tng loi t chc theo cc mc xp hng tng ng.

Bo m s thng nht trong c nc; Nng cao hiu

lc, hiu qu hot ng ca t chc s nghip, dch v
cng lp trong tng ngnh, lnh vc, i mi phng
thc u t cho mi loi t chc s nghip, dch v
cng lp theo h thng phn loi, xp hng.
Sau 06 nm thc hin Thng t s 23/2005/TTBYT ngy 25 thng 8 nm 2005 ca B Y t hng
dn xp hng cc n v s nghip y t trn phm vi
ton quc, c bn thu c nhiu kt qu. Cc tiu
ch xp hng ph hp vi thc trng hin nay ca cc
c s y t cng lp. Tuy nhin, sau qu trnh thc hin
cng bc l mt vi vng mc nht l khi cc m hnh
t chc ngy cng pht trin v a dng. Cc vn bn
hng dn v ph cp chc v cha th ph ht cc
m hnh . Do vy vic nghin cu, nh gi vic
thc hin Thng t s 23 sau 06 nm thc hin l rt
cn thit. T thc trng trin khai, rt ra cc bi hc
cn thit, tm nhng bt cp xut, kin ngh cp
c thm quyn sa i, b sung cc vn bn nhm
hon thin hn na vic xp hng cc t chc s
nghip y t cng lp t gp phn vo s thng
li ca chin lc bo v, chm sc, nng cao sc
kho nhn dn.
2. Kin ngh

- ngh nghin cu ban hnh b sung tiu chun

xp hng v mc ph cp chc v ca cc m hnh t
chc trong ngnh y t cn thiu v cho thc hin rt
kinh nghim v s hon chnh khi b sung sa i
Thng t s 23
- Tin hnh nghin cu nh gi vic thc hin xp
hng cc n v s nghip y t cng lp theo Thng t
s 23 nm 2005 chun b sa i thay th Thng t
s 23 khi ci cch tng th ch tin lng.
KT QU NGHIN CU
1. B Y t (2005) Hng dn xp hng cc n v s nghip
y t.
2. B Y t (2006) Hng dn thc hin ch ph cp chc
v lnh o trong cc n v s nghip y t khng thc hin vic
xp hng
3. B Y t (2007) Sa i khon 3, mc IV Thng t s
23/2005/TT-BYT ngy 25 thng 8 nm 2005 ca B Y t hng
dn xp hng cc n v s nghip y t.
4. B Y t (2009) Nin gim thng k y t.
5. Chnh ph (2004) Ch tin lng i vi cn b, cng
chc, vin chc v lc lng v trang
6. Th tng Chnh ph (2005) Quy nh vic phn loi, xp
hng cc t chc s nghip
7. UBND cc tnh (2011) Bo co tnh hnh xp hng cc t
chc s nghip y t cng lp

VAI TR CHT CH IM KHI U (CEA, CA 19-9)

TRONG CHN ON V IU TR UNG TH BIU M TRC TRNG
TRNH HNG SN, QUCH VN KIN,
BI TRUNG NGHA, NGUYN THNH KHIM

T VN
Cht ch im khi u (Tumor Marker: TM) CEA, CA
19-9 l xt nghim c vai tr nht nh trong qu trnh
chn on, iu tr v theo di ung th biu m i trc
trng.
CEA l TM c p dng rng ri nht bnh
nhn ung th i trc trng. CEA l ch s chn on
sm s ti pht sau phu thut trit cn ung th i
trc trng. CA 19-9, c xc nh bng khng th n
dng chut k hiu 1116 NS 19-9. Mt s nghin cu
ch ra mi lin quan ca nng CA 19-9 trong huyt
thanh vi phn loi giai on bnh Dukes. Tuy nhin
ng dng lm sng ca CEA v CA 19-9 vn cha
thc s r rng.
Mc ch ca nghin cu ny l nh gi vai tr
ca CEA v CA 19-9: mi lin quan nng CEA, CA
19-9 vi phn loi giai on bnh TNM, di cn hch, di
cn xa v bit ho ung th trc trng.
I TNG V PHNG PHP NGHIN CU
1. i tng: 600 bnh nhn (BN) ung th trc
trng c phu thut ti bnh vin Vit c giai on
t thng1.2006 n thng 12.2010. Tt c cc bnh
nhn u c kt qu gii phu bnh l
Adenocarcinome. Loi b cc trng hp khng c kt

130

qu gii phu bnh hoc c nhng khng phi ung th

biu m (600 bnh nhn c nh lng CEA trc
m v 597 bnh nhn c nh lng CA19-9 trc
m).
2. Phng php
- Hi cu m t.
- Cc BN c nh lng cht ch im khi u
bng my Adcia Centaur (M, sn xut nm 2006)
bng phng php ha quang min dch ti bnh vin
Vit c.
- CA 19-9 > 37 ng/mL v CEA > 5 ng/mL c coi
l tng.
- Cc ch tiu nghin cu:
. Tnh t l % CEA, CA 19-9 cao, thp
. Nng CEA trc m vi giai on T sau m
(theo phn loi TNM ca UICC). C 4 BN khng nh
gi c giai on T sau m do c lm hu mn
nhn to trong s 600 BN).
. Nng CEA trc m vi giai on Dukes sau
m (theo phn loi Dukes). C 19 BN khng nh gi
c giai on Dukes sau m trong s 600 BN).
. Nng CA 19-9 trc m vi giai on T sau m
(4 BN khng nh gi c giai on T sau m trong
s 597 BN).

Y hc thc hnh (792) - s 11/2011

. Nng CA 19-9 trc m vi giai on Dukes

sau m. C 19 BN khng nh gi c giai on
Dukes sau m trong s 597 BN.
. Nng CEA, CA 19-9 vi bit ho ca u
(phn loi bit ha theo WHO).
- X l s liu: phng php thng k thng thng.
KT QU NGHIN CU
Bng 1: T l CEA, CA 19-9 cao thp
Cht ch im khi u
n
%
<5
356
59.3
CEA
>5
244
40.7
(ng/mL)
Tng s
600
< 37
454
76
37 - 370
120
20.1
CA 19-9
(ng/mL)
> 370
23
3.9
Tng s
597
Nhn xt:
- C 600 BN c lm xt nghim CEA, 40.7% BN c
CEA > 5 ng/mL, gi tr thp nht = 0.00; gi tr cao nht =
15460.
- C 597 BN c lm xt nghim CA 19-9, 24% BN c
CA19-9 > 37 ng/mL, gi tr thp nht: 0.00; gi tr cao nht:
77390.
Bng 2: Nng CEA trc m vi giai on T sau m
Giai on T sau m
CEA
Tng
P
T1
T3
T4
T2
64
186
104
5
354
P<
(68,8%) (64,4%)
48,6%)
0,05
29
103
110
>5
242
(Q=
(31,2%) (35,6%) (51,4%)
16,72)
Tng
93
289
214
596
Nhn xt:
- 88% BN c CEA > 5 ng/mL giai on T3-T4.
- T l nhm CEA > 5 ng/mL 3 giai on l khc nhau
vi P < 0.05
Bng 3: Nng CEA trc m vi giai on Dukes sau
m
Dukes
CEA
Tng
P
A
C
D
B
226
90
31
5
347
(64%) (62,1%) (37,3%)
P < 0,05
127
55
52
>5
234
(Q=20,32)
(36%) (37,9%) (62,7%)
Tng
353
145
83
581
Nhn xt:
- 45,7% BN c CEA > 5 ng/mL giai on Dukes C
D.
- T l nhm CEA > 5 ng/mL 3 giai on l khc nhau
vi P < 0.05
Bng 4: Nng CA 19-9 trc m vi giai on T sau
m
Giai on T sau m
CA
Tng
P
T1
19-9
T3
T4
T2
80
227
145
37
452
(86,9%) (78,8%) (68,1%)
P < 0,05
12
61
68
> 37
141 (Q=15,00)
(13,1%) (21,2%) (31,9%)
Tng
92
288
213
593
Nhn xt:
- 91.5% BN c CA 19-9 > 37 ng/mL giai on T3-T4.

Y hc thc hnh (792) - s 11/2011

- T l nhm CA 19-9 > 37 ng/mL 3 giai on l khc

nhau (P < 0.05)
Bng 5: Nng CA 19-9 trc m vi giai on Dukes
sau m
Dukes
CA
Tng
P
19-9
AB
C
D
290
107
47
37
444
(82,6%) (73,8%) (57,3%)
P < 0,05
61
38
35
> 37
134 (Q=24,89)
(17,4%) (26,2%) (42,7%)
Tng
351
145
82
578
Nhn xt:
- 54.5% BN c CA 19-9 > 37 ng/mL giai on Dukes
C D.
- T l nhm CA 19-9 > 37 ng/mL 3 giai on l khc
nhau (P < 0.05)
Bng 6: CEA vi bit ho ca u
bit ho u
CEA
Tng
P
Rt bit
Bit ho
Km
ho
va
bit ho
101
218
20
5
339
P<
(69.2%) (57.1%) (48.8%)
0.05
45
164
21
>5
230
(Q=
(30.8%) (42.9%) (51.2%)
8.571)
Tng
146
382
41
569
Nhn xt:
- CEA >5 ng/mL U rt bit ho: 30.8%; U bit ho
va: 42.9%; U km bit ho: 51.2%. S khc bit c ngha
thng k vi P < 0.05
Bng 7: CA 19-9 vi bit ho u
bit ho u
CA
Tng
P
Rt bit
Bit ho
Km
19-9
ho
va
bit ho
118
288
32
37
438
(81.4%)
(76%)
(78%)
P>
27
91
0.05
> 37
9 (22%)
127
(18.6%)
(24%)
Tng
145
379
41
565
Nhn xt: T l CA 19-9 > 37 ng/mL rt bit ho, bit
ho va, km bit ho tng ng l 18,6%; 24%; 22%. S
khc bit khng c ngha thng k v t l CA 19-9 tng
cao.
BN LUN
CEA l mt trong nhng cht ch im khi u chnh
ca ung th i trc trng, c m t ln u tin
nm 1965 bi Gold v Freedman. CEA l mt
Glycoprotein c trng lng phn t 200 kDa. Chc
nng sinh l hc ca CEA gi mt vai tr trong s kt
dnh t bo v c ch s cht c chng trnh ca t
bo (Apoptosis). Tr s bnh thng ca CEA trong
huyt thanh l 0 5ng/mL. CEA tng trong cc trng
hp ung th biu m tuyn giai on mun, khi c
biu hin di cn xa v thng khng tng khi bnh
giai on sm.
Nghin cu ca chng ti c 600 BN c lm xt
nghim CEA (bng 1): 40,7% BN c CEA > 5 ng/ml
thp hn nghin cu ca Hong Mnh Thng [1] (
62,8%), nhng cao hn ca Nguyn Cng Hong [2]
(31,1%). Gi tr thp nht: 0,0; gi tr cao nht : 15.460.
CA 19-9 l cht ch im khi u c xc nh bi
Magnani v cng s. Chc nng sinh l hc ca CA
19-9 c th lin quan n s kt dnh t bo. Trong

131

ung th i trc trng, CA 19-9 ch tng trong 30%

trng hp v khng c cho l cht ch im khi u
sng lc, chn on, phn loi gian on, theo di
v gim st bnh nhn ung th i trc trng [3]. Khi
nghin cu trn 597 BN c lm xt nghim CA 19-9,
ch c 24% BN c CA 19-9 > 37 ng/mL tc l nhy
ca cht ch im khi u ny thp hn khi so snh vi
CEA, trong 23/143 BN (16,1%) c CA 19-9 > 370
ng/mL. Gi tr thp nht l 0,0 ng/mL; gi tr cao nht l
77390 ng/mL. T l CA 19-9 tng trong nghin cu ca
Zheng l 24% [4].
1. Mi lin quan ca CEA v CA 19-9 vi giai on
bnh theo TNM
T l CEA > 5 ng/ml ba nhm T1-T2, T3, T4
tng ng l 31,2%; 35,6%; 51,4% (bng 2). Nng
trc m CA 19-9 > 37 ng/ml vi giai on T sau m:
T1-T2, T3, T4 tng ng l 13,1%; 21,2%; 31,9%. S
khc bit ny c ngha thng k vi p< 0,05. Nh
vy, nng CEA > 5 ng/ml; CA 19-9 > 37 ng/ml c
lin quan n giai on bnh theo TNM. 88% trng
hp CEA > 5 ng/ml l ung th giai on T3 v T4. Kt
qu ny cho thy CEA tng c ngha khi u giai
on tin trin, tc l khi u xm ln ra thanh mc v
xm ln tng ln cn.
2. Mi lin quan ca CEA v CA 19-9 vi giai on
bnh theo Dukes
Khi nghin cu mi lin quan vi giai on bnh
theo Dukes, t l CEA giai on c di cn hch v di
cn xa l 45,7%. T l CEA > 5 ng/ml trong nhm di
cn xa (Dukes D), nhm di cn hch (Dukes C), nhm
Dukes A-B tng ng l 62,7%; 37,9%; 36% (bng 4).
S khc bit c ngha thng k vi P < 0,05 cho
thy CEA tng c lin quan ti di cn hch v di cn
xa. Nghin cu ca Nguyn Cng Hong[2] cng cho
kt qu tng t.
Nghin cu ca chng ti cng nh gi mi tng
quan ca CA 19-9 vi phn loi giai on Dukes: t l
CA 19-9 cao giai on A-B; C; D tng ng l 17,4%;
26,2%; 42,7%. V s khc bit ny ba nhm c
ngha thng k vi P < 0,05. Giai on Dukes D : t l
CA 19-9 cao mt cch c ngha. Kt qu ny ph
hp vi nghin cu ca Filella [5] v cng s khi nh
gi mi tng quan ca CA 19-9 vi phn loi giai
on Dukes (CA 19-9 cao giai on B, C, D tng ng
l 18%; 34%; 58%) Nghin cu ca Zheng [4] cho bit:
CA 19-9 cao 33% bnh nhn c di cn t 1-3 hch,
v 46% bnh nhn c di cn > 3 hch, tuy nhin
nhy ca CA 19-9 thng thp khi ung th i trc
trng cn giai on sm. Nghin cu ca Filella [5]
cho rng tc dng ch yu ca CA 19-9 trong ung th
i trc trng l gi tr tin lng, khng phi trong
chn on. Nguy c ti pht, v t vong BN c CA
19-9 > 37 ng/ml trc phu thut cao gp 2,95 ln so
vi nhm c CA 19-9 < 37 ng/mL. Tc gi ny kt
lun CA 19-9 l mt yu t tin lng hu hiu BN
ung th i trc trng, v l cng c hu hiu trong la
chn bnh nhn iu tr b tr [6], [7].
4. Lin quan ca CEA v CA 19-9 vi bit ho u

132

T l CEA tng trong cc nhm rt bit ho, bit

ho va v km bit ho tng ng l 30,8%; 42,9%;
51,2% (bng 6). S khc bit ch s ny gia cc
nhm l c ngha thng k vi P < 0,05.
T l CA 19-9 tng trong cc nhm rt bit ho,
bit ho va v km bit ho tong ng l 18,6%;
24%; 22% (bng 7). Khng c s khc bit v ch s
ny gia cc nhm.
Hi ngh ca hip hi ung th M (ASCO) nm
2006 khuyn co: CEA, CA 19-9 tng vn khng
c coi l cng c sng lc ung th i trc trng.
Tuy nhin, cc tc gi a ra mt s p dng lm
sng chnh ca CEA [3]: Mt l: xt nghim tham gia
chn on BN ung th i trc trng giai on mun.
Hai l: theo di sau m phu thut trit cn ung th i
trc trng. Nn xt nghim CEA mu 3 thng/ln trong
vng t nht 3 nm u sau phu thut BN ung th
giai on II hoc III. Nu CEA tng, cn phi tin hnh
cc phng php chn on cao hn pht hin tn
thng di cn xa. Tuy nhin, iu tr ho cht c th
lm cho nng CEA tng sai. Ba l: cht ch im
khi u c s dng theo di p ng ca BN vi
cc phng php iu tr b tr sau m.
Nghin cu ca chng ti cho thy: ch c 40,7%
BN c CEA tng, cn CA 19-9 th thp hn nhiu, ch
c 24% (bng 1). Tuy nhin, hn 85% CEA v CA 199 tng giai on T3, T4 v > 45% hai cht ny tng
giai on Dukes C v D. Vi kt qu ny, chng ti
thy p dng lm sng trn l hp l.
KT LUN
Trong ung th biu m trc trng, 40.7% BN c
CEA cao hn bnh thng trong khi ch c 24% BN
c CA19-9 cao hn bnh thng.
Nng CEA v CA 19-9 tng c ngha khi u
xm ln ra thanh mc v xm ln tng ln cn. CEA
tng cao th u km bit ha. CA 19-9 tng cao
khng c ngha thng k i vi bit ha u.
TI LIU THAM KHO
1. Hong Mnh Thng. Nhn xt c im lm sng, cn
lm sng v kt qu iu tr ung th trc trng giai on T3-T4
ti bnh vin K. Lun vn bc s ni tr bnh vin. Trng i
hc Y H Ni, 2009.
2. Nguyn Cng Hong. Nghin cu c im lm sng,
cht ch im khi u CEA v s bc l P53, HER-2/NEU ca
ung th trc trng iu tr phu thut ti bnh vin K. Lun
vn thc s y hc, trng i hc Y H Ni, 2008.
3. Locker, G.Y., et al. ASCO 2006 update of
recommendations for the use of tumor markers in
gastrointestinal cancer. J Clin Oncol, 2006. 24(33): 5313-27.
4. Zheng, C.X., et al. The prognostic value of preoperative
serum levels of CEA, CA19-9 and CA72-4 in patients with
colorectal cancer. World J Gastroenterol, 2001. 7(3): 431-4.
5. X. Filella, et al. Prognostic Value of CA 19.9 Levels in
Colorectal Cancer. Ann. Surg, 1991. july 1992.
6. Nakayama;, T., et al. CA19-9 as a predictor of recurrence
in patients with colorectal cancer. J Surg Oncol; 1997. 66(4):
238-243.
7. Kuusela, P., et al. Comparison of CA 19-9 and
carcinoembryonic antigen (CEA) levels in the serum of patients
with colorectal diseases. Br J Cancer, 1984. 49(2): 135-9.
8. Duffy;, M.J. and P. McGing. Guidelines for the Use of
Tumour Markers. 2005. Third-Edition, April 2005.

Y hc thc hnh (792) - s 11/2011