tc mt. Tnh trng tc

mt k o di cui cng dn n suy gan, suy dinh dng, suy thn, ri lon
ng mu, vim ng mt v t vong
Ung th ng mt on cui ng mt ch, c xp vo nhm ung th

vng quanh bng Vater. Ung th vng quanh bng Vater l bnh l{ c tnh ca
cc cu trc cch bng Vater trong phm vi 1 cm. C bn bnh l{ c tnh
vng quanh bng Vater, tng ng vi 4 loi t bo biu m khc nhau: nim
mc t trng, ng mt, ng tu v bng Vater chnh danh. Trong 4 loi ung
th ca vng quanh bng Vater, ung th bng Vater chnh danh c tin lng
tt nht. Chn on phn bit ung th bng Vater chnh danh v cc ung th
vng quanh bng Vater cn li da vo x t nghim sinh hc: thnh phn cht
nhy trong u bng Vater l sialomucins, trong khi t bo ca cc u vng quanh
bng Vater khc tit mucins sulfat ho.
Cc ung th vng quanh bng Vater c chung mt thi chn on v iu
tr.
Ung th ng mt ngoi gan nm mt nhnh ng mt chnh (ng gan

phi hay ng gan tri), tuy chim mt t l nh trong ung th ng mt ngoi
gan, nhng biu hin lm sng li tng i khc bit vi ung th ng mt
ngoi gan cc on khc: vng da din tin chm hn, phn gan tng ng
vi ng mt b tc b x ho v mt chc nng khi BN nhp vin.
Ung th ng mt ngoi gan on 1/3 gia ng mt ch thc t him gp.

Nu c, ung th 1/3 gia ng mt ch thng l ung th th pht, do s xm
ln trc tip t ung th ti mt, hn l ung th nguyn pht ti ng mt.
2-Chn on:
2.1-Chn on lm sng:
Vng da do tc mt xy ra trong 100% cc trng hp (nu tnh lun ung th

ng mt trong gan, t l ny l hn 90%). c im ca vng da trong ung
th ng mt l: vng da tc mt hon ton (da vng sm, nga, phn trng
nh ct c), khng au, khng km st.
Cc triu chng khc bao gm: au m vng h sn phi, chn n, st cn
Khi thm khm lm sng, ngoi vng da, gan to l du hiu thng gp nht.
Gan thng to mm vi b t. Gan to, mt chc, b sc l biu hin ca x
gan do tc mt, gp trong ung th khu tr mt ng gan.
BN b ung th on cui ng mt ch s c ti mt cng to (du hiu
Courvoisier). BN b ung th on vng quanh bng Vater c th c cc biu
hin sau:
Thiu mu (do chy mu r r vo lng t trng) Vim tu, tiu phn m (do
tc nghn ng tu)
St l triu chng him khi xy ra trong ung th ng mt ngoi gan. St,

nu c, thng xut hin sau cc can thip ng mt chn on (PTC, ERCP).
X t nghim chng t c s tc mt ngoi gan: Bilirubin (ch yu trc tip) tng

rt cao AST, ALT tng
Phosphatase kim tng
Cn ch { l nu BN b ung th mt ng gan nhp vin giai on cha xut

hin vng da, kt qu x t nghim s cho thy AST, ALT, phosphatse kim tng
nhng nng bilirubin huyt tng li bnh thng.
CA 19-9 tng > 100 IU/mL (bnh thng < 33 IU/mL) c gi tr chn on ung
th ng mt vi
nhy 89% v c hiu 86%.
S tng nng CEA v CA 19-9 BN b vim ng mt x ho nguyn pht

c c hiu
100% trong chn on ung th ng mt, v th chng thng c s dng

nh l phng tin tm sot ung th ng mt BN b vim ng mt x
ho nguyn pht.
Siu m v CT kh quan st trc tip khi u, cng nh xc nh v tr tc nghn.

Hnh nh dn ng mt trong gan, nhng ng mt ngoi gan v ti mt
xp gi { tn thng ng ba ng gan. Ngc li, trong ung th ng mt ch,
ng mt trong gan dn v ti mt cng to.
Siu m qua ni soi, vi hnh nh c phn gii cao, c th quan st cc tn

thng on cui
ng mt ch cng nh nh gi di cn hch.
Chp ng mt xuyn gan qua da (PTC) v qua ni soi mt tu ngc dng

(ERCP) l phng tin chn on X-quang quan trng nht. PTC v ERCP cho
thy r hnh nh gii phu ca ng mt cng nh v tr tc nghn. Ring i
vi ung th vng quanh bng Vater, ERCP l phng tin chn on c la
chn v c th quan st trc tip cng nh sinh thit khi u.
MRCP c gi tr chn on tng ng PTC v ERCP nhng c u im hn

PTC v ERCP c im khng xm ln (hnh 2).
Hnh 2- Ung th ng mt rn gan (t{p II) trn MRCP

X-quang mch mu v MRI t khi c ch nh nh gi kh nng xm ln
ca khi u vo mch mu ln cn.
2.3-Chn on phn bit:
Trn lm sng, cc bnh l{ sau y cn c chn on phn bit vi ung th

ng mt ngoi gan:
Ung th u tu Ung th t trng Ung th ti mt Nang ng mt
Vim ng mt x ho nguyn pht
Hp ng mt do cc nguyn nhn lnh tnh khc
U lnh tnh bng Vater

Hoi t bng Vater
Vim tu mn
2.4-Thi chn on:
Vng da tc mt hon ton, khng au bng v khng st xy ra BN ln tui l

tam chng gi { c s b tc ng mt ngoi gan do nguyn nhn c tnh.
Nu s thy ti mt cng to khi thm khm bng, v tr b tc nm bn di

ng ba ng ti mt v ng mt.
Do khi u c kch thc nh, cc phng tin chn on hnh nh c gi tr hn

ch trong vic nh gi tnh cht ca khi u. Vai tr ch yu ca cc phng tin
chn on hnh nh l cho thy hnh nh ca ng mt on trn v tr tc (dn
to) v di v tr tc (xp hay kch thc bnh thng). PTC, ERCP v MRCP cho
thy hnh nh ng mt r nht.
ERCP cn c tc dng sinh thit nu khi u vng quanh bng Vater.
Vi kt qu ca cc phng tin chn on hnh nh, nu kt hp vi CA 19-9

tng cao, chn
on ung th ng mt ngoi gan l hu nh chc chn.
Nu CA 19-9 bnh thng, BN vn c ch nh phu thut (gii p ng mt),

vic chn on xc
nh ung th ng mt s c thc hin trong lc m.

o T1: khi u cn gii hn trong ng mt
o T2: khi u xm ln ra ngoi ng mt
o T3: khi u xm ln vo gan, ti mt, tu, nhnh gan phi hay tri ca tnh mch
ca hay
ng mch gan
o T4: khi u xm ln vo d dy, i trng, t trng, thnh bng, thn chnh ca

tnh mch ca hay ng mch gan chung
Di cn hch:
o N0: khng di cn hch
o N1: c di cn hch
Di cn xa:
o M0: khng di cn xa
o M1: c di cn xa
nh gi giai on ung th ng mt (theo AJCC) (bng 2):
Giai on T N M
IA 1 0 0
IB 2 0 0
IIA 3 0 0
IIB 1 1 0
2 1 0
3 1 0
III 4 Bt kz 0
IV Bt kz Bt kz 1
Bng 2- nh gi giai on ung th ng mt (theo AJCC)
3-iu
tr:
3.1-Cc phng php iu tr v ch nh:
Phu thut l phng php iu tr duy nht ung th ng mt ngi gan. Ho

tr khng ci thin
c tin lng sng.
Phng php phu thut ph thuc vo v tr v giai on tin trin ca khi u:

Ung th ng ba ng gan:
Bismuth t{p I v II: ct khi u v ni hng trng vi hai ng gan. Bismuth t{p III:
ct khi u km theo ct gan phi hay gan tri. Bismuth t{p IV: phu thut gii
p ng mt:
Phu thut Longmire: ct b ngoi thuz gan tri, bc l ng gan phn thuz II
v III, ni hng trng vo mt ct gan cn li (hnh 3).
X ng gan phn thuz III hay V, ni ng gan (phn thuz III hay V) vi hng trng
(hnh 4).
Ung th on cui ng mt ch: ct on cui ng mt ch-u tu-t trng

(phu thut
Whipple). Trng hp khi u khng ct c: ni ti mt-hng trng.
Hnh 3- Phu thut

Longmire.
Hnh 4- Cc phng php phu thut gii p i vi ung th ng ba ng gan
khng ct c (Bismuth type IV): A-phu thut Longmire, B-ni ng gan phn
thuz III-hng trng, C- ni ng gan phn thuz V-hng trng
BN khng c ch nh phu thut: gii p ng mt bng cch t stent xuyn

qua bu. Vic t c thc hin qua da (PTC) hay qua ERCP.
Cng vic chun b trc phu thut c mt s vn cn ch {:
Vn gii p ng mt: thng khng c t ra trc m, tr cc

trng hp sau: BN b vim ng mt
BN b suy thn
BN mc cc bnh l{ ni khoa, ton trng yu, suy dinh dng, suy gim chc
nng min dch, khng th c phu thut ngay
BN c d tr ct b mt phn ln gan km theo ct khi u ng mt

(Bismuth typ III). Phn gan cn cha li s ti to nhanh hn nu khng b
mt.
Vn nhim trng ng mt: BN b vim ng mt, t pht hay sau cc

th thut chn on c tnh cht xm ln (PTC, ERCP), nn c gii p ng
mt v s dng khng sinh thch hp cho n khi tnh trng nhim trng c
dp tt. Thi gian iu tr trung bnh 3 tun.
Vn suy thn: tnh trng tc mt c nguy c dn n suy thn nu nh c

mt trong cc yu t thun li phi hp: thiu nc, h huyt p, nhim
trng, thuc cn quang, khng sinhCn ch { bi hon y nc BN tc
mt. Truyn dch cho BN trc cc th thut c tim thuc cn quang vo
trong lng mch. Hn ch s dng khng sinh c c tnh trn thn
(aminoglycoside). Ch nh thch hp cc loi thuc h p BN b cao huyt p
trnh bin chng tt huyt p. i vi BN b suy thn, cn hon cuc m v
iu tr cho n khi chc nng thn tr v bnh thng.
Vn suy dinh dng v suy gim chc nng min dch: BN b suy dinh
dng v suy gim chc nng min dch cn c iu tr cho n khi tnh
trng dinh dng v chc nng min dch tr li bnh thng. Tuz theo tnh
trng dinh dng hin ti, thi gian iu tr c th ln n 4-6 tun.
Vn ri lon chc nng ng mu: BN c ri lon chc nng ng mu do

tc mt cn c iu tr bng huyt tng ti v vitamin K. Ngay c khi x t
nghim ng mu cha cho thy c s bt thng, BN cng cn c cho
vitamin K ti thiu 24 gi trc m phc hi li kho d tr vitamin K ca c
th.
Khng sinh d phng: lun cn thit. i vi BN c t stent ng mt
trc , nn ch nh khng sinh ph rng v thi gian s dng khng sinh d
phng c th k o di hn bnh thng (2-3 ngy sau m).
3.2-Kt qu v tin lng: T l sng 5 nm:
Ung th ng ba ng gan c phu thut iu tr v b ct m tnh: 10-20%.
Ung th on cui ng mt ch c phu thut iu tr v b ct m tnh:

28-45% (thi gian sng trung bnh 32-38 thng).
20. UNG TH GAN NGUYN PHT
1-i cng:
Ung th gan nguyn pht c phn lm hai loi chnh: Ung th biu m
(chim hu ht)
Ung th khng phi biu m (ung th t bo lt tng, lymphoma, sarcoma)

Ung th biu m gan bao gm:
Ung th t bo gan (HCC: hepatocellular carcinoma): (90%) Ung th ng

mt (trong gan) (CCA:cholangiocarcinoma)
Phn loi v mt t bo hc ca ung th biu m gan: HCC
Fibrolamella HCC Cholangiocarcinoma

Hn hp (gia HCC v cholangiocarcinoma) Khng bit ho
Hepatoblastoma (rt him gp ngi ln) Ung th t bo gan (HCC):
Ph bin nht ng Phi v ng-nam . BN thng tui 40-50.
cc nc Chu u, bnh him gp. BN thng tui 70. Nam thng

mc bnh hn n. T l nam:n = 2-8:1
80% BN b HCC c x gan v HCC thng a . BN khng x gan, HCC

thng mt
Cc yu t nguyn nhn: X gan
Vim gan do virus, c bit vim gan B v C. Ngi b nhim virus vim gan C
(HCV) c nguy c b HCC cao hn ngi b nhim virus vim gan B (HBV).
c t aflatoxin ca nm Aspergillus flavus
Ru
Cc steroid ng ho
Bnh gan: chng nhim sc t st (haemochromatosis), x ng mt nguyn

pht
Tin lng ph thuc vo:

Giai on pht trin ca khi u
Mc x (v suy) gan
Ch 5% BN b HCC c th iu tr bng phu thut . Ung th ng mt (CCA)

trong gan:
Chim khong 10% bnh l{ c tnh ca gan v 10% bnh l{ c tnh ca ng

mt.
tui thng b mc bnh nht: 50-60
Nam thng b mc bnh hn n (t l 1,5:1)
Yu t nguy c (xem bi ung th ng mt ngoi gan)

C 3 th gii phu bnh (th khi, thng a trung tm v c cc khi u v tinh),
th x
ho lan to quanh ng mt v th u nh trong lng ng mt. BN thng khng

c x gan km theo.
Fibrolamella HCC (FHCC) l mt bin th ca HCC v c tin lng tt hn HCC

(bng 1)
c im HCC FHCC
T l nam:n 2-8:1 1:1
tui trung bnh 45 25
Khi u Xm ln, hoi t trung Khu tr, x ho trung tm
Kh nng ct b 25% 50-75%
X gan tm
90% 5%
AFP (+) 80% 5%
Vim gan siu vi B 65% 5%
Bng 1- So snh fibrolamella HCC v HCC
Phu thut l mt phng php iu tr trit cn ung th gan duy nht. phu
thut gan, cn thit phi nm vng gii phu phn thuz gan (hnh 1,2) cng nh
h thng mch mu ca gan.
Hnh 1- Gii phu phn thuz gan (nhn trc)
Hnh 2- Gii phu phn thuz gan (nhn di)
2-Chn on:
2.1-Chn on lm sng:
Triu chng c nng thng gp nht l au bng (90%). Cc triu chng c

nng khc bao gm chng bng (40%), st cn (35%), suy xp (30%), chn n
(25%), nn i (8%), vng da (7%).
Cc triu chng thc th khi thm khm mt BN b ung th gan c th l: khi

u gan (90%), lch to (65%), bng bng (50%), vng da (40%), st (40%), ting
thi trong gan (30%).
Cc du hiu sau gi { chn on ung th gan:
Tnh trng tin trin nng nhanh chng ca BN x gan
au m , khi u di sn phi
Mt mi, st cn, st nh
Vng da xut hin trong giai on mun
Hi chng bng cp trn BN x gan, do khi u gan v

Chy mu ng mt
Xut huyt tiu ho do v dn tnh mch thc qun
2.2.1-Cht nh du ung th:
2.2.1.1-AFP:
AFP tng trong 70-90% cc trng hp HCC.
Nng AFP trn 400 ng/mL c gi tr chn on HCC vi c hiu 95%.
BN x gan, c khi u di sn v khng vim gan cp c nng AFP trn

400 ng/mL: 100%
cc trng hp l HCC.
Nng AFP cng cao, tin lng HCC cng k m.
2.2.1.2-CA 19-9:
Nng CA 19-9 trn 100 UI/L (bnh thng di 40 UI/L) c nhy 75% v
c hiu 80%
trong chn on ung th ng mt BN b vim ng mt x ho nguyn
pht.
2.2.2-Cc phng php chn on hnh nh (siu m, CT, MRI):
Siu m: kh nng pht hin khi u n c trn siu m l 75-80%. T l ny

cao hn khi khi u a . Trong trng hp CCA th x ho lan to quanh ng
mt, siu m hu nh khng pht hin c tn thng. Mt trong nhng
du hiu gin tip ca ung th ng mt trong gan l dn ng mt khu tr
trong gan.
Siu m Doppler: c th nh gi xm ln tnh mch ca v loi tr u mch

mu ca gan. CT l phng tin chn on xc nh c chn la cho ung
th gan.
Hnh nh in hnh ca HCC (hnh 3) trn CT:
Khi gim m khi cha bm thuc cn quang
Tng quang r trong th ng mch
C hnh nh v bao gi trong th ng-tnh mch
Khi c s hoi t trong khi u: khi u tng quang khng ng nht (vng tng
quang kt hp vi vng gim m v khng tng quang).
Hnh nh in hnh ca CCA trn CT:
Khi u tng quang chm. y l c im dng chn on phn bit vi
HCC. Tuy nhin, CCA c th khng tng quang, tng quang nh vng ngoi vi
hay tng quang vng trung tm.
So trung tm hnh sao
ng mt tng quang (biu hin ca vim ng mt mn phi hp) Dn

ng mt khu tr trong gan.
Khi khi u c kch thc nh: gi tr chn on ca siu m v CT s gim. MRI

c gi tr chn on cao hn. CT kt hp vi X-quang mch mu, c bit X-
quang mch mu vi Lipiodol, s cho kt qu chn on chnh xc nht.
A B
Hnh 3- Hnh nh ca HCC trn CT (hai BN khc nhau): A-trc khi bm thuc
cn quang: khi u a v gim m , B-th ng mch: khi u tng quang
r, trong lng c nhng vng hoi t (gim m v khng tng quang.
2.2.3-Sinh thit khi u di s hng dn ca siu m, CT hay sinh thit qua

ni soi xoang bng: Ch nh:
Khi u nh (ng knh 2-3 cm): sinh thit chn on phn bit vi cc lon
sn khu tr trn nn x gan
AFP, CA 19-9 khng tng hay tng t
BN khng c ri lon ng mu
Vic sinh thit khi u khng lm tng nguy c chy mu hay gieo rc t bo
ung th trong xoang bng.
2.2.4-Cc chn on cn lm sng khc:
X-quang ng mch gan: c ch nh nh gi cu trc gii phu ca

ng mch gan. Bt thng v gii phu ng mch gan c th dn n cc tai
bin phu thut.
Cc xt nghim nh gi chc nng gan: lun cn thit, c ch nh iu tr

thch hp. Cc phng php pht hin di cn xa: X-quang phi, x hnh xng,
CT s no...
2.3-Chn on phn bit:
U t bo gan lnh tnh (adenoma): trn CT, adenoma cho hnh nh khi u c
gii hn r, ng b khng a cung. Trong th ng mch, khi u tng quang
ng nht (tuy nhin, c im ny cng tng t HCC, ung th gan th pht
v tng sn dng nt khu tr ca gan).
U mch mu ca gan (hemangioma): khi u gii hn r, tng quang mnh

trong th ng mch v vn cn tng m so vi m gan chung quanh trong
th tnh mch.
Cc chn on phn bit khc: Ung th gan th pht
Cc tng sn dng nt ca x gan
2.4-nh gi giai on (theo AJCC) (bng 2):

Khi u:
o T1: u n c khng xm ln mch mu
o T2: u n c xm ln mch mu hay nhiu u kch thc nh hn 5cm
o T3: nhiu u kch thc ln hn 5cm hay u xm ln mt nhnh chnh ca tnh

mch ca hay tnh mch gan
o T4: u xm ln vo tng ln cn khng phi ti mt hay u ph hu bao gan
Di cn hch:
o N0: khng c di cn hch
o N1: c di cn hch
Di cn xa:
o M0: khng di cn xa
o M1: c di cn xa
nh gi giai on ung th gan (theo AJCC) (bng 2):

Giai on T N M
I 1 0 0
II 2 0 0
IIIA 3 0 0
IIIB 4 0 0
IIIC Bt kz 1 0
IV Bt kz Bt kz 1
Bng 2- nh gi giai on ung th gan (theo AJCC)
2.5-Thi chn on:
Chn on HCC da vo nng AFP tng cao v s hin din ca khi u trn
cc phng tin chn on hnh nh. Nu CT cho thy cc du hiu in hnh,
khng cn thit phi sinh thit gan.
Khc vi trng hp HCC, chn on CCA thng cn sinh thit gan. Kt qu

sinh thit gan l adenocarcinoma cng ch c gi tr xc nh khi loi tr ung
th gan th pht do di cn t cc tng khc trong v ngoi xoang bng. tm
sot cc tn thng c tnh cc ni khc, c th ch nh cc chn on hnh
nh lng ngc, xoang bng v vng chu, ni soi ng tiu ho trn v di, chp
nh nh
3-iu tr:
3.1.1-Ct gan:
C hai phng php ct gan:
Ct gan bn phn (bng 3, hnh 4):

Phng php ct gan (bn phn) Phn thuz gan c ct
Ct gan phi V-VI-VII-VIII
Ct gan tri II-III-IV
Ct gan thuz phi (ct gan phi m IV- V-VI-VII-VIII (i khi bao gm phn
rng, trisegmentectomy)
Ct gan thuz tri thuz
II-III I)
Ct gan tri m rng II-III-IV-V-VIII
Bng 3- Cc phng php ct gan (bn phn)
Ct phn thuz gan: ngy nay, nh hiu r gii phu ca tng phn thuz gan, c
bit nh s pht minh ra dao ct siu m, phu thut ct gan c th c thc
hin trn tng phn thuz gan.
Phu thut ct gan cho kt qu tt hn nu: Khng c x gan
Khi u nh hn 2 cm
Fibrolamella HCC
B ct cch khi u ti thiu 1 cm
Hnh 4- Cc phng php ct gan bn phn
Chun b trc
m:
BN thng ln tui, do cn nh gi ton din chc nng tim phi v c

bin php
iu tr thch hp.
i vi BN c ton trng k m, cn nng tng trng, truyn m, truyn
albumine. Chun b mu
Cho khng sinh d phng
Hi sc trong lc m: nguy c ng ngi nht khi ct gan l chy mu. t

thng ng mch bi hon kp thi s mt mu trong lc m. Thng tnh
mch trung tm cng cn thit. Do ngun chy mu chnh khi ct gan l t cc
tnh mch gan, vic duy tr p lc tnh mch trung tm di
5 mmHg s hn ch lng mu mt. S mt mu trong lc m c bi hon

bng dch v mu. Nu lng mu mt trn 20 % tng lng mu hay c tt
huyt p trong lc m, BN cn phi c truyn mu. Kim tra Hct thng
xuyn trong qu trnh phu thut. Nu huyt p bnh
thng, ch s Hct ti thiu chp nhn c l 29% i vi BN c bnh l{ tim

mch v 24% i
vi BN khng mc bnh l{ tim mch. Lu lng nc tiu ti thiu chp nhn

c trong lc m
l 25 mL/gi.
Cc bc chnh trong phu thut ct gan:
nh gi giai on v kh nng ct c ca khi u
Di ng gan tt bng cch ct cc dy chng lim v dy chng tam gic
Kim sot cc mch mu n gan: phu tch, buc v ct cc nhnh ng

mt, ng mch gan, tnh mch ca tng ng vi phn gan c ct.
Kim sot cc mch mu ra khi gan (tnh mch gan) Ct gan
Dn lu di honh. ng bng. Chm sc sau m:
Ht cch qung ng dn lu vi p lc -5-10 cmHR2RO
Dch truyn nn cha phospho kch thch s ti to t bo gan.
Nu gan c ct vi khi lng ln, kim tra in gii , cng thc mu v

thi gian prothrombin (PT) ngay sau m v sau mi ngy trong 3-4 ngy
u. Truyn hng cu lng nu Hct di 8 mg/dL. Truyn huyt tng ti
nu PT ln hn 17 giy.
Ch { chnh liu thuc gim au v s chuyn ho thuc qua phn gan cn li

gim so vi trc m.
Cho BN n bt u t ngy hu phu th ba, nu khng c ming ni mt-

rut.
Ph ngoi vi sau m l hin tng bnh thng v c th c iu tr

bng spironolacton.
Nu st xut hin sau m, hay nng bilirubin huyt tng tng trong khi
chc nng gan bnh thng, c th c tnh trng t dch sau m. Siu m hay
CT c ch nh pht hin t dch. Phn ln cc trng hp t dch c
x tr bng chc ht qua da.
Bin chng sau m: Chy mu
T dch di honh
Suy gan/hn m gan. Nguy c suy gan sau m t l nghch vi khi lng v
chc nng ca phn m gan cn li sau phu thut.
T vong phu thut: 5%. Khi c x gan, t l ny tng ln 20%.
Nu khi u ct c vi tnh cht trit cn, t l sng 5 nm ca BN l 30-60%.

T l ti pht sau 5 nm: 80%.
3.1.2-Ghp gan:
Ch nh: HCC trn BN x gan c suy gim chc nng gan (Child B,C). Kt qu:
T vong phu thut: 10-20% Di cn sau gh p gan: 30-40%
Sau gh p gan, t l sng 5 nm nh hn 20%
3.1.3-Cc phng php iu tr tm:
Hu khi u bng phng php gy tc mch:
Cht gy tc mch: cellulose, cc vi ht, lipiodol, bt gelatin, ht xp gelatin.
T l p ng: 60-80%. Tuy nhin, phng php ny cha chng minh c s

ci thin trn tin lng sng.
Ho tr ti ch: thuc thng c s dng l doxorubicin. C th kt hp ho

tr ti ch v gy tc mch (liu php ho-thuyn tc-chemoembolisation)
Hu khi u bng sng cao tn: dng u d a vo trong khi u, di s
hng dn ca siu m, pht ra sng cao tn ph hu khi u.
Hu khi u bng nhit lnh (cryotherapy)
Hu khi u bng ethanol qua da: thch hp cho cc khi u ngoi vi gan,
ng knh < 3cm. Ho tr ton thn:
Cc loi thuc c s dng ph bin nht: doxorubicin, ciplastin, fluorouracil.

T l p ng thp (di 10%)
Ho tr khng ci thin tin lng sng
a ho tr khng chng minh c li im so vi n ho tr
X tr t khi c ch nh do t l p ng thp v c th gy vim gan.
Liu php ho thuyn tc (TOCE - transcatheter oily chemoembiolization, TACE

- transcatheter arterial chemoembolization):
c ng dng tng i rng ri trong thi gian gn y.
Nguyn tc: bm hn hp thuc ho tr v thuc cn quang du vo trong

ng mch nui khi u, c th tng cng thm bng cc ht xp gelatin
(phng php sandwich), vi mc ch:
Gy tc mch mu nui khi u, dn n hoi t khi u
Nht thuc ho tr trong khi u, thuc gii phng t t v ti ch
Ch nh:
Khi u xm ln ti ch, khng th phu thut ct b
Nhiu khi u
Chc nng gan cn tng i tt (Child A). Chun b trc m:
nh gi chc nng gan
Thc hin cc chn on hnh nh nh gi v tr, kch thc, s lng, mc
xm ln v bn cht ca khi u.
Chp ng mch gan nh gi ton b cc nhnh ng mch gan, cc

nhnh nui v cc nhnh c gii phu bt thng (ng mch ti mt, ng
mch v phi, ng mch v tri, ng mch ca dy chng lim...).
Phng php:
Ho tan doxorubicin vo thuc cn quang tan trong nc (iopamidol): 10 mg

doxorubicin pha vi 0,5 mL iopamidol.
Trn dung dch doxorubicin-iopamidol vi thuc cn quang du (Lipiodol)

to thnh nh dch: t l doxorubicin/ thuc cn quang du=50 mg/15 mL
Bm nh dch vo ng mch nui khi u. Nu thy thuc cn quang khng

thot qua cc nhnh tnh mch ca l thnh cng.
Nu c hin tng thot qua tnh mch ca: gy tc cc nhnh thng ni ng

mch gan-tnh mch ca trc bng cc ht xp gelatin, k bm nh dch,
sau cng l cc ht xp gelatin (phng php sandwich).
Bin chng:
Bin chng thng gp nht v nghim trng nht l suy gan. Mc d tp
trung ch yu trong khi u, mt phn nh dch vn c th thot ra phn nhu
m gan cn li, dn n hoi t t bo gan.
Tc cc nhnh mch mu nui cc tng ngoi khi u , c th dn n hoi t

ti mt, lch, b cong nh d dy, hoi t da vng rn....
Tc ng mch phi
p-xe ho khi u hoi t, c th dn n nhim trng huyt
X hp ng mt, dn n hnh thnh u mt (biloma)
Kt qu: thay i, ph thuc vo tnh cht ca khi u v chc nng gan cng
cc yu t nguy c khc. Theo Park JH Chung, thc hin trn 1000 ca TOCE, t
l sng 1,3,5 nm ln lt l 77%, 46%, 23%.
3.2-Ch nh:
Khi u cn khu tr v c th ct c (T1-2N0M0): ct gan.
Khi u cn khu tr nhng khng th ct c (T1-3N0M0, u nm v tr c

bit, BN c bnh l{ ni khoa nng) hay khi u pht trin ti ch (T4N0M0):
Khi u nh hn 5cm: hu khi u bng phng php gy tc mch, sng cao tn,
nhit lnh hay ethanol.
Ghp gan
Ho tr ti ch
Ho tr ton thn
iu tr a m thc: kt hp cc phu thut ct khi u, hu khi u bng nhit

lnh, hu
khi u bng sng cao tn vi ho tr, x tr.
Khi u c hai thuz hay c di cn xa: khng c phng php iu tr tiu

chun. Cc th nghim lm sng ang hng v cc hot cht sinh hc mi. Ho
tr, x tr hay cc phu thut thuyn gim c th c cn nhc n.
Khi c di cn, 60-70% BN t vong trong vng 1 nm, 100% BN t vong trong
vng 3 nm.
Tin lng ung th gan ph thuc vo: s lng u, kch thc u, AFP, xm ln
tnh mch ca, x
gan, tui tc, loi t bo v b ct u.
3.4-Tm sot HCC:
Bao gm x t nghim AFP v siu m gan i vi nhng ngi c nguy c.
21. UNG TH PHI
1-i cng:
1.1-i cng v nt n c phi:
Nt n c phi c nh ngha l mt sang thng phi c quan st

thy trn X-quang c cc tnh cht nh sau:
C kch thc nh hn 3 cm ng knh (cc khi c ng knh trn 3 cm hu

nh l tn thng c tnh).
c bao quanh b i nhu m phi

Khng kt hp vi xp phi v bnh l{ hch
Nt n c phi c pht hin vi t l 1/500 cc film chp X-quang ngc. T

l ny s
cao hn i vi CT ngc.
C rt nhiu nguyn nhn ca mt nt n c phi (bng 1).
Lnh tnh Mch mu Bt ton ng tnh mch (Arteriovenous

Nhim trng malformations
Lao ) Phnh ng mch phi
Mycobacterium avium Aspergilloma

Histoplasmosis Echinococcosis Blastomycosis
Cryptococcosis Coccidioidomycosis Ascariasis
Dirofilariasis
Vim Nt dng thp
Bm sinh Sarcoidosis
Nang i ca rut trc (Foregut duplication cyst)
Bnh l{ khc Xp phi dng trn (rounded atelectasis) Chng
U ht Wegener
U lnh tnh thoi ho bt ca phi (amyloidosis)
Hamartoma
c tnh Ung th U m phi t bo nh: T bo tuyn T bo vy

Khng
phi U
Tsi
bo ln
nguyn pht
Ph qun-ph nang
Di cn phi t T
ibo nh Carcinoid Lymphoma
trng
cc bnh l{ Tinh hon Melanoma Sarcoma V

c tnh ca:
Bng 1- Nguyn nhn ca nt n c phi
1.2-i cng v ung th phi nguyn pht:

Ung th phi l bnh l{ c tnh ph bin nht trn th gii. Hoa kz, ung th
phi ch ng sau ung th tin lit tuyn (nam) v ung th v (n).
Ung th phi nguyn pht c th c xp thnh hai nhm chnh: ung th t
bo nh v ung th
khng phi t bo nh.
Ung th t bo nh (chim khong 20%) c bn cht v sinh hc cng nh lm

sng hon ton khc vi ung th khng phi t bo nh. Khi c chn on,
ung th t bo nh thng xm ln v cho di cn xa. Hn na, ung th t
bo nh nhy vi cc loi thuc tr ung th. Phng php iu tr ung th t
bo nh, v th, ch yu l ho tr. Ch mt s rt t BN b ung th t bo nh
(5%) c iu tr bng phu thut (nhng BN ny nhp vin trong bnh cnh
mt nt phi n c).
Ung th khng phi t bo nh, ngc li, c tin lng hon ton khc hn
ung th t bo nh. Tin lng ca ung th khng phi t bo nh ph thuc
vo giai on pht trin ca khi u. Trong giai on sm (I,II), phu thut hon
ton c th l phng php iu tr trit cn.
Bi ny ch cp n ung th khng phi t bo nh.
1.3-i cng v ung th phi khng phi t bo nh:
Ung th phi loi khng phi t bo nh chim a s (75-85%), bao gm: ung
th tuyn (35-40%), ung th t bo vy (25-30%), ung th t bo ln (10-
15%). Ung th ph qun-ph nang, chim
5%, c xem nh mt nhm nh ca ung th tuyn.
40% khi u ngoi bin (ngoi cc ph qun tiu thuz).

Ung th phi ph bin nam gii hn l n gii. Him khi ung th phi
c chn on
ngi di 40 tui. Tn sut ung th phi cao nht tui 70-80. Nguyn
nhn:
Thuc l l nguyn nhn trong 90% cc trng hp. BN khng ht thuc,

nguyn nhn l do ht thuc th ng.
Nhim bi aming
Cc hydrocarbon vng thm, beryllium, nickel, ng, chromium, cadmium

Khi c chn on:
15% tn thng cn khu tr
2/3 tn thng tin trin giai on mun.
2-Chn on:
2.1-Chn on lm sng:
7-10% BN b ung th phi khng c triu chng. Bnh c pht hin tnh c
khi chp X-quang phi.
Triu chng lin quan n khi u nguyn pht:
U trung tm (thng l ung th t bo vy): Ho (70%)
Ho mu (30%)
Kh th (60%), th kh kh
Xp phi
Vim phi sau tc nghn
U ngoi bin (thng l ung th tuyn v ung th t bo ln): Ho
Kh th
Trn dch mng phi
au ngc (do xm ln thn kinh lin sn)
Triu chng do xm ln hay di cn n cc cu trc ln cn:

Chn p tnh mch ch trn Chn p thn kinh quc ngc Chn p thn kinh
honh
Chn p m ri thn kinh cnh tay
Chn p m ri thn kinh giao cm c (hi chng Horner) Hi chng cn ung

th:
Adenocarcinoma: ngn tay di trng, hi chng Trousseau
Ung th t bo vy: tng can-xi huyt tng
2.2.1-X t nghim m tm t bo c tnh:
Hu ht cc trng hp dng tnh l ung th t bo vy.
n gin, d thc hin, kt qu dng tnh c gi tr chn on cao (t l

dng tnh gi 1%). T l m tnh gi: 40%.
2.2.2-X-quang phi:
c ch nh trc tin, khi nghi ng c bt kz tn thng no trn phi.

Hnh nh:
Khi u ngoi vi:
Khi u hnh cu hay bu dc, b phng hay khng u, nhiu cung. Hnh nh
vng ho quang
Hnh nh ui mng phi
S to hc
Khi u trung tm:
Hnh nh xp phi thuz, ng b hnh ch S ngc. Hnh nh khi u: khng

r rng nh u ngoi vi
Rn phi ph i
Cc hnh nh khc, xut hin trong giai on mun ca cn bnh: Trn dch
mng phi (di cn mng phi)
Ph i trung tht (di cn hch trung tht) Hu xng sn (xm ln xng

sn) Lit c honh (xm ln TK honh)
2.2.3-CT ngc (v phn trn bng-bao gm gan v tuyn thng thn): L tiu
chun ti thiu chn on v nh gi giai on.
Hnh nh:
Khi u ngoi vi:
Hnh nh khi u: hnh cu hay bu dc, b phng hay khng u, nhiu cung.
Khi bm thuc cn quang, khi u tng quang trn 20 HU c gi tr chn on
ung th phi vi chnh xc 98% v c hiu 73%. Cc du hiu khc: s
to hc, hnh nh ng vi
Ph qun: hnh nh ng kh (air bronchogram), nt nhy, xp Khi u trung

tm:
Hnh nh khi u tng t nh khi u ngoi vi
Hnh nh xp phi thuz
Ph qun hp, nham nh
Cc du hiu cho thy khi u c th phu thut c: Khi u tip xc vi trung

tht < 3 cm.
Cn hin din ca lp m gia khi u v trung tht (tuy nhin lp m b xo c

th do vim hay xm ln).
Cc du hiu cho thy khi u khng th phu thut c: Khi u tip xc vi

trung tht > 3 cm
Khi u xm ln carina
Khi u da vo hay bao quanh ng mch ch ngc
2.2.4-MRI:
C u th hn CT trong vic nh gi xm ln vo mng tim, tim v cc mch

mu ln.
nh gi mc chn p tu sng ca khi u.
2.2.5-PET:
FDG-PET c u th hn CT trong:
Phn bit gia u phi lnh tnh v c tnh. Pht hin di cn hch trung tht.
2.2.6-Ni soi ph qun:
C gi tr chn on cao, c bit l cc khi u trung tm, nh quan st trc

tip v x t nghim t
bo hc.
2.2.7-Ni soi trung tht:
nh gi bn cht cc hch ph i trung tht trc khi tin hnh phu thut
tr liu.
2.2.8-Ni soi lng ngc:
Mc ch sinh thit cc nt n c ngoi bin v chn on nguyn nhn

trn dch mng phi.
2.2.9-Sinh thit qua da di s hng dn ca CT: Dnh cho cc u ngoi

bin.
2.2.10-X hnh xng, CT s no:
nh gi di cn xa.

o T1: khi u nh hn 3cm, c bao quanh b i nhu m phi (hay ph mc) v
khng xm ln ph qun gc.
o T2: khi u c mt trong cc c im sau:
n gc (cch carina 2cm)
o T3: khi u, bt kz kch thc no, c mt trong cc c im sau:
tim
carina)
o T4: khi u, bt kz kch thc no, xm ln vo mt trong cc cu trc sau y:
trung tht, tim, mch mu ln, kh qun, thc qun, carina, ct sng, hay gy
trn dch mng phi c tnh.
Di cn hch:
o N0: khng di cn hch.
o N1: di cn hch quanh ph qun v/hoc hch rn phi cng bn.
o N2: di cn hch trung tht v/hoc hch di carina cng bn.
o N3: di cn hch trung tht hay hch rn phi i bn; di cn hch thng n.
Di cn xa:
o M0: khng di cn xa
o M1: c di cn xa
Giai on T N M
0 is 0 0
IA 1 0 0
IB 2 0 0
IIA 1 1 0
IIB 2 1 0
3 0 0
IIIA 1 2 0
2 2 0
3 1 0
3 2 0
IIIB Bt kz 3 0
4 Bt kz 0
IV Bt kz Bt kz 1
3-iu tr:
3.1.1-Phu thut:
Phu thut l c hi iu tr tt nht cho ung th giai on sm, nu BN c th

chu ng cuc phu thut. i vi bnh giai on III, vai tr ca phu thut
cn ang bn ci. Nu giai on IV, BN khng c ch nh phu thut.
nh gi BN trc m: quan trng nht l chc nng h hp (v tim mch). Tt

c BN u phi
c o chc nng h hp trc m. Nu th tch th ra gng sc trong giy

u:
Ln hn 2 lt: BN chu ng tt cuc phu thut.
1,02 lt: BN c th chu ng cuc phu thut.
Nh hn 1 lt: BN khng th chu ng cuc phu thut. Phng php:
Ct thuz phi (km no hch hay ly mu hch): l phu thut tiu chun. Ct
phi: c t l suy h hp v t vong sau m cao.
Ct mt mu phi c khi u (wedge resection): t c chn do c t l ti pht

cao.
Bin chng sau m quan trng nht l suy h hp. T l t vong: 6% i vi phu
thut ct phi,
3% i vi phu thut ct thuz, 1% i vi phu thut ct mt mu phi.
Ho tr b tc sau m: ci thin tin lng sng nu khi u giai on IIIA v

ton trng BN cn tng i tt.
3.1.2-Ho tr:
Ung th phi khng phi t bo nh tng i nhy vi ho tr: p ng 15%
nu n ho tr vi cc thuc c in, 20-25% nu n ho tr vi cc thuc
mi (gembitacine, paclitaxel, docetaxel, vinorelbine), 50% nu a ho tr
(trong bao gm cc thuc mi).
Cc phc c s dng ph bin: carboplatin + paclitaxel, ciplastin +

gembitacine, ciplastin +
vinorelbine.
Ho tr trong ung th phi ch c tnh cch thuyn gim.
BN c th trng tng i tt (ch s Karnofsky >70%, khng mt qu 10%

TLCT) thch hp cho ho tr.
Hinh 1-Ct mt mu phi c khi u (wedge resection): mt phng php
chn on cc nt n c ca phi, ng thi cng l mt la chn iu tr
cho cc BN ung th phi khng c ch nh phu thut ln.
3.1.3-X tr:
X tr liu: trong giai on sm (I, II), x tr c ch nh khi BN khng c ch

nh phu thut
(chc nng h hp k m, ton trng yu). T l sng 5 nm: 12-16%.
X tr b tc sau m lm gim nguy c ti pht ti ch nhng khng lm ci

thin tin lng sng cn.
3.2-Ch nh iu tr:
3.2.1-iu tr ung th phi giai on IA, IB, IIA, IIB, IIIA: Ct thuz phi l phu
thut chn la trc tin.
X tr dnh cho cc khi u c th ct c nhng BN khng th chu ng cuc

phu thut. Ho tr sau m c th ci thin tin lng sng, nht l giai on
IIIA.
3.2.2-iu tr ung th phi giai on IIIA(N2), IIIB: Ho tr n thun
X tr n thun
Ho-x tr kt hp
Ho-x tr sau phu thut
3.2.3-iu tr ung th phi giai on IV:
X tr lm gim s tng tr ng m bu gy triu chng (chn p). Ho tr vi

cc phc :
Ciplastin + vinblastine + mitomycin
Ciplastin + vinorelbine Ciplastin + paclitaxel Ciplastin + gemcitabine Carboplatin

+ paclitaxel
T l sng 5 nm: M (14%), cc nc chu u v cc nc ang pht trin (8%).

T l sng 5 nm theo giai on: giai on I: 60%, II: 40%, III: 20%, IV: 2%.
22. UNG TH THC QUN
1-i cng:
L mt trong nhng loi ung th kh ph bin (ng hng th 9 trong cc bnh

l{ c tnh) v c tin lng ngho nn bc nht (t l sng 5 nm l 8% v thi
gian sng trung bnh l 9 thng).
tui thng mc bnh: 60-70. Nam c tn sut mc bnh cao hn n (5:1).
V tr: hu ht thc qun 1/3 gia v 1/3 di. Ung th thc qun ngc trn v
ung th thc qun c him gp.
95% tn thng c tnh ca thc qun l ung th t bo vy. 60% ung th t

bo vy phn b thc qun 1/3 gia v 30% thc qun 1/3 di. Ung th t
bo vy c 4 i th chnh: th xi, th lo t, th thm nhim v th polyp. Th
polyp c tin lng tt nht.
chu u v Bc M, phn ln ung th thc qun (hn 50%) l ung th t bo

tuyn. Ung th t bo tuyn c th xut pht t ng tuyn nim mc thc qun,
nhng ph bin nht l hu qu ca s chuyn sn c tnh ca lp biu m n
tng on cui thc qun (thc qun Barrett).
Tn thng thc qun Barrett l hu qu ca vim thc qun do tro ngc

k o di. vng thc qun c tn thng Barrett, lp t bo vy nhiu tng bnh
thng c thay th bng lp t bo tr n tng c cu trc dng nhung mao
nh nim mc d dy hay rut non. Cc t bo ny kh i u bng hin tng d
sn, sau chuyn sang lon sn v cui cng ung th ho. Nguy c ung th
ho t l thun vi mc lon sn. BN c thc qun Barrett s c nguy c ung
th (tuyn) thc qun tng 30-40 ln.
Thuc l c xem l yu t nguy c ca ung th t bo vy, trong khi vim

thc qun tro ngc l yu t nguy c ca ung th t bo tuyn (bng 1).
Ung th t bo vy Ung th t bo tuyn

Ru, thuc l Bnh vim thc qun do tro ngc
Co tht tm v Thc qun Barrett (c xem l tn

thng tin ung th)
Ti tha thc qun
Bo ph
Tn thng thc qun do bng
Bng 1- Cc yu t nguy c ca ung th thc qun
Chng khng tiu sng lng bn tay
(tylosis) Mc sng thp, iu kin v
sinhth
Ung n ung k m Thiu
thc qun vitamin
xm ln ti ch rt mnh m v cho di cn hch sm. S xm
ln
Hitheo ng
chng bch mch lp
Plummer-Vinson di nim c th lan rng trong mt khong
(thiu
cch
mukh xa so vi khi u nhn trn i th.
thiu
st, kh nut, mng ngn thc qun)

Vo thi im c chn on: 75% BN c di cn hch, 50% BN c di cn
xa hay khi u khng th ct c.
Nm vng phn on, s cung cp mu v dn lu bch mch ca thc qun

ng vai tr quan trng phu thut BN b ung th thc qun (hnh 1-4).
2-Chn on:
2.1-Chn on lm sng: Triu chng c nng:
Nut nghn, kh nut: l triu chng thng gp nht (74%). Nut au (17%)
St cn (57%)
17% BN c tin cn vim thc qun do tro ngc.

Triu chng chng t khi u xm ln ra ngoi thc qun: kh th , ho, sc,
khn ting,
au (au sau xng c, au sau lng, au bng vng thng v).
Triu chng lm sng, nu c, thng chng t bnh c di cn xa (hch

thng n tri, gan to, trn dch mng phi).
2.2.1-X-quang thc qun:
Thng c ch nh trc tin, khi BN n khm v triu chng nut nghn.

Hnh nh trn X-quang:
Mt on thc qun b cht hp, b nham nh (hnh 5)
Cc du hiu chng t ung th qu kh nng phu thut (on hp di hn

5 cm, thc qun b lch trc, thuc cn quang thot ra ngoi thc qun). Ch
{: khi BN c du hiu ho, sc, khn ting th khng chp X-quang thc qun.
Hnh 1- Thc qun bt u t c
tht trn (C6) v tn cng bng c
tht di (T11). Thc qun c
chia lm ba on: thc qun 1/3
trn bao gm thc qun c v thc
qun ngc trn, thc qun 1/3 gia
tng ng thc qun ngc gia,
thc qun 1/3 di bao gm thc
qun ngc di v thc qun bng.
Hnh 2- Dn lu bch mch ca thc
qun v cc nhm hch: quanh thc
qun, TM cnh trong, cnh kh qun,
di carina, thn tng, v tri.
2.2.2-Ni soi thc qun (v sinh thit):

L ch nh bt buc nu trn X-quang thc qun cho thy c tn thng khu
tr. Qua ni soi, ung th thc qun biu hin bng hnh nh khi u chi vo
lng thc qun, b v lo t b mt (hnh 5).
2.2.3-CT scan (ngc v phn trn bng):
Nhm nh gi mc xm ln, di cn hch, di cn gan.

Hnh 3- Cc ng mch cung cp mu
nui thc qun bao gm: M gip
2.2.4-Siu m qua ni soi:
di cung cp mu cho thc qun c,
nhnh ca M ph qun v cc
nhnh thc qun ca M ch ngc
cung cp mu cho thc qun
ngc, nhnh tri ca M di honh
v nhnh ca ng mch v tri cung
cp mu cho phn thc qun bng.
Hnh 4-Hi lu mu tnh mch thc qun sau v tnh mch n v
qun: t thc qun c l tnh mch bn n. T thc qun bng, mu tnh
gip di. T thc qun ngc l mch v tnh mch vnh v v di
m ri tnh mch quanh thc honh.
qun. m ri tnh mch quanh thc
L tiu chun vng nh gi mc xm ln ca u ( chnh xc 80-90%)

v di cn hch vng ( chnh xc 70-80%). Sinh thit chc ht di s hng
dn ca siu m qua ni soi c th nh gi giai on ung th vi chnh xc
trn 90%.
2.2.5-PET scan:
c xem l phng tin nh gi di cn hch ngoi hch vng v di cn xa

chnh xc nht.
2.2.6-Ni soi lng ngc hay xoang bng:
C th nh gi giai on ung th vi chnh xc cao (trn 90%). Tuy nhin,

y l phng php chn on xm ln.
2.2.7-X t nghim CEA, CA 19-9, CA 125:
C nhy v c hiu thp trong chn on xc nh, pht hin ti pht

cng nh tm sot ung th thc qun.
2.2.8-Soi ph qun:
c ch nh khi BN c triu chng nut nghn kt hp vi triu chng h
hp (vim phi ti din, sc, kh th , th rt) nhm loi tr kh nng khi u
xm ln kh-ph qun.
Hnh 5- Hnh nh ung th thc qun trn X-quang v ni soi
2.3-Chn on phn bit:
Ung th thc qun cn c chn on phn bit vi cc bnh l{ khc ca

thc qun c triu chng nut nghn:
Ri lon vn ng thc qun nguyn pht: co tht tm v (achalasia), co tht
thc qun. U lnh tnh ca thc qun (chim 0,5-0,8% bu tn sinh ca thc
qun)
Mng ngn thc qun
Ti tha thc qun
So hp thc qun do nhit, ho cht, chiu x
Cc khi t bn ngoi chn vo thc qun (phnh ng mch ch ngc, u trung

tht, ung th ph qun, thot v khe honh)
Vim thc qun (do nm candida, Herpes simplex virus) Tai bin mch mu
no
2.4-Thi chn on:
Khi mt BN nhp vin v triu chng nut nghn, cn khai thc k bnh s (tp
trung khai thc tnh cht ca nut nghn v st cn), thm khm lm sng (ch
{ ton trng v cc du hiu di cn xa).
X-quang thc qun bao gi cng c ch nh trc tin. y l mt phng

tin chn on n gin, r tin, ng thi cung cp nhiu thng tin c gi tr
v con ng thc qun. Nu c tn thng khu tr, ni soi thc qun v
sinh thit c ch nh tip theo. Nu nghi ng ri lon vn ng c nng ca
thc qun, c th ch nh p lc k thc qun, o pH thc qun 24 gi...
Ni soi l phng tin duy nht chn on xc nh ung th thc qun. Nu

chn on c khng nh, bc tip theo l nh gi giai on ca ung
th thc qun. CT ngc v phn trn bng thng c ch nh, cng nh
PET scan. Nu nghi ng khi u xm ln kh-ph qun, cn thit phi ni soi ph
qun. CT no, x hnh xng c th c ch nh nu nh nghi ng c di cn
xa.
Ni soi lng ngc hay xoang bng l phng tin nh gi giai on c tnh
cch xm ln, thng c thc hin ngay trc cuc phu thut, nu nh CT
v cc phng tin nh gi giai on khc cha cho kt lun ng tin cy..
o Tis: carcinoma in situ

o T1: carcinoma xm ln ti lp c nim hay di nim nhng cha qua
khi lp di nim
o T2: carcinoma xm ln ti nhng cha qua khi lp c
o T3: carcinoma xm ln lp mc quanh thc qun nhng cha xm ln

vo cc tng ln cn
o T4: carcinoma xm ln vo cc tng ln cn
Hch:
o N1: c di cn hch vng
Di cn xa:
o M0: cha di cn xa.
o M1a: khi u thc qun ngc trn di cn hch c, khi u thc qun ngc di
di cn hch thn tng
o M1b: di cn hch ngoi hch vng hay di cn xa
nh gi giai on ung th thc qun theo AJCC (bng 2)

Giai on T N M
0 is 0 0
I 1 0 0
IIA 2 0 0
3 0 0
IIB 1 1 0
2 1 0
III 3 1 0
4 Bt kz 0
IVA Bt kz Bt kz M1a
IVB Bt kz Bt kz M1b
3-iu tr:
3.1- Phu thut ct thc qun:
C ba phng php chnh: ct thc qun m ngc, ct thc qun khng m

ngc v ct thc qun ni soi. C hai loi phu thut ct thc qun m ngc:
phu thut Ivor-Lewis (ming ni nm trong lng ngc) v phu thut ba-vng
(ming ni nm c). Cha c phng php phu thut no chng t tnh u
vit hn cc phng php cn li.
Sau khi thc qun c ct, d dy l tng thng c chn ti to li

thc qun. Nu phu thut vin mun bo tn chc nng d dy (cha ng v
tiu ho thc n), i trng (phi hay tri) c th c chn ti to li thc
qun. Khi c dng ti to thc qun, i trng c nguy c thiu mu nhiu
hn so vi d dy. Do , vic bo tn cc mch mu nui ca i trng (cng
nh ca d dy) khi tin hnh ti to l bc rt quan trng trong cuc phu
thut.
Trong phu thut ct thc qun khng m ngc (transhiatal esophagectomy), d

dy c di ng qua ng m bng trn, thc qun c di ng tch khi
cc tng trung tht khc qua khe thc qun ca c honh m khng phi m
ngc, v d dy sau c ln qua trung tht sau ni vi thc qun c.
Phu thut ct thc qun khng m ngc c cc li im sau: b ct trn cch
xa khi u, khng c bin chng ca ming ni trong lng ngc v gim bt sang
chn phu thut. Bt li ca phu thut: khng ly c hch v khng quan st
c trc tip kh nng dnh ca thc qun vo cu trc chung quanh.
Mc d phu thut ct thc qun khng m ngc c th c ch nh cho bt

kz khi u v tr no, ch nh thch hp nht cho phu thut ny l ung th
phn cui thc qun v ung th vng ni thc qun-d dy. Mt s bnh l{
khng c tnh nhng giai on cui ca thc qun cng c ch nh ct thc
qun khng m ngc, th d cht hp thc qun do bng, do bnh tro ngc
thc qun, co tht tm v
Phu thut Ivor-lewis cho ph p quan st v bc tch thc qun trc tip qua
ng m ngc bn phi km theo ly cc hch di cn. Vic c no hch hay
khng trong phu thut ung th thc qun cn ang bn ci. Cho n ngy
nay, tin lng sng lu di ca BN c phu thut Ivor- Lewis v BN c
phu thut ct thc qun khng m ngc l ngang nhau.
Bt li ca phu thut Ivor-Lewis: nguy c xy ra bin chng h hp sau m

cao hn, nguy c x d ming ni nm trong trung tht (5%).
Phu thut Ivor-Lewis c cn nhc n khi nghi ng c s dnh ca thc

qun vo cu trc chung quanh.
Phu thut ba vng c k thut tng t nh phu thut Ivor-Lewis nhng kt

hp thm th bc tch di ng thc qun c v ming ni khng nm trong
trung tht m c.
Chun b trc m: BN b ung th thc qun hu ht u trong trng thi

suy dinh dng nng, do tng cng dinh dng l khu chun b then
cht, quyt nh n s thnh cng ca cuc phu thut (bng 3). BN cn
c nh gi chc nng h hp v tim mch trc m. Cc bnh l{ v h hp
v tim mch, nu c, cn c iu tr tch cc. Chun b sn mu v cc
phng tin hi sc cp cu khc (my th ). Chun b tt i trng nu nh
cuc m d tr kh nng to hnh thc qun bng i trng. Chun b tt on
thc qun phi trn khi u nu c s ng (t thng bm ra). Thng d
dy c t trc m. Khng sinh d phng lun cn thit lm gim nguy
c nhim trng hu phu.
Tng cng dinh dng
iu tr cc bnh l{ ni khoa, c bit bnh l{ h hp v tim mch
Tp vt l{ tr liu h hp
Chun b mu (2-4 n v)
V sinhon thc qun trn khi u
Chun b i trng Khng sinh d phng Thng d dy
Thng tiu
t catheter ng mch quay theo di p lc ng mch. t khi cn n ng

truyn tnh mch trung ng
Phng nga huyt khi tnh mch su sau m: heparin 5000 UI TDD khi bt
u dn m, bng p hai chi di.
Thng kh qun (thng ph qun i vi phng php ct thc qun m ngc)
Bng 3- Chun b trc m ung th thc qun
Chm sc sau m:
Cn nhc n ch nh h tr h hp mt thi gian sau m.
Lu BN trong phng chm sc c bit 2-3 ngy u sau m. Ch { pht hin

sm cc bin chng h hp v tim mch.
Cho n qua thng hng trng t ngy hu phu th nht
Ngy hu phu 6 kim tra ming ni: cho BN ung mt vi ngm nc: nu
dn lu khng ra dch th rt dn lu v cho BN bt u n qua ng ming.
Nu ng dn lu ra dch: lu ng dn lu, tip tc nui n qua thng hng
trng cho n khi l d lnh. Nu ming ni nm trong lng ngc (phu thut
Ivor-Lewis): chp X-quang kim tra ming ni. Thuc cn quang phi l loi tan
trong nc.
Thi gian nm vin trung bnh: 9-14 ngy.

Thng hng trng c th lu li cho n ln ti khm sau . Bin chng phu
thut:
Thng gp nht l suy h hp do xp phi, vim phi, trn dch mng phi
Nhi mu c tim, lon nhp tim
X, d ming ni
D dng chp do tn thng ng ngc
Vim trung tht (phu thut Ivor-Lewis).

Di chng:
Hp ming ni
Vim thc qun tro ngc
X tr, ho tr b tc trc hay sau phu thut khng lm thay i tin lng
sng ca BN.
y l phu thut ln, t l bin chng v t vong cao (bin chng phu thut
25-40%, t vong 3-
10%), do cn phi cn nhc gia iu tr phu thut v khng phu thut

trc tt c BN b
ung th thc qun.
Chng ch nh phu thut:
Di cn hch thng n tri, hch tng, di cn xa
Khi u xm ln vo cc cu trc ln cn
BN mc cc bnh l{ ni khoa nng, th tch kh th ra ti a trong giy u nh

hn 1 lt, phn sut tng mu tht tri nh hn 40%.
3.2-Ho tr:
Khng c tc dng iu tr trit cn.
3.3-X tr:
t c ch nh, c bit khi u giai on IV, v c nguy c gy d thc qun-

trung tht.
3.4-Cc th thut iu tr c tnh cch thuyn gim khc: Ni soi thc qun ,
t stent xuyn qua u
Ni soi thc qun, nong thc qun bng bng bm hi
Ni soi thc qun, hu khi u bng nhit in hay bng tia laser
3.5-Ch nh:
3.5.1-Ung th thc qun giai on I,II,III (tr T4):
Phu thut ct thc qun vn l la chn trc tin, nu ton trng BN cho
ph p. Ho tr kt hp vi x tr dnh cho nhng BN chng ch nh phu thut.
3.5.2-Ung th thc qun T4 v giai on IV:
Mc ch iu tr: lm thuyn gim cc triu chng v bin chng. Cc phng

php sau c th c cn nhc n:
Ni soi thc qun , t stent xuyn qua u

Ni soi thc qun, nong thc qun bng bng bm hi
Ni soi thc qun, hu khi u bng nhit, in hay bng tia laser
X tr thuyn gim: c th lm khi u nh li nhng c nguy c dn n d

thc qun-kh qun
Ho tr thuyn gim
3.6-Kt qu v tin lng: T l sng 5 nm:
Giai on I: 50-94% Giai on II: 15-65% Giai on III: 6-23%
Giai on IV: nh hn 5%
Thi gian sng trung bnh ca BN b ung th thc qun: 9 thng
4-Tm sot ung th thc qun:

Kh tm sot do:
Ung th thc qun l bnh l{ ung th khng ph bin
Cc triu chng ch xut hin trong giai on mun
BN b vim thc qun do tro ngc:
iu tr ni khoa tch cc
Soi thc qun nh kz mi 1-2 nm
BN c tn thng thc qun Barrett:
D sn: ni soi thc qun km sinh thit mi 12-24 thng.
Lon sn nng (adenocacinoma hin din trong 40% cc trng hp): c hai la
chn: Ni soi thc qun km sinh thit mi 3-4 thng
Phu thut: ct thc qun, nu phu thut vin c kinh nghim
23. U LYMPHO KHNG HODGKIN

U lympho khng Hodgkin (ULKH) l cc khi u c tnh c ngun gc t h thng li
bch huyt khng phi l bnh Hodgkin.
1. Chn on
1.1. Lm sng :
Biu hin lm sng l triu chng u, thay i khc nhau tuz thuc vo v tr u tin
pht v s lan to ca bnh.
Khi u c th bng, trung tht, hch ngoi bin, vng tai mi hng v cc ni khc
nh da, di da, xng, thn
1.2. Xt nghim chn on xc nh :
Da vo kt qu m bnh hc v ho m min dch qua sinh thit hch hoc khi u.
Da vo x t nghim ho m min dch phn ra ULKH t bo B, t bo T, khng B
khng T.
1.3. Chn on giai on : Theo bnh vin tr em St. Jude
Giai on 1 : Ch c 1 khi u hoc 1 vng hch (ngoi tr trung tht v bng)
Giai on 2 : Khi u v hch nhng vng cng 1 pha ca c honh 2 hay nhiu
vng hch.
2 khi u + c/khng tn thng hch.
Khi u u tin ng tiu ho, thng vng hi manh trng, c/khng c hch
mc treo rut.
Giai on 3 : Khi u v hch tn thng c 2 pha ca c honh
2 khi u ring bit
2 hay nhiu vng hch
U tin pht trung tht, mng phi, tuyn c
U bng nhng khng ct ht c
U cnh ct sng
Giai on 4 : C biu hin thm tu xng v h thn kinh trung ng
2. iu tr ulkh t bo b
+ Cch s dng cc thuc trong phc nh sau :
- Prednisolone : 60mg/m2 da, ung, 2 ln/ngy, ung lc no
- Vincristine : 1 2mg/m2 da, tim tnh mch chm trn 10 pht
- Doxorubicine : 60mg/m2, truyn tnh mch trn 1 gi
- Methotrexate : 3g/m2 da, truyn tnh mch trn 3 gi. Dch trc truyn
Methotrexate 4 gi : 125ml/m2 da/gi vi 60mmol/l Natribicarbonate, 5mmol/l KCl.
Dch sau truyn Methotrexate : 31/m2 da/24 gi.
- Acid Folinic : 15mg/m2 da, tim tnh mch 6 gi/ln, bt u tim 24 gi sau truyn
Methotrexate, tim trong 3 ngy.
- Aracytine : 60mg/m2 da, truyn tnh mch trong 24 gi.
- Endoxan : 500mg/m2/ln chia 2 ln/ngy, truyn tnh mch trn 30 pht, kt hp
vi truyn dch 31/m2/ngy.
- Mesna : 250mg/m2 da, chia 2 ln trc mi ln Endoxan. Sau , 500mg/m2 da/24
gi cng vi truyn dch sau truyn Endoxan.
- Etoposide : 200mg/m2 da, truyn tnh mch trn 2 gi sau liu cao ca Aracytine.
- Thuc tim tu sng :
Methotrexate Hydrerocortisol Aracytine

(MTX) (HC) (Ar C)
<1 tui 8mg 8mg 16mg
1 tui 10mg 10mg 20mg
2.1. Nhm A :
Bnh nhn c iu tr theo nhm A khi : Khi u khu tr bng giai on I v II
c ct b hon ton. Thi gian iu tr gm 2 t, mi t cch nhau 21 ngy.
Thi gian iu tr nhm A k o di 5 tun.
Thuc cho mi t :
Ngy 1 2 3 4 5 6 7
Prednisolone * * ** ** ** **
Vincristine #
Endoxan
Adriamycine
2.2. Nhm B
Bnh nhn c iu tr theo nhm B khi : c xc nh chn on l giai on I v
II vi v tr u vng u v c ;
Giai on III v IV nhng cha c thm nhim h thng thn kinh trung ng.
* t 1 : COP
Ngy 1 2 3 4 5 6 7
Prdenisolone ngy 1 - 7
Vincristine 1,0mg/m2 (ngy

1)
Endoxan 300mg/m2 (ngy

1)
Tim tu sng MTX + HC

(ngy 1)
* t 2 : COPADM1
Ngy 1 2 3 4 5 6 7
Ngy th 1 l ngy th 8 ca
phc
Prednisolone ngy 1 5
Vincristine 2mg/m2, ngy 1
Methotrexate ngy 1
Acid Folinic ngy 2 4
Endoxan ngy 2 4
Mesna
Adriamycine ngy 2
Tim tu sng MTX + HC (ngy 2, ngy 6)
Sau ngh 21 ngy, bt u dng t tip theo khi bch cu ht > 1000/mm3 v
tiu cu > 100.000/mm3.
* t 3 : COPADM2
Ngy th nht ca t 3 l ngy th 35 ca phc . Thuc v cch dng nh
COPADM1 tr Endoxan liu tng gp i. Sau t 3 ngh 21 ngy.
* t 4 : CYM1
Ngy 1 2 3 4 5 6 7
Ngy th 63 ca phc
Prednisolone ngy 1 5
Vincristine 1,5mg/m2, ngy 1
Methotrexate ngy 1
Acid Folinic
Cytarabine ngy 2 6
Tim tu sng ngy 2 :

MTX+HC
ngy 7 : HC + Ar-C
C th kim tra chc nng gan, thn, chp CT, chp xng, bnh nhn s c phu
thut ct ht khi u ln 2 nu phu thuth ln 1 cha ct ht trc khi bt u
CYM2.
* t 5 : CYM2 :
Ngy th 1 ca t 5 l ngy th 91 ca phc .Thuc v cch dng nh CYM1.
* t 6 : COPADM3 :
Ngy th 1 ca t 6 l ngy th 118 ca phc . Thuc v cch dng nh
COPADM1.
Sau khi hon thnh qu trnh iu tr, bnh nhn c th c kim tra chc nng
gan, thn, tu xng. Thi gian iu tr nhm B k o di 18 tun.
2.3. Nhm C :
Bnh nhn c iu tr theo nhm C khi c lymphoblast trong tu > 70% ; c thm
nhim h thng thn kinh trung ng.
* t 1 : COP :
Thuc v cch dng nh t 1 ca nhm B, tr tim tu sng ngy 1, 3, 5 vi thuc :
MTX + HC + Ar C.
* t 2 : COPADM1 :
Ngy th 1 ca t 2 l ngy th 8 ca phc . Thuc v cch dng nh COPADM1
ca nhm B tr Methotrexate liu 8gm2 da v tim tu sng ngy 1, 3, 5 vi thuc
MTX + HC + Ar C.
* t 3 : COPADM2 :
Bt u t ngy th 35 ca phc . Thuc v cch dng nh COPADM1 ca nhm
C.
* t 4 : CYT/VP : Ngy th 1 ca t 4 l ngy th 63 ca phc .
Ngy 1 2 3 4 5 6 7
Ar-C 50mg/m2 ngy 1 5
Ar-C 3g/m2 ngy 1 4
Etoposide ngy 1 4
Truyn Ar-C 3g/m2 trn 3 gi, bt u v kt thc ca 12 gi truyn dch cng vi

truyn Ar-C 50mg/m2.
* t 5 : CYT/VP :
Bt u t ngy th 91 ca phc . Thuc v cch dng nh t 4.
* t 6 : COPADM3 :
Bt u t ngy th 118 ca phc . Thuc v cch dng nh t 2.
Sau t 6, bnh nhn c tia x vng s vi liu 18Gy.
* t 7 : CYT/VP
Ngy 1 2 3 4 5 6
Ar-C 100mg/m2 , chia 2 ln, N1
5

Etoposide 150mg/m2, N2 - 4

Tim tu sng MTX + HC + Ar-
C, N2
* t 8 : COPAD :
Sau khi kt thc t 7 ba tun. Thuc v cch dng nh t 2 nhng khng c
Methotrexate.
* t 9 : CYT/VP : Thuc v cch dng nh t 7
Thi gian iu tr nhm C k o di 27 tun.
2.4. iu tr h tr :
iu tr nhng tc dng ph ca ho cht
- Nu bnh nhn gim sn tu nng, c th dng G-CSF (Neupogen) vi liu 5
microgam/kg/ngy cho n khi x t nghim cng thc mu ngoi bin mu tr v
mc bnh thng.
- Chng lo t ming : Thuc bi ming Zytee, Glycerine Borate
- Chng nhim khun : Dng khng sinh
- Chng nn : Primperan tim tnh mch hoc t hu mn.
- Gim au
- Nu c duhiu ca c gan v thn : ngng iu tr ho cht
24. UNG TH TUYN GIP
I. i cng:
Theo hip hi quc t chng ung th (Inernational Union against Cancer: IUAC)
th Ung th tuyn gip chim khong 1% cc loi Ung th. Ti cc nc c bnh
Bu c a phng t l ny thng ln hn. Tn sut mc bnh chun theo tui
Nam l 3/100 000 dn/nm, trong khi n cao gp 2-3 ln t l . Theo s liu ca
Bnh vin K H ni, Ung th tuyn gip chim khong 2% tng s cc Ung th,
trong t l mc bnh chun theo tui l 0,3/100 000 dn/nm.
Phn ln Ung th tuyn gip tin trin m thm, triu chng lm sng ngo
nn, giai on n bnh k o di. Bnh nhn c th sng 15-20 nm. V vy, c th ni
rng tin lng ca a s bnh nhn Ung th tuyn gip l tt nu c chn on
v iu tr sm v tch cc.
II. Nguyn nhn v bnh sinh:
Cn nhiu im cha r rng nhng cc yu t c lin quan n xut hin
bnh l:
+ Tui: c th gp Ung th tuyn gip mi la tui, nhng hay gp la tui
7-20 v 40-65.
+ Gii: N gii mc bnh nhiu hn Nam gii 2-3 ln.
+ Ni sinh sng:
- Ti nhng khu vc c bnh Bu c a phng th t l mc bnh Ung th
tuyn gip cao hn cc khu vc khc.
- Bnh nhn gn bin(n ung c Iot) khi c Bu gip th nhn th nguy
c bu l c tnh cao hn cc vng khc.
- Ti nhng khu vc b nhim x th t l mc Ung th tuyn gip cao hn cc
vng khc.
+ Tin s c dng tia x iu tr cc bnh lnh tnh khc vng u mt c
th khi c Bu gip nhn s c nguy c cao b c tnh.
+ Di truyn: Ung th tuyn gip th tu thng c tnh cht gia nh. c bit,
loi a ung th ni tit tip II ( MEN II: Multiple endocrine neoplasia type II) c Ung
th tuyn gip th tu km U tu thng thn v c th c U cc tuyn na...
c xc nh l c tnh di truyn.
III. Gii phu bnh:
Theo t chc y t th gii, da vo m bnh hc c th phn chia Ung th
tuyn gip ra 5 loi:
1. Ung th biu m th nh:
Chim khong 60-70% cc Ung th tuyn gip.
+ i th: u thng l mt khi n c.
+ Vi th: hnh nh chim u th l cu trc dng nh vi li ni m lin kt v
mao mch nng . i khi cng thy cu trc ti tuyn chim u th.
2. Ung th biu m th nang:
+ i th: c th dng mt khi u nh c v bc hoc mt khi u xm ln
mnh chim ton b mt thuz lm cho tuyn gip to ln khng u.
+ Vi th: c cu trc ging nh trong nang tuyn ang hnh thanh hay
tr ng thnh, nhng c th thy cc t bo Hrthle hoc cc t bo sng tng
vng hay khp khi u. Nu u c cu to hon ton b i cc t bo Hrthle hoc t
bo sng th c coi l mt bin th c hiu ca th ny, l ung th biu m t
bo Hrthle hoc t bo sng. C th bit ho r hoc loi bit ho Vita (cn gi l
Ung th biu m b).
3. Ung th biu m th tu: pht sinh t t bo C ca tuyn gip.
+ i th: c th c mt hoc nhiu u c hai thuz. U mm hoc c khi kh
chc, mu trng xm hoc vng nu. C khi U b hoi t chy mu v ph v bao
tuyn.
+ Vi th: U cu to b i nhng t bo trn a din hoc hnh thoi, thng cha
cht dng tinh b. Cu trc v chc nng ca cc t bo u ging vi t bo C.
4. Ung th biu m khng bit ho:
+ i th: thng l mt khi u ln vng c v bnh tin trin rt nhanh.
+ Vi th: c 3 loi theo hnh thi t bo trong u, l loi u t bo hnh thoi, u
t bo khng l v u t bo nh.
5. Ung th dng biu b:
Vi th thy trong cu trc u c cc cu sng, cc cu ni hoc ch c Keratin.
IV. Triu chng lm sng:
1. c im chung:
i a s ung th tuyn gip u tin trin m thm, chm chp v k o di
nn bnh nhn thng khng nhn thy c ngay nhng thay i ca ton thn,
vn lao ng v sinh hot bnh thng. Cho n khi xut hin nhng ri lon ti ch
do u chn p, xm ln(gy kh th v khng n ung c), khi u hoi t, bi
nhim v lo t th tnh trng ton thn mi sa st nng.
2. Cc triu chng sm:
+ Khi U: thng do bnh nhn hay ngi nh tnh c pht hin ra. U to ra
dn, di ng theo nhp nut, c th nm bt c v tr no ca tuyn gip. Thng
ch c mt nhn n c nhng cng c khi c nhiu nhn v nm c hai thuz
tuyn gip. Mt thng chc. B mt thng g gh.
+ Hch c: c khi U cha s thy c nhng c hch c to. Tuy nhin,
nhng triu chng sm ny kh phn bit vi mt bu lnh tnh, do khi c hch
c km theo khi U vi nhng tnh cht nh trn th lun phi cnh gic v tm cc
bin php chn on xc nh Ung th sm.
3. Cc triu chng mun:
+ Khi U: c khi kh ln, ln ra pha trc, ra sau, ln hai cc trn st hai gc
hm v xung di vo trong trung tht (khm lm sng khng s thy c cc
di ca U). B mt thng g gh, mt c ch cng chc c ch mm. c bit,
khi U dnh cht v xm ln vo cc c quan vng c nn ranh gii khng r v kh
nng di ng k m. C khi khi U xm nhim v lo t si qua da vng c, gy chy
mu v bi nhim ti ch.
+ Khn ting, kh th , kh nut, nut nghn. . . cc mc khc nhau do
khi U pht trin xm ln v chn p cc c quan xung quanh. Cc triu chng ny
gp vi t l cao v sm, nht l Ung th th khng bit ho.
+ Cm gic vng tc, b cht vng c: l triu chng thng gp. C khi
cm gic au tc ti U lan ln gc hm, mang tai cng bn do U chn p v kch
thch m ri thn kinh c.
+ Hch to vng c (dc hai bn kh qun, theo cc b trong, ngoi v sau hai
c c n chm, gc hm, h thng n. . . ).
V. Triu chng cn lm sng:
1. Chp X. quang:
+ Thng chp X. quang vng c 2 t th (thng v nghing)khng chun b
hoc c ung cn quang thc qun.
+ Xc nh c hnh nh khi U chn p kh qun v thc qun, hnh khi U
pht trin vo trung tht hoc c di cn vo phi (nu c).
2. Chp x hnh tuyn gip:
+ Thng dng I131 phng x chp tuyn gip. Hin nay nhiu ni cn dng
nhng khng th n dng c gn ng v phng x chp x hnh tuyn gip
nhm pht hin Ung th tuyn gip v cc di cn nh.
+ Trn x hnh cc khi Ung th tuyn gip thng c hnh nhn lnh. Tuy
nhin hnh nh ny khng c hiu cho Ung th v cc nhn nang tuyn gip cng c
hnh nhn lnh (c th kt hp vi chp Siu m chn on phn bit).
3. Siu m tuyn gip:
+ Siu m thng c tin hnh sau khi khm lm sng v chp x hnh
tuyn gip.
+ Xc nh c U l c hay Nang, o c kch thc, th tch v trng lng ca
U v tuyn gip.
4. Chp ct lp vi tnh (CT) v chp cng hng t (MRI):
+ Xc nh c v tr, hnh dng, kch thc...ca khi Ung th tuyn gip.
+ Xc nh c mc chn y, xm ln, tng quan gii phu... ca khi Ung
th vi cc c quan xung quanh nh: kh qun, thc qun, cc mch mu...
5. Chn on t bo hc:
+ Chn on t bo hc khi U bng sinh thit ht kim nh l mt phng
php chn on n gin, nhanh chng, r tin. Vi mt x t nghim vin c kinh
nghim th chnh xc ca chn on c th t ti 90 %.
+ C th chc ht c khi U v Hch c, chc nhiu v tr v chc nhiu ln
chn on chnh xc hn.
6. Xt nghim gii phu bnh l:
y l x t nghim cho gi tr chn on quyt nh Ung th tu{n gip c v
bnh l{ v cc type m bnh hc. Tuy nhin ch lm c sau khi m ct hoc
sinh thit khi U.
7. Xt nghim tm cht nh du khi U (Tumour marker):
Cc cht nh du khi U l cc cht c bit do cc khi U tit ra m bnh
thng khng c trong c th. Khi pht hin thy c cc cht trong mu th
chng t cc khi U ang c mt trong c th.
Trong Ung th tuyn gip c th pht hin thy cc cht nh du khi U nh: HTG
(Human Thyroglobulin), CEA (Carcino Embrionic Antigen)...
VI. Chn on:
1. Chn on xc nh: cn da vo
+ Nguyn nhn sinh bnh: c cc yu t nguy c mc bnh cao (tui, gii, ni
, tin s. . . ).
+ Tnh cht U v nhng ri lon cc b do U gy ra: U rn chc, xm nhim
mnh cc c quan xung quanh, di ng k m, ni khn, au tc lan ln vng gc hm
cng bn, lot da. . .
+ Kt qu chn on t bo hc v c bit l x t nghim m bnh hc khi U
sau m cho gi tr chn on quyt nh.
2. Chn on phn bit:
+ Cc vim tuyn gip khng c hiu (Hashimoto, Riedel. . . ): thng xc
nh c bng chn on t bo hc (sinh thit ht kim nh) v m hc sau m.
+ Bu gip th nang bin chng chy mu trong nang: bu gip to ra nhanh,
chc cng, au v cc biu hin chn p cc c quan vng c. Chc ht khi U thy
c mu, khng thy t bo Ung th.
+ Vim tuyn gip c hiu v Apxe tuyn gip: tuyn gip hay Bu gip to ra
nhanh, au, nng, . Chc ht sinh thit khng thy c t bo Ung th m l cc t
bo vim m. iu tr khng sinh c hiu qu.
3. Chn on giai on bnh:
Theo Hip hi quc t chng ung th (1994) c th phn loi Ung th tuyn
gip da theo T (Tumor), N (Node) v M (Metastasis) nh sau:
+T: U tuyn gip nguyn pht
- Tx : U nguyn pht khng ghi nhn c.
- T0 : khng c U nguyn pht.
- T1: U c ng knh < 1 cm, cn nm trong gii hn tuyn gip.
- T2: U c ng knh 1-4 cm, cn nm trong gii hn tuyn gip.
- T3: U c ng knh > 4 cm nhng vn cn nm trong gii hn tuyn
gip.
- T4: U c ng knh bt kz nhng xm ln ra ngoi v bao tuyn
gip.
+ N: Hch to vng c
- Nx: hch vng c khng khm thy.
- N0: khng c hch di cn vng c.
- N1: di cn mt hch cng bn, kch thc < 3 cm.
- N2: hch di cn c kch thc 3-6 cm.
. N2a: di cn mt hch cng bn.
. N2b: di cn nhiu hch cng bn.
. N2c: di cn hch hai bn hoc bn i din.
- N3: hch di cn c kch thc > 6 cm.
+ M: Di cn xa
- Mx: di cn khng pht hin thy.
- M0: khng c di cn.
- M1: c di cn xa.
VII. Mt s c im th bnh ca Ung th tuyn gip:
1. Th nh (Papillom carcinoma):
+ L th Ung th tuyn gip hay gp nht (chim 70% cc Ung th tuyn gip).
L th c tin lng tt nht.
+ Thng gp tui tr (hn 80% s bnh nhn l di 40 tui). Thng biu hin
ban u l mt khi U n c nh tuyn gip nn t khi pht hin c sm. Sau
khi c di cn hch c hoc khi U to ra v gy cc hin tng chn p vng c
th bnh nhn mi n khm iu tr. Th ny c th di cn vo phi, xng v
cc ni khc trong khi khi U nguyn pht vn cn nh.
+ T l sng sau m 10 nm c th t ti 70-80% nu c phu thut sm,
trit v iu tr b sung sau m y .
2. Th nang (Vesiculary carcinoma):
+ Chim khong 20-25% cc Ung th tuyn gip. Tuy cng l loi tin trin
chm nhng tin lng k m hn th nh.
+ Thng tui 50-60 v vng c bu c a phng. U thng mt thuz, t c
di cn hch c nhng giai on cui thng c di cn xa theo ng mu, c bit
l hay di cn n t chc xng.
3. Th tu (Medullary Carcinoma):
+ U pht sinh t cc t bo C (t bo cn nang c vai tr tit Canxitonin).
Chim khong 5-10% cc Ung th tuyn gip. Tuy cng thuc loi tin trin chm
nhng tin lng k m hn th nh v th nang.
+ Thng gp tui 50-60. Bnh c tnh di truyn v thng mang tnh cht Bnh
a U ni tit ( Multiple endocrine neoplasia: MEN ). Trn lm sng c th gp Hi
chng Sipple hay MEN IIA ( Ung th tuyn gip th tu, U t bo sc t tu thng
thn hai bn v U hoc tng sn tuyn cn gip).
+ Ung th tuyn gip th tu thng nm v tr tip gip 1/3 trn v 1/3 di
thuz tuyn gip (ni tp trung nhiu t bo C) v c th c hai thuz tuyn. Di cn
theo ng mu hoc bch huyt.
4. Th khng bit ho:
Chim khong 10% cc Ung th tuyn gip, thng thy cc bnh nhn
nhiu tui. y l loi Ung th tuyn gip tin trin nhanh nht v tin lng xu
nht, t bnh nhn sng qu 5 nm.
5. Ung th biu m tuyn gip th biu b:
Ch chim khong 1% cc Ung th tuyn gip. Cn phn bit vi cc d sn
Malpighi trong U tuyn gip lnh tnh hoc di cn ca mt Ung th biu b t ng
h hp hoc ng tiu ho trn vo tuyn gip.
VIII. iu tr ngoi khoa:
Trong Ung th tuyn gip, iu tr ngoi khoa ng vai tr c bn. iu tr ho
cht v phng x c x dng kt hp trc m v b xung sau m hoc iu
tr mang tnh cht tm thi khi bnh nhn khng cn kh nng phu thut na.
1. Ch nh cc phng php phu thut:
+ Ct b thuz c U km c Eo tuyn v ct gn hon ton thuz bn i din: khi
u c ng knh < 1 cm, ch nm gn hon ton trong mt thuz v l Ung th th
nh. Nu c hch to vng c th phi tin hnh m ly b hon ton cc hch .
+ Ct hon ton tuyn gip: khi U c ng knh > 3 cm v xm ln ra ngoi
v bao tuyn gip. Sau m cn iu tr b xung bng I131 phng x tiu dit nt t
chc tuyn cn st li.
+ Trong mi trng hp u phi m ly trit cc hch di cn hn ch
kh nng ti pht. Ngoi ra, sau m ct ton b tuyn gip bnh nhn thng c
dng Thyroxin k o di khng nhng nhm mc ch iu tr thay th m cn lm
gim TSH trong mu, nh gim c kh nng ti pht ca bnh.
2. iu tr ngoi khoa mt s th Ung th tuyn gip:
+ Th nang: ch nh m ct b hon ton tuyn gip, sau m cn iu tr b
xung bng I131 phng x.
+ Th tu: ch nh m ct b hon ton tuyn gip v U thng c c hai
thuz, ch { iu tr tnh trng a u ni tit nu c.
+ Th khng bit ho: nu U cn nh th c th m ct hon ton tuyn gip.
Tuy nhin a s bnh nhn u n mun v U pht trin xm ln mnh cc c
quan xung quanh, do nhiu khi phu thut ch mang tnh cht tm thi v khng
trit (nhiu khi m ch vi mc ch khai thng v duy tr ng th cho bnh
nhn). Phi kt hp iu tr bng ho cht, tia x...
+ Ung th tuyn gip c di cn: c th dng tia x v ho cht iu tr chun
b m, sau m ct b khi U v ly hch di cn cng trit cng tt theo iu
kin cho ph p, sau m tip tc iu tr b xung bng tia x, ho cht...
IX. Tin lng chung v Ung th tuyn gip:
Tin lng v Ung th tuyn gip ph thuc vo: th bnh (loi m bnh hc),
giai on bnh (u xm ln ph v v bao tuyn th tin lng xu), tui bnh nhn
(tui cng cao tin lng cng xu), gii (nam tin lng xu hn n). Nhn chung t
l sng sau 5 nm tnh theo th bnh thy nh sau:
+ Th nh: 80-90%
+ Th nang: 50-70%
+ Th tu: 40%
+ Th khng bit ho: di 5%.
25. U TRUNG THT

I. I CNG
U trung tht bao gm cc khi u nguyn pht hoc th pht, c tnh hoc lnh
tnh pht sinh vng trung tht, c th gp mi la tui vi nhiu nguyn nhn
khc nhau .
U trung tht chim 90% cc vn bnh l{ trung tht, phn ln l cc u c tnh
.
Trung tht l mt khoang cht chi cha nhiu c quan khc nhau, do hi
chng trung tht l du hiu chn p cc c quan trong :
+ ng th : Kh, ph qun .
+ ng tiu ho : Thc qun .
+ Thn kinh : Giao cm, qut ngc, honh dy X
+ Mch mu : Tnh mch (ch trn, ch i, phi, n), ng mch phi .
+ ng ngc : Tuz theo v tr ca khi u m c triu chng lm sng khc nhau,
c th c khi u rt nh m chn p nng, ngc li c trng hp khi u to m
chn p khng nhiu nh trng hp u lnh tnh hay u lao x nhim .
Trn lm sng c hi chng trung tht khng nht thit u do u trung tht
nh trong trn dch trung tht, vim trung tht,...
II. LM SNG :
Triu chng ca u trung tht thay i theo v tr, ln v tnh cht ca khi u
m c cc du hiu khc nhau sau :
2.1. Du hiu h hp : Ho, khi huyt, th rt th th vo, au ngc nhng
ni bt nht l kh th , th kh kh .
2.2. Du hiu v tiu ho : C th kh nut, nc lin tc do chn p thc qun
.
2.3.Du hiu v thn kinh :
- Hi chng Claude-Bernard Horner : Co ng t, hp mi mt, sp mi v
bng na mt do chn p thn kinh giao cm .
- Khn ting kh pht m: do chn p thn kinh qut ngc tri
- Hi chng Pancoast-Tobias : do chn p m ri thn kinh cnh tay.
- Lit vm honh do chn p thn kinh honh .
- Ri lon h hp, cao huyt p, chy nc di do chn p thn kinh ph
v .
2.4. Du hiu chn p tnh mch :
- Hi chngtnh mch ch trn: ph mi mt, ph mt, c, ph o khoc,
y h trn n .
- Tun hon bng h trc ngc: Gin mao mch di da, gin tnh mch
c, gin tnh mch thi dng, tnh mch y li, tng p lc tnh mch chi trn.
Tm ti, nhc u, ng g ng gt .
- Hi chng tmh mch ch di: Gan to, c chng, ph chi di nhng
thng t gp.
Nu chn p trn tnh mch n vo tnh mch ch trn th c tun
hon bng h thnh ngc. t gp chn p vo tnh mch v ng mch phi.
2.5. Du hiu chn p ng ngc:
t gp, nu c chn p th c mt hi chng gm c trn dng chp lng
ngc, c chng dch dng chp, ph t chi di n chi trn.
2.6. Du hiu thnh ngc:
- Sng vng ti mt v tr ca lng ngc.
- Sng vng vng xng c, vng trn hoc di xng n.
2.7. Du hiu ton thn:
- Hch vng c, trn xng n, thng do di cn.
- Hi chng Pierre-Marie(Ngn tay di trng mng tay mt knh ng h,
dy ct mc u chi, au cc khp bn chn, c tay, bn tay)
III. CHN ON :
- Thng da vo du hiu chn p trung tht nh trnh by trn.
Tuz theo v tr gii phu v ln ca khi u m cc triu chngtrn thay i theo
tng trng hp.
- Da vo hnh nh Xquang thng nghing v ct lp mt s trng hp
c khi phi chp thm ct lp c bm hi.
- Ngoi ra ngi ta c th chp x nhp nhy pht hin u tuyn gip .
- Chp ct lp t trng tn thng(Tomodensitometrie) gip cho phn
bit u mch mu, k n nc vi u m, u c.
- Phng php soi trung tht cho ph p thm d trung tht trc trn n
tn ch phn chia ca kh ph qun .
Ngoi ra ngi ta c th tin hnh cc phng php(tuz theo trng hp) nh
sau:
+ Sinh thit hch c bc thang(th thut Daniels)
+ Chc ht sinh thit t bo chn on .
+ Soi ph qun .
Soi thc qun .
IV. CHN ON PHN BIT :
4.1. Hi chng trung tht cp: Gp trong vim m trung tht, p xe trung tht,
thng thc qun, vim m hch trung tht. Bn cnh nhng triu chng nhim
trng, bnh nhn kh nut, kh th , au c, cui cng l suy th v tru tim mch.
4.2. Hi chng trung tht mn tnh: Gp trong trng hp x ho trung tht
hay vim x mn tnh(do lao hoc giang mai) biu hin bng hi chng tnh mch
ch trn.
4.3. Bnh gi u trung tht : Trn Xquang c th thy nhng bng m cnh
trung tht, nhng c nguyn nhn ngoi trung tht nh: Mt s ung th ph qun,
u lao cnh trung tht, trn dch mng phi cnh trung tht, p xe phi.
C th phn bit bng chiu, chp Xquang lng ngc theo cc t th: thng,
nghing, ch o, chp ct lp, chp bm hi trung tht, chp thc qun.
V. CHN ON NH KHU:
Tuz theo v tr m c nhng loi u trung tht khc nhau:
5.1. Khi u trung tht trc trn: bu trong trung tht, bu chm.
5.2. Khi u trung tht gia:
- K n biu b(hnh nh, xng, rng ng vi)
- U tuyn c(C th km theo triu chng nhc c hoc khng)
- Tuyn c ph i.
5.3. Khi u trung tht di: Kn tim-mng tim(thng bng gc tm
honh v gc c honh)
5.4. Khi u trung tht gia: K n ph qun, Hematom, u hch, lao hch x
nhim, Hogdkin, ung th ph qun di cn vo trung tht, u m, Lymphosaccom.
5.5. Khi u cnh trung tht sau: U thn kinh(thng trn dnh vi thn t
sng). Ung th thc qun.
VI. BNH L MT S TRNG HP C TH:
6.1.1. U trung tht pht sinh t cc tuyn:
+ Bu gip trong lng ngc c 2 loi:
- Bu gip c-lng ngc(bu gip chm)t c xung qu khe trn ca
trung tht, chim 85% ca loi bu trong lng ngc. y l loi u khng hon ton
ca trung tht.
- Bu sau xng c: Chim 15% ca loi bu trong lng ngc, thng
nm sau xng c, ngoi ra cn bu gip lc ch, pht trin sau kh qun, sau thc
qun, c gi chung l bu ca trung tht sau.
Lm sng ca cc bu gip trong lng ngc thng lng l sut trong
mt thi gian di nhiu khi do kim tra sc kho nh kz m pht hin c.
Khi c triu chng lm sng th l lc khi u tng i ln v tc ng
n c quan ln cn, y t gp hi chng chn p tnh mch ch trn.
Khong 10-25% bnh nhn b khn ting do tn thng thn kinh qut
ngc. mt s trng hp bnh nhn nut s thy bu t sau xng c chi ln
c . Trn Xquang bng m thng trung tht trc trnni tng ng vi bu .
Phim nghing bng m pha trc kh qun v sau xng c. Nht thit phi chp
x vi Iod ng v phng x chn on xc nh. Sm hay mun cc bu ny
u dn n cc bin chng nguy him nht l ung th ho. Bu hay chn p vo
kh qun, mch mu, thn kinh do cn ct b sm .
6.1. 2. U tuyn c v ph i tuyn c :
Gy nn bnh nhc c thng gp hng u l ph i tuyn c. Nhng
trng hp ny khng gy nhng du hiu g v chn p, nhng trng hp u tuyn
c gy du hiu chn p khi u pht trin n mt th tch nht nh. Triu chng
ca tuyn c: Trn phim Xquang thy hnh u ti vng ca tuyn c bng chp
thng hoc c khi phi bm hi trung tht . Triu chng lm sng l kh th , nht
l khi nm, c khi ni khn do tn thng thn kinh qut ngc . Km theo l
triu chng nhc c, yu c thay i trong ngy. Gy nn cc triu chng: Sp mi,
ni ngng, nhn i, n sc, nut nghn, yu tay chn , kh th . Test Prostigmine rt
c gi tr trong chn on bnh nhc c. Phu thut ct b tuyn c hoc u tuyn
c l mt bin php iu tr .
6.2. U phi trung tht: C 2 loi: u phi ng loi v u phi d loi .
6.2.1. U phi ng loi thng gm c:
+ K n c ngun gc ph qun.
+ K n phi-mng tim.
+ K n thc qun.
6.2.2. U phi d loi thng gm c:
+ U qui.
+ K n biu b.
Cc loi u phi xut pht t t bo lc ch trong thi kz phi thai n nm
trung tht, c 2 loi hay gp hn c l k n c ngun gc ph qun v u qui .
6.2.3. Kn c ngun gc ph qun:
Nhng u c ngun gc v phi thai t phi xung cung phi(c quan h
hp ni chung) chim 10% cacs u trung tht, thng ng ba kh- phqun. Trong
mt thi gian di khng xut hin triu chng g c bit. Khi u ng ba kh-ph
qun hoc cch xa nhng lan n vng th bnh nhn ho, c khi khc ra mu,
nhp tim nhanh. Trng hp u v vo ph qun lm cho bnh nhn ho rt nhiu, c
triu chng nhim khun, khc ra m hoc cht hoi t. Trn Xquang thy mt bng
m trn, u n, ng nht, m, b r rng, thng trung tht gia, khng di
ng khi nut. Cn ct b cng sm cng tt.
6.2.4. U qui v kn biu b:
Chim 25% s u trung tht, thng c t chc 3 l ca thi kz phi thai,
d ung th ho gp ngi tr tui(15-30 tui). Bnh tim tng, hi chng trung
tht xut hin mun, chn on ch yu nh vo Xquang
6.3. U thn kinh trung tht:
+U pht sinh t nhng thnh phn thn kinh trong lng ngc
+Hu ht nm rnh sng sn v trung tht sau.
+Thng t hch giao cm, t r tu sng, t khi t thn kinh ph v hoc
dy honh hay m ri thn kinh.
+ Chia cc loi(theo tn thng gii phu bnh):
- U soan: Hay gp v lnh nht(do s pht trin ca t bo soan thn kinh)
khng thc s l u thn kinh.
- U thn kinh chnh thc.
- U x thn kinh: L s pht trin ca si lin kt v dy thn kinh, loi
ny thng gp .
- U hch giao cm, nm tim tng trung tht, khi c triu chng l lc u
xm ln vo c quan trung tht.
6.4. U t t chc lin kt ca trung tht:
Gm nhiu loi khc nhau:
+ U m v u m sacom: t gp, xut hin khi c th pht ph, hay nm
tng di ca trung tht.
+ U x v u x sacom: t gp.
+ U c v u c sacom.
+ U sn v u sn sacom.
Cc loi u ny pht trin chm, sau m qua sinh thit mi chn on c
chnh xc .
6.5. Cc u do k sinh trng trung tht:
Nh bc nc do Echinocoque, trong qu trnh di chuyn u trng
Echinocoque hay dng li gan, phi v trung tht sau thnh bc nc
Echinocoque(loi ny t gp ta).
6.6. Cc u hch trung tht:
C 5 nhm hch trung tht: nhm trc, sau v bn kh qun, nhm ca
rn phi phi v tri, nhm ng ba kh-ph qun.
6.6.1. Cc u hch nguyn pht: Thng l cc Lymphsacom chim khong50-
60% cc bnh l{ v hch trung tht, v 5-10% cc bnh l{ v sacom hchca c th
ni chung. V lm sng c hi chng chn p trung tht trc trn(triu chng h
hp, triu chng chn p tnh mch ch trn, ri lon pht m), c khi c thm trn
dch mng phi. Trn Xquang c hnh m, b c khi r rt nhiu hnh cung hoc hnh
thng.
6.6.2. Cc u hch di cn: (hay gp) thng l di cn ca ung th ph qun t
bo nh, ung th thc qun, ung th d dy, ung th v, ung th i trng. Khi c di
cn hch trung tht th thng tnh trng nng kh nng iu tr hn ch.
6.6.3. Cc u hch do vim: C th do lao x nhim hoc cc bnh vim phi-
ph qun, bnh nm, bnh bi phi.
VII. IU TR :
U trung tht thng pht trin lng l, t khi pht hin sm, khi pht hin c
thng bnh nng. V iu tr ni chung cn phu thut sm. Chin thut chung
ca iu tr phi kt hp: Phu thut + ho cht+tia x.
7.1. iu kin ch nh phu thut: Bnh nhn khng qu gi, th trng tt.
7.2. Mc ch phu thut:
+ Ct b u.
+ Gii phng chn p.
7.3. V cm: Trong phu thut u trung tht ch yu phi dng bin php v
cm: Gy m ni kh qun. Nhng trng hp u tuyn c, trong nhc c th thun
li hn l bin php chm t, kt hp ni kh qun h tr.
7.4. ng m vo trung tht:
Thng thng s dng ng m m i trung tht mt phn hoc ton
th. Ngoi ra c th s dng ng m ngc trc bn, bn phi nu u pht trin
sang phi. Hoc ng m ngc trc bn, bn tri nu u pht trin sang tri.
7.5. Th thut i vi u: Ct b hon ton l tt nht, tuy nhin , nu khng
ct b c hon ton th phi gii phng c s chn p cc tng trong trung
tht. Sau th thut, trc khi ng ngc phi dn lu trung tht.
7.6. Nhng bin php iu tr h tr:
Phu thut l bin php iu tr c bn nht, trit nht, tuy nhin, cn
phi iu tr h tr bng cc bin php ni khoa khc nh: Tia x, ho cht, min
dch hc v cc bin php ng nam y kt hp.
Tia x v ho cht u phi da vo bn cht t bo hc ca khi u c ch
nh thch hp .
26. UNG TH THANH QUN
1. i cng:
- Ung th thanh qun l loi ung th hay gp Vit Nam, nu trong phm vi
vng Tai Mi Hng th ung th thanh qun ng vo hng th 4 sau ung th vm,
ung th mi xoang v ung th h hng.
- Cn c thng k ca nhiu nc trn th gii th ung th thanh qun chim
khong 2% tng s cc loi ung th thng gp.
- Ni n ung th thanh qun l ch khi u nm trong lng thanh qun bao gm
mt di thanh nhit, bng thanh tht, thanh tht Morgagni, dy thanh v h thanh
mn, cn cc khi u khc vt ngoi phm vi cc v tr trn thuc loi ung th h
hng.
- Tuyt i a s ung th thanh qun l ung th biu m, cn ung th lin kt
(sacm) rt him gp ch chim khong 0,5% (Leroux Robert v Petit), v vy ni
dung phn ny ch yu cp n ung th biu m thanh qun.
2. Nhng yu t lin quan n bnh sinh: Cho n nay vn cha tm ra c
nguyn nhn chnh gy bnh, nhng ngi ta cp ti cc yu t c lin quan ti
bnh sinh:
- Thuc l: Nhiu ngi cho l mt yu t quan trng gp phn pht sinh
ung th thanh qun cng nh ung th phi.
- Cc yu t kch thch: ca vi kh hu, nh h ng ca ngh nghip (phi tip
xc vi cc cht kh, bi bn, ho cht...) hoc vim thanh qun mn tnh (tin
ca mt ung th ho).
- V gii tnh: Ch yu hay gp nam gii, chim trn 90%, nhiu tc gi cho
rng ph n t b bnh ny l do t tip xc vi cc yu t c lin quan n gy bnh
so vi nam gii.
- V tui: Hay gp tui t: 50-70 (72%), t 40-50 tui t hn (12%). Ring
vi ph n nu b bnh ny th tui sm hn.
- Vi cc th vim thanh qun mn tnh nh tng sn (hyperplasie) tng sng
ho, bch sn l th d b ung th ho, v vy cc th ny cn c gi l trng thi
tin ung th.
- Cc u lnh tnh ca thanh qun cng d ung th ho nht l loi u nh thanh
qun ngi ln chim mt t l kh cao.
3. Gii phu bnh l:
3.1. i th: Thng hay gp 3 hnh thi sau:
- Hnh thi tng sinh: B ngoi ging nh u nh, mt s trng hp ging nh
mt polip c cung.
- Hnh thi thm nhim xung pha su: B ngoi nim mc c v nguyn vn,
i khi c hnh nh nm v, nim mc vng ny b y phng ln v di ng b hn
ch.
- Hnh thi lo t thng b khng u, chm vo d chy mu. Nhng hay gp
l th hn hp va tng sinh va lo t, hay va lo t va thm nhim.
3.2. Vi th:
- Phn ln ung th thanh qun thuc loi ung th biu m lt, gai c cu sng
chim 93% hoc sng, sau l loi biu m t bo y, loi trung gian v biu
m tuyn.
- Loi u bit ho th him gp ung th thanh qun. V lm sng, loi ny tin
trin nhanh nhng li nhy cm vi tia phng x.
4. Lm sng:
4.1. V tr v lan rng ca khi u.
Ung th thng thanh mn (tng trn) hay tin nh thanh qun.
- Thng pht sinh cng mt lc c bng thanh tht v mt di ca thanh
thit. N s lan nhanh ra pha i din, np phu thanh thit v vng sn phu bn
bnh thng to phng ln do b u thm nhim hoc do ph n. giai on u, y
bng thanh tht v dy thanh cn bnh thng. Mt thng rt kh nh gi chnh
xc thm nhim vo pha su, v vy cn phi chp ct lp thng thng hoc tt
nht l chp C.T.Scan th mi nh gi c h trc thanh thit.
- Ung th xut pht t thanh tht Morgagni thng l th tng sinh hay lo t v
thng bt u t pha y thanh tht hay thanh thit, nhng nhn chung th lo t
lan rt nhanh vo cc vng ln cn, xung di dy thanh v h thanh mn, ln trn
bng thanh tht, ra ngoi sn gip c khi c sn phu.
Ung th thanh mn (dy thanh) l loi hay gp nht v thng thng tn u cn
gii hn mt trn hay b t do dy thanh nu ta pht hin sm.
- Thng gp th tng sinh, him gp th thm nhim hoc lo t.
- Do triu chng kh pht m xut hin sm nn bnh nhn thng n khm
sm hn cc loi ung th khc. Ung th dy thanh tin trin tng i chm,
thng sau nhiu thng, c khi mt nm, b i v m lin kt di nim mc ca dy
thanh thng dy c v mng li bch mch th rt tha tht. M u lan dn dn
t mt trn ca nim mc xung lp su v sau mi bt u pht trin nhanh
xung vng h thanh mn v ln bng thanh tht.
- Ung th biu m ca dy thanh thng khu tr mt bn kh lu ri mi lan
sang pha dy thanh i din.
Ung th h thanh mn: t gp hn so vi hai loi trn nhng khm, pht hin cng
kh khn hn. Mun xc nh, phi soi thanh qun trc tip v chp ct lp.
- Loi ny thng gp l th thm nhim v thng pha di dy thanh, v
vy c cnh sn gip lm vt chn, nn u kh lan ra ngoi. U thng bt u t
mt di dy thanh v lan rng xung pha di nim mc, thm nhim vo pha
su, nhng b t do ca dy thanh vn bnh thng, v vy nu sinh thit soi qua
gin tip, t khi ly c chnh xc thng tn u m phi soi thanh qun trc tip,
thm ch c khi phi m sn gip (thyrotomie).
- Ung th thng pht trin nhanh sang pha i din vt qua m p trc
thanh qun, sau lan xung di sn nhn. C trng hp u lan xuyn qua mng
gip nhn hoc thm nhim ra pha mt sn nhn. Thng gp l u lan ln trn v ra
sau khp nhn phu lm cho dy thanh b c nh
4.2. Cc triu chng lm sng ca ung th thanh qun: Tuz theo v tr ca ung th
khc nhau m cc triu chng lm sng cng khc nhau, k c thi gian xut hin.
4.2.1. Triu chng c nng:
- Khn ting ngy cng tng v dn n pht m kh khn, khn c, mt ting.
- Kh th xut hin v tng dn mc d triu chng ny c t lu nhng
mc nh, bnh nhn thch ng c, nhng sau xut hin tng cn kh th ,
nguy kch nht l khi b kch thch dn n co tht thanh qun, i khi km theo mt
bi nhim th pht (t vim cp do cm cm, ph n do tia phng x) th kh th
nng.
- Ho: Cng l triu chng hay gp nhng kn o v mang tnh cht kch thch,
i khi c tng cn ho kiu co tht.
- au: Ch xut hin khi khi u lan n b trn ca thanh qun, nht l khi
khi u b lo t. au thng lan ln tai v au nhi lc nut.
- n giai on mun th xut hin nut kh v sc thc n, xut tit vo
ng th th gy nn nhng cn ho sc sa. giai on ny, ton trng cng b
nh h ng.
4.2.2. Khm lm sng:
- Ung th biu m dy thanh giai on u th u thng khu tr mt bn
dy thanh di hnh thi mt n si nh hoc thm nhim nh v hay gp na
trc dy thanh hoc m p trc. Di ng ca dy thanh giai on u nu l th
tng sinh th cha b nh h ng nhiu, nhng nu l th thm nhim th di ng b
hn ch nh. S nh gi di ng ca dy thanh rt c { ngha trong ch nh iu
tr.
- U h thanh mn th trc ht dy thanh di ng b hn ch ri lan ra qu
ng gia nn d nhm vi mt u ca thanh mn.
- U thng thanh mn th t khi pht hin c giai on sm, bng thanh
tht ph n che lp dy thanh cng bn, nim mc dy cm ln, chc cng, sau
lot lan nhanh ra np phu thanh thit v xoang l. V vy u vng ny thng hay
gp giai on mun di hnh thi thm nhim hay tng sinh, i khi km theo
lo t v lan vo h trc thanh thit.
- Nu ung th thanh qun khng c iu tr, thng ch k o di c mt
nm hoc 18 thng, t vong thng do ngt th cp tnh, bin chng vim ph qun
phi, suy kit hay chy mu t.
4.3. Di cn ca ung th thanh qun:
- Hch c: Tuz thuc vo v tr ca thng tn u, nn hch c di cn cng khc
nhau v n ph thuc vo h thng bch mch ca vng . H thng bch mch
ny thng c 2 mng li phn gii kh r rt: mt mng thng thanh mn,
mt mng h thanh mn, 2 mng ny c phn gii hn b i dy thanh. Mng
li thng thanh mn bao gm bch mch t tin nh thanh qun v thn
bch mch, chui qua phn bn ca mng gip mng v tn cng ca hch cnh trn.
Mng li h thanh mn cng kh phong ph tuy t dy c hn phn thng thanh
mn. Cn vng ranh gii tc dy thanh th h bch mch rt b , nm ri rc dc
theo dy thanh, sau ni vi mng li ca tin nh thanh qun hay h thanh
mn. V vy ung th vng thng thanh mn thng c hch c di cn sm, cn
ung th vng h thanh mn th di cn xut hin mun hn. Cc hch vng ny
thng su, nn khm pht hin lm sng kh hn.
- Di cn xa ca ung th thanh qun t gp hn ca ung th h hng, theo nhn
x t ca nhiu tc gi, thng hay gp l di cn vo phi (4%) sau l ct sng,
xng, gan, d dy, thc qun (1,2%). Cho n nay, vn cha xc nh c nhng
yu t g c lin quan gia u nguyn pht v di cn xa vo phi, ph qun, v vy vic
kim tra cc thng tn phi trc khi iu tr ung th thanh qun l ht sc cn
thit.
5. Chn on:
5.1. Chn on xc nh: Ung th thanh qun nu c chn on sm, iu tr kp
thi th c th khi c vi t l ngy cng cao. Khc vi ung th thng thanh
mn v ung th h hng, do cc triu chng ban u kn o, khng rm r. Nn
ngi bnh d b qua, khng i khm, cn ung th thanh mn (dy thanh) thng
xut hin sm, cc triu chng kh ni, khn ting, nn ngi bnh t i khm sm
hn.
Nhng trng hp c thng tn mt bn thanh qun, thng tn cn rt khu tr,
di ng ca dy thanh hi khc thng th phi kim tra theo di, lm cc x t
nghim cn thit loi tr mt ung th.
5.2. Chn on phn bit:
- Vim thanh qun mn tnh ph i, vi mt vim thanh qun th dy da
(pachidermic) cn khu tr, vi mt lo t do tip xc mm thanh hoc mt sa nim
mc thanh tht.
- Trong giai on u, v lm sng cn phn bit vi mt lao thanh qun (th
vim dy thanh hay th u lao tuberculome).Th thm nhim m p sau rt ging
mt thng tn lao, nhng thng tn lao rt t xut pht t v tr ny.
- Vi mt thng tn lupus, thng hay gp b thanh thit v tin nh
thanh qun nhng c c im l cng tn ti nhiu hnh thi trong mt thi im
(va c lo t, va c thm nhim, va c x so) nn chn on phn bit khng kh
khn lm.
- Giang mai thi kz th 3, giai on gm cha lo t cng d nhm vi loi ung
th thm nhim vng thanh tht hay bng thanh tht. Nu giai on lo t th
cn phn bit vi u tin nh thanh qun hay mt ung th h hng thanh qun. B
lo t khng u lo t hnh ni la, xung quanh rn, mu nh mu tht b, khng
au lm l c im ca lot giang mai.
- Dy thanh mt bn khng di ng cn phn bit vi mt lit hi qui hoc mt
vim khp nhn phu.
- Vi cc u lnh tnh, cn phn bit vi mt polip, mt u nh v cc u ny d ung
th ho, nht l ngi c tui, nam gii. V vy, nhng trng hp nay phi khm
nh kz, theo di v cn thit th phi lm sinh thit nhiu ln.
- giai on mun, do cc triu chng nh mt ting, kh th , nut kh, hch
c b c nh... r rng, nn chn on khng gp kh khn lm, nht l khi soi
thanh qun th khi u kh r rt, to, chon gn ht vng thanh qun v c trng
hp lan ra c m ln cn.
6. Phn loi:
Theo phn loi ca Hip hi quc t chng ung th (UICC): cn c di ng ca
dy thanh, s xut hin hch c, di cn xa xp sp theo h thng T.N.M
T (Tumor): khi u.
- Ung th thng thanh mn:
Tis: U tin xm ln.
T1 : U khu tr mt di thanh thit, hoc mt bn np phu thanh thit, hoc
mt bn thanh tht, hoc mt bn bng thanh tht.
T2 : U thanh thit lan n thanh tht hoc bng thanh tht.
T3 : U nh T2 nhng d lan n dy thanh.
T4 : U nh T3 nhng lan ra xoang l, mt sau sn nhn, rnh li thanh thit v
y li
- U thanh mn:
Tis : U tin xm ln.
T1 : U mt bn dy thanh, dy thanh cn di ng bnh thng.
T2 : U c hai dy thanh, dy thanh di ng bnh thng hay c nh.
T3 : U lan xung h thanh mn hoc lan ln thng thanh mn.
T4 : Nh T1. T2. T3. nhng ph v sn gip lan ra da, xoang l hoc sau sn nhn.
- U h thanh mn :
Tis : U tin xm ln.
T1: U khu tr mt bn h thanh mn.
T2 : U lan ra c hai bn ca h thanh mn.
T3 : U h thanh mn lan ra dy thanh.
T4 : Nh T1. T2.T3 nhng lan vo kh qun, ra da hoc vng sau sn nhn.
N (Node): hch c.
N0 : Hch khng s thy.
N1 : Hch mt bn cn di ng.
N1a : nh gi hch cha c di cn.
N1b : nh gi hch c di cn.
N2 : Hch i din hoc hch hai bn cn di ng.
N2a: nh gi hch cha c di cn.
N2b : nh gi hch c di cn.
N3 : Hch c nh.
M Metastasis): di cn xa.
M0 : Cha c di cn xa.
M1 : c di cn xa.
7. iu tr: Phng php iu tr c hiu qu nht l phi hp phu thut vi tia x
sau m. T trc n nay, c 3 phng php ch yu: tia x n thun, phu thut
n thun v phi hp phu thut vi tia x. Nhng trng hp n giai on
sm, cn khu tr, cha c hch c di cn th c th phu thut hoc tia x n
thun.
Phng php phu thut: v nguyn tc c hai loi, phu thut bo tn hay ct mt
phn thanh qun, sau phu thut ny, ngi bnh c th pht m th theo ng
sinh l t nhin, cn phu thut tit cn hay ct b thanh qun ton phn, sau phu
thut ny ngi bnh phi th qua l ca kh qun trc tip khu ni ra vng da
c v pht m khng qua ng sinh l t nhin c (ging ni thc qun, qua mt
thit b h tr pht m hay qua mt phu thut pht m).
Tuz theo v tr, lan rng ca u cng nh tnh trng hch c di cn m chn la
phng php phu thut.
- Ct b mt phn thanh qun.
- Phu thut ct b thanh thit kiu Huet.
- Ct thanh qun ngang trn thanh mn kiu Anlonso.
- Phu thut ct dy thanh.
- Phu thut ct thanh qun trn bn kiu Leroux-Robert.
- Phu thut ct thanh qun trn trc.
Ct na thanh qun kiu Hautant.
- Ct b thanh qun ton phn.
Phng php iu tr bng tia x: Cho n nay, vic s dng cc ngun tia x
iu tr cc khi u c tnh l mt trong nhng bin php quan trng v c bn, nht
l cc u thuc phm vi vng u c. iu tr bng tia x c nhiu phng php khc
nhau, nhng c nhng bin php ch yu sau:
- iu tr tia x n thun.
- iu tr tia x phi hp vi phu thut, c th trc hoc sau phu thut hoc
phi hp xen k, tia x- phu thut- tia x (Sand-wich).
Cc phng php iu tr ung th thanh qun khc: Ngoi hai phng php c bn
v hiu qu nht trong iu tr ung th thanh qun nu trn th gn 10 nm li
y, mt s tc gi, ch yu l cc nc Ty u, Hoa Kz phi hp iu tr ho
cht nhng kt qu cn ang bn ci.
Kt qu iu tr ung th thanh qun Vit Nam: Ung th dy thanh, nu pht hin
sm v iu tr kp thi, c th cha khi hon ton, t t l 80%. V vy, mt s tc
gi cn gi ung th dy thanh l loi " ung th lnh tnh" nhm mc ch nhn mnh
kt qu iu tr m mn ca loi ung th ny. Mt khc cng nhc nh nhng
ngi thy thuc ni chung, nht l thy thuc Tai Mi Hng ni ring phi c tinh
thn trch nhim cao, khm v theo di t m nhng trng hp nghi ng, nu b
st, lt li mt ung th thanh qun, c bit ung th dy thanh th phi xem
nh mt sai st iu tr v loi ung th ny xut hin triu chng lm sng kh sm,
vic khm pht hin cng d dng, thun li, khng i hi nhiu cc trang thit
b k thut phc tp, t tin.
i vi cc th ung th thanh qun khc cn khu tr trong lng thanh qun cha lan
ra vng h hng th kt qu iu tr ngy cng t t l cao, theo nhn x t ca chng
ti (t 1950-1980 T l k o di tui th qu 5 nm t trn 45%).
8. Phng bnh: Nhiu bo co cc hi nghi quc t u cho rng ht thuc l l
mt trong cc yu t c lin quan n ung th phi cng nh ung th thanh qun.
V vy cn phi tuyn truyn rng ri trong nhn dn v thng qua cc bin php ca
nh nc ngn cm tnh trng ht, nghin thuc l. Mt khc, cn thng qua cc
c quan thng tin i chng ph bin cc kin thc c bn v loi ung th ny
ngi bnh n khm c cng sm th hiu qu cng cao. i vi ngi thy
thuc chuyn khoa, phi trnh chn on nhm trong ung th thanh qun.
27. UNG TH AMIAN KHU CI
1. i cng.
Ung th Amian khu ci l mt trong nhng loa ung th vng Tai Mi Hng th-
ng gp Vit Nam. Bao gm cc khi u thnh h Amian, cng nh tr trc, tr
sau. Trong nhiu trng hp rt kh xc nh im xut pht, khng r l t Amian
hay l t cc thnh h Amian v chng lin quan mt thit vi nhau.
1.1. M bnh hc: Amian c t chc biu m v m lin kt v vy cu trc khi u
c tnh ca n cng chia thnh hai nhm ung th biu m v ung th lin kt. Loi
ung th th nht thng hay gp Vit Nam (90%), cn loi th hai him thy
(10%).
- Ung th biu m Amian: v i th thng gp l th hn hp lo t thm
nhim, sau na l th tng sinh, lo t, thm nhim. V vi th, thng pht sinh t
biu m malpighi, vi mc bit ho khc nhau. Trn thc t, bit ho khng
phi l mt c tnh c nh ca khi u, n thay i tuz theo phng php v v tr
lm sinh thit.
- Loi ung th lympho biu m: c miu t nh l kt qu ung th ho cng
mt lc cc t chc biu m v lympho ca amian ngha l va c hnh thi mt
ung th biu m va l mt sacom lympho. Loi ung th ny thng Amidan vm
v rt t pht trin Amian khu ci.
- Di cn hch: ung th biu m Amian rt hay c di cn hch c, cn vi loi
dng biu b, th di cn khng c lin quan trc tip vi bit ho. Ung th lympho
biu m cng rt hay di cn vo hch. Trong thc t ta thng pht hin mt hch
di cn c, cn bnh tch nguyn pht Amian th khng biu hin r, c trng
hp sau 1 - 2 nm mi pht hin thng tn Amian. Nhng nm gn y, nhiu
bo co ca cc nh ung th hc nhn x t nhng hch c ca ung th Amian c
mt s trng hp dng k n (kystique) v Amian xut pht t ti mang th hai.
1.2. Dch t v cc yu t lin quan n bnh sinh:
- T l mc bnh: Trong phm vi vng u c th ung th Amian ng vo
hng th 7, 8. Bnh ch yu ca nam gii, v tui hay gp 50-70 (vin Gustave
Roussy).
- Cc yu t lin quan n bnh sinh: mt s tc gi cho rng ru v thuc l
l nhng yu t c lin quan mt thit nh phn ln ung th ca ng n v
ng th . Cng cn ni n cc yu t kch thch mn tnh khc nh khi, bi... i
vi nim mc. Nhiu tc gi cn cho rng nhng ngi b ung th biu m vng
hng ming thng l nhng ngi c tin s ht thuc ung ru nhiu, cn i
vi loi sacom th cc yu t ny khng c lin quan g.
2. Ung th biu m Amian.
2.1. Lm sng.
2.1.1.Triu chng c nng: giai on bt u cc triu chng rt kn o v trong
thc t ngi bnh rt him n khm giai on ny. Giai on ny tin trin rt
lng l v k o di kh lu i vi mt s trng hp. Triu chng bt u thng l
nut kh hoc cm gic vng mt bn hng nh c d vt nht l lc nut nc
bt, c im l cm gic ny thng c nh mt v tr v mt bn hng, sau
vi tun hoc mt vi thng th nut kh lc n v dn dn nut au, c bit l au
nhi ln tai. Mt s bnh nhn khi khc c m ln t mu.
Ngoi ra c mt s ngi bnh khi n khm th nh mt vim hng bn cp hoc
nh mt vim ty Amian v qua t dng khng sinh th hin tng vim gim
nh, mt s ngi bnh khi n khm ch v ni hch c hoc i khi do ngu nhin
khm sc kho nh kz m pht hin s thy hch.
2.1.2. Khm lm sng.
Giai on u: Cn gy t nim mc hng thun li cho vic khm, pht hin
thng tn, thng c th thy c mt vt lo t b hay ln mang tnh cht ca
mt lo t ung th, lot si thng l nng, b hi cng, chm vo d chy mu. Ta
cn xc nh v tr ca thng tn. Nu thng tn cc ui hoc mt sau tr tr-
c th dng gng soi gin tip. Ngoi ra chng ta phi s Amian nh gi
thm nhim vo chiu su hoc lan ra vng ln cn. Trng hp thng tn vng
rnh Amian li, ngoi soi khm ra cng cn s vo vng y li.
Giai on r rt: Ngi bnh thng n khm giai on ny, lc triu chng lm
sng kh r rt: au lin tc v nht l lc nut th au nhi bn tai, ngi bnh
khng chu ng ni nn thng dng cc thuc gim au. Ngoi ra giai on ny
thng km theo bi nhim nn rt au v th thng c mi thi, pht m c
ging ni mi kn hay ngm mt ht g ming, khi khm cn xc nh r thng
tn ca Amian v hch.
Tn thng Amian thng r rt, ta cn nh gi s lan rng, thm nhim vo
t chc ln cn. Ung th c nhiu hnh thi khc nhau:
- Hnh thi lot: lo t c th nng hay su, y nh ni la, rn, thng thm
nhim vo cc thnh h Amian.
- Hnh thi si: tng sinh lm cho th tch Amian to ln rt ging mt ung th
lin kt hay sacom, hnh thi ny thng nhy cm vi tia x.
- Hnh thi thm nhim: th ny thng lan vo pha su nn s chc rn.
- Th hn hp: lo t si, lo t thm nhim. Thng do bi nhim nn mu sc
thng tn u mu xm bn hoc hoi t, c trng hp bnh nhn b kht hm nn
gy kh khn cho vic khm vng hng, Amian.
Kim tra v pht hin hch c: hch thng di gc hm v dy cnh, phi khm
t m xc nh th tch, s lng, v tr di ng ca hch. Thng thng tn
Amian th b nhng hch th kh ln, c bit c trng hp th ngc li. Hin nay
c th da vo hch (t bo hc) cng gip cho vic chn on, nh hng tr-
ng hp c bit th mi cn thit lm sinh thit hch.
2.1.3. Cc hnh thi lm sng ca ung th biu m Amian: Cn c vo v tr gii
phu ca thng tn u:
- Ung th cc trn Amian: im xut pht thng h mn hu-khu ci, bt
u l mt nt thm nhim mu v n v vy Escat t tn l gi gm. giai on
u chn on hi kh, nhng sau ung th lan ra mn hu v t chc ln cn.
- Ung th cc di Amian: cn dng gng soi thanh qun kim tra v phi s
vo Amian, n thng lan ra tr trc v b ca li hay gp l th lo t, thm
nhim nn ngi bnh rt au.
- Ung th gia Amian: thng him gp, ch chim 5-6%. Thc t n xut
pht t y khe ri lan ra pha ngoi.
Ung th rnh Amian: tc l ch tip gip y li v cc di Amidan, v n
ch ng ba nn hng lan rng ra nhiu pha, tin lng xu (th ny chim khong
5%).
2.2. Chn on.
2.2.1. Chn on xc nh.
Ch yu da vo kt qu vi th, trong trng hp sinh thit gp kh khn do lo t
hoi t chy mu ca t chc Amian ta cng c th da vo kt qu ca sinh thit
hch.
Khi chn on cng cn nh gi lan rng ca khi u v vy ngoi khm trc tip
ra ta cn s vo t chc Amian v vng ln cn cng nh vic nh gi cc hch b
di cn.
C th ni c khong 20% ngi bnh khi n khm ln u ch v ni hch c v
khong 75% bnh nhn khi n khm do ung th Amian th c hch c s thy
d dng.
2.2.2. Chn on phn bit: Ni chung v ngi bnh thng n giai on mun
nn chn on khng kh khn lm, tr trng hp giai on sm v nht l vi
cc th thm nhim, khng lo t, thng phi phn bit vi cc bnh sau y:
- Vi mt khi u lo t thm nhim: tuy nhin t gp nhng cn trnh nhm ln
vi mt th lao lo t si nhng thng tn lao ni chung t khi tr u Amian v t
thm nhim xung pha su, thng hay gp bnh nhn b lao phi ang tin
trin. Cn ch { n mt giang mai (hoc l mt h cam Amian th n mn hoc
mt gm lo t giang mai thi kz 3). Chn on phn bit ngoi kt qu vi th cn da
vo phn ng huyt thanh v cc x t nghim v lao.
- Vi thng tn lo t Amian: Hay gp l vim hng Vincent nhng bnh ny
din bin cp tnh v c mt s c im nh lo t khng u, y lo t bn c m
mu hoc lp gi mc bao ph, b lo t khng rn v thng km theo c hch vim
c din bin nhanh, ch ngh ngi v v sinh vng rng ming tt. Nhng cng
cn ch { vim hng Vincent pht trin trn mt thng tn ung th Amian
nhng ngi ln tui m Le Maitre cp n.
- Vi trng hp mt Amian th thm nhim lm cho Amian to ra cn ch {
phn bit s pht trin ca bn thn t chc Amian v trng hp Amian b khi
u vng ln cn y li ra nh khi u bn hng, u tuyn mang tai, hch c to y li
Amian... hoc do cc u ca vng vm, mt sau mn hu, ng ba hng thanh qun...
Cc u hn hp v u tr (cylindromes) ca vng mn hu giai on cui c th b
lo t v lan n Amian, nhng cc t chc u ny tin trin chm, qu trnh din bin
tng i di hay b ti pht nn d chn on. Trong thc t, quan trng nht
trong chn on phn bit l nh gi chnh xc v t chc hc ca thng tn. Vic
nh gi v tr nguyn pht ca u l Amian hay mn hu trong giai on mun rt
kh v cng khng c { ngha g ln i vi phc iu tr. Ring nhng trng
hp bt u biu hin bng ni hch c th cn chn on phn bit vi cc vim
hch c mn tnh nh: lao, ung th mu, lympho c tnh, Hodgkin v Non Hdogkin.
2.3. Tin trin.
Nu khng c iu tr th ngi bnh ch k o di s sng trong vng 12-16 thng
do khi u v hch pht trin km theo b vim bi nhim gy chy mu v suy kit
dn.
Khi u Amian to dn lm cho ngi bnh khng n ung c, au n v kht
hm cng lm cho bnh trm trng thm.
Khi hch to dn chn p cc thn kinh v thm nhim v cc mch mu ln vng
c dn n lit thn kinh hoc chy mu t.
Bi nhim, n su vo ng th v di cn vo cc c quan, tng ph l giai on
cui cng dn n t vong.
V bnh nhn n giai on mun nn nu c c iu tr th t l ti pht cng
kh cao, nh h ng xu n kt qu iu tr.
2.4. iu tr: Nhng nm gn y i vi ung th Amian khu ci th iu tr ch
yu bng tia x k c hch c, v ni chung loi ung th ny u nhy cm vi tia x.
Phu thut ch gii quyt nhng trng hp tia ri nhng u Amian hoc hch
cn st li. Ngoi ra, nhng trng hp b nghi ng ung th Amian nhng sinh
thit nhiu ln vn m tnh th phu thut nhm hai mc ch: ct rng t chc
Amian v gi ton b bnh phm lm sinh thit tm t chc ung th.
2.4.1. Phng php iu tr tia x vi khi u Amian: Thng dng tia qua da
(transcutane). Tuz theo cc ngun nng lng khc nhau (coban xa telecobalt),
betatron (gia tc thng accelerateur lineaire) v mc ch ca vic iu tr, thng
tia vo khi u nguyn pht v c vng hch c
Liu lng tia: i vi khi u thng tia t 10Gy-12Gy/1 tun (trung bnh mi ngy
2 Gy). Tng liu khong 70-75Gy trong 7-8 tun i vi u Amian v hch. Khi lng
tia t 45Gy th thu hp din tch tia trng pha sau trnh v bo qun
on tu sng khng vt qu 45Gy trong 4 tun ri. i vi hch c di thi
tia d phng khong 45 Gy tong 4 tun ri .
Phng php cm kim phng x: C th p dng i vi cc u cn b hoc u cn
st li sau tia. C th dng kim Radium hoc Iridium 192, loi ny c u im l
mm mi, liu lng tnh chnh xc c sau khi kim tra, lng tia thng dng
70-80 Gy trong 7- 8 ngy. C th cng kt hp vi tia Co qua da vc th dng mt l-
ng tia cao vng amian 80-90Gy.
2.4.2. Phng php phu thut: Hin nay nhiu tc gi ch trng ch nh phu
thut trong trng hp u cn st li sau tia hoc ti pht sau tia m khng cn kh
nng tia na. C nhiu phng php phu thut bng cch qua ng ming t
nhin hoc i ng ngoi qua xng hm. Khc vi phu thut ct Amian thng
thng v vng bc tch d chm n t chc ung th, do phi ct rng cn gi
l ct Amian ngoi v bao (extra-capsulaire). Di chng phu thut t v t l t vong
sau m cng t gp.
2.4.3. iu tr bng ho cht: Nhng nm gn y mt s tc gi tin hnh iu
tr bng ho cht c kt hp vi tia phng x hoc phu thut. C nhiu { kin khc
nhau v phng php phi hp v cc ho cht, Vit Nam vn ny cha c
s dng nn kh c kt lun v nh gi. Cc loi ho cht thng dng l
Bleomycine, Methotrexate, 5FU... c th dng trc, sau tia v xen k l tuz ch nh
ca thy thuc trn bnh nhn c th.
2.4.4. iu tr i vi hch c di cn:
- Ch yu l tia qua da ng thi vi u Amian, cn cm kim Ir192 ch dng i
vi hch ti pht sau tia. iu tr bng phu thut trong trng hp khi hch cn
b , di ng v thng tin hnh l no v t hch c ton b bao gm ct b cc nhm
hch di cm hm, tnh mch cnh trong, cc dy hch mng cnh, dy ct sng v
c ngang. Nu hch c c 2 bn th tin hnh 2 th cch nhau 15-20 ngy nhng mt
bn phi gi li tnh mch cnh trong.
- No v t hch c c th tin hnh trong 2 iu kin khc nhau, hoc trn mt
bnh nhn c hch s c (th cn thit phi no v t) hoc trn mt bnh nhn
cha s thy hch (th no v t theo nguyn tc). Trong trng hp ny ta thng
no v t hch bo tn tc l ct b hch v t chc lin kt vng c nhng gi li c
c n chm, tnh mch cnh trong v dy thn kinh ct sng (spinat). Cn ct b
hch n thun ch tin hnh trong mt s trng hp hch cn st li hoc hch
ti pht sau tia phng x.
Hin nay c 3 phng php iu tr ch yu:
- Phu thut n thun: trc y cho rng kt qu iu tr bng phu thut
n thun rt xu, nhng gn y nh c nhiu ci tin v tin b nn mang li
nhiu kt qu ng khch l. Do cch chn bnh nhn khc nhau nn kh nh gi
v so snh 1 cch chnh xc c gia tia x v phu thut n thun (theo bo co
ca vin ung th Gustave - Roussy, Php th t l sng trn sau 5 nm xp x bng
nhau 19-20%).
- Tia x n thun: c nhiu tc gi cp n v nhn x t rng s dng tia
Co mang li kt qu kh quan, nht l i vi u cn b cha c hch c hoc hch
b cn di ng. Theo Ennuyer v Bataini (Php) th sng trn 5 nm t 44% i vi
T1,T2-No,N1 v 9% i vi T3,N3.
- Phi hp tia x v phu thut: hin nay tuy c mt s phng php phi hp
khc nhau: Theo Pletcher v Ballantyne Bnh vin Andreson (Houston) i vi
T1,T2 th dng tia Co n thun k c T3,T4 nu l th si v nhy cm vi tia. Bnh
nhn phi c theo di k sau khi tia c 50Gy, nu l nhng thng tn thm
nhim hoc cn li t chc u th sau 6 tun phi ct b c khi (monobloc), nu cn
hch st li sau khi tia th phi no v t hch sau 6 tun. Kt qu sng thm sau 5
nm l 36%. vin Gustave- Roussy (Php), vi T1,T2,T3 th tin hnh 2 hoc 3 th
tuz theo c hch s c hay khng.
3. Sacoma Amian: Phn ln hay gp l cc loi u lympho c tnh Non Hodgkin trong
phm vi vng waldayer. Theo mt s thng k, t l u lympho c tnh Non Hodgkin
ca amian khu ci thng chim ton b vng Waldayer l 59% (theo
Ennuyer1970), 58% (Alseleem), 53% (Wang 1969), 40% (Banfi.1970), 30% vin
Gustave-Roussy.1970), ng vo hng th hai sau Hematosarcome hc mi va cc
xoang mt.
3.1. Triu chng ban u: Nut kh u tin l triu chng hay gp (2/3 s trng
hp), rt t khi au, nu u to qu th ni ging mi, rt t khi c triu chng kht hm,
1/3 trng hp th c du hiu bo ng l ni hch c, v vy trc mt hch th
lympho th phi kim tra k vng Waldayer, c bit l ch { n amidan khu ci.
5.2. Khm lm sng: U amian biu hin nh mt amian th ph i, y cc tr
vo trong, nim mc amian mu i khi hi sm mu, khng rn v khng thm
nhim,i lc b mt amian c mt lp nh gi mc hoc hoi t lo t, thot nhn
ta c th thy r nhng c mt s trng hp th kn o hn nh mt u nh cc
trn amian, hoc amidan hi to, hi nhng mt bnh thng, hoc di
nim mc th ri rc c mt ht nh (micronodulaire). Nu giai on mun th cc
tr, mn hu, i khi y li v h hng u b lan rng do khi u qu to gy kh
th . giai on ny thng c hch c chim 3/4, mt s trng hp (Ennuyer
78%, Terz Farr 65%) mt s trng hp th c hch c c hai bn. Hay gp l
nhm hch di gc hm, th tch ln b rt khc nhau, mt thng chc hoc
cng phng, c khi l mt khi gm nhiu hch.
Trc mt bnh nhn nghi ng l b sacoma amian th phi lm sinh thit amian
lm hch (t bo hc) v phi khm ton thn nht l cc vng bch mch, lm
huyt , tu , tc lng mu, chp phi, d dy...
5.3. Chn on phn bit: Phn bit gia mt ung th biu m vi mt sacom
amian thng khng kh khn lm, ch yu da vo kt qu sinh thit nhng cng
cn trnh nhm ln sau y, ng nn cho rng l mt amian ph i thng th-
ng ri khng theo di, lm sinh thit, hoc l mt p xe amian ri rch dn lu,
cho khng sinh m khng kim tra theo di, hoc trc mt m hch c chc v
khng sng th kt lun vi vng l hch lao m khng kim tra amian. iu tr
th bng tia x xem nhy cm trc khi lm sinh thit cng l mt sai lm
v sinh thit lm sau tia thng l m tnh, khng kt lun c g.
5.4. iu tr: Ch yu tia x qua da v loi u ny rt nhy cm vi tia. Gn y nhiu
nc phi hp iu tr ho cht trc hoc sau tia cng mang li kt qu tt nht
l i vi loi lympho c tnh c tnh cao.
- iu tr bng tia x: Nu c hch c s thy hoc k c cha s thy hch u
phi tia ton b vng Waldayer v ton b vng hch c hai bn k c dy hch c
thng n.
- iu tr bng ho cht: Cc ho cht thng dng phi hp l: prednisolon
40mg/ngy/4tun. Vincristine (oncovin) tim tng mch 1.5mg/m2/tun.
Cyclophosphamide (Endoxan) tim bp hoc tnh mch 400mg/m2/ngy x 4 ngy
cho 3 t tip nhau, mi t cch nhau 15 ngy.
Cch phi hp sau y:
iu tr tn cng (theo Gustave-Roussy)
Prednisolon+Vincristine
Vincristine (2ngy+Cyclophosphamide (4ngy)
V.M 26 +Cyclophosphamide (nh trn)
iu tr cng c: ch yu dng Cyclophosphomide (600mg/m2/1 ln cho 15ngy),
vi loi u lympho c tnh c tnh cao thng hay dng:
Vincristine tim tnh mch 1,5mg/m2/ngy trong 4 tun
Vincarbazine (Velbe) tnh mch 6mg/m2/tun
Procarbazine(Natulan)ung 150mg/m2/ngy trong 20ngy.
V.M 26 v VP16
Ch nh iu tr: Nu th khu tr th iu tr n thun, liu lng phi y mc
giu khi u b i rt nhanh. Tuz kt qu sinh thit u thuc loi lympho c tnh 40-
60Gy hoc hng v hch c 2 bn c tnh thp, trung bnh hay cao m dng liu
50-60Gy. Nu hch to qu hoc cn st li sau khi tia th phi tia thm 10Gy trong
mt tia trng c gii hn. Trng hp c di cn vng hch xa (vng bng,
khung chu) th trc ht iu tr bng ho cht (tn cng) sau tia phng x (tia
vng c trc sau c tia vng di c honh) sau cng l iu tr ho cht vi liu l-
ng iu tr cng c. Nu giai on mun (cc tng b di cn M1) th ch yu
iu tr triu chng bng ho cht.
- Kt qu iu tr: Theo thng k ca mt s tc gi nc ngoi th sng thm
qu 5 nm c th t t 30-40% (Ennuyer 35%, El.saleem 40%, Terz v Farr 35%)
nhng nu thng tn cn khu tr ti ch th kt qu t cao hn 51% (Ennuyer),
79%(Wang). Nu thng tn lan ra vng ln cn th kt qu b hn ch dn 48%
(Wang), 32% (Ennuyer). trng hp lan rng th khng c trng hp no sng
thm qu 5 nm.
- Tin trin bnh sau khi iu tr: C th ti pht u hoc hch c, thng gp
nm u (1/3 s trng hp theo Terz v Ferr) th c th dng tia x hoc phu
thut ly hch. C th xut hin mt sacom xa vng c mt thng hay gp
trong 6 thng u (VinGustave-Roussy 55%) nh d dy, xng... trng hp ny
tin lng xu v 75% t vong do nguyn nhn ny.
28. UNG TH CC XOANG MT
1. i cng: Ung th cc xoang mt ch nhng thng tn vng hm, mi, mt.

Cc xoang mt bao gm: xoang sng trc v sau, xoang hm, xoang bm, xoang
trn. Hay gp nht l ung th xoang sng, xoang hm. Khi mt trong hai xoang b
ung th th d c s lan to ung th vo xoang ln cn.
Thc ra thut ng ung th cc xoang mt" cng cha tht chnh xc v mt gii
phu nh khu b i v cc u c tnh vng ny thng xut hin t xng hm trn,
hoc t vung ln cn xng hm trn, chng hn nh ung th tin pht c th t
xoang sng trc, hoc xoang sng sau hoc t xng khu ci. Theo nhiu tc gi
ung th xut pht t xoang sng sau hoc t ranh gii ca xng hm trn l hay
gp nht, t ung th lan vo xoang hm gy nn cc triu chng ung th xoang
hm.
1.1. Cc yu t lin quan n bnh sinh:
- Vi bnh tch vim nhim mn tnh ti ch nh bnh tch thoi ho vim
xoang sng thnh polip vi ung th xoang sng.
- Do bnh ngh nghip: Tip xc vi ha cht nh cc cng nhn tip xc vi
niken, acsenic, crom, amiant...
1.2. T chc hc:
- Hay gp nht l loi ung th biu m lt (chim trn 80%), thng gp th-
ng tn xut pht t nim mc bao ph cc xoang mt v hc mi. Loi biu m ca
cc nim mc trn l t bo tr c lng chuyn, ung th xut pht t mang tnh
cht lt v do cc xoang b vim nhim dn n s di sn t bo lt v mang tnh
cht tht s trng thi tin ung th. Loi ung th biu m ny ni chung hay gp l
hnh thi mt ung th biu m dng b v t khi c cu sng.
- Cn loi ung th lin kt (sacoma) th t gp hn v c nhiu chng loi hn.
l: sacoma sn, sacoma xng, sacoma x (fibrosarcome), sacoma tu, sacoma
li...
2. Triu chng lm sng: V cc xoang mt c lin quan mt thit vi nhau v ph-
ng din gii phu hc nn cc triu chng lm sng tuy rt a dng nhng c th
qui np vo 5 hi chng sau y:
- Hi chng mi: hay gp nht, biu hin tc ngt mi mt bn, chy mi
nhy ln chy m hay ln mu, chy mu cam.
- Hi chng mt: au vng h mt, nhn cu, chy nc mt, vim ti l.
- Hi chng bin dng: mt b y li, m b y phng, r mi b dn rng, mt
rnh mi m, cng hm... tuz theo v tr v lan rng ca khi u.
- Hi chng thn kinh: au u, au vng trn mi, t b vng da mt, mt
khu gic, gim th lc, m...
- Hi chng hch c: thng xut hin giai on mun.
3. Phn loi ung th cc xoang mt: Nhiu tc gi v cc y vn trn th gii u da
trn c s gii phu, phi thai hc chia lm 3 loi: ung th thng tng cu trc, ung
th trung tng cu trc, ung th h tng cu trc.
3.1. Ung th thng tng cu trc: ch yu ni n ung th vng xoang sng trc
v xoang sng sau, xut pht t cc t bo sng.Trong thc t loi u ny thng
vng ranh gii gia xoang sng v hm nn cn gi l ung th ranh gii. Loi ung
th ny bao gm th xut pht t gc trn v sau ca xoang hm.
Ung th xoang sng trc: Hay gp l ung th biu m malpighi v ung th biu
m tr.
- Ung th biu m malpighi: l ung th biu m khng bit ho, cc t bo ung
th ny hnh tr hoc di, hay c phn bo v nhn to. Mt s t trng hp l ung
th biu m t bit ho v c th ri rc c th c cu sng.
- Ung th biu m tr: Thng pht hin trn mt nim mc xoang sng cha
pht trin n giai on d sn malpighi, v t chc hc trc y, ngi ta cn sp
xp phn loi thnh ung th biu m tuyn l loi t bo u t nhiu c trng thi
bnh thng, ung th biu m khng in hnh (atypique) v ung th biu m nhy
l loi ung th sn sinh ra cht nhy.
Ung th xoang sng sau: Pht sinh t nhm sau cc t bo sng, tc l nhm pha
sau v trn xng cun gia (nhm t bo sng sau, nhm t bo sng - khu ci v
nhm t bo sng - bm) c th lan ln n mng no cng. Tri li ung th xoang
sng trc v cn mt khong cch xng gia sng trc v sng sau, nn t lan
n mng no cng. Ung th xoang sng sau thng lan rt nhanh ra ngoi, v mng
xng giy rt mng, d b ph hu, u lan vo hc mt, nn khi bao tenon b
thm nhim th nhiu tc gi cho rng phi kho t b nhn cu. Ra pha sau l xoang
bm nn thng b bi nhim hn l b ung th thm nhim, nu u lan vo mt
trc v sn xoang bm ri th phi ct b 2 phn ny. pha trong u thng
thm nhim mnh sng v mng ng xoang sng lan sang pha i din.
Cc triu chng lm sng: Do khi u trong hc xng, khi cha lan ra ngoi th cc
triu chng rt kn o, d nhm vi vim xoang sng mn tnh. Trong thc t, phn
ln cc bnh nhn n khm giai on mun, nn cc triu chng thng gp l
tc mi, chy mu mi, au nhc vng mt mi, sng vng r mi, mi-mt, gy
nn hi chng nhn cu.
Giai on u:
- Ngt tc mi: thng mt bn v tin trin t nh n nng, ngt hon ton
ng thi km theo chy mu mi, m nhy.
- Chy mu mi: l triu chng quan trng, c th chy t nhin hoc do va
chm... chy mu mi ngy cng tng v s ln v lng mu chy (khi khm bnh
thy khng phi chy im mch do cao huyt p).
- au: thng xy ra mun hn v t gp giai on ny, ngi bnh c cm
gic nng vng r mi hay vng trn, mt s trng hp c bit th c tng cn
au d di vng trn.
- Sng vng mi - mt: Trong thc t thng gp nhiu nht l du hiu bin
dng vng mt v mt do t chc u lan ra qu gii hn xoang sng lm cho r mi
phng ra, sng vng g m v nht l bin dng vng mt-nhn cu cng bn (nhn
cu li ra trc v ra ngoi), i khi mi trn b sng n. Ngoi ra mt s bnh nhn
c hin tng gim th lc, song th. Mt s c bit b bi nhim vng l o.
Giai on r rt:
giai on ny, cc triu chng trn ngy cng nng dn (l do bnh nhn n
khm). Cc triu chng hay gp thng vng trn, quanh h mt hay vng r mi.
Nguyn nhn chnh l do vim xoang trn, v phn ln ung th xoang sng trc th-
ng gy vim xoang trn, dng cc loi khng sinh, chng ph n th triu chng
au gim dn nhng nu do ung th lan vo xoang trn th cn au s k o di, lin
tc. Nu u xoang sng sau th au nh u hay vng chm, cn au tuy khng
d di nhng lin tc m (cn au vng trn) ging nh cn au do vim xoang
bm, thng l au na u v lan ra sau ging hi chng Sluder.
- Ngt tc mi: Cng l du hiu hay gp 60% ngi bnh khi n khm c
du hiu ny, do u pht trin dn bt u tc nghn mt bn sau u y vch
ngn sang pha i din v gy nn tc hai bn lm cho bnh nhn phi th bng
ming.
- Chy mu mi: Giai on ny bnh nhn thng b chy mu mi nhiu ln
chim 30%), lng mu nhiu t tuz tng bnh nhn, c ngi th khi x mi c ln t
mu, c ngi th chy mu ti nh git, nhng phn nhiu l mi nhy ln mu.
C bit c ngi chy mu t phi cp cu. V vy nhng bnh nhn c tin s
chy mu mi th phi thn trng nn lm sinh thit (tt nht cho bnh nhn nm
lu).
- Ri lon khu gic: Triu chng ny t gp, nu c do u phn cao ca xoang
sng hoc u thn kinh khu gic. Khu gic c th gim nhng cng c th mt hon
ton, nguyn nhn do t bo thn kinh khu gic b tn thng hoc do u lm tc -
ng lu thng khng kh.
- D dng: do u lan ra ngoi phm vi xoang sng ph v thnh trc v thnh
ngoi ca xoang lm cho gc trong ca mt b phng ln hoc nhn cu b y li,
triu chng ny rt quan trng trong chn on.
- Cc triu chng v mt: Ngoi nhn cu b y li ra cn mt s triu chng
khc ca mt cng hay gp nh: chy nc mt, vim tuyn l, ph n mi mt c khi
vim kt mc khin bnh nhn thng n khm khoa mt trc tin.
Khm lm sng:
- Soi mi trc: Thng hc mi cha nhiu xut tit nhy ln m c mi hi v
b bi nhim. Sau khi ht sch dch mi c th thy phn cao, trn ca hc mi
hoc khe gia c t chc si, chm vo d chy mu, thng cc xng cun b ph
n, cng t do phi gy t v dng thuc co mch trc kim tra c r
hn. Mt s trng hp c hnh thi ging nh mt polip mu hng, trn u bm
cht vo xng cun hay khe gia ging nh mt t chc vim mn tnh, cn t
chc ung th thng b che lp pha su, do sau khi ct polip ri th t chc si
mi l r.
- Soi mi sau: Rt quan trng nhng cn phi gy t tt mi kim tra c.
Nhiu trng hp soi mi sau khng pht hin c thng tn g trong khi mi trc
y thng tn u, khi u lan ra ca mi sau thng l mt t chc ht si c th
che lp c ca mi sau v lan vo vm. Nu khi u b bi nhim c th c lo t hoc
lp gi mc bao ph.
- U lan vo xoang trn: Ung th xoang sng trc thng gy nn vim xoang
trn do nhiu khi kh xc nh c phi c u thm nhim khng, v cc triu chng
lm sng cng tng t nh mt vim xoang trn thng thng, au gc trong
mt v au vo thi gian nht nh, thng vo bui sng, ch c th da vo hnh
nh X- quang phn on mt phn.Trong thc t khi phu thut xoang trn li
thy t chc nh mt nim mc thoi ho thnh polip, t chc ung th thng ln
trong m nim mc ny, v vy sinh thit phi ct nhiu tiu bn.
- U lan vo xoang bm: Trng hp ny t gp hn xoang trn. Cc triu
chng lm sng rt kh xc nh, chn on da vo X-quang nht l chp C.T.Scan
c th thy r hnh nh thnh trc xoang bm b ph hu.
- U lan vo xoang hm: L trng hp hay gp nht Vit Nam. giai on
tin trin ny, kh phn bit l ung th tin pht xoang no, v vy thng gi l
ung th sng hm.V phng din gii phu hc th t khi ung th t xoang sng
trc lan xung xoang hm v xoang sng trc ch lin quan trc tip vi xoang
phn di trong. Ngc li cc khi u xoang sng sau thng lan xung di v ra
ngoi v vy hay lan xung xoang hm. Cc triu chng lm sng th hin s thm
nhim xung xoang hm l cm gic t b vng da rnh mi m tng ng vi
vng chi phi ca thn kinh di hc mt, cm gic t b ny lan n vng mi trn
c khi c mt trong ca mi trn. Mt s bnh nhn c cm gic nng vng
xoang hm v thng km theo bi nhim ca mt vim xoang hm, vi chy mi
nhy m ln mu. Chp X- quang, nht l chp C.T.Scan s gip ta thy hnh nh
thm nhim ny. Trong thc t cc trng hp b ung th sng hm th trn 30%
c du hiu thm nhim vng mt, nhn cu.
- U lan vo h chn bm hm: Trng hp ny xut hin giai on mun v
c cc biu hin sau: au vng thn kinh hm di chi phi v vng do thn kinh
hm trn. Nhng t ph n mi mt, h thi dng, cng hm l du hiu mun
nht v tin trin t t, sau cc c chn bm hm cng b thm nhim.
- U lan vo mng no cng v no: l giai on cui cng v trm trng nht
ca ung th xoang sng, trn lm sng ngi bnh thng c tng cn au na u
pha bn bnh rt d di, chn on da vo X- quang nht l chp C.T.Scan c th
thy r mnh sng b n mn v ph hu. Giai on ny th iu tr ch yu l triu
chng.
2.2. Ung th trung tng cu trc: L ung th xoang hm xut pht t nim mc
hoc vch xng ca xoang hm. Thng k ca nhiu tc gi cn nhiu im khc
nhau, mt s nhn x t rng ung th xoang hm t gp hn xoang sng. Theo nhn
x t bc u ca chng ti: ung th xoang sng chim t l nhiu hn ung th
xoang hm.
Triu chng lm sng:
- Giai on u: cc triu chng lm sng ca ung th xoang sng rt kn o
khng mang tnh c hiu v rt ging cc triu chng ca mt vim xoang sng
mn tnh thng thng, nh ngt tc mi mt bn, ngy cng tng dn v thng
km theo bi nhim nn hay km theo chy mi m c khi ln mu. Thnh thong
bnh nhn ku au du nhng khng d di lm, dng thuc gim au th hn.
Khm soi mi trc giai on ny thng cha pht hin c thng tn g tr
mt s trng hp bnh nhn khe gia c dch nhy m hoc ln mu, do bi
nhim nn nim mc cc xng cun hoc cc khe mi thng b n , xung huyt,
c bit c t chc si, chm vo d chy mu. Trn phim X-quang thng c hnh
nh m u nhng cha c hin tng xng b ph hu.
Tm li: giai on u ung th xoang hm rt d nhm vi vim xoang hm mn
tnh (vy trn thc t c mt s bnh nhn c chn on v iu tr nh mt
vim xoang hm mn tnh). Mt s khi phu thut mi pht hin nghi ng c ung
th do nhng bnh tch khng bnh thng ca nim mc hay thnh xoang c mt
s hin tng chy mu nhiu lc m v in hnh nht l sau khi m khng lu,
bnh s ti pht nhanh v c bnh cnh c tnh (au u cng tng, sng n na
mt bn m, thm ch xut hin cc triu chng thn kinh v bin dng vng mi,
m...).
- Giai on r rt: bnh nhn thng n giai on ny mi n bnh vin, cc
triu chng ngy cng tng dn c v cng v thi gian. au u hoc au nhc
vng h mt v m. Cm gic t b vng di mt hoc na mt bn bnh, ngoi
ra do bi nhim vng xoang nn ngoi ngt tc mi thng x mi c ln mu v mi
hi thi.
Khm soi mi trc: thy vch mi - xoang b y dn v pha trong, khe gia c t
chc si, d chy mu tuz khi u to nh m hc mi b chon mt phn hoc ton
b, vch ngn c th b dn sang pha i din gy ngt mi c hai bn v ni c
ging mi kn.
Soi mi sau: c th c mt s trng hp lan ra ca mi sau hoc vo vm.
Tin trin ca bnh: Tuz theo s lan rng ca khi u m cc du hiu lm sng cng
khc nhau.
- Nu u lan ra mt trc xoang hm th y phng h nanh v g m.
- Nu u lan ra pha nc xoang hm, ph v sn hc mt th nhn cu b y dn
ln trn v ra trc gy ph n mi di, c th lan vo xng g m v xng sng.
- Nu lan vo xoang sng th cc triu chng ging nh ung th t xoang sng
lan xung xoang hm v kh xc nh c im xut pht ca t chc ung th.
- Nu u lan xung y xoang hm th xng khu ci b ph v nim mc khu
ci b thm nhim ri lan n chn rng lm cho rng b lung lay ri rng dn.
- Nu bnh nhn khng c iu tr th bnh s pht trin rt nhanh, thng
tn ti ch lan rng km theo bi nhim, bnh nhn suy kit dn do au n, khng
n ng c v cui cng dn n t vong hoc do chy mu t cc mch mu
ln vng mt (hoi t kt hp vi bi nhim v t chc ung th lan rng) hoc do c
th suy kit km theo mt bi nhim trong sng hoc do di cn xa.
Chn on: giai on u thng gp kh khn. Phn ln bnh nhn thng n
giai on mun nn c th da vo cc triu chng lm sng, khm thc th, kt
qu sinh thit v phim X-quang (Blondeau, Hirtz, C.T. Scan) c th chn on -
c chnh xc. Vn l nh gi c thng tn c mt phc iu tr hiu
qu.
Chn on phn bit:
- Vim xoang hm mn tnh: Cn au do ung th gy nn thng d di hn v
cc thuc gim au s mt dn tc dng thng au vng xng hm trn, vng
hc mt, xut tit mi thng l dch m nhy ln mu, trn phim X- quang hnh nh
xoang hm b m u, lan rng, b khng u v c hin tng b ph hu b x-
ng thnh xoang.
- U nang quanh rng: Loi ny tin trin chm, triu chng lm sng khng rm
r, th trng bnh nhn bnh thng, ti ch khng c du hiu thm nhim, phim
X- quang c th thy r b ca u nang.
- U lnh ca xoang hm: nh u nhy, u xng, u sn, u x, cc u ny thng
tin trin rt chm, khng au, khng b bi nhim, t xut tit, phim X- quang th-
ng c hnh nh m u, r rng.
- au dy thn kinh tam thoa hay au rng thng au tng cn, au tng cn
v khng c hin tng bin dng.
- Vim xoang do nm: Bnh tin trin chm th trng chung bnh thng, t khi
c hch nhng li thm nhim rng nn thng c nhiu l r.
- Ung th li: D nhm vi cc loi u si xut ngoi ca ung th vng bm
hm nn cn khm k.
2.3. Ung th h tng cu trc: Hay cn gi l ung th th rng, ung th rng ming
ni r v tr ung th v s lin quan vi chuyn khoa rng hm mt. Thng tn
ung th thng xut pht t ranh gii rng ca xng hm trn. Loi ung th ny
c thun li l d pht hin c giai on sm do triu chng r rng, tr mt s
trng hp c bit (khi bnh lan rng) th kh xc nh c ung th tin pht.
Triu chng lm sng: au rng dai dng, c khi cn au d di, cc rng c th b
lung lay v vy khi bnh nhn n khm c nh rng t mt tuyn trc nh-
ng cn au khng gim m cn tng thm. Nu khm k s thy cc ca chn rng
b nh khng lin li m cn mc ln cc n si hoc t chc ht, chm vo d
chy mu. Cc thng tn ny ngy cng lan rng v thm nhim ra vng li ln cn
lm cho rnh mi li b y phng v cc rng cng b lung lay. Nim mc ca vng
li cng b thm nhim s tr thnh mu sm, c nhiu mch mu cng t,
nim mc vm khu ci cng b y phng xung di khin cho ta t ng nhm l
ung th xut pht t hm ch. Sau , vng m cng b sng phng ln v thng
tn ung th b thm nhim n vng quanh rng nanh.Trong mt s trng hp
c bit, thng tn ca ung th li xut pht t rng ca v vy vm khu ci b
thm nhim sm, sau lan ln n vng xng hm hai bn. Trong mt s trng
hp, thng tn ung th ny b bi nhim gy nn hoi t, chy m thi ging nh
mt ct tu vim rng. Nu ung th xut pht t cc rng khn th d thm nhim
vo h chn bm hm gy nn kht hm, trng hp ny rt ging du hiu ca
mt rng khn mc lch hoc mt ung th biu m ca li. Khi ung th lan vo
h chn bm hm v gy nn kht hm th bnh nhn rt au n, khng n ng -
c ton trng gy st nhanh chong v tin lng ni chung l rt xu.
Chn on: Ni chung khng kh khn lm, da vo triu chng lm sng, khm
pht hin, lm sinh thit cng ly ng thng tn ung th. Ngoi ra trn phim
X- quang (th Hirtz) thy thng tn vng chn bm hm m lm sng kh nh
gi.
Giai on ton pht (lan rng) ca ung th cc xoang mt: C tc gi gi l ung th
lan rng ca xng hm trn. y l giai on cui cng ca ung th cc xoang mt
lan rng ra cc vng ln cn khng cn kh nng xc nh im xut pht ca
ung th na. Giai on ny b mt ca bnh nhn tr thnh qui d do tn thng
ung th ph hu t chc xng v lan ra c phn mm. Th trng chung ca bnh
nhn cng b suy sp nhanh chng li km theo bi nhim nn khng cn kh nng
iu tr na. Ch yu l iu tr triu chng, chng bi nhim v gim au, v
theo kt qu m t thi nhiu tc gi ghi nhn 65% c di cn xa.
2.4. Mt s hnh thi khc ca ung th vng mi xoang: U tr (cylindrome) so vi
ung th biu m th u tr t gp hn nhng khng phi l him thy. Nm 1859 Biltroth
l ngi u tin miu t loi u ny. Danh t u tr cng xut pht t hnh dng khi
c thy trn tiu bn ca thng tn (hnh tr). Lun vn ca Yvesl -Maltre (Php)
trnh by kh y v bnh ny. Trong y vn ca Anh th rt t khi dng n t ny,
ni chung cc ti liu trc y hay gi l ung th biu m t bo y ( pith lioma
cellules basales).
- Bnh l gii phu: U tr c c im l t chc u thnh tng m, hnh trng
(bu dc), thu quang (hyatin) hoc nhy. Do l nhng th hnh trng ng u
nhau i khi c hnh li. T chc m rt thay i, thng l t chc x to thnh
cc vch ngn phn chia cc m t bo thnh thuz. U tr thng xut pht t t
chc tuyn, tin trin dn v rt chm, c bit khng c di cn vo hch nhng li
c di cn vo phi. V tr u tr c th t xoang sng thng gp l phn trc khi
bn, t khi gp phn sau, trn thc t hay gp phn trn ca vch ngn.
- Tin trin bnh: U pht trin chm y dn cc t chc ln cn, khng gy
thm nhim, nhng cc thnh xng lin k c th b l ch hoc bin mt. Sau khi
ct b thng tn, bnh tch li c th b ti pht, tuy khong thi gian c th di
ngn khc nhau. Di cn xa ch yu hay gp phi nhng phi sau nhiu nm, c khi
10-15 nm.
Nu khng iu tr: bnh tin trin theo tng t, gia cc t c khong n nh
hoc thoi trin k o di nhiu thng. c bit l khi bnh c di cn phi, tin
trin chm, nh thng tn tin pht mi xoang, v vy nhiu tc ga nhn x t
rng, trn nhng bnh nhn b u tr c di cn phi ri, vn c th tin hnh
iu tr bng phu thut m khng nh h ng n s pht trin u v di cn phi.
- iu tr: Ch yu l iu tr ct b thng tn u v phi ct b nhiu ln nu u
b ti pht. trnh ti pht hoc k o di khong cch thi gian th cn ct b rng,
c th dng dao in hoc ng in phi hp lc m.
Phi hp tia x: Hin nay cn nhiu { kin tri ngc nhau v vic phi hp tia x
sau m, nhng gn y th c nhiu { kin cho rng vic phi hp tia x lm cho
bnh nhn c n nh v k o di thi gian ti pht hn hn so vi nhng bnh
nhn khng c tia x, mc d loi u tr rt khng tia. Bnh nhn u tr thng k o
di cuc sng hng chc nm nu c iu tr, hoc theo di kp thi, t vong th-
ng do khi u pht trin qu ln, chn p nht l nn s, hoc l do di cn phi.
IV. iu tr ung th biu m cc xoang mt: Cho n nay phu thut kt hp vi tia
x l bin php ch yu iu tr loi ung th ny. Nhng nm gn y, c
nhiu bo co v kt qu ng khch l ca phi hp thm vi ho cht trc v sau
khi m, tia x.
1. iu tr bng phu thut: La chn phng php phu thut l thuc vo v tr
lan rng ca ung th. Vi vng thng tng kin trc, khi u cha qu lan rng c th
ct mt phn xng hm trn, mt phn thnh di v thnh trong hc mt cng
vi xng chnh ca mi bn bnh. Vi u vng trung tng: phn ln bnh nhn n
giai on mun nn nhiu tc gi ch ng ct b ton b xng hm trn. Cn
i vi u h tng kin trc cn c vo bnh tch c th m tin hnh phu thut bo
tn (ct mt phn xng hm trn).
2. iu tr bng tia x: L s phi hp quan trng, c th dng hai cch: thng th-
ng l tia x qua da Co60, lng tia hng ngy v tng liu cng ging nh ung th
khc ca vng u mt c, thng 2Gy/ngy, mi tun t 10-12Gy (trong 4-5tun).
Mt s tc gi ch trng t p ngun tia x vo ngay h m, thng dng ngun
Co60 hay radium, gn y nhiu ngi s dng indium192 v kinh nghin cho thy
radium hay gy hoi t xoang v nhiu bin chng nng.
3. iu tr bng ho cht: Ho cht c th s dng qua ng tnh mch hoc ng
mch. Cc ho cht hay dng l 5Fu, Bl omycin, M thotrexate. Vic iu tr ho
cht trong iu tr phi hp ung th mi xoang c trng phi Nht bn ht sc
quan tm.
4. Kt qu iu tr: 20 nm trc y khi ni n ung th vng mi xoang nht l
khi khi u lan qu mt vng gii phu (qu mt xoang) th kt qu iu tr ni
chung l xu, hn na phu thut ct b xng hm trn gy nhiu bin chng v di
chng cho ngi bnh nn tin lng xu. Gn y, nhiu tc gi c nhng nhn
x t kh quan hn do s phi hp iu tr gia phu thut, tia x v ho cht.
- Nu iu tr bng tia x n thun: kt qu rt k m, theo Lederman trn 55
bnh nhn ung th biu m xoang sng th ch c 5% sng qu 5 nm. Nhng theo
Errington (1985), iu tr 43 bnh nhn b ung th vng mi xoang lan rng (85% l
T4) bng neutron vi nng lng yu (7,5 MeV) cho 17 bnh nhn ung th dng
biu b, 11 u tr, 8 ung th tuyn, 5 ung th biu m chuyn tip, 1 ung th biu m
khng bit ho v 1 u hc t c tnh th kt qu k o di tui th 3 nm l 47% v
72%, cn sau 5 nm l 30% v 55%.Tc gi nhn x t rng s d t c kt qu trn
l do tnh cht t chc hc ca u, do tc dng ca neutron so vi photon vi cc t
bo thiu oxy.
- Nu iu tr bng phu thut n thun th ch nn p dng i vi cc khi u
cn b, cha lan ra vng xoang hoc cc t chc ln cn. Kt qu tt nht l i vi
loi ung th biu m ca h tng cu trc, t 30-50% c th sng hn 5 nm.
- iu tr phi hp: Nu phi hp iu tr phu thut vi tia x th r rng l kt
qu t cao nht so vi hai phng php trn. Vn l tia x trc hay phu thut
trc. Nhiu bo co cho thy kt qu ca tia trc hay phu thut trc u
khng khc nhau my. Lp lun ca trng phi tia x trc l ct lm b li khi u,
nht l tiu dit cc bnh ung th rt b ri rc xung quanh tn thng chnh m
mt thng khng thy c v c th lan to ra xa trong khi phu thut. Trng
phi tia x sau khi m nhn mnh tnh cht khng tia ca khi u lan vo xng,
ngoi ra cn nhn x t rng m trc th vt m s lin tt hn. Phi hp tia x sau
khi m l phng thc iu tr ph bin.
- Phi hp phu thut vi tia x i vi ung th biu m vng mi xoang ni
chung c th t kt qu sng trn 3 nm khong 55% v sau 5 nm khong 48%
(vin Gustave Roussy Php nm 1990). Gn y, nhiu tc gi Nht bn
(Yamashta, Sato, Sakai, Shibuya v cng s) c nhiu bo co ni r kt qu ca
vic s dng ho cht (dng mt cht hay nhiu cht) phi hp phu thut v tia x
nng cao hiu qu iu tr cng nh trnh c mt phu thut qu rng (thay
th mt phu thut ct b ton b xng hm trn bng mt phu thut ct b mt
phn xng hm) nhng kt qu ny ang cn trong giai on thc nghim v c
nhiu { kin khc nhau, tuy nhin vic s dng ho cht c p dng rng ri
nhiu nc trong lnh vc ny.
5. Ung th xoang trn: Loi ung th ny him gp, thng th pht t xoang sng
thm nhim ln, ch yu l ngi ln v c hai gii u mc bnh nh nhau, v t
chc hc loi ung th biu m chim khong hn 80%, cn sacoma th rt him.
5.1. Triu chng lm sng: giai on u, cc triu chng ging nh mt vim
xoang trn mn tnh hoc vim xoang trn c m. Phn ln bnh nhn khi n khm
thng giai on mun, nn cc triu chng rm r hn nh au u d di,
hoc u ph v thnh trc xoang trn lm cho vng r mi v vng da gc
trong lng my b y phng.
5.2. Chn on: Da vo cc triu chng khm lm sng, bnh tin trin nhanh
chng, d ph v cc thnh xng thm nhim vo cc vng ln cn, trn phim X
- quang thy r cc thnh xng b ph hu.
Chn on phn bit:
- giai on u, cn phn bit vi mt vim xoang mn tnh, vi u xoang trn.
Cc bnh ny c lch s bnh v tin trin bnh lu nm, cc triu chng khng rm
r, trn phim X- quang c hnh nh m u khng c hin tng ph hu xng.
- giai on rm r cn phn bit vi u nhy xoang trn, c tin s k o di
hng nm, c khi 8-10 nm, th trng ton thn khng nh h ng g, khm lm sng
v X- quang c cc du hiu c trng ca u nhy (u mm, n vo c cm gic nh
v qu bng bn, chc d bng kim to ht ra c dch nhy, trn phim X- quang
thnh xng b n mn ch khng b ph hu nham nh ...).
5.3. iu tr v tin lng: Ch yu l phu thut phi hp tia x, nhng phn ln
bnh nhn n khm giai on mun nn kh nng iu tr rt hn ch v bnh
nhn thng cht do vim mng no hoc thm nhim vo no.
6. Ung th xoang bm: Cng rt him gp, thng l ung th biu m, rt t
sacoma.
6.1. Triu chng: giai on u cc triu chng rt kn o v ngho nn, n giai
on r rt th triu chng rt ging nh mt vim xoang bm c m, nhng din
bin nhanh v nng hn, bnh nhn au u lin tc v sau u lan rng gy nn
cc triu chng nng nh: vim th thn kinh dn n m, vim mng no, vim tc
tnh mch xoang hang v cc hi chng thn kinh khc. Ngoi ra th trng ton thn
suy sp v thng km theo bi nhim.
- Soi mi sau hoc qua ng soi vi Eutasche (salpingoscopie) c th thy r t
chc si l xoang bm.
- Trn phim Hirtz v s nghing thy c bng m ca khi u v hin tng
ph hu xng.
6.2. Chn on: Trong thc t bnh nhn n khm giai on mun nn chn
on khng phc tp lm, nht l bnh cnh giai on cui, ung th lan rng ra
cc vng lan cn.
6.3. iu tr: Cho n nay phng php iu tr ung th vng xoang bm (nguyn
pht hay th pht) cn gp nhiu kh khn v kt qu rt hn ch v v tr gii phu
ca khi u cng nh giai on mun ca bnh nhn khi n khm, phn ln cht do
bin chng no.
7. Cc loi sacoma vng xoang mt: Cc xoang mt c nhiu loi sacoma khc nhau,
chn on hon ton phi da vo kt qu ca t chc hc.Trn thc t, loi
sacoma ny cng him gp, theo thng k ca nhiu tc gi th rt khc nhau, chim
t l trong cc ung th xoang mt t 7-15%. Thng gp l sacoma x
(fibrosarcomes), sacoma sn (chondrosarcomes), sacoma xng, sacoma c vn
(rhabdomyosarcomes), sacoma mch (angiosarcome)...
7.1. Triu chng: Tuz theo v tr thm nhim ca u m cc triu chng lm sng khc
nhau (nh ung th xoang sng, ung th xoang hm, xoang bm, xoang trn, vng
h tng cu trc...). c bit sacoma khc vi loi ung th biu m l bnh tin trin
rt nhanh, hay gp tr em v ngi gi (trc 15 tui v sau 65 tui) nhng cng
c th gp bt c tui no.
7.2. Chn on: Ch yu l da vo cc triu chng lm sng nht l cc din bin
bnh nhanh chng, da vo kt qu sinh thit v phim X- quang.
7.3. Tin trin bnh: Nu khng c chn on v iu tr kp thi th bnh pht
trin rt nhanh ti ch v sm c di cn xa (hay gp l phi v xng).
7.4. iu tr: Sacoma ni chung l nhy cm vi tia x v ho cht v vy iu tr ch
yu l phi hp tia x vi ho cht. Phng php phi hp l thuc vo giai on
bnh cng nh s trng ca thy thuc lm sng, c th tia trc hoc iu tr ho
cht trc, hoc phi hp xen k ha cht-tia x-ho cht.
7.5. Kt qu iu tr: Ni chung bnh s thuyn gim rt nhanh, kt qu trc mt
rt ng khch l nhng t l ti pht ti ch hoc di cn cng hay gp, nht l trong
vng 2 nm u sau khi iu tr v vy bnh nhn cn c theo di thng xuyn
kp thi x l nu b ti pht. Mt s ch trng dng ho liu php nh kz tim
hoc ung vi liu lng cng c. y cng l nhng { kin ang cn tranh lun.
29. U BUNG TRNG
I i cng:
Khi u bung trng l mt bnh l{ ph khoa c th gp tt c cc la tui ph n
t tr cha dy th n ngi gi mn kinh, t l 3-6 % nhng gp nhiu nht la
tui sinh (18-49 tui). Triu chng ngho nn, khi triu chng rm r th mun
hoc l c tnh, chn on khng kh lm, tin trin phc tp, tin lng iu tr v
cng kh khn. .
II Cc khi u dng nang.
1.U nang c nng:
L nhng khi u kch thc nh, v u mng, trong cha dch, tin trin nhanh, c
th t bin mt trong mt vi chu kz kinh nguyt.
1.1 Nang bc non.
L nang Graaf, khng v vo ngy phng non nn khng c giai on hong th,
bc nang tip tc ln ln, c khi ng knh 10 cm. Nang tit nhiu Estrogen d
bnh nhn b chm kinh. khi nang v, c du hiu au bng, rong kinh, chm kinh
d nhm vi cha ngoi t cung. C t cung c nhiu cht nhy, nhit c th
di 37 , phin m o cng estrogen.
1.2. Nang hong phm:
L nang c kch thc ln hn bc non, gp mt hay hai bn bung trng, v
nang mng, trong nang cha nhiu dch vng Lutein, thng gp bnh nhn cha
trng, u t bo nui, bnh nhn v sinh dng nhiu thuc kch thch rng trng liu
cao. U c th mt i trong vi ba chu kz.
1.3. Cc nang ca hong th:
Gp nhng ngi c thai, c bit nhng ngi nhim c thai ngh n, a thai.
Do tuyn vng hot ng mnh v ch tit nhiu Estrogen v Progesteron
2. U nang thc th
Thng l cc u lnh tnh c mt hoc hai bn bung trng. Tuy nhin cng c th
tin trin thnh ung th.
2.1. Phn loi:
- Nang nc: Thnh nang mng c mt lp t bo lt n, trong nang c ti cha
dch trong thng c mt bn bung trng, cung di, di ng mnh, d xon
nhng cng c nang tin trin nhanh kch thc ln.
- Nang nhy: C th gp mt bn bung trng, v dy, c hai lp, ngoi l t chc
x, trong l lp thng b tr n, bn trong c vch cha dch c, c khi l cht
nhy mu vng c. Nang nhy c th dnh vo cc tng xung quanh, khi nang v
hoc nt dch trn vo bng, t chc nhy dnh vo phc mc c th ti pht
nhiu ln.
- Nang b: L khi nang thng gp c hai bn bung trng, thnh nang ging t
chc ca da gm mt lp thng b k p dt, vi lp sng, lp m
tuyn m hi v lng, dch nang c nh b u, c tc c rng, c th c xng
sn. Nang b c ngun gc t bo thai, di hnh thi l mt u qui (Teratoma)
2.2. Triu chng chn on
*Triu chng c nng:
Cc nang bung trng khi kch thc cn nh triu chng ngho nn, c nhng khi
u tin trin m thm, ngi bnh c cm gic hi tc hoc m ch vng h chu, t
gy nh h ng ri lon kinh nguyt nn thng b qua. Khi u pht trin nhanh bnh
nhn t s thy hoc cc triu au tng ln, i but, i dt, i kh, i tin kh.
Thng l giai on mun. Vi nhng u c cung di, xut hin cc triu chng
ngoi khoa: au bng d di, t ngt, c khi nh dao m buc bnh nhn phi i
bnh vin cp cu.
* Triu chng thc th:
U c kch thc ln d dng s c qua thnh bng, khi u li ln lm bng vng
cao, c ranh gii r, mt mm hoc cng, s c th di ng, c khi khng di ng.
Thm m o hoc thm trc trng s c khi u cnh t cung, ranh gii r
khoc khng r, mt u mm hoc cng, c khi u ln t cung v kh xc nh.
* Cn lm sng:
- Siu m: m vang tha hoc long. Nu c khi u ng knh < 5cm th cn theo
di u c nng.
C th dng thc o bung t cung chn on u nang bung trng.
- Chp XQ:
+ Chp bng khng chun b c hnh cn quang m m l u b bung trng
+ Chp XQ t cung vi trng c bm thuc cn quang c th thy hnh nh u gin
tip.
- Soi bng c th thy c cc khi u khi cn nh.
- Nu u qu to, siu m khng th pht hin c ranh gii ca u th phi dng CT
Scanner.
2.3. Tin trin v bin chng:
U nang bung trng thc th thng tin trin chm, m thm qua nhiu
nm. Khi triu chng r rt tc l u to v chn p vo cc tng xung quanh hoc
c bin bng.
Bin chng xon cung nang gp nhng trng hp u nh cung di, di
ng v c th a n chy mu trong nang, nt u hoc hoi t cung u, cn c
chn on khn trng iu tr kp thi, phu thut cp cu ct u. Tuyt i khng
c dng thuc gim au v khng c tho xon trc khi ct cung u
phng sc phn v do t chc hoi t trong u trn vo mu.
Bin chng nt v nang c th do u qu to, gp cc chn thng va p lm nt
v nang dch nang thot vo bng.
Do thai to chn p lm v phi m cp cu ct u nu thai cha thng.
U to chn p gy sy thai, non, ngi bt thng, nhim khun. Khi gp va c
u va c thai nn cn nhc ch nh.
Tt c cc u nang thc th u c th tin trin thnh ung th, nang nc gp
nhiu hn.
2.4. iu tr:
Khi chn on u nang thc th nn m ct u sm.
Nang nc gp ngi ln tui nn ct c hai bung trng
Nang nhy cn ct b c hai bn bung trng trnh ti pht.
Nang b ct b khi u c gng bo tn nhu m lnh.
Nu nang bung trng hai bn ngi tr tui cn bo tn bn lnh.
Nang ngi c thai nu c ch nh gi thai nn ct b nang vo thng th t.
U nang c du hiu nt v cn sinh thit tc th phng ung th.
U nang to ngi gi ch { trnh lm gim p lc t ngt bng.
Nu cc u nang pht trin trong y dy chng rng, bc tch cn thn phng
phm niu qun, rut, bng quang.
30. UNG TH C T CUNG
I.i cng:
L bnh hay gp chim t l cao trong tng s cc loi ung th (chim 11% trong
ton b cc loi ung th ca c 2 gii, chim 22,35% trong ung th sinh dc n)
Tui thng gp trong khong 30-59, nh cao 45-55, tuy nhin vn c th gp
tui 20, 90-95% trng hp l ung th thng b gai (spinous cell carcinoma), 5-10%
cn li l ung th thng b tuyn (adeno carcinoma)
Cc yu t thun li:
- Giao hp sm trc 17 tui
- Giao hp vi nhiu ngi
- Sinh nhiu ln
- Nhim khun sinh dc, c bit l vius herpes type II (HVII) v Papiloma vius 16-18,
31-33 (HPV 16-18, 31-33 gy condyloma c t cung) bnh ny ly qua ng tnh
dc la tui 18-30, c bit l trong lc c thai, hu ht condyloma t khi sau 6th -
1nm hoc sau iu tr, 10% bin thnh nghch sn)
Kh i u ca ung th c t cung khng c triu chng lm sng nhng c t cung
c th d dng s c, nhn c nn c th pht hin c ung th c t cung
Pht hin sm ung th c t cung c { ngha quan trng v giai on ung th trong
biu m c th iu tr khi 100% vi phng php: Laser, kho t chp, ct t cung
Giai on I-IIa: khi 80-85% trong 5 nm vi cc phng php diu tr nng n tn
ph nh bin php Curi, ct m o m rng, v t hch, b xung bng liu php
Cobalt
Giai on IIb: Khi ch cn 55% trong 5 nm
Giai on III: Khi ch cn 25% trong 5 nm
II. Gii phu bnh l:
1. i th:
- Hnh thi si: Cc n si d rng, d chy mu, d nhim khun, hnh thi ny thm
nhim t, lan trn chm
- Hnh thi lo t: C b lm su xung, b rn, nn c nhiu n nh, nhiu m, ung
th tin trin a n hoi t c t cung gy thnh 1 h lm, hnh thi ny thm
nhim v lan trn su, phn ph v cc hch bch huyt di cn nhanh
- Hnh thi thm nhim: t gp hn, tn thng l mt vng thm nhim cng, ung
th n su vo lp m trong khi mt ngoi c t cung t ng nh bnh thng
nhng c t cung thay i th tch, loi ny lan trn v di cn nhanh
- Hnh thi ng c t cung: Tn thng ung th trong CTC giai on u chn
on kh v mt ngoi CTC khng thay i trong khi ung th kho t su vo lp
m
1.Vi th:
- Ung th biu m k p dp gai 90-95%
- Ung th biu m tuyn 5-10%, tin lng xu hn ung th t bo gai
2. S pht trin lan rng v di cn ca ung th c t cung:
- Lan theo b mt: lan n eo t cung, xung m o, lan ln mt trc m o,
sang bng quang, c th thng gy d bng quang m o, lan sang trc trng gy
d trc trng m o
- Lan n dy chng rng 2 bn, dy chng t cung cng, chn p niu qun.
- Di cn theo ng bch huyt: n cc hch nm dc cc mch chu
n cnh ng mch ch
- Lan rng theo ng mu: gy di cn cc tng trong bng, phi, mng phi
nh gi lan rng: Thm m o, thm trc trng v nn dy chng rng.Soi bng
quang nh gi tn thng bng quang, chp bch mch, UIV, soi trc
trng,Scanner...
Phn chia giai on
- Giai on 0: Ung th bn trong biu m
- Giai on I: T chc ung th khu tr c t cung
Ia: Tn thng ng knh <2cm, chn on da vo vi th
Ib: Tn thng ng knh >2cm, c th pht hin bng mt thng
- Giai on II: Ung th lan ti m o
IIa:Ung th cha lan qu 1/3 trn m o 1 hoc 2 bn dy chng rng phn st t
cung
IIb:Ung th lan ra 2/3 trn m o vo nn 2 dy chng rng
- Giai on IIII: Ung th lan ti 1/3 di m o
IIIa:1/3 di m o b xm nhim nhng vch chu cha b xm nhim
IIIb: Xm nhim ti vch chu
- Giai on IV: Ung th lan ti c quan vng chu v xa hn
IVa: Ung th lan ti cc c vng chu
IVb: Ung th lan xa hn
III. Chn on
C nng:
1. Ra mu khi c va chm: mu , s lng t khi c giao hp, lm v sinh. Ra mu
lp li nhiu hn
2. Kh h hi, thi do t chc ung th hoi t, nhim khun gy nn.
3. au: l triu chng mun khi co chn p r thn kinh
4.Triu chng tit niu: nhim khun ng niu, i rt, but, i kh khi ung th
c t cung xm ln ti bng quang
5.Thiu mu: do chy mu
Thc th:
Khm: c th thy cc dng si lo t d chy mu,c t cung to, cng
CLS:
- Phin t bo m o, c t cung.
- Sinh thit c hng dn b i soi c t cung: cho ph p nhn r ranh gii khu tr tn
thng sinh thit ng ch (gia biu m lt v tr, cc tn thng lt , chm
y...)
- Kho t chp CTC chn on:
IV.Thi x tr:
1. Giai on ung th trong biu m (invitro):
ph n tr cn mong mun c thai => kho t chp, hoc ct ct c t cung, sau
theo di bng phin m o v soi c t cung 6thng/ln.
2. Giai on 1:
Liu php Curie trc phu thut 6 n 8 tun, PT ct t cung hon ton + ct 2
phn ph, ct b phn trn m o (PT Wertheim-Meigs) trit hn c th ct b
t chc t bo cnh t cung, trn ng niu qun, v t hch h chu sau dng
liu php Cobalt sau PT
3. Giai on 2: Phc
Liu php Curie- liu php Cobalt - PT
Hoc liu php Curie- PT- liu php Cobalt
4. Giai on III;IV :
Ch dng cc liu php chiu x Cobalt n thun hoc kt hp Curie PT ch dn lu
tm thi.
V. Tin lng
Sng trn 5 nm 100% vi K trong biu m.
80% vi I, IIa
50% vi IIb
35% vi III
5 n 10% vi g IV
31. UNG TH NGUYN BO NUI

I. i cng:
UTNBN l mt khi u c tnh pht trin t t bo nui ca cc t chc rau thai, ri
xm ln vo c th ngi m.
Bnh xut hin tui sinh , t ngi mi c thai ln u n ngi sp mn kinh.
Gp nhng ngi cha trng, thng, sy thai thng; VN: Sau cha trng
93%, sau sy thai, , thai cht lu l 7% t l UTNBN VN l 1/500 c thai. Chu
u, chu M Bnh UTNBN gp cha trng l 50%, sy thai l 25%, sau l 25%, t
l 1/5000 c thai.
Khi u c c im ch tit HCG v n c coi l 1 ch tiu theo di
tin trin ca bnh
Thi gian xut hin: c th rt sm ngay khi ang cha trng, thng l 3 thng u
sau no trng. Mt s khc sau 6 thng n mt nm. Bnh xut hin sm th c
tnh cng cao.
II. Gii phu bnh l
1. i th:
T cung to mm, UTNBN thng to 1 vi cm, si ln, khng u, mu tm sm. Khu
tr nim mc t cung, vng rau bm, c khi n su vo c t cung v pht trin li
vo vng t cung ph thng t cung, trong lng u c nhiu cc mu, i khi thy ti
trng.
Bung trng: Nang hong tuyn mt hay hai bn bung trng, ng knh
4-5cm n 9 - 10cm, v mng cha dch vng chanh, c Lutein.
2. Vi th:
UTNBN khng cn cu trc lng rau, t bo nui lon sn, lp hi bo b ph v, t
bo Langhans v hi bo nui c tnh lan trn vo lp c t cung gy hoi t xut
huyt rng, ph hu t chc, cc t bo ny lan trn ti ch v di cn xa.
Cha trng xm ln: Cn thy cu trc lng rau, lp hi bo b ph v tng mng,
t bo nui qu sn, thm nhp vo t chc t cung, t chc lin kt b lon dng,
t bo nui thng xm ln lan trn ti ch gy chy mu.
III. Triu chng:
1. C nng
Ra huyt l triu chng ch yu v trung thnh nht, mu ti hoc en, ra t
nhin, t mt, k o di lm bnh nhn thiu mu.
Ton thn thiu mu. Nu c di cn th c triu chng vng c quan
Di cn m o: Khi u v, c th chy mu.
Di cn phi: Kh th tc ngc, ho ra mu
Di cn no: Nn, nhc u, m mt, lit, hn m.
2. Thc th:
m o mm, c th thy nhn di cn l mt nt nh mt vi mm n vi cm
C t cung mm, to hn bnh thng, di ng.
C nang hong tuyn mt hoc hai phn ph, di ng.
3. Xt nghim:
HCG (+) k o di > 4 tun
Chp bung t cung nu nhn UTNBN pht trin v pha BTC th thy hnh khuyt v
BTC nham nh .
No BTC thy t bo ung th.
Chp phi: C th thy hnh di cn phi.
Chp chn lc /m chu: Hnh nh ri lon tun hon t cung v h chu.
Siu m, chp ct lp pht hin di cn phi, no...
IV. Chn on
1. Chn on xc nh:
Tin s cha trng v t nht mt ln v sy.
Ra mu m o
T cung to mm, nhn di cn trong m o.
XN: Cc XN trn
2. Chn on phn bit:
- St rau: Phn bit bng no sinh thit.
C thai sau no ( khng ra mu, HCG ht li pht trin): Phn bit bng siu m.
V. Tin trin v bin chng:
Nu khng chn on sm v iu tr kp thi, bnh tin trin nhanh v bnh nhn
s cht v cc bin chng: V nhn di cn, thng t cung, gy chy mu, nhim
khun t cung, xon nang tuyn, cc bin chng thng gp l:
Di cn: Theo ng tnh mch
Di cn phi 39%, kh th , ho ra mu, chp phi c di cn ri rc
Di cn m o gp khong 28%, nhn di cn mu tm, mm, khng au, chm vo
chy mu. Thng gp thnh trc m o, gn l niu o.
Di cn no gp khong 5%, gy chn p no, hoc chy mu no, bnh nhn lit, hn
m t vong nhanh.
Cn li l xng, lch, gan, thn ...
Chy mu: Nhn ung th pht trin trong bung t cung ri n thng t cung, gy
chy mu trong nng.
Nhim khun: C th nhim khun ti ch hoc ton thn, gy st, au, ung th
pht trin nhanh.
Nu UTNBN ch khu tr t cung, cha di cn th phu thut + ho niu php bnh
nhn c th khi hon ton.
VI. iu tr:
D phng: Qun l theo di st bnh nhn sau no trng.
HCG(+) sau no 4 tun th theo di UTNBN
Vi ph n con nn ct t cung hon ton. Cha con, iu tr bng
Methotrexat 0,3- 0,4mg/ kg/ ngy trong 5 ngy, ngh 7 ngy, dng nhiu t cho ti
khi HCG c c, nc tiu (-) hoc kt hp nhiu ho cht khc.
1.Cc phng php iu tr chnh:
- Phu thut: Ct t cung hon ton + 2 phn ph nhm loi b tn gc UTNBN
Ho cht: MTX liu nh trn .
+Actinomycin D, ng 0,5mg, liu 0,5mg/ngy, mi t dng 05 ngy, ngh 02 tun
dng tip mt t sau. Tng liu tuz mc pht trin ca bnh v kh nng chu
thuc ca bnh nhn , cho n HCG huyt thanh (-). Khi dng ho cht theo di
cng thc mu phng suy tu v cc bin chng khc. Ngoi ra cn c ho cht
khc Cyclophotphamid, Cisplatin...
Quang tuyn: tia x Cobalt khi di cn m o, hn ch pht trin ca t bo ung th.
2. iu tr c th
UTNBN t cung cha c di cn:
+ Bnh nhn cn tr, cn nhu cu : iu tr ho cht, khng c kt qu, m ct t
cung.
+ Bnh nhn ln tui, con, m ct t cung hon ton, trc v sau m dng ho
cht ngn nga di cn.
+UTNBN di cn m o: m ct t cung hon ton + 2 phn ph + ly nhn di cn
m o + ho liu php trc v sau cha UTNBN di cn phi: Ct t cung hon
ton + 2 phn ph + ct phn thuz phi + ho liu php.
UTNBN di cn lan trn: Ho cht + quang tuyn.
32. UNG TH NIM MC T CUNG
I. I CNG:
- Ung th nim mc t cung l khi u c tnh t nim mc t cung. Ung th nim
mc t cung him hn ung th c t cung ( t l 1/9).
- Thng gp ph n mn kinh ( c khong 15% gp ph n cha mn kinh)
- Khng lan nhanh sang 2 bn dy chng rng, v vy tin lng tt hn ung th c
t cung.
II. YU T THUN LI:
- Ni bt l tui v cng Estrogen.
- Tui l yu t quan trng nht, v 90% ung th ni mc t cung xut hin sau tui
50.
- Cng Estrogen: Vi giai on di cng Estrgen tng i lm tng nguy c mc
bnh.
- Rng trng khng u, dy th sm, mn kinh mun, v sinh tng nguy c nh.
- B o bu lm tng cng chuyn ho Androstenedio t chc m di da gy
cng Estrogen l yu t nguy c quan trng.
- Vin thuc trnh Estrogen trc v Progestin sau, dng Estrogen thay th sau mn
kinh u lm tng nguy c ung th nim mc t cung.
- Tin s gia nh c ngi b ung th nim mc t cung cng l mt yu t nguy c.
III. GII PHU BNH:
1. i th:
- Thng khi u l mt Polip sn si, c nhng n nh d chy mu.
- Hnh thi lo t t gp hn.
2. Vi th:
i b phn l ung th biu m tuyn, mt s t trng hp l ung th biu m k p
dt gai loi khng bit ho.
III. S LAN TRN:
- Theo b mt bung t cung hay su xung lp c t cung hoc bung c t cung.
- Trong tiu khung ung thuwlan theo vi trng, bng quang, i trng, phc mc tiu
khung.
- Ung th cn lan theo ng bch huyt n cc hch h chu v dc M ch.
IV. CHN ON:
1. C nng:
- Rong huyt sau mn kinh, s lng t, mu en. Ra mu bt thng, xut hin
trong vi ngy ri t cm. C th nhiu kh h, mu hng, ln m hoc mu, mi hi.
- au bng: Do t cung co bp y dch hoc mu trong t cung, au theo cn. Khi
ung th lan trn vo t chc dy chng v cc b phn khc h chu au bng
nhiu.
2. Thc th:
Thy mu trong bung t cung chy ra. Giai on u t cung bnh thng. Khi
bnh tin trin t cung to, mm, khng au, di ng. Phn ph, c t cung bnh
thng.
3. Cn lm sng:
- Siu m: Nim mc t cung hnh rng ca.
- No bung t cung kim tra gii phu bnh l{.
- Chp bung t cung : Ch thc hin khi khng ra mu v khng c nhim trng, tm
hnh khuyt, bung t cung nham nh , to ra, bin dng.
- Soi bung t cung tm vng nim mc tn thng lm sinh thit.
- Qut t bo cng sau, kt qu ch (+) 60% trng hp.
V. PHN GIAI ON :
( Theo FIGO: Federation International de Genecologie et Obstetrique) 1988
Giai on I : Khu tr t cung.
Ia : Tn thng nim mc t cung
Ib. Tn thng lan trn vo c, di 50%
Ic: Tn thng lan trn vo c, trn 50%
Giai on II: Lan xung c t cung.
IIa: Lan trn vo nim mc v tuyn c t cung.
IIb: Lan trn vo lp m c t cung.
Giai on III: Lan vo tiu khung
IIIa: Lan ti lp phc mc, vi trng.
IIIb: Lan vo m o.
IIIc: Lan vo tiu khung v cc hch cnh ng mch ch.
IV:Giai on IV: Lan ra ngoi t cung
IVa: Lan vo bng quang hay rut.
IVb: Di cn xa, k c hch trong bng v hch bn
V. TIN TRIN:
Thng tin trin chm. Do chy mu r r k o di, bnh nhn c th thiu mu.
VI. IU TR:
1. Phu thut:
L phng php iu tr ch yu. Ct t cung hon ton v 2 phn ph qua ng
bng. Mt s tc gi ch trng ct t cung rng v v t ht hch.
2. Tia x:
Thng tia x ti ch mm ct ( sau m) d phng ti pht khi ung th l lan vo
c.
Tia x tiu khung bng Cobalt 60 khi lan ti hch tiu khung.
Tia x c th hn ch ti pht ti ch vng tiu khung, nhng khng k o di c
cuc sng cho ngi bnh.
3. Ho liu php:
Khng dng cho bnh nhn> 70 tui. Ch dng cho bnh nhn t tui hn,c ti pht
c di cn. Thuc thng dng l FAC + Melphalan hay 5. FU + Cisplatin.
T l p ng tt khong 30%.
VII. CH NH IU TR THEO GIAI ON:
- Giai on 0:
Ct t cung hon ton v phn ph.
- Giai on I:
Tia x trn t cung m o, ct t cung hon ton ( c ly hch hoc khng tuz th
trng bnh nhn), tia x tiu khung c di cn hch, ni tit liu php ( medroxy
progesteron + taxmoxifen) nu thuc loi bit ho.
- Nu bnh nhn khng th m c, tia x liu iu tr phi hp thm liu php.
- Nu c nhim trng th m trc tia x sau.
- giai on II:
- Phu thut rng, iu tr nh ung th c t cung ( Tia x, phu thut Werthiem +
ly hch, tia x hu phu)
- Giai on III:
Ct b t cung gim khi lng ung th, sau tia x. Nu khng m c tia x ti
ch ( Radium) v tia x cobalt) kt hp vi ni tit liu php.
- Giai on IV:
Thng dng ni tit v iu tr triu chng, phu thut t c cp.
VIII. IU TR D PHNG, THEO DI:
- Dng Progestin nu c qu sn nim mc t cung, ri lon rng trng 70% ti pht
trong 2 nm u, 70% ti pht trong m o v tiu khung, 80% ti pht tiu khung
c di cn phi, xng, bng gan.
- Theo di sau m 3 thng mt ln trong 3 nm u, 6 thng mt ln trong 2 nm
sau, cn li mt nm 1 ln.
- Theo di th trng chung, cn nng, khm ton thn, m o tiu khung.
- Chp phi 1 nm 1 ln trong 5 nm u, siu m 3 thng sau m, siu m tiu
khung hng nm, chp v 2 nm 1 ln. nh lng CA 125 hng nm.
- iu tr tt ng cch t l sng 5 nm l: GI: 90%, GII: 75%, G III: 31%, GIV:
9,1%.
TI LIU TRA CU
1. Bi Ging Ung Th i Hc Y Dc Hu
2. Ngoi Khoa Thc Hnh h Y Phm Ngc Thch
3. B Y T, Bnh Vin K, 1999. Hng Dn Chn on V iu Tr, Nxb Y Hc
4. i Hc Y H Ni, 1999. Bi Ging Ung Th Hc, Nh Xut Bn Y Hc
5. Uicc, 1995.Ung Th Hc Lm Sng
6. Nguyn B c, Nguyn Chn Hng, 2002. Cng Tc Phng Chng Ung Th Vit
Nam V Vai Tr Ca Ghi Nhn Ung Th Trong Cng Tc Phng Chng Ung Th. Ti
Liu Tp Hun Ghi Nhn Ung Th
7. Phm Thy Lin, 1999 Tnh Hnh Ung Th Vit Nam, Nh Xut Bn Nng.
8. Nguyn B c. 2003. Ha Cht iu Tr Bnh Ung Th. Nh Xut Bn Y Hc
9. Nguyn Chn Hng. 2004. Ung Bu Hc Ni Khoa. Nh Xut Bn Y Hc
10. i Hc Y H Ni, 2008. B Mn Ngoi, Triu Chng Hc Ngoi Khoa
11. L nh Roanh, 2001. Bnh Hc Cc Khi U, Nh Xut Bn Y Hc
12. website : ngoaikhoathuchanh.info, benhhoc.com, medicinenet.com,

emedicine.com, cimsi.org.vn, webmd.com,...
II. TI LIU TING ANH

1. Jim Cassidy,2005. Oxford Handbook Of Oncology 2005
2. Vincent T. Devita, 2001. Principles & Practice Of Oncology
3. Richard R. Love.1995. Cm Nang Ung Bu Hc Lm Sng (Ti Liu Dch T

Manual Of Clinical Oncology). Nh Xut Bn Y Hc Tp Hcm.
4. David S. Fischer, M Tish Knobf, Henry J. Durivage, Nancy J. Beaulieu. 2003. The
Cancer Chemotherapy Handbook - Mosby Press.
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