Y HC HT NHN IU

TR

MC TIU:

Nm vng cc nguyn tc chung ca x tr v c s

khoa hc ca n.
Hiu r nguyn l, ch nh, chng ch nh v k thut
tin hnh iu tr (T) cc bnh tuyn gip (TG) bng 131I,
nht l i vi bnh cng gip v ung th (UT) gip th
bit ho, bnh a hng cu
Bit ch nh T bng cc dc cht phng x ngun h
i vi mt s bnh xng khp, T gim au do di cn
(DC) UT vo xng v mt s bnh UT khc.
1. i cng.
Hin nay cc VPX nhn to gi vai tr chnh trong T
UT v mt s bnh khc. C s ca vic dng VPX trong
T l hiu ng sinh vt hc ca cc bc x ion ho trn c
th sng.

1.1. Lch s pht trin v cc loi hnh T bng bc x ion

ho
T u th k XX, sau khi ng b Pierre v Marie Curie
tm ra Radium, cht phng x thin nhin ny sm c
p dng vo T UT. Tip theo , nhiu VPX thin nhin
hoc nhn to di dng ngun chiu ngoi nh: ngun
60
Co, 137Cs, hoc p ln da (applicator) nh tm p 32P T
cc u mu nng v kim t vo cc hc t nhin ca c
th nh: kim Ra t vo hc mi, ming, m o Gn y
cn c phng php a ngun phng x ti st v tr cn
chiu qua mt h thng ng dn. Phng php c gi
l T p st np ngun sau (after loading brachytherapy).
Vo khong nhng nm 40 ca th k XX, nhiu VPX
nhn to ra i, phm vi ng dng phng x trong T mi
c m rng. l k thut YHHN T thc hin bng
phng php chiu trong, a hn VPX vo trong c th
ngi bnh bng ng ung hoc ng tim.

1.2. Nhim v ca iu tr bng y hc ht nhn

C 3 phng thc T bng bc x in ho (Radio therapy):
- T chiu ngoi (Teletherapy): s dng cc my chiu
tia X, tia Gamma cng v c cc my gia tc hu dit cc
t chc bnh.
- T p st (Brachytherapy): Dng li dao Gamma
(Gamma Knife) cha cc bnh mch mu trong s, ng
dng T cc t chc ngoi da nh cc u mu nng
dng tm p 32P (applicator). Phng php a ngun ti
st v tr cn chiu qua mt h thng ng dn cn gi l
phng php T p st np ngun sau (after loading
therapy) T UT trc trng, UT c t cung Dng kim
Radi t vo cc hc t nhin ca c th.
- T chiu trong hay cn gi l T bng ngun h:
nguyn l ca phng php c da trn nh
Henvesy (1934): C th sng khng c kh nng phn bit
cc ng v ca cng mt nguyn t. Thuc phng x tp
trung ti t chc bnh s pht huy tc dng T.

So vi chn on, vic s dng VPX trong T cn c

nhiu hn ch. T l dng nng lng cc tia lm thay
i chc nng hay hu dit mt t chc bnh l nht nh.
Liu T phi ln gp hng ngn, hng vn ln so vi liu
chn on. Bc x ion ho tc ng ln t chc ch
(target tissue) nhng ng thi cng tc ng ln t chc
lnh. chnh l mt trong nhng kh khn trong T bng
bc x. Trong T bc x cng c th gy mt tn hi nht
nh cho BN. Song cn d on trc v hn ch ti a tc
hi . Ci hi l nh so vi ci li ln m bt c mt
phng thc T no khc cng c th nh vy: VD: nh
phu thut, ho cht
2 . Nhng yu t nh hng trong T bng YHHN.
2.1. Bn cht ca bc x
Bc x Alpha (): c tc dng ph hu mnh, t c
dng trong lm sng. Cc loi VPX nhn to thng dng
u khng pht tia Alpha.

Bc x Bta (): Bn cht l cc in t (electron) v

thng do VPX nhn to pht ra. Chng d b hp th bi
lp vt cht i qua nn c qung chy ngn. Trong cc m
sinh hc ch i c vi milimet. Loi bc x ny cho hiu
ng sinh hc ng k v c ion ho ln. Tnh chn lc
v v tr trong iu tr cao. C th ni, iu tr bng phng
php chiu trong chnh l iu tr bng tia Bta. i vi
VPX va pht Bta, Gamma th trn 95% hiu qu iu tr
l do tia Bta.
Bc x Gamma (): Bn cht ging tia X, c kh nng
m xuyn ln nn c ch li nhiu trong iu tr bng
phng php chiu ngoi. Khi a VPX vo trong c th,
vai tr iu tr ca tia Gamma khng ln v ion ho trong
m thp, tnh c hiu v v tr tc dng iu tr t.

2.2. Nng lng ca bc x.

i vi mt s t chc nht nh, hiu ng sinh vt
hc ca bc x t l vi nng lng bc x c hp th
ti t chc . Ni cch khc, hiu qu iu tr t l vi
liu bc x. n v tnh liu hp th l Gray (Gy) hoc
rad (radiation absorbed dose). 1Gy = 100rad. 1Gy l liu
bc x gy mc hp th nng lng 1Jul trong 1kg vt
cht m n truyn qua.
2.3. S chuyn ho ca ng v phng x trong c th
Cc cht di dng dung dch ho tan, sau khi tim
vo mu c phn b ng u trong c th, tr mt s
cht c tp trung chn lc ti c quan c hiu (th d
Na131I dng dung dch, 131I c bt gi tuyn gip).
2.4. Thi gian bn r hiu dng
VPX c a vo c th mt mt chu qu trnh
phn r vt l (Tp), mt mt b chuyn ho.

Thi gian bn r hiu dng (Tef) l khong thi gian qua

hot tnh ca mt VPX gim i mt na va do bn thi
sinh hc (Tb), va do bn r vt l (Tp). Tef cng ngn th
hiu qu iu tr cng t v liu hp th gim.
2.5. c im ca t bo m v c th bnh nhn
nhy cm phng x tu thuc vo loi t bo, vo giai
on sinh trng v mc bit ho v hon chnh cu
trc ca n.
3. An ton phng x trong iu tr bng y hc ht nhn
3.1. An ton cho bnh nhn
3.2. An ton cho nhn vin
3.3. An ton cho mi trng
4.3. iu tr chiu trong (L ni dung chnh ca YHHN T)

A. iu tr mt s bnh TG bng thuc phng x 131I

a) Bnh l ca TG rt a dng v phc tp c th chia thnh
cc nhm sau:
- Vim TG (do t min, do vi khun, do k sinh trng )
- Suy TG.
- Bu TG n thun (bu c n thun).
- Bu TG c, lan to (bnh Basedow).
- Bu nhn TG cc loi.
- Ung th TG.
Trong thc t lm sng T mt bnh ca TG c th c
nhiu phng php khc nhau. Tu theo bnh, tnh trng
BN, iu kin c th v kinh nghim ca thy thuc m la
chn phng thc T thch hp.
b) It phng x 131I c th s dng T mt s bnh TG
sau y:
- Bu gip c lan to
- Bu nhn c tuyn gip
- Ung th tuyn gip bit ho.

c) It phng x 131I:
L VPX ca It thng (khng phng x) 127I. 131I c
sn xut t l phn ng ht nhn (Reactor) . 131I c thi gian
bn r vt l T1/2=8,04ngy, VPX pht tia vi mc nng
lng ch yu (80%) l 360KeV v tia vi mc nng lng
ch yu (87%) l 0,61MeV. Tia ca 131I c qung chy trong
t chc ln thng dng ghi o chn on, tia c
qung chy trong m mm (t chc TG) mt vi mm chnh l
phn em li hiu qu T. Dng DCPX s dng l Sodium
Iodide dung dch ung, tim tnh mch hoc ng thnh
capsule c HPX theo yu cu.
A.1. iu tr bnh bu gip c lan to (bnh Basedow)
bng 131I
Bnh bu gip c lan to l tnh trng bnh l biu
hin bng s tng sinh, ph i lan to t chc tuyn, cng
chc nng, ch tit nhiu hormon qu mc bnh thng gy
ra tnh trng nhim c hormon TG.

a) Mc ch iu tr bnh Basedow bng 131I

Lm cho bu TG nh li, a chc nng TG t cng
nng v bnh thng (bnh gip).
b) C ch tc dng ca 131I
Di tc dng ion ho ca tia t bo bu tuyn b hu
hoi hoc tn thng gim sinh, cht dn, cc mch mu
nh trong tuyn b x ho, dn n gim ti mu cho nhu
m tuyn hu qu: bu tuyn nh li, gim chc nng.
c) Ch nh v chng ch nh
* Ch nh:
- BN c chn on xc nh l Basedow c th qua T
ni khoa bng thuc khng gip trng tng hp khng
khi, ti pht hoc khng th T tip do d ng thuc, vim
gan, gim sinh tu
- BN c chn on xc nh l Basedow m khng T PT
c hoc ti pht sau PT.
- BN c chn on xc nh l Basedow cha T g, chn
T 131I ngay t u.

- BN c tp trung 131I ti TG cao: TT 131I sau 24 gi:

T24>50%: T tt; T24 t 30 n 50%: C th T c;
T24<30%: Phi cho liu cao, hiu qu km nn cha T.
- Bu TG khng qu to, nu bu qu to gy nut nghn,
sc, kh th th nn ch nh T PT gii phng trc.
- Tui BN: Trc y do cha hiu bit y , ngi tc hi
ca bc x nn ch T cho cc BN ngoi tui sinh , nay
ch nh rng ri hn T cho c cc BN tui thanh, thiu
nin nu khng th p dng bin php T no khc.
* Chng ch nh:
- Ph n c thai: V 131I qua rau thai s tp trung vo TG
thai nhi gy tn thng.
- Ph n ang cho con b: V 131I cng c bi tit qua
sa, tr b sa s b hu qu xu. Nu trng hp bnh
nng cn phi T bng 131I th buc phi cai sa cho con
trc khi T.

- BN c tnh trng nhim c nng, c nguy c xy ra cn

bo gip (thyroid storm), phi T chun b ni khoa trc,
khi tnh trng BN n nh mi T bng 131I.
- Nu BN ang dng thuc khng gip trng tng hp th
phi ngng thuc trc 12 tun. Nu bnh nhn - ang
dng cc thuc, ch phm c It th phi ngng ti thiu 1
thng TT It TG tng cao, T mi hiu qu.
d) Cc bc tin hnh
* Chun b bnh nhn:
- BN c gii thch v tnh hnh bnh tt v cc mt li hi
ca vic dng thuc phng x 131I T bnh. BN lm giy
cam kt t nguyn T bnh bng thuc phng x.
- BN c hng dn thc hin cc quy nh v v sinh, an
ton phng x khi T bng 131I.
- T nng cao th trng, v cc triu chng: tim mch, ri
lon tiu ho, thn kinh trc khi ung thuc phng x.

* Tnh liu iu tr:

Liu 131I T thay i tu thuc: trng lng bu (xc
nh bng siu m, x hnh, CT hoc s nn bng tay);
mc cng nng (da vo nng hormon, triu
chng lm sng); tp trung 131I TG; nhy cm phng
x ca t bo TG mi bnh nhn. C cc cch tnh liu
hin c p dng nh sau:
- Phng php cho liu c nh:
Ngi thy thuc YHHN cn nhc cc yu t nu trn ri
cho bnh nhn liu 131I theo kinh nghim. Liu trung bnh
cho mt bnh nhn cng gip mc va, bu II l
khong 6mCi. Nu bu to, tp trung thp th tng liu;
nu bu nh, cng nng nng tp trung cao th gim
liu, h s iu chnh l thm hoc bt 13mCi.

- Phng php ch nh liu theo liu hp th bc x ti TG:

Qua cc nghin cu thy rng, t c hiu qu T
bnh Basedow th liu cho phi t c mc hp th ti
TG khong t 6.00010.000rad vi liu hp th thp
4.0005.000rad th t l nhc gip thp, vi liu hp th
cao 7.50011.000rad th t l nhc gip cao hn song hiu
qu iu tr nhanh hn. Quimby-Marinelli xut cng thc
tnh liu nh sau:
L.m
D=
x 100
90.T24
Trong : D l liu 131I ch nh tnh bng Ci; L l liu hp
th cn thit ti bu gip tnh bng rad; m l trng lng
bu gip tnh bng gam; 90 l hng s da trn hp th
phng x ca tuyn gip vi thi gian bn r hiu ng l 6
ngy; T24 l tp trung 131I ti tuyn gip sau 24 gi (%).

- Phng php ch nh liu theo HPX cho 1 gam TG:

Phng php ny da trn cc ch s trng lng bu,
tp trung 131I ti tuyn sau 2gi, liu ch nh cho 1 gam
tuyn. Cng thc tnh liu T c Rubenfeld xut:

C.m
D=

x 100

T24
Trong : D l liu T tnh bng Ci; C liu 131I cho 1gam
TG thng t 80160Ci; m l trng lng bu gip tnh
bng gam; T24 l tp trung 131I TG sau 24 gi (%).
e) Hiu qu iu tr bnh Basedow bng 131I
Trn lm sng hiu qu T thng bt u th hin t 2
n 4 tun sau khi BN nhn liu T. Hiu qu t ti a sau
8 n 10 tun, bi vy nn nh gi kt qu T sau 3 thng.

Hiu qu T c nh gi da trn cc ch tiu v triu

chng c nng, thc th, tnh trng bu TG v cc xt
nghim siu m, x hnh nh gi kch thc, cu trc,
trng lng TG v cc xt nghim nh lng hormon T3,
T4 v TSH nh gi tnh trng chc nng TG sau T. Ty
theo mc p ng T, 3 kh nng sau y c th xy ra:
- Kt qu tt: bu TG nh li, chc nng tuyn gip tr v
bnh thng, khng phi x tr g thm. Hn khm theo di
nh k tip 6 thng 1nm/ln.
- Bnh nhn b nhc gip: Cn b sung hormon tuyn gip
thay th.
- Bnh nhn vn cn tnh trng cng gip: Nu bu cn
to, mc cng nng va hoc nng: cho liu b sung
ln 2. Trng hp bu nh nhiu, mc cng nng
cn nhng nh cn phi cn nhc theo di thm. Nu cn
thit cho liu 131I ln 2 sau 6 thng.

f) Cc bin chng iu tr bnh Basedow bng 131I

* Bin chng sm:
- Vim tuyn gip do bc x: Tuyn gip v t chc xung
quanh sng n, nng, , au - thng nh c th t khi,
nu nng c th cho cc thuc chng vim, gim au,
corticoid, an thn, chm lnh vng bu gip b sng.
- Cn bo gip kch pht: Nguyn nhn l do tc dng ca
tia bc x ph hu cc t bo, nang tuyn gii phng o t
vo mu mt lng ln hormon TG. Thng xy ra sau khi
nhn liu T 4872gi, nhng BN bu mch, vn tnh
trng cng nng gip nng. BN thy bun nn, kch thch,
nhc u, kh ng, st, tim nhanh, nhp tim c th ln n
140160ln/pht. Nu khng x tr kp thi BN c th b
shock, hn m v t vong. y l mt cp cu ni khoa, cn
phi x tr tnh cc theo phc cp cu ngay khi pht hin
BN c nhng du hiu u tin.

* Bin chng mun:

- Nhc gip l bin chng hay gp, t l thay i tu liu 131I
s dng, mc nhy cm phng x ca BN v thng
tng dn theo thi gian. Liu cng cao, t l nhc gip
cng nhiu. Thi gian theo di cng di t l nhc gip
cng tng, tuy nhin bin chng ny c th gii quyt mt
cch n gin bng cch cho BN dng ch phm hormon
Thyroxine (Levothyrox) 2-4 microgam/kg/ngy l thay
th.
- Cc ri lon di truyn, sinh UT do bc x: cho n hin
nay sau hn 50 nm s dng 131I T cho hng ngn BN theo
tng kt ca WHO v tng kt qua 20 nm T ti bnh vin
Bch Mai cha c trng hp no c ghi nhn.
T Basedow bng 131I l phng php T an ton, kinh t,
d thc hin v hiu qu, cn ph bin v p dng rng ri
ng nh tng kt v khuyn co ca U ban nng lng
nguyn t quc t IAEA v ca T chc y t th gii WHO.

A.2. iu tr bu nhn c tuyn gip bng 131I

Bu nhn TG l biu hin lm sng chung ca nhiu
bnh l TG c th l: vim TG khu tr (focal thyroiditis),
bu nhn TG n thun (simple nodular goiter), bu
nhn TG nhim c (toxic nodular goiter), nhn UT TG
(malignant thyroid nodule).
Bu c th l n nhn (single nodular goiter) cng c
th l nhiu nhn (multi nodular goiter). Nhn c khi l th
c (solid) cng c th l nhn lng dng nang (cyst).
iu tr bu nhn tuyn gip nhim c bng 131I
a) Mc ch iu tr
Mc ch iu tr bu nhn tuyn gip nhim c
bng 131I l nhm a chc nng tuyn gip tr v bnh
thng, nhn cng nng mt i hoc nh li.

b) C ch tc dng
BN dng mt liu 131I bng ng ung hoc tim tnh
mch, 131I vo mu s c tp trung tng i c hiu
vo nhn cng nng ca TG v tia do 131I pht ra vi
qung chy trong t chc 12 mm s pht huy tc dng ti
ch m t nh hng n nhu m tuyn lnh xung quanh.
Cc t bo u nng ca nhn s b ph hu, b tn thng
cu trc do tia bc x dn n gim sinh v cht dn, cc vi
mch nui nhn s b x ho gim ti mu. Kt qu l
nhn s bin mt hoc nh li, chc nng chung ca tuyn
gip s v bnh thng.
c) Ch nh v chng ch nh
* Ch nh:
- Bnh nhn c chn on xc nh l bu nhn TG
nhim c (bu nhn c tuyn gip), loi tr UT.
- Nu c lm nghim php kch thch TSH chn on th
ch tin hnh iu tr sau mt tun 131I khng tp trung
vo t chc gip bnh thng, trnh gy nhc gip.

- Nu phn TG ngoi nhn trn x hnh khng hon ton

b c ch bi nhn cng nng, vn ln hnh trn
Scintigram th nn cho BN dng thm T3 liu 75
microgam/ngy trnh khng cho 131I tp trung vo vng ny,
phng nhc gip v sau.
* Chng ch nh:
- Ph n c thai.
- Ph n ang cho con b.
- Nu nhn kch thc ln, cng gip nng th phi
c chun b tt bng ni khoa trnh cc bin chng
nng khi iu tr bng 131I liu cao.
d) Cc bc tin hnh
* Chun b bnh nhn:
- Bnh nhn c gii thch v tnh hnh bnh tt v cc
mt li hi ca vic dng 131I T bnh.
- Bnh nhn lm giy cam oan ng t nguyn c
iu tr bnh bng thuc phng x 131I.

- BN c hng dn thc hin cc quy nh v v sinh

an ton bc x khi iu tr bng 131I.
- BN c T cc triu chng v tim mch, thn kinh,
tiu ho, nng cao th trng trc khi nhn liu 131I T.
* Ch nh liu 131I:
Liu s dng thng cao hn trong T bu gip nhu
m lan to nhim c t 2050%. Theo Doumith vi liu
hp th 15.00030.000rad s em li hiu qu tt, nhn u
nng mt i mt cch nhanh chng. Liu thng thng l
150250Ci/1g t chc bu. Tng liu trung bnh t 10
n 15mCi 131I mt ln cho mt BN.
e) Hiu qu iu tr bu nhn c tuyn gip bng 131I
Kt qu l tng l nhn bin mt, chc nng TG t u
nng tr v bnh thng, BN ht tnh trng nhim c gip.
Theo Z. Diensthier th nhn c t tr T bng 131I t kt
qu tt t 60100% cc trng hp vi liu trung bnh t
810mCi. F.S.Greenspan vi liu 20mCi kt qu tt trn 90%
s BN, ch 2% cn T tip ln 2.

nh gi kt qu T bng cc ch tiu lm sng: tnh

trng chung ca BN, bu - nhn TG, cc du hiu lm
sng khc. Cc ch tiu xt nghim T3, FT3, T4, FT4 v
TSH, x hnh tuyn gip vi 131I, siu m... Sau 36
thng nu BN cn tnh trng cng gip th cn T tip
ln 2.
f) Bin chng do iu tr nhn c tuyn gip bng 131I
- Bin chng sm c th gp l vim t chc TG do
bc x. Hay gp cc trng hp nhn ln, cng nng
nng, T liu cao. X tr bng cc thuc chng vim
gim au, corticoid.
- Bin chng mun: Nhc nng gip t gp hn so vi
iu tr Basedow bng 131I do thuc ch tp trung tc dng
ti nhn, t nh hng ti t chc gip lnh.

The end