Gii phu bnh hc ung th biu m gan nguyn pht Muc tiu 1 Hiu bit c mt s nguyn nhn v yu t mguy

c gy ung th gan. 2 Trnh by c cc hnh thi i th v vi th ung th gan. 3.Phn bit c ung th biu m gan v u nguyn bo gan Cc u c tnh nguyn pht ca gan c th pht sinh t thnh phn biu m hoc t thnh phn khng phi biu m, trong ung th biu m l loi hay gp nht v gi v tr quan trng nht trong bnh hc ung th gan. V phn loi, nm 1978 t chc y t th gii (WHO) a ra bng phn loi cc khi u gan v nm 2000 c sa chnh b sung. Bng phn loi ca t chc y t th
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gii c p dng rng ri nhiu nc trn th gii v Vit Nam. Theo phn loi ny, ung th biu m gan gm c: Ung th biu m t bo gan (Hepatocellular Carcinoma HCC). - Ung th biu m ng mt trong gan (Intrahepatic Cholangio Carcinoma ICC) - Th h hp t bo gan t bo ng mt (Combinet Hepatocellular and Cholangiocellular Carcinoma). - U nguyn bo gan (Heptoblastoma). 1. UNG TH BIU M T BO GAN 1.1. nh ngha: Ung th biu m t bo gan l u c tnh pht sinh t t bo gan, l loi hay gp nht chim khong 90% trong cc u biu m c tnh gan.
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Cc yu t nguyn nhn thng gp l virus vim gan B (HBV), rirus vim gan C (HCV), n thc phm mc c c t aflatoxin B1 v nghin ru mn tnh. 1.2. i th: Hnh nh i th ca u thay i tu theo kch thc, s lng u v c hay khng c x gan km theo. Nhn chung, hu ht ung th biu m t bo gan i km vi x gan c xu hng l mt u lan rng c bao x v vch si trong u. Trng hp khng km theo x gan thng l mt khi khng c v bao bc. Khi u nh gan thng khng to, trng lng khng tng. Khi u ln c th chim c thu gan hoc ton b gan, khi trng lng gan c th ti 2 n 3kg. S a
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dng v xm nhp, huyt khi u tnh mch ca v di cn trong gan thng gp ph bin cc u giai on mun s lm thay i hnh dng i th, mu sc v mt u. Trng hp nhiu nt u nh c phn b lan to, khp gan khi s c kh khn phn bit vi cc nt ti to x gan.V i th, ung th gan gm cc th sau: * Th nt (Nodular type) * Th khi ln (Massive type) * Th lan to (Diffuse type) Ngoi nhng th thng gp trn cn c mt th c bit l th x lt (fibrolamellar carcinoma).

Ngy nay nh tin b ng k trong k thut chn on hnh nh kt hp vi sinh thit kim nh pht hin c nhng ung th gan sm khi kch thc u 2cm ng knh. 1.2.1. Ung th th nt Th nt c th l mt nt c nht 5cm ng knh hoc gm 2, 3 nt vi kch thc khc nhau. V tr u c th gan phi hoc gan tri hoc c hai, nhng gan phi gp nhiu hn. Nt c th vi su trong nhu m gan hoc li trn b mt gan. Qua mt ct, u c ranh gii tng i r rt vi m gan lnh. Khi nt pht trin trn x gan thng c v x bao bc kh r. U c mu vng nht trn nn nu ca gan. Trng
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hp c mt nt n c vi trong nhu m gan c gi l th hnh nhn. Khi nt c bao bc bi v x dy r c gi l th c v bc (Encapsulated type). Th c v bc kch thc nh thng l 2 3cm, pht trin chm, tin lng tt. 1.2.2. Ung th th khi U c kch thc > 5cm, u ln c th chim mt phn hay ton b thu gan. c im u l xm ln tnh mch ca, di cn trong gan lm thay i hnh dng khi u. Qua mt ct thng c tn thng phi hp nh mt c mu vng hoc chy mu c mu loang l tp sc. Trng hp m u km c nui dng hoi t nhn nh b

u hoc lng nh m lm ta c th lm tng vi p xe gan. 1.2.3. Ung th th lan to: C nhiu nt u phn b lan to khp ton b gan phi, gan tri. Cc nt ny c th nh 1 2mm cho ti 1 2cm hoc ln hn. Cc nt nh rt kh phn bit vi x gan. Cc nt c ngn cch nhau bi gii x. Khi nhiu nt st nhp vi nhau s to thnh th gi khi, gan to. Qua mt ct nhn thy cc nt c bao quanh bi cc vnh x. Th gi khi cng c th b hoi t, chy mu, nhim mt nh trong ung th th khi. 1.3. M bnh hc

Ung th biu m t bo gan gm cc t bo ging t bo gan. M m bao gm cc khe mch dng xoang c lp bi lp t bo ni m. Cc t bo ni m ny khng ging vi t bo ni m trong gan bnh thng, chng dng tnh vi CD34 v cc khng nguyn lin quan ti yu t VIII. Quan st trn siu cu trc cho thy mt cu trc dng mng y gia cc t bo ni m v t o u. Cu trc ny (+) vi lamidin v collagen typ IV. Do vy cc khong mch dng xoang ging nh cc mao mch v c gi l mao mch ho. Trong cc xoang mch ny c mt s lng i thc bo a dng (+) vi

lysozym, CD68 v ging nh t bo Kupffer cc u bit ho r. Ung th t bao gan thng a dng v cu trc v t bo. Nhng kiu cu trc khc nhau v nhng bin th v t bo thng xuyn cng xy ra. 1.3.1. Cc th cu trc 1.3.1.1. Th b y l th ph bin nht v thng gp ung th bit ho r v va. Cc t bo u xp xp thnh dy, thnh b, c dy khc nhau t hai ti nhiu hng t bo. Cc b c tch bit bi cc xoang mch ph bi t bo ni m thp dt. Cc t bo Kuffer khng c hoc c vi s lng t. Cc si collagen tng sinh trong cc khong Disse
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bao quanh cc xoang v mng y v chng tr thnh mao mch ho. M m x t hoc khng c, tr khi t bo u xm nhp vo vch x gan. 1.3.1.2 Th gi tuyn v tuyn nang Cc t bo u sp xp to thnh cu trc gi tuyn, thng l mt lp t bo u. Mt s tuyn hoc cu trc nang c to thnh do gin cc knh mt gia cc t bo u. Cc knh ny cha mt, thng khng c m m. Cc tuyn gi thng cha cht dch protein c mnh vn t bo, i thc bo. Cht dch ny nhum dng tnh vi PAS nhng khng bt mu vi mucicarmin v xanh alcian. i khi cc tuyn gi gin thnh nang. Cc tuyn b gin ny c th
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c to nn do s thoi ho ca cc b t bo dy. Ni chung trong u bit ho r cu trc tuyn thng nh hn trong cc u bit ho va. 1.3.1.3 Th o. Cc t bo u hp thnh m to nh khng u nhau ng tch bit nhau. Mi m c t bo ni b bao quanh chng t chng cch bit nhau bi cc xoang mch dn rng khin ngi ta c cm gic nh nhng hn o khi quan st di vt knh nh ca knh hin vi quang hc. C l y l cc b ung th b ct ngang. 1.3.1.4. Th nh

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Cc t bo u bm quanh trc lin kt. Cc nh ny thng hnh thp, chn nh nhiu hng t bo, phn nh nh thng ch c mt hai hng t bo. hnh thi nh c th thy cc t bo nhn ln, nhiu nhn khng u nhau nh cc hp bo. 1.3.1.5. Th c Cu trc c bn vn l b, nhng cc t bo u qu sn lm cho cc xoang hp li do b chn p nn kh nhn bit to cho m u c hnh nh c. 1.3.6. Th t bo sng Cc t bo c bo tng sng chim u th thng vn xp thnh cc b, m v tch bit bi cc xoang mch. S sng ca bo tng hu ht l do cha lng ln
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glycogen, nhum PAS dng tnh, nhng c th do nc v m. 1.3.1.7. Th x Th ny t gp, hnh nh c trng l s x ho ni bt dc theo cc khe mch dng xoang vi cc mc teo khc nhau ca cc t bo u. Th ny c th thy cc u nh, nhng thng thy trong cc trng hp sau ho tr, x tr v gy tc mch. 1.3.1.8. Th t bo a hnh thi Cc t bo u thiu s kt dnh, do vy khng thy kiu b r rng, chng thng tch ri nhau, phn tch lan to. C s thay i r rt v kch thc, hnh thi v tnh cht bt mu ca t bo v nhn. Tng ch s nhn chia. Thng thy cc t bo khng
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l n nhn hoc a nhn k qui. Th a hnh thi t bo thng gp trong cc u bit ho km. 1.3.1.9. Th dng sarcom Ung th biu m t bo gan i khi c hnh nh dng sarcom, c trng bi tng sinh t bo hnh thoi v cc t bo khng l k qui. Khi u ch ton thnh phn t bo dng sarcom s kh phn bit sarcom tht nh sarcom x, sarcom c. Tuy nhin s thay i ny ch mt phn u. Ho m min dch s gip cho chn on xc nh (bng 1) Bng 1. Cc market sau y c dng chn on ung th biu m t bo gan.
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Khng nguyn

Kt qu dng trong chn on)

Hepatocyte (Dako) Dng tnh (thng s Polyclonal carcinoembryoni antigen Alpha fetoprotein Fibrinogen Dng tnh hoc m tnh Dng tnh hoc m tnh Cytokeratins 8 and Thng dng tnh 18 Cytokeratins 7 and Thng dng tnh 19 Cytokeratin 20 Epithelial Thng dng tnh m tnh
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Dng tnh (canlicular pattern)

membrane antigen BER EP4 m tnh

Mt s c im c t bo u - Tit mt: C th thy mt s trng hp, y l tnh c hiu ca ung th t bo gan. Mt c th di dng nhng git mt trong bo tng ca t bo, nhng hay gp hn c l trong cc tiu qun mt, i khi c c trong lng tuyn gi. - Cc th vi: + Th vi hyalin hnh cu: nm trong bo tng t bo v thng nm cnh nhn, hnh trn nh. Khng ng nht, c qung sng bao quanh, a toan mnh, PAS (+), bt mu da cam ti khi nhum 3
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mu Masson v dng tnh vi

anti

trysin. Loi th vi ny thng thy trong ung th biu m t bo gan, him gp trong cc u khc. + Th vi hyalin mallory: thy trong bo tng, hnh dng khng u, mt s trng hp c trung tm nht mu v vin ngoi thm mu, a toan, PAS (-), nht mu vi nhum 3 mu Masson. N c to nn do s tp trung cc si trung gian v (+) vi cc antiubiquitin. Loi ny thng thy trong ung th biu m t bo gan. + Th vi nht mu: trong bo tng t bo, hnh trn hay bu dc, khng bt mu hay a toan nh. Chng hin din nh s tch t ca cc cht v nh hnh trong li
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ni bo b gin rng, nhum (+) vi antifibrinogen. Th ny thng thy trong ung th th x lt, nhng cng c th thy trong cc typ thng thng ca ung th biu m t bo gan, c bit trong typ x (scirrhous HCC). + Th vi knh m: gp bnh nhn HBs Ag (+).Th ny bt mu vi Orcein, xanh Victoria hay aldehyde fuchsin v ho m min dch (+) vi khng th khng HBs Ag. Th ny khng thy u xm nhp tnh mch ca hoc di gan v hu nh c ngh l do cc t bo gan c HBs Ag (+) b mc kt trong m u. - Glycogen: cc t bo u cha mt lng glycogen khc nhau biu hin di nhng
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ht nh phn tn. Trong ung th gan t bo sng, t bo u cha lng ln glycogen. - Thay i m: trong t bo u c th thy nhng ht nh hoc di dng hnh cu kch thc khc nhau. Thay i m dng lan to thng gp nht trong cc u nh giai on sm. T l ny gim xung vi s gia tng kch thc ca u v tng i t gp u giai on mun. Ri lon chuyn ho lin quan ti to u v cung cp mu khng trong giai on sm ca u. C ch ca s hnh thnh cc ht m trong cc t bo nht l ung th giai on sm c th l do ri lon chuyn ho ca t bo v s cung cp mu khng to nn. Tuy

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nhin c ch ny vn cha c xc nh r. 1.4 Phn m hc u (WHO 2000) Theo m hc, ung th biu m t bo gan c chia thnh bit h r, va, km v khng bit ho. 1.4.1 Bit ho r Loi bit ho r thng thy nht trong cc u nh, giai on sm, u 2cm, him khi gp cc u giai on mun. M u v t bo u gn ging vi t bo gan bnh thng. Tng nh cc t bo khng in hnh ti thiu, t l nhn trn bo tng tng nh, b t bo mng thng c cu trc gi tuyn hay tuyn nang v thng c thay i m

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(nhim m). Hu ht cc u > 3cm bit ho r nm vng ngoi vi u. 1.4.2. Bit ho va Thng gp nhng u c ng knh > 3cm. M u v t bo u c s khc bit tng i r rt so vi m v t bo gan bnh thng. Cc t bo u sp xp thnh b thng c 3 hng t bo hoc hn. T bo u c bo thng rng a toan, nhn trn v ht nhn r. T l nhn trn bo tng tng ng nh t bo gan bnh thng hoc hn va phi. M u c th thy kiu gi tuyn v cc tuyn ny thng cha mt hay dch protein. 1.4.3. Bit ho km

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M u v t bo u c s khc bit r rt so vi bnh thng. T bo u pht trin dy c khng th phn bit c cc mch mu dng xoang v ch thy cc mch dng khe trong cc u ln. Cc t bo u c t l nhn trn bo tng tng r, a hnh thi t bo v c c cc t bo khng l k qui. Loi bit ha km cc k him trong cc u giai on sm. 1.4.4. Th khng bit ho Cc t bo u khng bit ho c bo tng t, nhn trn hoc hnh thoi ngn, tng sinh trong vng c hoc vng tu. Chn on ung th th ny rt kh khn nu ch da vo hnh thi m hc, cn s dng ho m min dch chn on xc nh. y l th
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him gp, t l < 2% cc ung th biu m t bo gan. Tin lng xu. c im lm sng, v tr, triu chng v du hiu, quy trnh chn on khng khc bt vi ung th biu m t bo gan ni chung. Nhn chung ung th biu m t bo gan rt thay i v mt m hc ngay c trong mt nt n c. Nhn t s phn m hc hu ht cc nt <2cm c s phn b ng dng ca cc m ung th bit ho r, ngc li khong 40% cc u c ng knh 2 - 3 cm c trn 2 kiu ca m hc. M t bit ho thng nm bn trong v bao quanh pha ngoi l m bit ho r. Cc vng bit ho r gim khi kch thc ca u tng v chng s b thay th hon ton bi
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m ung th km bit ho khi u ln ln 3cm ng knh. 2. UNG TH BIU M NG MT TRONG GAN 2.1. nh ngha Ung th biu m ng mt trong gan l u c tnh bao gm nhng t bo ging t bo biu m ng mt, pht sinh t cc ng mt ln hoc nh trong gan. Ung th xut pht t ng gan phi hay tri ti vng ni hay gn c gi l ung th ng mt rn gan v c xem nh l u ngoi gan. Ung th ng mt trong gan chim khong 15% ung th biu m gan phi gi v tr th 2 sau ung th t bo gan.
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Bnh c t l thp hu ht cc nc, tuy nhin ng Nam c t l cao hn cc khu vc khc. Bnh c lin quan ti nhim sn l gan loi Opisthorchis viverrini v Clonorchis sinensis, vim ng mt mn do si trong gan. Mt s nguyn nhn khc nh nhim Epstein Bar virus, d dng ng mt, x gan ho gan bm sinh cng c cp ti. 2.2. i th U c th pht sinh mi v tr ca ng mt trong gan. U c mu xm hay trng xm, chc v c. Mt s u pht trin ni ng, mt s to polyp. U c th l mt khi n l, nhng thng gm nhiu c kch thc khc nhau, thng dnh vo nhau v
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hay xm ln vo tnh mch ca. Mt ct u c th hoi t trung tm, so x v cht nhy. X ho c bit r trung tm v trong mt s trng hp c calci ho. Nhng ung th ng mt i km vi si gan c xu hng lan rng dc theo cc ng mt cha si. Ung th ng mt trong gan thng lan rng trc tip vo nhu m gan, vo cung tnh mch ca v vo ng mt. C t l di cn vo hch vng cao, sau l vo phi, xng, tuyn thng thn, lch tu. 2.3. M hc Ung th biu m ng mt trong gan gm cc typ sau: - Ung th biu m tuyn: cu trc tuyn ng c th hin trong ung th biu
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m ng mt. Hnh nh tuyn ng l ph bin nhng cng c mt s u c cu trc nh. Cc t bo u sp xp thnh cc ng tng i ng dng, hoc to thnh cc ng rt hp ging nh ng Hering. Ngi ta gi nhng u thuc tp ny vi ci tn Ung th biu m t bo tiu qun mt. Trong cng mt u c th c nhiu typ cu trc khc nhau. C th gp kiu dy nhng him khi t bo u tp trung thnh mt khi c. Cc t bo u khi th ln, khi th nh, hnh khi vung hay hnh tr hoc a hnh thi. a s t bo c bo tng nht mu hoc i toan. Nhn t bo nh, ht nhn t ni r nh trong ung th t bo gan: a s t bo c th ch nhy di dng ny hay dng
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khc, i khi t bo c bo tng sng v ln ging t bo i. Cht nhy ny c li protein 1, 2 v 3 c th pht hin bng nhum PAS v xanh alcian, mucicarmin. T bo u c th nhum ho m min dch vi CK7, CK19, CEA, EMA. Typ ung th tuyn nh t gp, cc nh c nng bi trc lin kt x mch. M m lin kt phong ph l c im quan trng ca loi u ny. Thng trung tm ca u, x nhiu, t bo u t v ngc li vng ngoi vi tng sinh t bo u nhiu hn. Mt s t trng hp t bo u tch xa nhau bin dng hoc teo t do s pht trin lan rng ca m m ngho t bo

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hoc b hyalin ho, i khi b vi ho thnh . M ung th pht trin lan rng c th gy chn p t bo gan hoc thm nhim dc theo cc xoang mch, cng c th xm nhp quanh cc dy thn kinh c bit l cc khong ca ln. Mt c th xut hin do ng mt tc nhng mt bao gi cng ngoi t bo v thng chu vi khi u. Ung th biu m t bo ng mt him khi xut hin trong nhng ti nang bm sinh ca cc ng mt (hi chng Caroli) v him khi kt hp vi x gan.

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- Ung th biu m tuyn vy: Cu to m u gm cu trc tuyn c s lng ln t bo vy quy quanh cc tuyn. - Ung th biu m t bo vy: M u ch gm t bo vy, c th dng bit ho cao, bit ho va hay bit ho thp. - Ung th biu m tuyn nhy: thnh phn nhy nhiu c th thy bng mt thng, cht nhy trn ra m m. Cc t bo u cng cha cht nhy. - Ung th biu m t bo nhn: cc t bo u cng trn cha y cht nhy y nhn lch v mt pha, t bo u ging nh chic nhn. rt him gp t bo nhn n thun.

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- Ung th biu m dng sarcom: y l bin th rt c tnh ca ung th biu m ng mt trong gan. M u gm cc t bo hnh thoi ging sarcom x hay ca m bo si c tnh. Thnh thong cn thy cc t bo ung th biu m. - Bin th t bo sng: hnh nh c trng l t bo u c bo tng sng trong cu trc tuyn hoc tuyn nang, nhum PAS (-). 2.4. Phn Ung th biu m ng mt trong gan c th phn thnh loi bit ho cao, bit ho va v km bit ho.

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Typ ung th biu m tuyn loi bit ho cao c cu trc tuyn ng hoc nh tng i ng nht; loi bit ho va cc ng b vn xon dng sng, hoc kiu dy; loi bit ho km c cu trc vn xon nhiu v a dng thi t bo. 3. UNG TH BIU M HN HP T BO GAN T BO NG MT. 3.1. nh ngha: L u him cha cc thnh phn khng cn i ca c ung th t bo gan v t bo ng mt, cc thnh phn ny ln vo nhau. 3.2. i th Khng c s khc bit r rt v mt i th so vi ung th biu m t bo gan. Cc trng hp c thnh phn ung th biu m
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ng mt vi m m x nhiu, mt ct rt chc. 3.3. M bnh hc U cha c hai thnh phn ung th biu m t bo gan v biu m t bo ng mt. Cn tm kim s hin din c hai thnh phn mt v cht nhy u ny. Tuy nhin, quy tc ny khng ng dng c i vi nhng tn thng, trong mt th ny hay mt th khc khng c kh nng bit ho nhn bit chc chn. Ho m min dch c th s gip trong chn on. Cc t bo gan ch yu biu hin CK8 v 18, cn t bo biu m ng mt l CK7 v 19. Tuy nhin cc kiu khc nhau m khng th xc nh r rng c, vic
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chng minh cc tiu qun mt bng CEA a dng (hn hp glycoprotein mt) kt hp vi Hep Par biu hin min dch cho chn on thnh phn ung th t bo gan v cht nhy biu m trung tnh cho phn ng vi PAS chn on thnh phn ung th biu m ng mt. 4. U NGUYN BO GAN (HEPATOBLASTOMA) 4.1. nh ngha: l u c tnh vi nhng dng khc nhau ca s bit ho, t nhng t bo ging t bo gan thai n nhng t bo phi thai v cc m bit ho bao gm m dng xng, m lin kt si v cc si c vn.

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y l u gan thng gp nht tr em: 4% lc mi sinh, 68% trong nm u v 90% trc 5 tui, t l nam/n t 1,5 2/1. 4.2. i th: U ln, kch thc 5 22cm, nng t 150 1000g. Th 1 u chim khong 80%, th nhiu u 20%. U thu phi chim 58%, thu thi 15% v c hai thu l 27%. U c gii hn r, thng li ln trn mt gan. B ca u tch bit vi m gan lnh bng mt v bao gi. U nguyn bo gan thai n thun c mu nu bnh thng ca gan lnh, trong khi u gan hn hp c mu sc thay i t nu n vng hay trng. U thng c nhng vng chy mu hoi t v
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c th c hnh nh dng gelatin mu nu n . 4.3. M bnh hc U c nhiu kiu m hc khc nhau vi nhng t l khc nhau, mt s bao gm ton b cc t bo biu m bo thai ng dng hay nhng t bo khng bit ho nh, trong khi cc trng hp khc c nhiu loi m khc nhau bao gm nhng t bo biu m gan bo thai v nhng t bo phi thai, m lin kt si, cht dng sn, si c vn, nhng t bo biu m vy v nhng t bo cha sc t melanin. V mt m hc u chia lm 6 loi: trong c 4 kiu biu m chim 56% v 2 kiu

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hn hp thnh phn biu m v tng m chim 34%. - Kiu biu m gm typ bo thai n thun, typ phi thai, typ b ln v typ t bo nh khng bit ho. - Kiu hn hp gm typ khng c c trng ca u qui, typ c trng ca u qui. 4.3.1. Typ bit ho biu m bi thai n thun: Typ ny chim khong 30%, cc t bo sp xp thnh b dy 2 3 hng t bo. Cc t bo ny hnh khi vung nh ging t bo gan ca bo thai ang pht trin, nhn trn nh, cht nhim sc mn v ht nhn khng r. Bo tng rng nhiu thay i t dng ht mn n sng, phn nh s lng
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khc nhau ca glycogen v lipid cha bn trong to nn hnh nh sng ti ca tn thng trn phng i thp. Cc xoang mt c th thy gia cc t bo gan nhng him khi cha mt. Ngoi ra cn thy cc to mu ngoi tu gm cc t bo tin thn dng hng cu, dng tu nm trong cc xoang mch. Cc xoang mch c lp bi t bo ni m v t bo Kupffer, chng dng tnh lan to vi nhum UEA-1 v anti - CD34, trong khi t bo ni m ca gan bnh thng ch c dng tnh khu tr. 4.3.2. Typ phi hp biu m bo thai v phi thai Khong 20% cc trng hp biu hin kt hp cc t bo bo thai vi cc mng
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hay m t bo phi c kch thc nh, hnh trn hay c gc cnh vi bo tng t c dng ht m mu bao quanh nhn c cht nhim sc tng. Cc t bo ny thng lin kt vi nhau rt t nhng c th xp theo cu trc gi hoa hng, tuyn, hay tuyn nang. Cc t bo bt mu xanh c kch thc nh trn ging cc t bo mm trong u nguyn bo thn, u nguyn bo thn kinh v nhng u phi thai khc tr em. Cc ca t bo phi thai thng kt hp vi cc t bo bo thai, cc t bo ny khng c glycogen v lipid, PAS(-). Hot ng nhn chia thng nhiu vng t bo phi thai v c biu l -TGF thp. C th thy cc to mu ngoi tu.
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4.3.4. Typ b ln B ln dy t 6 12 hng t bo hoc hn. Typ ny chim khong 3%. Cc b ny c cc t bo biu m bo thai v phi thai v mt kiu t bo th 3 ln hn c bo tng rng v nhn ln.Thut ng b ln ch dng trong trng hp c cc b ln l c trng ni bt ca tn thng. Nhng trng hp c t bo phi thai hay t bo trung m vi mt to b ln n c th vic phn loi da trn thnh phn t bo phi thai hay trung m v khng xem nh l loi b ln. 4.3.4. Typ t bo nh khng bit ho U bao gm cc t bo ging t bo nh ca u nguyn bo thn kinh, sarcom Ewing,
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u lymph v sarcom c vn. U ny c gi l u nguyn bo gan khng bit ho t bo nh, chim khong 3%. Cc t bo ny pht trin trong cc b nhng khng dnh vi nhau, thng gp nhn chia, khng to glycogen, cc git m hay sc t mt. C cc xoang mch, nhng s lng gim so vi typ biu m bo thai. Trong t bo c protein cn bn ngoi bo v c s lng ln si c phn ng min dch vi collagen typ III. Hin vi in t v ho m min dch s dng khng th khng cytokeratin a dng gip cho chn on xc nh. 4.3.5. Typ hn hp biu m v trung m

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Typ hn hp biu m v trung m cha mt lng ln khc nhau cc t bo ca typ bo thai v typ phi thai trn ln vi trung m nguyn thu v nhng m khc xut pht t trung m. Thnh phn trung m nguyn thu c mt t bo cao, gm cc t bo hnh thoi, di c bo tng t v nhn mp di vi hai u trn. Mt s vng cc t bo c xu hng xp song song vi nhau vi cc si collagen v cc nguyn bo si non, trong khi nhng vng khc c th c nhiu t bo xp lng lo dn n hnh nh dng nhy. Cng c th thy vch si trng thnh hn vi cc nguyn bo si bit ho r v collagen nm dc theo nhng vng ca m dng xng v sn. Cc t bo
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nm trong nhng dng xng c vin ngoi gc cnh khng u v nhng chi ngn c mt hay nhiu nhn trn hay bu dc lm cho chng ta khng th phn bit c vi nguyn bo xng. Tuy nhin, cc nghin cu v ho m min dch xc nh cht ging xng ny nh c to ra trong qu trnh bit ho biu m. 4.3.6. Typ hn hp t trng u qui Khong 20% cc u hn hp trung m v biu m c cha thm cc thnh phn c trng khc gm c vn, sn, xng, biu m nhy, biu m vy tng v sc t melanin.Cc m ny c th ng ring bit hay xen ln vo cc m khc.

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im quan trng chn on u qui tht l trong u qui tht khng c chim nhng vng biu m bo thai thay phi thai. Nghin cu ho m min dch vi AFP, HCG, CEA, EMA, CK, Vimentin, - antitypsin,
1

- antichymo - trysin, chromogramin A,

S.100 v NSE vi mt t l a dng. AFP bc l typ t bo phi v thai, HCG typ t bo khng l, vimentin typ t bo khng bit ho, CK bc l vi cc t bo dng xng. Nghin cu siu cu trc cho thy cc bo quan quanh bo tng n gin, mt vi ti th, knh mt c vi nh, li ni bo dn rng ra hoc th vi v nh hnh.
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Cu hi 1. Hy nu mt s nguyn nhn v yu t nguy c gy ung th gan ? 2. M t c im hnh thi i th ung th biu m t bo gan ? 3.Trnh by cc tp vi th ung th biu m t bo gan ? 4.Trnh by m hc v mt s c im v t bo ca ung th biu m t bo gan ? 5.Trnh by c im hnh thi i th v cc tp vi th ung th biu m ng mt trong gan? 6.Trnh by c im hnh thi i th v cc tp vi th u nguyn bo gan ? 7. Hy nu mt s phng php chn an ung th gan ?
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